1.

When preparing a client with a draining vertical incision for ambulation, where should the nurse apply the
thickest portion of a dressing?
A. At the top of wound
C. At the base of the wound
B. In the middle of the wound
D. Over the total wound
2. A client whos dehydrated has urinary incontinence and excoriation in the perianal area. Which of the
following action would be a priority?
A. Keeping the area clean and dry
D. Applying moist warm compresses to
B. Offering the urinal every 3 hours
the clients groin
C. Maintaining the fluid intake of IL/day
3. A client with HIV/ AIDS is confused and has been dislodging his I.V. access. He scheduled to receive I.V.
medications. Which of the following actions would be most appropriate for the nurse to take?
A. Place bilateral wrist restraints on the client
B. Ask the physician to give a client a tranquilizer
C. Delay giving the drug until the clients confusion ceases
D. Tell a nursing assistant to stay with the client during the infusion
4. The nurse is caring for a geriatric client with a pressure ulcer on the sacrum. When teaching the client about
dietary intake, which food should the nurse plan to emphasize
A. Legumes and cheese
C. Fruits and vegetables
B. Whole grain products
D. Lean meats and low-fat milk
5. A nurse manages a unit that has four full-time vacant positions, and nurses volunteer to work extra shifts to
cover the staffing shortage. One of the staff nurses havent volunteered and states, forty hours a week of
nursing is all I can manage to do. I wont volunteer for overtime. The nurse manager says to an attending
physician on the unit, Ill adjust her schedule to make wish shed volunteered. The physician to whom she
commented should:
A. Choose to ignore the comment because it isnt the physicians domain
B. Report the nurse- manager to the labor relations board
C. Ensure that the nurse-manager receives counseling about her comment
D. Tell the staff nurse what the manager said about her
6. Nursing care for a client includes removing elastic stockings once per day. What is the rationale for this
intervention?
A. To increase blood flow to the heart
B. To observe the lower extremities
C. To allow the leg muscles to stretch and relax
D. To permit veins in the leg to fill with blood
7. A client has a wound with drain. When cleaning around the drain, the nurse should wipe in which direction
A. Laterally, from the center to the
C. In a circle, from the center outward
opposite side
D. None of the above
B. From top to bottom
8. What does the nurse do when making a surgical bed?
A. Leaves the bed in the high position when finished
B. Places the pillow at the head of the bed
C. Rolls the client to the far side of the bed
D. Tucks the top sheet and blanket under the bottom of the bed
E.
9. A nurse manager receives several complains from day-shift nurses that the night-shift nurses arent
performing the daily calibration of the glucose monitoring sheet, which is their responsibility. It would be most
prudent for the nurse-manager to:
A. Immediately remind the night-shift nurses of the daily calibrations
B. Arrange a meeting of the day-shift and night-shift nurses
C. Review the capillary glucose monitoring calibration log book
D. Counsel the night charge nurse about the discrepancy
10. The physician orders supplemental oxygen for a client with respiratory problem. To provide the highest
possible oxygen concentration, the nurse expects to use which oxygen delivery service?
A. Nasal cannula
C. Partial re-breathing mask
B. Venturi mask
D. Non-rebreathing mask
11. A client twists the right ankle while playing basketball and seeks care for ankle and swelling. After the nurse
applies ice to the ankle for 30 minutes, which statement by the client suggests that ice application has been
effective?
A. I need something stronger for pain
C. My ankle appears redder now.
relief.
D. My ankle feels very warm.
B. My ankle looks less swollen now.
E.
12. Which action by the nurse is essential when cleaning the area around a Jacksonian wound drain?
A. Cleaning from the center outward in a circular motion
B. Removing the drain before cleaning the skin
1

13.

14.

15.

16.
17.

18.

19.

20.

21.

22.

23.
24.
25.
26.

