1. A resident often carries a doll
with her, treating it like her baby. One day she is wandering around crying that
she can’t find her baby. The nurse aide should
A. Ask the resident
where she last had the doll.
B. Ask the activity department if they
have any other dolls.
C. Offer comfort to the resident and help her look for her baby.
D. Let the other
staff know the resident is very confused and should be
watched
closely.
2. Which of the following is a job
task performed by the nurse aide?
A. Participating
in resident care planning conferences
B. Taking a
telephone order from a physician
C. Giving medications to assigned
residents
D. Changing sterile
wound dressings
3. A resident who is lying in bed
suddenly becomes short of breath. After calling for help, the nurse aide’s next
action should be to
A. Ask the resident to take deep breaths.
B. Take the resident’s vital signs.
C. Raise
the head of the bed.
D. Elevate the resident’s feet.
4. Gloves should be worn for which of
the following procedures?
A. Emptying
a urinary drainage bag
B. Brushing a
resident’s hair
C. Ambulating a
resident
D. Feeding a
resident
5. Which of the following statements is
true about residents who are
restrained?
A. They
are at greater risk for developing pressure sores.
B. They are at
lower risk of developing pneumonia.
C. Their posture
and alignment are improved.
D. They are not at
risk for falling.
6. When feeding a resident, frequent
coughing can be a sign the resident is
A. Choking.
B. Getting full.
C. Needs to drink more fluids.
D. Having
difficulty swallowing.
7. A resident gets dressed and comes
out of his room wearing shoes that are
from two
different pairs. The nurse aide should
A. Tease the resident by complimenting the
resident’s sense of style.
B. Ask if
the resident realizes that the shoes do not match.
C. Remind the resident that the nurse aide can
dress the resident.
D. Ask if the resident lost some of his shoes.
8. When a resident refuses a bedbath,
the nurse aide should
A. Offer the resident a bribe.
B. Wait
awhile and then ask the resident again.
C. Remind the resident that people who smell don’t
have friends.
D. Tell the resident that nursing home policy
requires daily bathing.
9.
During lunch in the dining room, a resident begins yelling and throws a
spoon at
the nurse aide. The best response by the nurse aide is to
A. Remain
calm and ask what is upsetting the resident.
B. Begin removing all the other residents from the
dining room.
C. Scold the resident and ask the resident to
leave the dining room
immediately.
D. Remove the resident’s plate, fork, knife, and
cup so there is nothing
else
to throw
10. When trying to communicate with a resident
who speaks a different
language
than the nurse aide, the nurse aide should
A. Use
pictures and gestures.
B. Face the resident and speak softly when
talking.
C. Repeat words often if the resident does not
understand.
D. Assume when the resident nods his/her head that
the message is
understood.
11. When a resident is expressing anger, the
nurse aide should
A. Correct the resident’s misperceptions.
B. Ask the resident to speak in a kinder tone.
C. Listen
closely to the resident’s concerns.
D. Remind the resident that everyone gets angry.
12. A nurse aide finds a resident looking in the
refrigerator at the nurses’
station at
5 a.m. The resident, who is confused, explains he needs
breakfast
before he leaves for work. The best response by the nurse aide is
to
A. Help the resident back to his room and into
bed.
B. Ask the
resident about his job and if he is hungry.
C. Tell him that
residents are not allowed in the nurses’ station.
D. Remind him that he is retired from his job and
in a nursing home.
13. Residents with Parkinson’s disease often require
assistance with walking
because
they
A. Become confused and forget how to take steps
without help.
B. Have poor attention skills and do not notice
safety problems.
C. Have visual problems that require special
glasses.
D. Have a
shuffling walk and tremors.
14. A resident who is incontinent of urine has
an increased risk of developing
A. Dementia.
B. Urinary tract infections.
C. Pressure sores.
D. Dehydration.
15. A resident is on a bladder retraining program.
The nurse aide can expect
the resident to
A. Have a fluid intake restriction to prevent
sudden urges to urinate.
B. Wear an incontinent brief in case of an
accident.
C. Have an indwelling urinary catheter.
D. Have a
schedule for toileting.
16. The doctor has told the resident that his cancer
is growing and that he is
dying.
When the resident tells the nurse aide that there is a mistake, the
nurse aide
should
A. Understand
that denial is a normal reaction.
B. Remind the resident the doctor would not lie.
C. Suggest the resident ask for more tests.
D. Ask if the resident is afraid of dying.
17. To help prevent resident falls, the nurse
aide should
A. Always raise siderails when any resident is in
his/her bed.
B. Leave residents’ beds at the lowest level when care is
complete.
C. Encourage residents to wear larger‐sized,
loose‐fitting clothing.
D. Remind residents who use call lights that they
need to wait patiently
for
staff.
18. As the nurse aide begins his/her assignment,
which of the following should
the nurse aide do first?
A. Collect linen
supplies for the shift
B. Check all the
nurse aide’s assigned residents
C. Assist
a resident that has called for assistance to get off the toilet
D. Start bathing a
resident that has physical therapy in one hour
19. When a sink has hand‐control faucets, the nurse aide should use
A. A paper towel to turn the water on.
B. A paper
towel to turn the water off.
C. An elbow, if possible, to turn the faucet
controls on and off.
D. Bare hands to turn the faucet controls both on
and off.
20. The resident’s weight is obtained routinely
as a way to check the resident’s
A. Growth and development.
B. Adjustment to the facility.
C. Nutrition and health.
D. Activity level.
21. Considering the resident’s activity, which
of the following sets of vital signs
should be
reported to the charge nurse immediately?
A. Resting: 98.6°‐98‐32
B. After eating: 97.0°‐64‐24
C. After walking
exercise: 98.2°‐98‐28
D. While watching
television: 98.8°‐72‐14
22. The nurse is assessing the growth and
development of a healthy three
year-old
child. The nurse should expect the child to be able to:
A. Ride a bicycle
B. Jump rope
C. Throw
a ball overhead
D. Hop on one foot
23. A patient with congestive heart failure and
severe peripheral edema has a
nursing
diagnosis of fluid volume excess What are the two MOST important
interventions
for the nurse to initiate?
A. Diuretic therapy
and intake and output
B. Nutritional
education and low-sodium diet
C. Daily
weights and intake and output
D. Low-sodium diet
and elevate legs when in bed
24. A nurse is providing care to a patient with
a new skin graft on the leg. The
patient is
upset and the nurse notes copious red drainage oozing around
the dressing
the nurse should immediately:
A. Lift the
dressing to assess the area
B. Ask if the
patient is having any pain
C. Apply
firm pressure for 10 to 15 minutes
D. Assess the
apical pulse
25. To minimize a toddler from scratching and
picking at healing skin graft, the
nurse
should utilize:
A. Mild sedatives
B. Hand
mittens
C. Punishment for
picking
D. Distractions
26. The nurse calls together an interdisciplinary
team with members from
medicine,
social service, the clergy, and nutritional services to care for a
patient
with a terminal illness. Which of the following types of care would
the team
MOST likely be providing?
A. Palliative
B. Curative
C. Respite
D. Preventive
27. A patient recently underwent coronary artery
graft (CABG) surgery.
Which of
the following nursing diagnose PRIORITY?
A. Anxiety
B. Impaired gas
exchange
C. Acute
pain
D. Sleep
deprivation
28. A child with asthma has an order for
albuterol, before administration of the
medication
the nurse MUST.
A. Pre-oxygenate
the patient
B. Assess the
patient's heart rate
C. Obtain venous
Access
D. Feed the patient
a snack
29. A 52 year- old woman is scheduled to undergo an abdomino-
perineal
resection
in three days for removal of a cancer of the rectum. The nurse
reviews
the care plan with the patient. The patient will receive prophylactic
antibiotics
and will be given a mechanical bowel preparation the day
before. Which
additional preparation should the patient undertake at this
time?
A. Wear pressure
stockings
B. Perform leg strengthening exercises
C. Maintain
high- protein, low- residue diet
D. Take daily ferrous iron tablets
30. As the office nurse, you are
reviewing client messages for a return call.
Which client should the nurse call back first.
A.
Client 36 weeks gestation
complaining of facial edema
B.
A client 24 weeks gestation
complaining of urinary frequency
C.
A client 12 weeks gestation whose
had five episodes of vomiting in 36 hours
D.
A client 20 weeks gestation
complaining of white, thick vaginal discharge
31. A 62 year old client has a
history of coronary heart disease and is brought
into the ER complaining of chest pain. What initial action should
be taken
by the nurse?
A.
Give the client ntg gr 1/150 sl now
B.
Call the cardiologist about the
admission
C.
Place the client in a high Fowlers
position after loosening the shirt
D.
Check blood pressure and note
the location and degree of chest pain
32. As a nurse working the ER, which
cient needs the most immediate
attention?
A.
A 3 yr old with a barking cough,
oxygen sat of 93 in room air, and occasional inspiratory stridor
B.
A 10 month old with a tympanic
temperature of 102, green nasal drainage, and pulling at the ears
C.
An 8 month old with a harsh
paroxysmal cough, audible expiratory wheeze and mild retractions
D.
A 3 year old with complaints
of a sore throat, tongue slightly protruding out his mouth, and drooling
33. After completing assessment
rounds, which finding would the nurse report
to the physician immediately?
A.
Client who has not had a bowel
movement in 4 days abdomen is firm
B.
Client who had a pulse of 89
and regular now has pulse of 100 and irregular
C.
Client who is very depressed and
has eaten 10% of meals for the last 2 days
D.
Client who has developed a rash
around the neck and face who has been on iv penicillin for 2 days
34. A patient arrives at the emergency department
complaining of mid-sternal
chest
pain. Which of the following nursing action should take priority?
A. A complete history with emphasis on preceding events.
B. An electrocardiogram.
C. Careful assessment of vital
signs.
D. Chest exam with auscultation.
35.
The charge nurse on the cardiac unit is planning assignments for the day.
Which
of the following is the most appropriate assignment for the float
nurse
that has been reassigned from labor and delivery?
A. A one-week postoperative
coronary bypass patient, who is being
evaluated for placement of a pacemaker prior to
discharge.
B. A suspected myocardial infarction patient on telemetry, just
admitted
from the Emergency Department and scheduled for an
angiogram.
C. A patient with unstable angina being closely monitored for pain
and
medication titration.
D.A
post-operative valve replacement patient who was recently
admitted to the unit because all surgical beds were filled.
36.
A patient arrives in the emergency department and reports splashing
concentrated
household cleaner in his eye. Which of the following nursing
actions
is a priority?
A. Irrigate the eye repeatedly
with normal saline solution.
B. Place fluorescein drops in the eye.
C. Patch the eye.
D. Test visual acuity.
37.
A patient is admitted to the hospital with a calcium level of 6.0 mg/dL.
Which
of the following symptoms would you NOT expect to see in this
patient?
A. Numbness in hands and feet.
B. Muscle cramping.
C. Hypoactive bowel sounds.
D. Positive Chvostek's sign.
38.
A nurse cares for a patient who has a nasogastric tube attached to low
suction
because of a suspected bowel obstruction. Which of the following
arterial
blood gas results might be expected in this patient?
A. pH 7.52, PCO2 54 mm Hg.
B. pH 7.42, PCO2 40 mm Hg.
C. pH 7.25, PCO2 25 mm Hg.
D. pH 7.38, PCO2 36 mm Hg.
39. The follow lab results are received for a patient.
Which of the following
results
are abnormal? Note: More than one answer may be correct.
A. Hemoglobin 10.4 g/dL.
B. Total cholesterol 340 mg/dL.
C. Total serum protein 7.0 g/dL.
D. Glycosylated hemoglobin A1C 5.4%.
40.
A hospitalized patient has received transfusions of 2 units of blood over the
past
few hours. A nurse enters the room to find the patient sitting up in
bed,
dyspneic and uncomfortable. On assessment, crackles are heard in the
bases
of both lungs, probably indicating that the patient is experiencing a
complication
of transfusion. Which of the following complications is most
likely
the cause of the patient's symptoms?
A. Febrile non-hemolytic reaction.
B. Allergic transfusion reaction.
C. Acute hemolytic reaction.
D. Fluid overload.
41. A
nurse is counseling the mother of a newborn infant with
hyperbilirubinemia.
Which of the following instructions by the nurse is NOT
correct?
A. Continue to breastfeed frequently, at least every 2-4 hours.
B. Follow up with the infant's physician within 72 hours of
discharge for
a recheck of the serum bilirubin and exam.
C. Watch for signs of dehydration, including decreased urinary
output
and changes in skin turgor.
D.Keep the baby quiet and
swaddled, and place the bassinet in a dimly lit
area.
42. A nurse is giving discharge
instructions to the parents of a healthy
newborn.
Which of the following instructions should the nurse provide
regarding
car safety and the trip home from the hospital?
A. He infant should be restrained in an infant car seat, properly
secured in the back seat in a rear-facing position.
B. The infant should be restrained in an infant car seat,
properly secured in the front passenger seat.
C.
The
infant should be restrained in an infant car seat facing forward or rearward in
the back seat.
D.
For
the trip home from the hospital, the parent may sit in the back seat and hold
the newborn.
43.
The mother of a 14-month-old child reports to the nurse that her child will
not
fall asleep at night without a bottle of milk in the crib and often wakes
during
the night asking for another. Which of the following instructions by
the
nurse is correct?
A. Allow the child to have the bottle at bedtime, but withhold the
one
later in the night.
B. Put juice in the bottle instead of milk.
C. Give
only a bottle of water at bedtime.
D. Do not allow bottles in the crib.
D. Do not allow bottles in the crib.
44.
A child is admitted to the hospital with suspected rheumatic fever. Which
of
the following observations is NOT confirming of the diagnosis?
A. A reddened rash visible over the trunk and extremities.
B. A history of sore throat that was self-limited in the past month.
C. A negative antistreptolysin O titer.
D. An unexplained fever.
B. A history of sore throat that was self-limited in the past month.
C. A negative antistreptolysin O titer.
D. An unexplained fever.
45.
An infant with congestive heart failure is receiving diuretic therapy at
home.
Which of the following symptoms would indicate that the dosage
may
need to be increased?
A. Sudden weight gain.
B. Decreased blood pressure.
C. Slow, shallow breathing.
D. Bradycardia.
B. Decreased blood pressure.
C. Slow, shallow breathing.
D. Bradycardia.
46.
A patient taking Dilantin (phenytoin) for a seizure disorder is experiencing
breakthrough
seizures. A blood sample is taken to determine the serum
drug
level. Which of the following would indicate a sub-therapeutic level?
A. 15 mcg/mL.
B. 4 mcg/mL.
C. 10 mcg/dL.
D. 5 mcg/dL.
B. 4 mcg/mL.
C. 10 mcg/dL.
D. 5 mcg/dL.
47.
A nurse is caring for a cancer patient receiving subcutaneous morphine
sulfate
for pain. Which of the following nursing actions is most important
in
the care of this patient?
A. Monitor urine output.
B. Monitor respiratory rate.
C. Monitor heart rate.
D. Monitor temperature.
B. Monitor respiratory rate.
C. Monitor heart rate.
D. Monitor temperature.
48.
A patient arrives at the emergency department with severe lower leg pain
after
a fall in a touch football game. Following routine triage, which of the
following
is the appropriate next step in assessment and treatment?
A. Apply heat to the painful area.
B. Apply an elastic bandage to the leg.
C. X-ray the leg.
D. Give pain medication.
B. Apply an elastic bandage to the leg.
C. X-ray the leg.
D. Give pain medication.
49. A nurse is evaluating a post-operative patient and
notes a moderate
amount
of serous drainage on the dressing 24 hours after surgery. Which
of
the following is the appropriate nursing action?
A.
Notify
the surgeon about evidence of infection immediately.
B.
Leave
the dressing intact to avoid disturbing the wound site.
C.
Remove
the dressing and leave the wound site open to air.
D.
Change
the dressing and document the clean appearance of the
wound site.
50.
Which patient should NOT be prescribed alendronate (Fosamax) for
osteoporosis?
A. A female patient being treated for high blood pressure with an
ACE
inhibitor.
B. A patient who is allergic to iodine/shellfish.
C. A patient on a calorie restricted diet.
D. A patient on bed rest who must maintain a supine position.
B. A patient who is allergic to iodine/shellfish.
C. A patient on a calorie restricted diet.
D. A patient on bed rest who must maintain a supine position.
51.
Which of the following strategies is NOT effective for prevention of Lyme
disease?
A.
Insect
repellant on the skin and clothes when in a Lyme endemic
area.
B.
Long sleeved shirts and long
pants.
C. Prophylactic antibiotic
therapy prior to anticipated exposure to ticks.
D. Careful examination of skin and hair for ticks following anticipated
exposure.
52.A
nurse is counseling patients at a health clinic on the importance of
immunizations.
Which of the following information is the most accurate
regarding
immunizations?
A. All infectious diseases can be prevented with proper
immunization.
B. Immunizations provide natural immunity from disease.
C.
Immunizations
are risk-free and should be universally administered.