C. Cleaning briskly around the site with alcohol

D. Wearing sterile gloves and a mask
A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which of the
following contributing factors would the nurse recognize as most important?
A. History of increased aspirin use
C. An active daily walking program
B. Recent pelvic surgery
D. A history of diabetes
The nurse is assigned to care for a client with tracheostomy tube. How can the nurse communicate with this
client?
A. By providing a tracheostomy plug to use for verbal communication
B. By placing the call button under the clients pillow
C. By supplying a magic slate or similar device
D. By suctioning the client frequently
The physician has ordered a wet-to-dry dressing for an infected pressure ulcer the nurse knows that the
primary reason for this treatment is to accomplish which action?
A. Preventing the spread of infection
C. Keeping the wound moist
B. Debriding the wound
D. Reducing pain
Which member of the health care team is responsible for obtaining informed consent from a client:
A. The primary nurse
C. The nurse working with the physician
B. The physician
D. The physician assistant
While examining a clients leg, the nurse notes an open ulceration with visible granulation tissue in the
wound. Until a wound specialist can be contacted, which of the following types of dressing is most
appropriate for the nurse to apply
A. Dry sterile dressing
C. Moist sterile saline gauze
B. Sterile petroleum gauze
D. Povidone-iodine soaked gauze
When following standard precautions, the nurses primary responsibility is to:
A. Wear gloves for all contact with the client
B. Consider all body substances potentially infectious
C. Place a body substance isolation sign on the clients door
D. Wear gloves and a gown if the client is in respiratory isolation.
While assessing the incision of a client who had surgery 2 weeks ago. The nurse observes that the suture
line has a shiny, light pink appearance. Which of the following would the nurse take next?
A. Notify the physician because the wound may be dehiscing
B. Apply normal saline solution to keep the wound moist
C. Do nothing because this is a granulation tissue
D. Prepare the client for debridement of the suture line
A client is being discharged after undergoing abdominal surgery and colostomy formation to treat colon
cancer. Which nursing action is most likely to promote continuity of care?
A. Notifying the rural health unit of the clients diagnosis
B. Requesting the nutritionist to provide adequate nutritional counseling
C. Referring the client to a community health nurse for follow-up visits to provide colostomy
care
D. Asking a physical therapist to evaluate the client at home
Which nursing action is essential when providing continuous enteral feeding?
A. Elevating the head of the bed
B. Positioning the client on the left side
C. Warming the formula before administering it
D. Hanging a full days worth of formula at one time
The nurse is evaluating a postoperative client for infection. Which sign or symptom would be most indicative
of infection?
A. The presence of an indwelling urinary catheter
B. Rectal temperature of 100 F(37.8 C)
C. Red, warm, tender incision
D. White blood cell (WBC) count of 8,000/ ul
Which nursing theorist addressed self-care deficits in her nursing theory?
A. Dorothy Johnson
C. Dorothea Orem
B. Virginia Henderson
D. Martha Rogers
When bandaging a clients ankle, there nurse should use which technique?
A. Figure-eight
C. Recurrent
B. Circular
D. Spiral reverse
A client in oxygen therapy should be monitored by the nurse for:
A. Combustion
C. Excoriation
B. Infection
D. Fluid retention
An employer establishes a physical exercise area in the workplace and encourages all employees to use it.
This is an example of which level of health promotion?
A. Primary prevention
C. Tertiary prevention
B. Secondary prevention
D. Passive prevention

27. The nurse has just removed an IV catheter from a clients arm because fluid has infiltrated the arm. The
physician orders warm soaks for the area. Based on the principles of heat and cold application the nurse
would:
A. Keep the area covered with the warm soaks continuously
B. Remove the warm compress after 20 minutes for at least 15 minutes
C. Alternate warm compresses with cold compresses
D. Question the order because heat increases edema
28. A client has a soft wrist safety device and wrist restraint. Which assessment finding should the nurse
consider abnormal?
A. A palpable radial pulse
C. Cool, pale fingers
B. A palpable ulnar pulse
D. Pink nail beds
29. The nurse has been teaching a client about a high-protein diet. The teaching is successful if the client
identifies which of the following meals as high in protein?
A. Baked beans, hamburger and milk
C. Bouillon, spinach and soda
B. Spaghetti with cream sauce, broccoli
D. Chicken, spinach, and soda
and tea
30. Following a tonsillectomy, a client returns to the medical-surgical unit. The client is lethargic and reports
having a sore throat. Which position would be most therapeutic for this client?
A. Semi-fowlers
C. High-fowlers
B. Supine
D. Side-lying
31. A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and
nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual
reason for such situation is:
A. Unhappiness about the change in leadership
B. Unexpressed feelings and emotion among the staff
C. Fatigue from the overwork and understaffing
D. Failure to incorporate staff in decision making
32. Which intervention should the nurse try first for a client who exhibits signs of sleep disturbance?
A. Administer sleeping medication before bedtime
B. Ask the client each morning to describe the quality of sleep during the previous night
C. Teach the client relaxation techniques, such as guided imagery, meditation, and progressive pole
relaxation
D. Provide the client with normal sleep aids, such as pillows, back rubs and snacks.
33. To follow standard precautions, the nurse should carry out which of the following measures?
A. Recapping needles after use
B. Wearing a gown when bathing a client
C. Wearing gloves when administering I.M. medication
D. Wearing gloves for all client contact
34. When leaving the room of a client in strict isolation, the nurse should remove which protective equipment
first?
A. Cap
B. Mask
C. Gown
D. Gloves
35. A client suddenly loses consciousness. What should the nurse do first?
A. Call for assistance
C. Palpate for a carotid pulse
B. Assess for responsiveness
D. Assess for papillary response
36. The nurse must apply a wet-to-dry dressing over an ulcer on a clients left ankle. How should the nurse
proceed?
A. Apply the saturated fine-mesh gauze dressing over the wound.
B. Apply an occlusive dressing over the saturated fine-mesh gauze dressings.
C. Cover the saturated fine-mesh gauze dressings with an elastic bandage.
D. Pact the moistened fine-mesh gauze dressings into all depressions and grooves of the
wound.
37. A 66-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks
the nurse. How long will it take for my scars to disappear? Which of the following statements would be the
nurses best response?
A. The contraction phase of wound healing can take 2 to 3 years.
B. Wound healing is very individual but within 4 months the scar could fade.
C. With your history and the type and location of the injury, its hard to say.
D. If you dont develop an infection, the wound should heal anywhere between 1 and 3 years.
38. When discussing the food guide pyramid with a 75-year old client, the nurse should remember that the guide
has been modified for older people. Unlike the standard food guide pyramid, the version for elderly
individuals;
A. Includes 8-oz glasses of water at the base of pyramid
B. Sets upper limits on servings of most food and water
C. Increases the amounts of recommended milk and dairy products
D. Eliminates the portion of the pyramid for fats, oils and sweets
E.

39. A client at risk of fluid volume excess. Which nursing intervention would ensure the most accurate
monitoring of the clients fluid status?
A. Measuring and recording fluid intake and output
B. Weighing the client daily at the same time each day
C. Assessing vital signs every 1 hour
D. Checking the lungs for crackles every shift
40. A client has a nursing diagnosis of ineffective airway clearance related to poor coughing when planning this
clients care the nurse should include which intervention?
A. Increasing fluids to 2,500 ml day
B. Teaching the client how to deep breath and cough
C. Improving airway clearance
D. Suctioning the client every 2 hours
41. The nurse is assisting with a subclavian vein central line insertion when the clients oxygen saturation rapidly
drops. He complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax
has developed. Further assessment findings supporting the presence of pneumothorax include:
A. Diminished or absent breath sounds on the affected side
B. Paradoxical chest wall movement with respirations
C. Tracheal deviation to the unaffected side
D. Muffled or distant heart sounds
42. During discharge teaching, a client with fractured toe asks the nurse why ice should be applied to the
fracture site. The nurse should explain that ice application has which effect?
A. Maintains proper bone alignment
B. Relieves swelling by reducing blood flow to the injury site
C. Helps prevent skin laceration at the injury site
D. Reduces pain by promoting vasodilation at the injury site
43. The nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How
should the nurse proceed?
A. Irrigate continuously until the solution becomes clear or all of the solution has been used
B. Moisten the area around the wound with normal saline after the irrigation
C. Apply wet-to-dry dressing to the wound after the irrigation
D. Rapidly instill a stream of irrigating solution into the wound
44. The nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which of the following
instructions should the nurse include?
A. Encourage a high-calorie, high
C. Limit salt intake to 2g per day
protein diet
D. Encourage foods high in vitamin B
B. Restrict fluids to 1,500 ml per day
45. The physician orders hourly urine output measurement for a postoperative client. The nurse records the
following amounts of output for 2 consecutive hours 8 a.m. 50ml; 9 a.m. 60ml; based on these amounts,
which action should the nurse take?
A. Continue to monitor and record
C. Irrigating the indwelling urinary catheter
hourly urine output
D. Increasing the I.V. fluid infusion rate
B. Notifying the physician
46. Which of the following assessment would be most supportive of the nursing diagnosis impaired skin integrity
related to purulent wound drainage?
A. Heart rate of 88 beats/minute
C. Oral temperature of 101 F (38.3 C)
B. Wound healing by first intention
D. Dry and intact wound dressing
47. The nurse is giving nutritional counseling to the mother of a child with celiac disease. Which statement by
the mother would indicate understanding?
A. My son cant eat wheat, rye, oats or barley.
B. My son needs a diet rich in gluten.
C. My son must avoid potatoes, rice, flour, and cornstarch.
D. My son can safely frozen and packaged foods.
48. Which finding indicates that suctioning has been effective?
A. Respiratory rate of 24 breaths/minute
C. Brisk capillary refill
B. Heart rate of 104 breaths/minute
D. Clear breath sounds
49. For healing by second intention, a clients wound has been packed with medicated dressings. When
evaluating the wound, which of the following findings indicates that healing takes place?
A. The surrounding tissue is red in color.
B. The wound drainage is serious.
C. The skin around the wound is edematous.
D. The granulation tissue is at the wound edges.
50. A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which
intervention in the plan of care?
A. Putting on an individually fitted mask when entering the clients room
B. Instructing the client to wear a mask at all times
C. Wearing a gown and gloves when providing direct care
D. Keeping the door to the clients room open to observe the client
4