D.
Immunization
provides acquired immunity from some specific
diseases
53. A
patient at a mental health clinic is taking Haldol (haloperidol) for
treatment
of schizophrenia. She calls the clinic to report abnormal
movements
of her face and tongue. The nurse concludes that the patient
is
experiencing which of the following symptoms:
A.
Co-morbid
depression.
B.
Psychotic
hallucinations.
C.
Negative
symptoms of schizophrenia.
D.
Tardive
dyskinesia.
54. A 67 year-old man
is admitted to the Post-anesthesia Recovery unit
following
chest surgery. The patient has a right chest tube that is attached
to low
suction. Three hours after admission to the unit, the nurse observes
the
drainage output from the chest tube is 300 milliliters.
What is
the most appropriate initial intervention?
A.
Notify
the doctor
B.
Reduce IV
infusion rate
C.
Strip tube with
roller device
D.
Re-position in
left lateral decubitus
55. An elderly patient with severe degenerative
joint comes to the clinic for
routine
follow up of management. The patient reports that over the
month, the
pain has begun to increase in severity patient requests an
increase
in dosage of the medication. The nurse recognizes that this is
most
likely due to?
A.
Drug addiction
B.
Drug
tolerance
C.
An improvement in
condition
D.
Lack of efficacy
of the current medication
56. The nurse has been assigned to care for a 60
year old critically ill patient
with a
triple-lumen central venous line. The doctor's orders include daily
care of
the insertion site and catheter device. The nurse creates care plane
based on
the nursing diagnosis, Risk for infection related to insertion of a
venous
catheter. Which intervention is most likely to prevent infection?
A.
Re-cap access hub
after drawing blood
B.
Maintain clean
technique
C.
Wash
hands before performing catheter care
D.
Clean catheter
tubing with isopropyl alcohol
57.The nurse is inserting a nasogastric (NG) tube
into patient as prescribed.
The nurse
has advanced the into the patient's posterior pharynx. The nurse
show now
ask the patient to?
A.
Hold the breath
B.
Stare upwards
with the eyes towards the ceiling
C.
Perform the
Valsalva maneuver
D.
Lower
the chin towards the chest
58. A 42 year- old
patient is in a lower body cast following a motor vehicle
accident.
In order to minimize muscle strength loss while in the cast, the
nurse will
instruct the patient in the performance of.
A.
Isometric
exercises
B.
Passive range of
motion exercises
C.
Active-assistive
range of motion exercises
D.
Resistive range
of motion exercises
59. A newborn was delivered pre-term weighing 2700 grams with. Apgar
scores of
4 and 6, respectively. When the mother had presented to the
Obstetrical
Triage Unit, she was already 7 centimeters dilated and fully
effaced.
Her due date was unknown as she had no parental care. The infant
showed signs of
fetal distress and was finally delivered by Cesarean section.
At birth a large, thin, membranous sac was protruding from the
umbilical
base. What is the priority nursing intervention at birth?
A.
Maintain
cardio respiratory stability
B.
Protect the
herniated viscera
C.
Manage fluid
intake and output
D.
Establish
vascular access
60. A child is treated for superficial
(first-degree) thermal burns to the thigh.
The child
is in great discomfort and does not eat.Which of the following
diagnoses
should receive PRIORITY?
A.
Altered nutrition
B.
Impaired skin
integrity
C.
Risk for
infection
D.
Acute
pain
61. A
patient is being prepared for a right breast biopsy under general
anesthesia.
The patient asks the nurse about the surgical scar and possible
postoperative
complications.Which of the following actions would be
appropriate
for the nurse to take?
A.
Review the
postoperative risks with the patient
B.
Notify
the surgeon about the patient's questions
C.
Compete the patient's
preoperative check list
D.
Show the patient
photos of breast surgical scar
62. A 27 year-old
woman presents with stomach cramping with alternating
constipation
and diarrhea. She had been diagnosed with irritable bowel
syndrome
two years before and has so far managed the illness with
lifestyle
changes, including diet and exercise. What is the most appropriate
advice?
A.
Increase dairy
intake
B.
Use antacids to
relive pain
C.
Increase dietary
fiber
D.
Avoid
emotional stress triggers
63. A patient with Addison's disease asks a nurse for nutrition
and diet advice.
Which
of the following diet modifications is NOT recommended?
A. A diet high in grains.
B. A diet with adequate caloric intake.
C. A high protein diet.
D. A restricted sodium diet.
B. A diet with adequate caloric intake.
C. A high protein diet.
D. A restricted sodium diet.
64.
A patient with a history of diabetes mellitus is in the second post-operative
day
following cholecystectomy. She has complained of nausea and isn't
able
to eat solid foods. The nurse enters the room to find the patient
confused
and shaky. Which of the following is the most likely explanation
for
the patient's symptoms?
A. Anesthesia reaction.
B. Hyperglycemia.
C. Hypoglycemia.
D. Diabetic ketoacidosis.
B. Hyperglycemia.
C. Hypoglycemia.
D. Diabetic ketoacidosis.
65.
Your plan of care includes use of iontophoresis
in the management of
calcific
bursitis of the shoulder. To administer this treatment using the
acetate
ion, the current characteristics and polarity should be:
A.
Monophasic
twin peaked pulses using the positive pole
B.
Monophasic twin
peaked pulses using the negative pole
Continuous monophasic using the positive pole
D.
continuous monophasic using the negative pole
66. Following cast
immobilization for a now healed supracondylar fracture of
the
humerus, a
patient’s elbow lacks mobility. To increase elbow range of
motion,
joint mobilization in the maximum loose-packed position should
be
performed at:
A.
full extension
B.
90 degrees of flexion
C.
70 degrees of flexion
D.
30 degrees of flexion
67. A patient wishes to improve her aerobic fitness.
She currently jogs four
days a
week for 30
minutes at 70% of her age-predicted maximum heart
rate. The
recommendation that would not result in improved aerobic
fitness
is:
A.
increasing the
distance covered in the same 30 minutes
B.
increasing the
jogging time to 45 minutes while keeping at 70% of the
age-predicted heart rate
C.
changing
to interval training with maximum burst of running for 15
seconds, followed by a 30 second rest. Complete 4 sets per day, 4
days per week.
D.
changing to
interval training for 4 days per week by doing 90 seconds
of comfortable
running followed by 90 seconds of rest for a period of 30 minutes
68. A patient with degenerative joint disease of
the right hip complains of pain
in the anterior
hip and groin, which is aggravated by weightbearing. There
is
decreased range of motion and capsular mobility. Right gluteus medius
weakness
is evident during ambulation and there is decreased tolerance of
functional
activities including transfers and lower extremity dressing. In
this case, a
capsular pattern of joint motion should be evident by
restriction
of hip:
A.
flexion,
abduction and internal rotation
B.
flexion,
adduction and internal rotation
C.
extension,
abduction and external rotation
D.
flexion,
abduction and external rotation
69. Confirmation of a diagnosis of spondylolisthesis can be made
when viewing
an oblique radiograph
of the spine. The tell-tale finding is:
A.
posterior displacement of L5 over S1
B.
bamboo appearance of the spine
C.
compression of the vertebral bodies of L5 and S1
D. bilateral pars interarticularis defects
70. You
are working with a patient who exhibits a fluent aphasia. This form of
aphasia is usually
characterized by:
A.
normal auditory comprehension
B.
very slow speech
C.
impaired reading and writing
D.
impaired articulation
71. A client with portal hyertention
and ascites is given 2 units of salt-poor
albumin
IV. The purpose of salt-poor albumin is to :
A.
Provide parenteral nutrients.
B.
Increase the client`s circulating blood volume.
C.
Elevate the client`s circulation blood volume.
D.
Temporarily divert blood flow away from the liver.
72. After a chlid has a craniotomy.
The nurse performs an assessment of the
chlid`s
neurologie status by observing the level of conseiuosness, pupillary
acttivity,
reflex activity. Ang :
A.
Bblood pressure
B.
Monitor function.
C.
Rectal temperature.
C.
Head circumference.
73. A 68 year-old man is admitted to the hospital
with an exacerbation of
chronic
obstructive pulmonary disorder. He has breathing difficulties,
restlessness
and anxiety. He also has a moist and productive cough. The
lower
extremities are swollen with pitting edema 4+. A blood gas specimen
is
collected and sent to the laboratory. The patient has not been on
supplemental
oxygen therapy at home (see lab results)
Blood
pressure 180/90 mmHg
Heart
rate 90/min
Respiratory
rate 28/mm
Body
Temperature 37.1°C
Oxygen
Saturation 86 % an room air
Test
Result Normal Values
ABG
PCO2 7.33 4.7-6.0 kPa
PH
7.32 7.36-7.45
ABG
PO2 7.73 10.6-14.2 kPa
What
is the most likely percentage rate per liter for oxygen
administration
via nasal cannula for this patient?
A.
0.5-1
B.
.5-2
C.
2.5-3
D.
5-6
74. A 40 year-old woman is undergoing an elective
rhinoplasty under general
anesthesia.
The patient is in the pre-operative room and the nurse is
prepared
to administer pre-operative intravenous medications. The patient
states
that she does not have any drug allergies. Which additional
nursing
action is
most important prior to administering the medicine?
A.
Request the
patient urinate
B.
Perform blood
typing and cross matching
C.
Ensure
the consent form has been signed
D.
Clarify contact
numbers of her family members
75. The nurse is caring for a 4 year-old patient
with a diagnosis of cystic fibrosis
and
pneumonia. The child is feeling better on the 3rd day of the
hospitalization
and "wants to play" What would be the BEST choice of
entertainment?
A.
Blowing
bubbles
B.
Looking at
picture books
C.
Watching videos
D.
Riding in a wagon
76. During the immediate postoperative period, a
patient reveals an oxygen
saturation
level of 91 %. The nurse should
A.
Position the
patient on the left side
B.
Administer
supplemental oxygen
C.
Continue to
provide supportive care
D.
Lower the
temperature of the room
77. A home care nurse visits a patient who is wheelchair
bound due to a recent
motor vehicle
accident. The patient has been sitting in the wheelchair for
extended
periods of time, which has resulted in the development of a
stage I
pressure sore on the right buttocks. What is the BEST nursing
intervention?
A.
Instruct
the caretaker to change the patient's position every 2 hours
B.
Apply hydrogel to
the stage I pressure sore every 8 hours
C.
Refer the patient
to a wound care specialist for debridement
D.
Encourage the
patient to consume an increased amount of calcium
78. A patient who sustained extensive abdominal
injuries in a motor vehicle
accident
has developed a large stage II pressure ulcer on the coccyx. A new
diagnosis
of alteration in skin integrity is added to the care plan.
What is
the BEST short-term goal for the patient?
A.
Show evidence of
healing within one week
B.
Have no
discomfort from the pressure ulcer
C.
Eat at least 50%
of each meal
D.
Verbalize
strategies to prevent further skin breakdown
79. A 55 year-old man has become very anxious about skin lesions he
has
developed.
On the lower right forearm, there is a well demarcated round
patch of
skin that he feels could be cancerous. It is 2.5 centimeters in
diameter
and slightly raised. On palpation it is scaly, dry and rough. The
affected
area appears sun tanned and reddened. The condition has been
persistent
for the past four years but has only recently become itchy.
What is
the most likely underlying problem?
A.
Seborrheic
keratosis
B.
Actinic keratosis
C.
Eczematous
dermatitis
D.
Lupus
erythematosus
80. A 65 year-old woman with a history of unstable
angina and hypertension
presents
to the Emergency Department with a dull chest pain that she
describes
as similar to heartburn. The pain radiates down the left arm. She
had taken
sublingual nitroglycerin tablets without any relief. An
electrocardiograph
is performed and shows elevated S- T segments. The
nurse is
to administer a thrombolytic by intravenous infusion.
Which
factor places this candidate at high risk for bleeding?
A.
Unstable angina
B.
Hypertension
C.
Age
D.
Elevated S- T
segments
81.The nurse administers the first series of
immunization to a 2-month-old.
The nurse
instructs the mother that, if the site becomes inflamed. She
should
give the prescribed acetaminophen and :
A.
Place a warm compress on the area.
B.
Put a witch hazed compress on the site.
C.
Give a cool sponge bath for 15 minutes.
D.
Apply an ice pack to the inflamed area for 20 minutes.
82. A child cooley`s anemia is being discharged
from the hospital. The nurse
should
plan to instruct the parents regarding the need to :
A.
Restrict activty.
B.
Prevent
infection
C.
Encourage fluid.
D.
Provide small
frequent meals.
83. A 10-years –old child who has sickle-cell anemia
is admitted to the hopital
with
vaso-occlusive creisis. When assignining a room, it is most appropriate
for the
nurse to place the child with a roommate who has :
A.
Pneumonia.
B.
Thalassemia.
C.
Osteomyelitis.
D.
Acute
pharyngitis.
84. The nurse. Preparing a12 years old child for
a bone marrow aspitastion,
would know
that the child does not understand the teaching about the
procrfure
when the child states :
A.
I can out of bed after the doctor is finished.
B.
I will have a tight dressing to put pressure on the area.
C.
The doctor is going to inject a needle into the center of one of my hip
bones.
D. The only pain I should feel
is when the doctor puts in the shot so it
won`t hurt.
85. One of the aims of therapy for sickle cell anemia
is the prevention of the
sickling
phenomenon. Which is responsible for the pathological sequela.
A plan of care directed toward prevention of a crisis should consist of
:
A.
Promotion of adequate oxygenation and hemodilution.
B.
Administration of an iron-fortified formula as nourishment
C.
Measures to decreas tissue oxygen requirements and Maintain
Hemoconcentration
D. Enforced periods of bed rest to minimize energy expenditure and
oxygen
utilization
86. A4-year-old child is admitted wiiiith a
tentative diagnosis of acute
iymphoblastic
leukemia (ALL). When obtaining a health
history from the
parents,
the nurse would expect that the child has:
A.
Alopecia and petechiae
B.
Anorexia and
insomnia
C.
Anorexia
and petechiae
D.
Alopecia and
bleeding gums
87. A2-year-old child has been admitted to the pediatric
unit with a diagnosis
of
thalassemia (Cooley`s anemia). The parents are told that there is no
cure.But
the anemia can be treated with freequet transfusions. The father
tells the
nurse he is glad that there is a treatment that “fixes” his child`s
problem.
The nurse should respond :
A.
Blood trsnfusions
correct correct the anemia but also present a risk
of
hepatitis.
B.
While
blood trsnfusions temporarlily correct the anemina, this
treatment may cause other problem.
C.
Blodd trsnfusions
are a supportive treatment, and as your child grows
older
fewer of them will be needed.
D.
Tes, a blood
transfusions replace the defective red blood cell. It`s like
giving
insulin to a preson cells. It`s giving insulin to a person with diabetes.
88. When obtaining a health history from the
parents of a toddler who is
admitted
to the hospital with acute lymphocytic leukemia (ALL), the nurse
would be
surprised if the parents report that the first sign they observed
was :
A.
A loss of appetite.
B.
Sores in the mouth.
C.
A paleness of the skin.
D.
Purplish spots on the skin.
89.
The mother of a chlid who has been recently diagnosed as having
hemophilia
is pregnant with her secound chlid. She asks the nurse what the
chances
are that this baby will also have hemophilia. The nurse`s best
response
would be :
A.
There is no chance the baby will be affected.
B.
Theres is a 25% chance the baby will be affected.
C.
There is a 50% chance the baby will be affected.
D.
There is a 75% chance the baby will be affected.
90. The nurse administers the first series of immunizations
to a 2 month old.
The nurse
instructs the monther that, if the site becomes inflamed, she
should
give the prescribed acetaminophen and :
A.
Place a warm compress on the area.
B.
Put a with hazel compress on the site.
C.
Give a cool sponge bath for 15 minutes.
D.
Apply an ice pack to the inflamed area for 20 minutes.
91. he nurse is supervising care given to a group
of patients on the unit. The
nurse observes a staff member entering a patient’s
room wearing gown
and gloves. The
nurse knows that the staff member is caring for which of
the following
patients?
A.
An 18-month-old with respiratory
syncytial virus.
B.
A 4-year-old with Kawasaki disease.
C.
A 10-year-old with Lyme’s disease.
D.
A 16-year-old with infectious mononucleosis
92. A 14-year-old client is scheduled for a below-knee
(BK) amputation
following a
motorcycle accident. The nurse knows preoperative teaching
for this client
should include
A.
explaining that the client will be walking
with a
prosthesis soon after surgery.
B.
encouraging the client to share his
feelings and fears about the surgery.
C.
taking the informed consent form to the client
and asking him to sign it.
D.
evaluating how the client plans to maintain
his schoolwork during hospitalization.
93. A client has returned from surgery with a fine,
reddened rash noted around
the area where
Betadine prep had been applied prior to surgery. Nursing
documentation in
the chart should include
A.
the time and circumstances under which the
rash was noted.
B.
the explanation given to the client and family
of the reason for the rash.