51. The nurse has been teaching a client who to use an incentive spirometer that must be used at home for
several days after discharge. Which client action indicates an accurate understanding of the technique?
A. The client take slow, deep breaths to elevate the spirometer
B. The client takes rapid, shallow breaths to elevate the ball
C. The client tilts the spirometer down when using it
D. The client uses the device while lying supine
52. A scrub nurse in the operating rooms has which responsibility?
A. Positioning the client
C. Handling surgical instruments to the
B. Assisting with gowning and gloving
surgeon
D. Applying surgical drapes
53. For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml
and a fluid intake of 800 ml. The clients urine is dark amber. These assessments indicate which nursing
diagnosis
A. Impaired urinary elimination
C. Imbalanced nutrition: Less than body
B. Deficient fluid volume
requirements
D. Excessive fluid volume
54. The nurse is assessing a client for the risk of falls. The nurse should collect what information about the
client?
A. Gait and balance information
C. The familys psychosocial history
B. The agencys restraint policy
D. The clients dietary preferences
55. The nurse must apply an elastic bandage to a clients ankle and calf. She should apply the bandage
beginning at the clients:
A. Foot
C. Lower thing
B. Ankle
D. Knee
56. During a teaching session, the nurse demonstrate how to change a tracheostomy dressing then the nurse
watches as the client returns demonstration. Which client action indicates an accurate understanding of the
procedure?
A. The client cleans around the insertion site, using gauze squares and full-strength hydrogen
peroxide
B. The client rinses around the clean incision site, using gauze squares moistened with normal
saline
C. The client around the clean incision site, suing gauze squares moistened with tap water
D. The client applies cotton-filled gauze squares and sterile dressing after cleansing
57. A client, age 43, has no family history of breast cancer or other risk factors for this disease. The nurse
should instruct her to have a mammogram how often?
A. Once, to establish a baseline
C. Every 2 year
B. Once per year
D. Twice per year
58. A nurse implements a teaching plan for a client whos scheduled for discharge. Which client behavior best
demonstrates effective teaching?
A. Exhibiting a positive change in behavior
B. Verbally repeating the instruction
C. Making statements indicating that the client understands
D. Exhibiting nonverbal signs as nodding the head to indicate yes
59. Which of the following outcome criteria would be most appropriate for the client with a nursing diagnosis of
Ineffective airway clearance?
A. Presence of congestion on X-ray
C. Continued rate of 24 breaths/ minute
B. Breath sounds clear on auscultation
D. Respiratory rate of 24 breaths/ minute
60. To collect a clean-catch midstream urine specimen from a female client. The nurse instructs her to clean the
area at the external urinary meatus with an antiseptic. How should the client do this?
A. By swabbing the labia minora from
C. By cleaning the labia majora from back
front to back
to front
B. By cleaning the labia minora back to
D. By swabbing the entire perineal area
front
61. The nurse is transforming a client from the bed to a chair. Which action does the nurse take during this client
transfer?
A. Positions the head of the bed flat
D. Places the chair facing away from the
B. Helps the client dangle the legs
bed
C. Stands behind the client
62. The nurse is teaching a group of patient-care attendants about infection control measures. The nurse tells
the group that the first line of intervention for preventing the spread of infection is:
A. Wearing gloves
C. Washing hands
B. Administering antibiotics
D. Assigning private rooms for clients
63. What is an appropriate nursing intervention for a client with arm restraint?
A. Applying the restraints loosely to prevent pressure on the skin
B. Trying the restraint to the side rail
C. Positioning the restrained arm in full extension
D. Monitoring circulatory status every 2 hours
5

64. The physician orders a bland, full-liquid diet for a client. The nurse understands that this clients diet may
include:
A. Orange juice, farina, and coffee
B. Apple juice, cream of chicken soup, and vanilla ice cream
C. Pineapple juice, a bran muffin, and milk
D. Orange juice, custard and tea
65. When changing the dressing on a pressure ulcer, the nurse notes that the wound has necrotic tissue on the
edges. Which action should the nurse anticipate that the physician will order?
A. Incision and drainage
C. Debridement
B. Culture
D. Irrigation
66. A client asks to be discharged from the health care facility against medical advice (AMA). What should the
nurse do?
A. Prevent the client from leaving
D.
B. Notify the physician.
E. Call a security guard to help detain the
C. Have the client sign an AMA form.
client.
67. The physician orders chest physiotherapy for a client with respiratory congestion. When should the nurse
plan to perform chest physiotherapy?
A. After meals
C. When the client has time
B. Before meals
D. When the nurse has time
68. A client on prolonged bed rest has developed pressure ulcer. The wound shows no signs of healing even
though the client has received skin care and has been turned every 2 hours. Which factor is most likely
responsible for the failure to heal?
A. Inadequate skin care
C. Inadequate massaging of the affected
B. Inadequate protein intake
area
D. Low calcium level
69. During a meal, a client with Hepatitis B dislodges her I.V. line and bleeds on the surface of the over-the-bed
table. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with:
A. Alcohol
C. Acetone
B. Ammonia
D. Bleach
70. For the past few days, a client has been having calf pain and notices that the painful calf is larger than the
other one. The right calf is red, warm, achy and tender to touch. Which of the following questions about the
pain should the nurse include in the assessment?
A. Does the pain worsen in the morning upon risen?
B. Does the pan increase with activity and lessen with rest?
C. Is the pain relieved by position changes?
D. Is the pain worse with the toes pointed toward the knee?
71. Which of the following laboratory test results is the most important indicator of malnutrition in a client with a
wound?
A. Serum potassium level
C. Albumin level
B. Lymphocyte count
D. Differential count
72. A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus
feeding, the client vomits and begins choking. Which of the following actions is most appropriate for the
nurse to take?
A. Clear the clients airway
C. Start cardiopulmonary resuscitation.
B. Make the client comfortable.
D. Stop the feeding and remove the NGT.
73. Which strategy can help make the nurse a more effective teacher?
A. Including the client in the
C. Providing detailed explanations.
discussion.
D. Using loosely structured teaching
B. Using technical terms.
sessions.
74. Which assessment finding by the nurse contraindicates the application of a heating pad?
A. Active bleeding.
C. Edematous lower leg.
B. Reddened abscess.
D. Purulent wound drainage.
75. A client hasnt voided since before surgery, which took place 8 hours ago. When assessing the client the
nurse will:
A. Be unable to palpate the bladder.
B. Feel that the bladder is full.
C. Palpate the bladder above the symphysis pubis.
D. Palpate the bladder at the umbilicus.
76. To help minimize calcium loss from the bones of a hospitalized client, the nurse should:
A. Reposition the client every 2 hours.
B. Encourage the client to walk in the hall.
C. Offer dairy products at frequent intervals.
D. Provide supplemental feedings between meals.
77. The physician orders an intestinal tube to decompress a clients GI tract. When gathering equipment for this
procedure, the nurse identifies which of the following as an intestinal tube?
A. Sengstaken-Blakemore tube
C. Levins tube
B. Miller-Abbott tube
D. Salem Sump tube
6

78. A nurse works on a general medical-surgical unit where nurses work on 12-client pods. Each pod is staffed
by two registered nurses. When one of the nurses leaves the unit for any reason, the remaining nurse cares
for all 12 clients. If she needs help, she can call the agencys in-house resource nurse. One evening when a
coworker nurse left the unit, the remaining nurse, who was making rounds on the departed nurses clients,
found medications left at bedsides and a client with a blood-draw tourniquet remaining on his arm, In
addressing the problems, the nurse should:
A. Inform the nurse-supervisor right away.
B. Correct the problems and submit a written report.
C. Speak to the coworker when she returns to the unit.
D. Ask for a meeting with the coworker and a manager.
79. Which of the following groups of clients is at increased risk for developing a wound infection?
A. Clients who require frequent pain medication
B. Clients who are 15-lb (6.8 kg) overweight
C. Clients who ambulate after the first postoperative day
D. Clients who are undernourished
80. A child with rheumatic fever complains of painful joints. What non-pharmacologic measures should the nurse
use to reduce the childs pain?
A. Perform gentle passive-range of motion exercises.
B. Gently massage the painful joints.
C. Use a bed cradle to keep linens off the joints.
D. Encourage position changes in bed every 2 hours.
81. Four clients injured in an automobile accident enter the emergency department at the same time and are
immediately seen by the triage nurse. The nurse would assign the highest priority to the client with the:
A. Lumbar spinal cord injury and lower extremity paralysis.
B. Maxillofacial injury and gurgling respirations.
C. Severe head injury and no blood pressure.
D. Second trimester pregnancy in premature labor.
82. Which of the following clients would qualify for hospice care?
A. A client with late-stage acquired immunodeficiency syndrome (AIDS)
B. A client with left-sided paralysis resulting from a cerebrovascular accident (CVA)
C. A client whos undergoing treatment for heroin addiction
D. A client who had coronary artery bypass surgery 2 weeks before.
83. Nursing licensure and practice are regulated by:
A. Nurse practice acts
C. Civil law
B. Standard of care
D. The American Nurses Association
84. The physician inserts a chest tube into a client to treat a pneumothorax. The tube is connected to water seal
drainage. The nurse can prevent chest tube air leaks by:
A. Keeping the chest drainage system below the level of the chest.
B. Keeping the head of the bed slightly elevated.
C. Checking and taping all connections.
D. Checking patency of the chest tube.
85. The nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin:
A. restores the inflammatory response
C. reduces edema
B. enhances oxygen transport to tissues
D. enhances protein synthesis
86. A client with terminal breast cancer is being cared by a long-time friend whos a physician. The client has
identified her twin sister as the agent in her durable power of attorney. The client loses decision- making
capacity, and the twin sister says to the nurse, There will be a different physician caring for my sister now.
Ive dismissed her friend. In response, the nurse should:
A. Inform the sister that she doesnt have the power to assign a different physician.
B. Ask the dismissed physician if the client ever stated she wanted a different physician.
C. Abide by the wishes of the sister who is the durable power of attorney agent.
D. Politely ignore the sisters statement and continue to call and dismissed physician for orders.
87. A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best
action for the nurse to take would be to:
A. Remove the raised skin because the blister has already broken.
B. Wash the area with soap and water to disinfect it
C. Apply a weakened alcohol solution to clean the area.
D. Clean the area with normal saline solution and cover it with gauze dressing.
88. The nurse is obtaining a sterile urine specimen from a clients indwelling urinary catheter. To prevent
infection, the nurse should:
A. Aspirate urine from tubing port, using a sterile syringe and needle.
B. Disconnect the catheter from the tubing and obtain urine.
C. Open the drainage bag and pour out some urine.
D. Wear sterile gloves when obtaining urine.
89. An obese, malnourished client has undergone abdominal surgery. While ambulating on the 4th
postoperative day, she complains to the nurse that her dressing is saturated with drainage. Before this
activity, the dressing was dry and intact. Which of the following is the best initial action for the nurse to take?
7