C.
notation on an allergy list and
notification of the doctor.
D.
the need for application of corticosteroid
cream to decrease inflammation.
94. The home care nurse is performing an
assessment of a client with
pneumonia
secondary to chronic pulmonary disease. Which of the
following goals
is MOST appropriate?
A.
Maintain and improve the quality of
oxygenation.
B.
Improve the status of ventilation.
C.
Increase oxygenation of peripheral
circulation.
D.
Correct the bicarbonate deficit
95. The physician diagnoses Graves’ disease for a
28-year-old woman seen in
the clinic. The
nurse would expect the client to exhibit which of the
following
symptoms?
A.
Lethargy in the early morning.
B.
Sensitivity to cold.
C.
Weight loss of 10 lb in 3 weeks.
D.
Reduced deep tendon reflexes
96.
Which of the
following nursing interventions is MOST important when
caring for a
client who has just been placed in physical restraints?
A.
Prepare PRN dose of psychotropic medication.
B.
Check that the restraints have been
applied correctly.
C.
Review hospital policy regarding duration of
restraints.
D.
Monitor the client’s needs for hydration and
nutrition while restrained.
97. The nurse is aware that which of the following
assessments would be
indicative
of hypocalcemia?
A.
Constipation.
B.
Depressed reflexes.
C.
Decreased muscle strength.
D.
Positive Trousseau’s sign.
98. When obtaining a specimen from a client for
sputum culture and sensitivity
(C and S), the
nurse knows that which of the following instructions is BEST?
A.
After pursed-lip breathing, cough into a
container.
B.
Upon awakening, cough deeply and
expectorate into a container.
C.
Save all sputum for three days in a covered
container.
D.
After respiratory treatment, expectorate into
a container
99. A patient has a Levin tube connected to
intermittent low suction. At 7 AM ,
the nurse charts
that there is 235 cc of greenish drainage in the suction
container. At 3
PM , the nurse notes that there is 445 cc of greenish
drainage in the
suction container. Twice during the shift, the nurse irrigates
the Levin tube
with 30 cc of normal saline, as ordered by the physician.
What is the
actual amount of drainage from the nasogastric tube for the 7
to 3 shift?
A.
150 cc.
B.
210 cc.
C.
295 cc.
D.
385 cc
100.
The physician
prescribes lithium carbonate (Lithobid) 300 mg PO QID for a
47-year-old
woman. The nurse in the outpatient clinic teaches the client
about the
medication. The nurse should encourage the client to make
sure her diet has
adequate
A.
Sodium.
B.
Protein.
C.
Potassium.
D.
Iron.
101. A college student comes to the college health
services with complaints of
a severe
headache, nausea, and photophobia. The physician orders a
complete blood
count (CBC) and a lumber puncture (LP). Which of the
following lab
results would the nurse expect if a diagnosis of bacterial
meningitis were
made?
A.
Cerebrospinal fluid (CSF) cloudy,
Hgb 13 g/dL, Hct 38%, WBC 18,000/mm3
B.
CSF with RBCs present, Hgb 10 g/dL, Hct 37%,
WBC 8,000/mm3.
C.
CSF cloudy, Hgb 12 g/dL, Hct 37%, WBC
7,000/mm3 .
D.
CSF clear, Hgb 15 g/dL, Hct 40%, WBC 11,000/mm3
.
102. A Miller-Abbott tube is ordered for a client.
The nurse knows that the
main reason this
tube is inserted is to
A.
Provide an avenue for nutrients to flow past an
obstructed area.
B.
Prevent fluid and gas accumulation in the
stomach.
C.
Administer drugs that can be absorbed directly
from the intestinal mucosa.
D.
Remove fluid and gas from the
small intestine
103. A female client
is scheduled for a hysterectomy When discusing the preoperative preparation,
the Nurse identifies that the client has on under-standing Of the surgery. The
nurse should:
A. Describe the proposed surgery to the
client
B. Proceed with implementing the
preoperative plan
C. Notify the physician that
the client needs information
D. Explain to the client gently that she
should have aksed more
questions
104. New parentes are asked to sign the consent for their son to be
circumcised.
They ask for the nurse’s opinion of the procedure. The best
response
by the nurse would be:
A.
you should talk
to the physician about this if you have any questiones.
B.
it is absolutely
safe, and it is best for all male infants to be circumcised.
C.
There
are advantages and disadvantages to circmcision. Let’s talk about it.
D.
Although it is a
somewhat painful experience for the baby, i would allow it if i were you
105. When obtaining informed consent for sterilization from a
depelovmentally
challenged adult client, the nurse must be sure that the:
A.
Parent or
guardian signs the consent
B.
Client
comprehends the outcome of the procedure
C.
Client is fully
able to explain what the procedure entails
D.
Parent or
guardian has encouraged the cliant to make the decision
106. A. Postpartum adolescent mother confides to the nurse that she
hopes
her baby
will be good and sleep through the night. The nurse should plan
to teach
the mother to:
A.
Cuddle
the baby and talk softly when crying occurs
B.
Put a sof, cuddly
toy next to the baby at bedtime
C.
Add cereal to the
bedtime bottle to ensure deep sleep
D.
Keep the baby
awake for longer periodes during the day
107. A client with
mild preeclampsia is told that she must remain on bed rest
at
home. The client starts to cry and tells the nurse that she has two small
children
at home who need her. The nurse’s best response would be:
A.
How do
you plan to manage with getting child care help?
B.
Are you worried
about how you will be able to handle this problem?
C.
You can get a
neighbor to help out, and your husband can do the housework in the evening.
D.
You’ll be able to
fix light meals, and the children can go to nursery school a few hours each
day.
108. The nurse should be aware of the stages of parental adjustment
that
follow
birth of an infant at risk who is in the neonatal intensive care unit (NICU).
To better plan nursing care, nirsing observation and assesments should be based
on the recognition that the:
A.
Mother should not
see the infant until she has completed the necessary grief work
B.
Mother
should be reunited with her infant as soon as possible to enhance adjustment
C.
Parents should be
encouraged to visit the newborn within the firts 24 hours after birth
D.
Nurse should wait
until the parents requist to see the newboarn before suggesting a visit
109. On the third postpartum day, a client who had an unexpected
cesarean
birth
is found crying during morning rounds. She says,” I know my baby is
fine,
but i can’t help crying. I wanted natural childbirth so much. Why did
this
have to happen to me?”The nurse respond knowing that:
A.
The client’s
feeling will pass after she has bonded with her baby
B.
The client is
probably suffering from a postpartum depression and needs special care
C.
A woman’s
self-concept is severly affected by a cesarean birth, and the client’s statment
reflects this
D.
A cesarean
birth may be a traumatic psychologic experience in addition to an acute
abstetric emergency
110. A common concern of the mother after and unexpected cesarean birth
that the
nurse should anticipate would be the:
A.
Postoperative
pain and scarring
B.
Prolonged periode
of hospitalization
C.
Sense
of faulire in the birthing process
D.
Inability to
assume her mothering role
111. A client at 37 week’s gestation delivers a healthy boy. When
inspecting
her
newborn in the brithing room the client asks, what’s this sticky white
stuff all
over him? The nurse’s most appropriate response would be:
A.
It’s a secretion
from the baby’s fat cell and is called milia.
B.
Your baby was
born three week’s early and we expect to see this.
C.
This is
vernix, which helps protect the baby while he’s in the uterus.
D.
It’s nothing to
be concerned about. All newborn babies are covered withit.
112. After a difficult labor aclient gives birth to a 9-pound boy who
dies shortly
afterward. That evening the client tearfully describes to the
nurse her
projected
image of her son and what his future would have been. The
nurse’s
most therapeutic response would be:
A.
It must
be difficult to think of him now.
B.
I am sure he
would have been a wonderful child.
C.
Don’t dwell on
this now. It only increase the pain.
D.
I guess that both
you and your husband wanted a son.
113. A 49-year-old client ia admitted with a diagnosis of cervical
cancer. While
obtaining
he health history she tells the nurse, “I have not had a pap
smear for
over five years. I probably would’t be in the hospital today if i’d
had those
tests more often.” The nurse should respond:
A.
Can you tell me
why you havent gone?
B.
You
feel like you’ve neglected your health.
C.
It’s never too
late to start taking care of yourself.
D.
Most women hate
to have pap smears done but it’s really omportant.
114. A husbnd is
sitting in the in the waiting room while his wife is getting her
infertikity
prescriptior reffiled by the clinic pharmacist. The nurse sits
down
beside him and he blurts our, “It’s like there are three of us in bed
my wife
me, and the doctor.” This is reflective of his feelings of:
A.