A. Splint the abdomen with a pillow and call the surgeon.

B. Apply an abdominal binder.
C. Reinforce the existing dressing with another dressing.
D. Lift up the dressing to assess the wound.
90. The nurse measures clients temperature at 102 F. What is the equivalent Centigrade temperature?
A. 39 C
C. 38.9 C
B. 47 C
D. 40.1 C
91. The nurse plans to obtain client information from a primary source. Which of the following is a primary
information source?
A. A family member
C. The client
B. The physician
D. Previous medical records
92. Which of the following correctly described the anatomic position?
A. The body is supine
C. Palms are turned forward
B. Arms are elevated at shoulder level
D. The body is facing backward
93. Which of the following is the most common source of airway obstruction in an unconscious victim?
A. A foreign subject
C. The tongue
B. Saliva or mucus
D. Edema
94. When performing an abdominal assessment, the nurse should follow which examination sequence?
A. Inspection, auscultation, percussion, and palpation
B. Inspection, auscultation, palpation, percussion
C. Inspection, percussion, palpation, auscultation
D. Inspection, palpation, percussion, and auscultation
95. When testing a clients pupils for accommodation, the nurse should interpret which findings as normal?
A. Constriction and divergence
C. Constriction and convergence
B. Dilation and convergence
D. Dilation and divergence
96. The nurse is caring for a client who has suffered a severe cardiovascular accident (CVA). During routine
assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respiration are:
A. Progressively deeper breaths followed by shallower breaths with apneic periods.
B. Rapid, deep breaths with abrupt pauses between each breath
C. Rapid, deep breaths and irregular breathing without pauses
D. Shallow breaths with an increased respiration rate
97. Which pulse should the nurse palpate during rapid assessment of an unconscious adult?
A. Radial
B. Brachial
C. Femoral
D. Carotid
98. A client reports abdominal pain. Which action would aid the nurses investigation of this complaint?
A. Using deep palpation
C. Assessing the painful area first
B. Assessing the painful area last
D. Checking for warmth in the painful area
99. A client has just undergone bronchoscopy. Which nursing assessment is most important at this time?
A. Level of consciousness (LOC)
C. Personality changes
B. Memory
D. Intellectual ability
100. Tachycardia can result from:
A. Vagal stimulation
C. Fear, pain or anger
B. Vomiting, anger or suctioning
D. Stress, pain or vomiting
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.
U.
V.
W.
X.
Y.
Z.
AA.
AB.
AC.
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AD.
AE.
AF. A1 PASSERS TRAINING, RESEARCH, REVIEW AND DEVELOPMENT COMPANY
AG. FUNDAMENTALS OF NURSING
AH. Foundation of Nursing & Fundamentals of Nursing
AI. Set 2
AJ.
1. The nurses use a stethoscope to auscultate a clients chest. Which statement about stethoscope with a bell
and diaphragm is true?
A. The bell detects high-pitched sounds best
B. The diaphragm detects high-pitched sound best.
C. The bell detects thrills best
D. The diaphragm detects low pitched sound best.
2. Hyperactive bowel sounds can result from all of the following except:
A. Hunger
C. Intestinal obstruction
B. Paralytic ileus
D. Diarrhea
3. When obtaining a clients history, the nurse develops a genogram. What is the purpose of developing a
genogram?
A. To identify genetic and familial health problems
B. To identify previously undetected disease and orders
C. To identify the clients chief complaint
D. To identify the clients chronic health problems
4. A client comes to the clinic for diagnostic allergy testing. Why is intradermal injection used for such testing?
A. Intradermal injection is less painful
C. Intradermal drugs diffuse more rapidly
B. Intradermal drugs are easier to
D. Intradermal drugs diffuse more
administer
slowly
5. Why shouldnt the nurse palpate both carotid arteries at one time?
A. The pulse cant be assessed accurately unless the arteries are palpated one at a time
B. It may cause transient hypertension
C. It may cause severe bradycardia
D. It may cause severe tachycardia
6. When assessing a gerontologic client, the nurse expects to find various aging-related physiologic changes.
These changes include:
A. Increased coronary artery blood flow
C. Decreased peripheral resistance
B. Decreased posterior thoracic curve
D. Delayed gastric emptying
7. At 8 a.m. the nurse assesses a client whos scheduled for surgery at 10 a.m. During the assessment, the
nurse detects dyspnea, a non productive cough and back pain. What should the nurse do next?
A. Check to see that the chest X-ray was done yesterday as ordered
B. Check the serum electrolyte and complete blood count (CBC)
C. Notify the physician immediately of these findings
D. Sign the preoperative checklist for this client
8. The client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later the nurse
identifies which finding as an early sign of shock?
A. Restlessness
C. Heart rate of 110 beats/minute
B. Pale, warm, dry skin
D. Urine output of 30 ml/hour
9. The nurse is assessing a clients pulse. Which pulse feature should the nurse document?
A. Timing in the cycle
C. Pitch
B. Amplitude
D. Intensity
10. Why should the nurse inspect first and then auscultate when performing an assessment of a pediatric client?
A. Because the nurses touch may calm the child