Guilt
B.
Anger
C.
Depression
D.
Unworthiness
115. The nurse should
instruct the client taking oral contraceptives to increast
her
dietary intake of:
A.
Calcuim
B.
Potassium
C.
Vitamin E
D.
Vitamin
B6
116.
When counseling a client with diabetes
mellitus who requests
contraceptive
information, it would be most therapeutic for the nurse to
focus on:
A.
Rhythm
B.
The IUD
C.
A
diaphragm
D.
Oral
contraceptives
117.
The school nurse is teaching a group of 16-yera-old
girls about the female
reproductive
system. One student asks how long after ovulation it is
possible
for conception to occur. The nurse’s most accurate response is
based on
the knowledge that an ovum is no longer viable after
A.
12 hours
B.
24
hours
C.
48 hours
D.
72 hours
118.
A couple at the prenatal clinic for a first
visit tells the nurse that their 2
year-old
has just been diagnosed with the cystic fibrosis. They state there
in no
family history of this disorder. They ask the nurse with the chances
are for
their having another child with cystic fibrosis. Based on the
knowledge
that this disorder has an aotosomalrecesive mode of
inheritance,
the nurse should respond that:
A.
There is a 50%
chance that this baby will also be affected
B.
If this baby is
male,there is a 50% chance of his being affected
C.
If this baby is
female, there is no chance of her being affected, but she wiil be a carrier
D.
There
is a 25% chance the baby will be affected, and a 50% chance it will be acarrier
119.
A client asks the nurse what she should do if
she forgets to take the pill
one day.
The nurse’s best response would be:
A.
Take your pill as
instructed.
B.
Call the
physician immediately.
C.
Continue a
susual; missing one day is not problem.
D.
The
next day take one pill in the morning and one before bedtime
120. The nurse instructs a pregnant client about
the sources of protein that
assist
in, meeting the daily requirements of:
A.
15 g
B.
30 g
C.
45 g
D.
60 g
121. A client in her second trimester is at the
prenatal clinic for a routine visit.
While
listening to the fetal heart, the nurse hears a heartbeat at the rate
of 136 in
the right upper quadrant and also at the midline below the
umbilicus.
The sources of these sounds are:
A.
Heart
rates of two fetuses
B.
Maternal and
fetal heart rates
C.
Fetal heart rate
and funic soulffle
D.
Uterine soulffle
and fetal heart rate
122. A pregnent client, interested in childbirth
education, asks how the lamaze
mothod
differs from the read method. The nurse explains that the lamaze
method:
A.
Is a mush easier
method to teach and learn
B.
Requires a good
deal of prenatal preparation
C.
Avoids
the use of pain-relieving drugs during labor
D.
Is a calm,
relaxed approach based on “childbirth withhout pain
123. During a
prenatal class the nurse is discussing nutrition requiremenets
throughout
pregnancy. The nurse explains that caloric needs in the
second and
third trimesters increase daily by:
A.
100 calories
B.
300
calories
C.
500 calories
D.
700 calories
124. A 34 year- old quadriplegia patient resides at home with his wife.
In order
toprevent
contractures of all extremities, the community care nurse will
instructthe
patient’s wife in performance of:
A.
Active range of motion exercises .
B.
Passive range of motion exercises .
C.
Active- assistive range of motion exercises .
D.
Resistive range of motion exercises .
125. A patient complains of left eye redness and itching, the doctor
told you to
putatropine
eye drops for the patient to examine his eye. The nurse
should
instillthe eye drops into:
A.
The left eye .
B.
The right eye .
C.
Both right and left eyes .
D.
Neither of the eyes .
126.
year-old man presented to the Mental Health
Clinic with a low-mood, a
general
loss of interest in activities and inability to experience pleasure.
He
admitted to suicidal thoughts and extreme lack of energy. He was
prescribed
a selective serotonin reuptake inhibitor to be taken daily. One
month
later, he presented to the clinic and reports feeling more
energetic,
but still has a low-mood.
What is the patient’s level of risk
committing suicide at this time?
A.
None
B.
Low
C.
Medium
D.
High
127. A nurse is suctioning fluids from a client
via a tracheostomy tube. When
suctioning,
the nurse must limit the suctioning to a maximum of:
A.
5 seconds
B.
10
seconds
C.
30 seconds
D.
1 minute
128.
A pregnant woman in the three months to have a
thrombus in the right
leg What
do you expect the doctor ordered
A.
Heparin
B.
b-Insulin
C.
Warfarin
D.
Aspirin
129.
Child has burns What is the nursing intervention
to prevent Aspiration for
this child
A.
Child sitting put all the time
B.
Keep the child seated 10 minutes after eating
C.
Keep baby sitting from 30-45 minutes after eating
D.
Keep baby sitting 24 hours
130. A man has been experiencing night-blindness.
What vitamin could he be
deficient
in?
A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D
131.
A one month old boy present with the head
tilted towards the left side
and the
chin rotated to the right side. There is a palpable mass of soft
tissue on
the right side of the neck near the clavicle:
A.
Passive stretching muscle
B.
Surgica release of the muscle.
C.
Surgical
removal of the mass
D.
It`s a normal mass in infants.
132. Acute pulmonary edema caused by heart
failure is usually a result of
damage to
which of the following areas of the heart?
A.
Left atrium
B.
Right atrium
C.
Left
ventricle
D.
Right ventricle.
133. The nurse knows that a client in early pregnancy undersatnd the
need to
increase
her intake of complete proteins during her pregnancy when she
reports
she is esthing more:
A.
Spinach and
broccoli
B.
Milk,
eggs, and cheese
C.
Beans, peas, and
lentils
D.
Whole grain
creals and breads
134.
The nurse understands that edema caused by inadequate nutrition is a
result
of the :
A. ADH mechanism.
B. Aldosterone mechanism.
C. Nitrogen balance mechanism.
D. Capillary fluid shift mechanism.
135.
The nurse can prevent a major reaction to total parenteral nutrition
infusions
by :
A. Administering the fluid
slowly.
B. Recording the intake and output.
C. Changing the site every 24 hours.
D. Checking the vital signs every 4 hours.
136.
After a thyroidectomy the client should be placed in the :
A. Prone position
B. Supine position.
C. Left Sims position
D. Semi Fowler`s position
137.
After being in labor for six hours a client is
admitted to the brithing room.
The client
is 5 cm dilated and at-1 station. In the next hour her
contractions
gradually become irregular but are more uncomfortable.
When
caring for her, the nurse should first check for:
A.
False labor
B.
A full
bladder
C.
Uterine
dysfunction
D.
A breech
presentation
138. A client in labor is admitted to the brithing room. The nurse’s
assessment
reveales
that the fetus as at-1 station, which means the presenting part is:
A.
Visible at the
vaginal opening
B.
One cm below the ischial spines
C.
One cm
above the ischial spines
D.
At the level of
the ischial spines
139. The nurse assesses a primigravid who had been in labor for five
hours. The
fetal
heart rate tracing is reassuring. Contractions are of mild instensity
lasting 30
second and are three to five minutes apart. An oxytocin
infusion
has been ordered. The priority nursing intervention at this time
would be
to:
A.
Check cervical
dilation every hour
B.
Keep the labor environmen
dark and quiet
C.
Infuse oxytocin
by piggibacking into the primary line
D.
Position
the client on the left side throughout the infusion
140. A vaginal examination reveals that a client labor ia 7 cm dilated.
Soon
afterward
she becomes nauseated, has the hiccups, and has an increase
in bloody
show. The nurse recognizes that these clinical manifestation
indicate
that the client is strarting the:
A.
Latent phase of
labor
B.
Active phase of
labor
C.
Transition
phase of labor
D.
Earlynactive
phase of labor
141. A client is to receive an epidural anesthetic during labor. After
the client is
anesthetized,
the nurse should monitor the client for:
A.
Lightheadedness
B.
Urinary
retention
C.
Decreased
temperature
D.
Decreased level
of consciousness
142. Twenty-four hours after an uncomplicated labor and birth, a
client’s CBC
reveals a
WBC count of 17,000/mm³. The nurse should interpret this WBC
count as
being indivative of:
A.
The usual
decrease in white blood cells
B.
The expected
response to the labor process
C.
An
acute sexsually transmitted viral disease
D.
A bacterial
infection of the reproductive system
143. When preparing a teaching plan about selfcare during the
postpartum
period,
the nurse undersatnds that on the fourth postpartum day the
lochia is
known as:
A.
Alba
B.
Rubra
C.
Serosa
D.
Purpura
144. A client arrives at the clinic with swollen, tender breasts and
“flu-like”
symptoms.
A diagnosis of mastitis is made. The nurse should furst plan to:
A.
Assist her to
wean the infant gradually
B.
Teach her to
empty her breasts frequently
C.
Review
breastfreeding techniques with her
D.
Send a
sample of her milk for culture and sensitivity
145. The nurse is caring for a group of postpartum clients. The one the
nurse
should
observe most closely would be a:
A.
Primipare who has
had an 8-pound baby
B.
Grand multipara
who experienced a labor of only one hour
C.
Primipara who
received 100 mg of demerol during her labor
D.
Multipara
whose placenta seperated and who delivered in 10 minutes
146. A 7-year-old client is brought to the E.R. He’s tachypneic and
afebrile and
has a
respiratory rate of 36 breaths/minute and a nonproductive cough.
He
recently had a cold. From his history, the client may have which of the
following?
A.
Acute
asthma
B.
Bronchial
pneumonia
C.
Chronic
obstructive pulmonary disease (COPD)
D.
Emphysem
147. A newborn was delivered pre-term weighing 2700 grams with. Apgar
scores of
4 and 6, respectively. When the mother had presented to the
Obstetrical
Triage Unit, she was already 7 centimeters dilated and fully
effaced.
Her due date was unknown as she had no parental care. The
infant
showed signs of fetal distress and was finally delivered by Cesarean
section.
At birth a large, thin, membranous sac was protruding from the
umbilical
base. What
is the priority nursing intervention at birth?
A.
Maintain
cardio respiratory stability
B.
Protect the
herniated viscera
C.
Manage fluid
intake and output
D.
Establish vascular
access
148. A 34 year- old quadriplegia patient resides at home with his wife.
In order
toprevent
contractures of all extremities, the community care nurse will
instructthe
patient’s wife in performance of:
A.
Active range of motion exercises .
B.
Passive range of motion exercises .
C.
Active- assistive range of motion exercises .
D.
Resistive range of motion exercises .
149. Which of the following intervention would the nurse implement to
enhance
the patient`s airway clearance ?
Heart
rate 80/min
Respiratory
rate 32/min
Temperature
40oc
A.
Administer oxygen as ordered .
B.
Maintain a comfortable position .
C.
Increase fluid intake .
D.
Administer prescribed analgesics.
150.
A 31 years- old woman with diabetes type 1
presents to the clinic with
fatigue,
blurred vision, and loss of appetite. Her breath smells like fruit
and she
leaves the room twice during the examination to use the toilet.
She has
brought a little bottle of water with her that she finishes while at
the
clinic. She reports that she has had a cold for the past three days, but
has not
taken additional insulin during the illness
Blood
pressure 130/70
mmhg
Heart
rate 90/min
Respiratory
rate 20/min
Body
temperature 38.0
Coral
What
is the most appropriate nursing diagnosis
A.
Risk for impaired
skin integrity related to circulation
B.
Deficient
knowledge related to illness management
C.
Risk for fluid
volume excess related to fluid intake
D.
Imbalanced
nutrition related to decreased appetite
151.
A patient has an acute inflammation of the
gallbladder. The physician
orders the
nurse to schedule the patient for surgery .
Which of
the following surgical procedures will the physician MOST likely
perform?
A.
Pancreatectomy .
B.
Cholecystectomy .
C.
Hepatectomy .
D.
Cricothoracotom .
152.
Hospitalized patient eats 20% of the meal and
states being too tired to eat more. What should the nurse do?
A. Offer to feed the patient after short rest period
B. Sncouraged the patient to finish the
fluids
C. Remove the meal tray and allow the
patient to rest
D. Encourage
the patient to finish the protein portion of the meal
153.
Which type of isolation category is indicated
for patient with diphtheria:
A. Airborne
B. Droplet
C. Contact
D. Blood
154.
The nurse in preparing to insert RYLE'S tube
(NGT) into an infant, the
nurse
knows that the length of the tube should be taken as following:
A. From the nose down to the chin and
then to the umbilicus
B. From the nose to the earlobe
and then to the xiphoid process
C. From the nose to the mouth to the
xiphoid process
D. From the nose to the earlobe to the
umbilicus
155. The charge
nurse enters the nursing diagnosis "Risk for ineffective airway
clearance
related to an inability to swallow" on the client's care plan.
Which
nursing intervention is most appropriate for managing the
identified
problem?
A. Keeping the client supine
B. Removing all head pillows
C. Performing oral suctioning
D. Providing frequent oral hygiene
156. Nurse
prepares to delegate tasks to the nursing assistant Among her
patients
is a 50 year-old woman who is day two of recovery following a
laparoscopic
resection of the colon post-operative orders are follow:
Ambulate
every six hours. Evaluate vital signs every two hours. Lactated
Ringer's
IV at 50 ml/hour. Wound assessment every eight hours.
Nasogastric
tube until bowel sounds present.
Which is
most appropriate to delegate?
A.
Ambulate the
patient.
B.
Evaluation of
vital signs.
C.
Change
intravenous fluid bags.
D.
Assess
nasogastric tube placement.
157. A 45 year-old patient has had difficulty sleeping and has lost ten
kilograms
despite having a large appetite on examination there is a
palpable
thyroid gland.
Blood
pressure 108/58
mmHg
Heart
rate 116/min
Respiratory
rate
22/min
Body
temperature 38.0 c oral
Height
164
Weight
5 0 kilograms
Which
additional symptom is most likely?
A.
Heart
palpitations.
B.
Depression.
C.
Anorexia.
D.
Paresthesia
158.
What is the Proper procedure for doing a
breast self-exam?
A. Use the palm of the hand to
feel for lumps.
B. Apply three different levels of
pressure to feel breast tissue.
C. Stand when performing a breast
self-exam.
D. Perform self-exam annually
159.
Which of the following is a desired expected
outcome 24 hours
postoperatively?
A. Gag reflex present.
B. Cerebral perfusion pressure, 68mmHg
C. Intracranial pressure, 21mmHg.
D. Decreased lacrimation
160.
RTA. The patient appears restless confused and
disoriented. He reports
that he
had hit his head against the steering wheel of the car when it had
collided
with the car directly in front of him.
Blood
pressure 110/68 mmHg
Heart
rate 100/min
Respiratory
rate 22/min
Body
Temperature 37.0
coral
Oxygen
saturation 98 % on room air
What
is the most important next step in management?
A.
Immobilize
head and neck.
B.
Administer
oxygen.
C.
Establish an
intravenous line.
D.
Arrange for an
MRI scan.
161.
A 30 year-old married man presents to the
clinic with complaints of feeling sad for the past three months. He is unable
to maintain a regular sleep routine, has lost his appetite and has difficulty
concentrating. He is prescribed a medication which prevents the reuptake of
specific neurotransmitters that could contribute to his mental health problem.
Which side effects would be most important for the nurse to advise the patient
of?
A. Polyuria
B. Photophobia
C. Fluid retention
D. Sexual dysfunction
162. A
female patient has been advised that laboratory tests confirm herpes simplex
virus (HSV), type 2. The nurse should teach the patient that a Papanicolaou
test (Pap smear) is recommended:
A.Every 6
months if symptoms persist despite treatment
B. Every year even if asymptomatic
C. Whenever symptoms recur
D. Every 3 years if other Pap smears have
been negative
163. A
three year-old has returned to the clinic 4 days after being diagnosed with
gastroenteritis and dehydration. A parent reports that the vomiting has
stopped, and the child is tolerating liquids, rice, applesauce, and bananas.
The diarrhea persists, but seems to be decreasing in volume. When evaluating
for signs of dehydration, the nurse will assess the patient's skin turgor by:
A. Grasping the skin over the abdomen with two fingers and raising
the
skin with two fingers
B.
Grasping the skin
over the forehead with two fingers and raising the skin with two fingers
C.
Holding the
patient's mouth open and assessing the tongue for deep creases or furrows
D.
Drawing two tubes
of blood and running a blood urea nitrogen (BUN) and creatinine (Cr)
164. A 12 year- old patient had a cast removed from the left leg after
wearing if for eight weeks. The patient wants to resume sports as soon as
possible. In order to regain muscle strength lost while wearing cast, the nurse
will instruct the patient in performance of:
A. Resistive range of motion exercises to
left leg
B. Passive range of motion exercises to
right leg
C. Active- assistive range of motion
exercises to the right leg
D. Active range of motion
exercises to both legs
165. A 45 year-old man who is hospitalized feels the constant need to
keep things in order, particularly whilst eating. The nurse observes him
arranging the food on his plate into symmetrical and equal bite-sized pieces.
He constantly worries that food served could be outdated and potentially cause
illness.