B. Because the child may cry as the assessment proceeds, making auscultation difficult
C. Because the nurses touch may frighten the child
D. Because the nurses hand or stethoscope may feel cold, making the child recoil
11. When auscultating a clients chest. How can the nurse differentiate a pleural friction rub from the abdominal
breath sounds?
A. Decreased bowel motility
C. Nothing abnormal
B. Increased bowel motility
D. Abdominal cramping
12. The nurse is auscultating a clients chest. How can the nurse differentiate a pleural friction rub from the other
abnormal breath sounds?
A. A rub occurs during expiration only and procedures a light, popping, musical noise.
B. A rub occurs during expiration only and may be heard anywhere.
C. A rub occurs during inspiration only
D. All of the above
13. To evaluate a clients chief complaint, the nurse performs deep palpation. The purpose of deep palpation is
to assess which of the following?
A. Skin turgor
C. Organs
B. Hydration
D. Temperature
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E.
14. The nurse prepares to palpate a clients maxillary sinuses. For this procedure, where should the nurse place
the hands?
A. On the bridge of the nose
C. Below the cheekbones
B. Below the eyebrows
D. Over the temporal area
15. When inspecting a clients skin, the nurse finds a vesicle on the clients arm. Which description applies to a
vesicle?
A. Flat, nonpalpable, and colored
B. Solid, elevated, and circumscribed
C. Circumscribed, elevated, and filled with serious fluid
D. Elevated, pus-filled, circumscribed
16. The nurse is examining a client with suspected peritonitis. How does the nurse elicit rebound tenderness?
A. Pressing the affected area firmly with the hand, releasing pressure quickly, and noting any
tenderness on release
B. Using light palpation, noting any tenderness over an area
C. Using deep ballottement, noting any tenderness over an area
D. Pressing firmly with one hand, releasing pressure while maintaining fingertip contract with the skin,
and noting tenderness on release
17. To help assess a clients cerebral function, the nurse should ask:
A. Have you notices a change in your memory?
B. Have you noticed a change in your muscle strength?
C. Have you had any coordination problems?
D. Have you had any problems with your eyes?
18. The nurse prepares to assess client who has just been admitted to the health care facility. During
assessment, the nurse performs which activity?
A. Collects data
C. Develops a plan of care
B. Formulates nursing diagnosis
D. Writes client outcomes
19. The nurse must assess a clients splinted extremity for neurovascular damage. What should she do?
A. Assess extremities, ensuring that the extremity with the splint feels cooler than the unsplinted
extremities
B. Move the clients fingers or toes to test movement
C. Compare the capillary refill of each extremity, making sure its the same bilaterally
D. Be aware that edema and pulse checks arent apart of the neurovascular assessment
20. The nurse is performing a preoperative assessment. Which statement by the client would alert the nurse to
presence of risk factors for the preoperative complications?
A. I havent been able to eat anything solid foods for the past two days.
B. Ive never had surgery before.
C. I had an open operation 2 years ago, and I dont want to have another one.
D. Ive cut any smoking down from two packs to one pack a day.
21. The nurse prepares to auscultate a clients carotid arteries for bruits. For this procedure. The nurse should:
A. Have the client inhale during auscultation
B. Palpate the radial artery during auscultation
C. Use the bell of the stethoscope
D. Use the diaphragm of the stethoscope
22. The nurse conducts a test for the Rombergs sign. What is the correct procedure for this test?
A. Have the client stand with feet together and arms at the sides and try to balance, first with
eyes open and then with eyes closed
B. Instruct the client to walk across the room on the heels and to return walking on the toes
C. Ask the client to touch the thumb of one hand to each finger on that hand and then repeat this action
using the other hand
D. Instruct the client to lie on the back and slowly slide the heel down the shin of the opposite leg from
the knee to ankle.
23. When a nurse enters the room, the client complains that shes spitting up blood when she coughs, the nurse
takes a quick health history that includes:
A. The history of the present problem, medications, review of systems, and recent major operations
B. The history of the present problem, allergies, medications, and recent major operation
C. The history of the present problem, medications, family history, psychosocial history, and review of
systems
D. The history of the present problem, allergies, medications, review of systems, and recent major
operations
24. During the physical examination, the nurse uses various techniques to assess structures, organs and body
systems. Which technique allows the nurse to feel for vibration and locate body structures?
A. Auscultation
C. Palpation
B. Inspection
D. Percussion
25. When auscultating a clients chest, the nurse assesses a second heart sound (S2).This sound results from:
A. Opening of the mitral and tricuspid valves
B. Closing of the mitral and tricuspid valves
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C. Opening of the aortic and pulmonic valves