Which nursing diagnosis is most
important?
A.
Ineffective
verbal communication
B.
Self-esteem
disturbance
C.
Impaired social
interaction
D.
Anxiety
166. A patient has a
central line catheter and is receiving a three-in-one total parenteral
nutrition that contains glucose, proteins and lipids. The pump is set to
deliver the infusion over a 12-hour period. After how many hours should the
intravenous administration set be changed?
A. 12
B. 24
C. 48
D. 72
167. A 68 year-old woman is receiving parenteral nutrition at home. The
district nurse visits the woman and notes that she has gained one kilogram of
weight since a health provider had visited one week ago. There is pitting edema
of 2+ of the lower extremities. The patient is alert, active and oriented.
Which nursing diagnosis is most
appropriate?
A.
Non-compliance
B.
Impaired gas
exchange
C.
Imbalanced
nutrition
D.
Fluid
volume overload
168. A 54 year-old woman presented to the Emergency Department with
sharp upper right abdominal pain that radiates to the right scapula. While
performing the admission assessment, the patient becomes nauseous and begins
vomiting. She states that she has had pain in the upper right quadrant
previously but that this time it was far worse. There's a positive
Murphy's sign and an ultrasound confirms gallbladder wall thickening and
pericholecystic fluid collections. Which of the following would most likely be
associated with her clinical findings?
A. Relief by drinking milk
B. Alleviation with exercise
C. Triggered by fatty meal
D. Worsening on empty stomach
169. A patient is preparing for a total knee replacement. During the
preoperative interview process the patient reports an allergic reaction to
penicillin.
Which of the following is considered a
side effect and not a true allergy to medication?
A.
Shortness of
breath
B.
Tingling lips and
tongue
C.
Rash
D.
Upset
stomach
170. A 67 year-old man was admitted to the hospital following a closed
bone fracture. An intramedullary nail is inserted and the patient is placed in
balanced skeletal traction. The following day, the patient becomes restless,
drowsy and confused, he has difficulty breathing and appears very tired.
Which additional sign or symptom would
require immediate intervention?
A.
Anxiety
B.
Cold
skin
C.
Constipation
D.
Petechiae on
chest
171. An 82 year-old patient has Parkinson's disease. During the
assessment, the nurse would expect which of the following actions to produce
the MOST tremor activity of the hands?
A. Eating with a fork
B. Resting hands in lap
C. Standing with hands loose at sides
D. Rolling a small pill between the
fingers
172. A 52 year-old man with congestive heart failure presents to the
Emergency Department with rapid and irregular heartbeats, and feeling dizzy and
light-headed. The attending physician verbally calls out an order to the nurse
to administer digoxin 0.25 milligrams by intravenous injection. How will the
nurse complete the paperwork for this order?
A. Write, sign and repeat order
back to the physician
B. Ask the physician to write and sign
the order
C. Write the order and ask the physician
to sign
D. Verbally repeat the order and
administer drug
173. The nurse is assisting a patient to ambulate in hall. The patient
has a history of coronary artery disease (CAD) and had coronary artery bypass
graft surgery (CABG) 3 days ago. The patient reports chest pain rated 3 on a
scale of 0 (no pain) to 10 (severe pain). The nurse should first:
A. Determine how long it has been since
the patient's last dose of
Aspirin
B. Obtain a chair for the
patient to sit down
C. Assess the patient's radial pulse
D. Ask the patient to take several slow,
deep breaths.
174. A five month-old boy has been vomiting
green colored vomit for ten hours. He has intermittent abdominal pain during
which he draws his legs up to his chest, turns pale and cries forcefully. On
observation, there is bleeding in the stool which has a jelly-like consistency.
Abdominal palpation reveals a long tube-like mass. There is no fever, rash nor
diarrhea. Bowel sounds are hyperactive in all quadrants.
Which
is the most likely form of initial treatment?
A.
Manual
manipulation
B.
Surgical
resection
C.
Barium
enema
D.
Endoscopy
175. A 30 year-old woman with type 1
diabetes mellitus receives mixed type of insulin in the morning and before bed
time. She reports that the level of her fasting blood sugar is constantly high
when she checks it every morning at home.
Which
dose of insulin is most likely causing this problem?
A.
Low morning,
regular insulin
B.
High morning NPHI
C.
High evening
regular insulin
D.
Low
evening NPH insulin
176. A client has a phosphorus level of 5.0mg/dL.
The nurse closely monitor
the client
for?
A.
Signs of tetany
B. Elevated blood glucose
C. Cardiac dysrhythmias
D. Hypoglycemia
177. A nurse is caring for a child with pyloric stenosis. The nurse
would watch out for symptoms of?
A. Vomiting large amounts
B. Watery stool
C. Projectile vomiting
D. Dark-colored stool
C. Projectile vomiting
D. Dark-colored stool
178. The nurse is teaching a mother whose daughter has iron deficiency
anemia. The nurse determines the parent understood the dietary modifications,
if she selects?
A. Bread and coffee
B. Fish and Pork meat
C. Cookies and milk
D. Oranges and green leafy vegetables
B. Fish and Pork meat
C. Cookies and milk
D. Oranges and green leafy vegetables
179. Which of the following is the most common clinical manifestation
of G6PD following ingestion of aspirin?
A. Kidney failure
B. Acute hemolytic anemia
C. Hemophilia A
D. Thalassemia
B. Acute hemolytic anemia
C. Hemophilia A
D. Thalassemia
180. The nurse anticipates which of the following responses in a client
who develops metabolic acidosis.
A. Heart rate of 105 bpm
B. Urinary output of 15 ml
C. Respiratory rate of 30 cpm
D. Temperature of 39 degree Celsius
C. Respiratory rate of 30 cpm
D. Temperature of 39 degree Celsius
181. The nurse assesses a client with an ileostomy for possible
development of which of the following acid-base imbalances?
A. Respiratory acidosis
B. Metabolic acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
B. Metabolic acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
182. Which of the following has mostly likely occurred when there is
continuous bubbling in the water seal chamber of the closed chest drainage
system?
A. The connection has been taped too
tightly
B. The connection tubes are kinked
C. Lung expansion
D. Air leak in the system
B. The connection tubes are kinked
C. Lung expansion
D. Air leak in the system
183. The nurse plans to frequently assess a post-thyroidectomy patient
for?
A. Polyuria
B. Hypoactive deep tendon reflex
C. Hypertension
D. Laryngospasm
B. Hypoactive deep tendon reflex
C. Hypertension
D. Laryngospasm
184. Which if the following young adolescent and adult male clients are
at most risk for testicular cancer?
A. Basketball player who wears supportive
gear during basketball games
B. Teenager who swims on a varsity swim team
C. 20-year-old with undescended testis
D. Patient with a family history of colon cancer
B. Teenager who swims on a varsity swim team
C. 20-year-old with undescended testis
D. Patient with a family history of colon cancer
185. An 18-month-old baby appears to have a rounded belly, bowlegs and
slightly large head. The nurse concludes?
A. The
child appears to be a normal toddler
B. The child is developmentally delayed
C. The child is malnourished
D. The child’s large head may have neurological problems.
B. The child is developmentally delayed
C. The child is malnourished
D. The child’s large head may have neurological problems.
186. An appropriate instruction to be included in the discharge
teaching of a patient following a spinal fusion is?
A. Don’t use the stairs
B. Don’t
bend at the waist
C. Don’t walk for long hours
D. Swimming should be avoided
C. Don’t walk for long hours
D. Swimming should be avoided
187. A nurse is preparing to give an IM injection of Iron Dextran that
is irritating to the subcutaneous tissue. To prevent irritation to the tissue,
what is the best action to be taken?
A.
Apply ice over the injection site
B. Administer drug at a 45 degree angle
C. Use a 24-gauge-needle
D. Use the z-track technique
B. Administer drug at a 45 degree angle
C. Use a 24-gauge-needle
D. Use the z-track technique
188. What should a nurse do prior to taking the patient’s history?
A. Offer the patient a glass of
water
B. Establish rapport
C. Ask the patient to disrobe and put on gown
D. Ask pertinent information for insurance purposes
B. Establish rapport
C. Ask the patient to disrobe and put on gown
D. Ask pertinent information for insurance purposes
189. A pregnant woman is admitted for
pre-eclampsia. The nurse would
include in the health teaching that magnesium will be part of the medical management
to accomplish the following?
A. Control seizures
B. promote renal perfusion
C. To decrease sustained contractions
D. Maintain intrauterine homeostasis
B. promote renal perfusion
C. To decrease sustained contractions
D. Maintain intrauterine homeostasis
Good
Luck ..