D. Closing of the aortic and pulmonic valves
A child with rheumatic fever must have his heart rate measured while awake and while sleeping. Why are
two readings necessary?
A. To obtain heart rate that isnt affected by medication
B. To eliminate interference from the jerky movements of chorea
C. To ensure that the child cant consciously raise or lower the heart rate
D. To compensate for the effects of activity on the heart rate
The nurse is assessing a 47-year-old client who has come to the physicians office for his annual physical.
One of the first physical signs of aging is:
A. Having more frequent aches and pains
B. Failing eyesight, especially close vision
C. Increasing loss of muscle tone
D. Accepting limitations while developing assets
Which of the following is true about crackles?
A. Theyre grating sounds
B. Theyre high pitched, musical squeaks
C. Theyre low pitched noises that sound like snoring
D. They may be fine, medium or course
When assessing the facial lacerations of a middle-aged client admitted to the facility 1 week ago, the nurse
observes scabs around the lacerations. Scabs indicate which phase of wound healing?
A. Contraction
C. Lag
B. Fibrinoplastic
D. Inflammation
The nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of
dehydration include:
A. Coma or seizures
C. Increased heart rate with hypotension
B. Sunken eyeballs and poor skin turgor
D. Thirst or confusion
The nurse correctly identifies which of the following as belonging to the dorsal cavity?
A. Mediastenum
C. Vertebral canal
B. Mouth
D. Reproductive organs
Which statement regarding heart sounds is correct?
A. S1 and S2 sound equally loud over the entire cardiac area
B. S1 and S2 sound fainter at the apex
C. S1 and S2 sound fainter at the base
D. S1 is loudest at the apex, and S2 is loudest at the base.
The nurse is obtaining the health history of a client whose background differs from the nurses. To develop
culturally acceptable strategies for nursing care, the nurse should assess which client factor?
A. Marital status
C. Financial resources
B. Cultural influences
D. Community involvement
The ear canal of an infant or young child:
A. Slants upward
C. Is horizontal
B. Slants downward
D. Slants backward
A client age 75 is admitted to the facility. Because of the clients age, the nurse should modify the
assessment by:
A. Shortening it
B. Talking in a loud voice
C. Addressing the client by the first name
D. Allowing extra time for the assessment
The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When
describing a healthy stoma, which statement should the nurse be sure to include?
A. The stoma should appear dark and have a bluish hue.
B. At first, the stoma may bleed slightly when touched.
C. The stoma should remain swollen distal to the abdomen.
D. At burning sensation under the stoma faceplate is normal.
The nurse must assess skin turgor of an elderly client. When evaluating skin turgor, the nurse should
remember that:
A. Over hydration causes the skin to taut
B. Dehydration causes the skin to appear edematous and spongy
C. Inelastic skin turgor is a normal part of aging
D. Normal skin turgor is moist and boggy
The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg.
During the teaching session, the nurse notices redness, swelling and induration at the wound site. What do
these signs suggest?
A. Infection
C. Hemorrhage
B. Dehiscence
D. Evisceration
Why should an infant be quite and seated upright when the nurse assesses his fontanels?
A. The mother will have less trouble holding a quite, upright infant
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B. Lying down can cause the fontanels to recede, making assessment more difficult
C. The infant can breathe more easily when sitting up
D. Lying down and crying can cause the fontanels to bulge
To evaluate a clients cerebellar function, the nurse should ask:
A. Do you have any problems with balance?
B. Do you have any difficulty speaking?
C. Do you have any trouble swallowing foods or fluids?
D. Have you noticed any changes in muscle strength?
The nurse is assessing a clients abdomen. Which finding should the nurse report as abnormal?
A. Dullness over the liver
B. Bowel sounds occurring every 10 seconds
C. Shifting dullness over the abdomen
D. Vascular sounds heard over the renal arteries
The nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51;
PaCO2, 28mmHg; PaO2, 70mmHg; and HCO3-, 24 mEq/L. What do these values indicate?
A. Metabolic acidosis
C. Respiratory acidosis
B. Metabolic alkalosis
D. Respiratory alkalosis
When palpating a clients body to detect warmth, the nurse should use which part of the hand?
A. Fingertips
C. Back (dorsal surface)
B. Finger pads
D. Ulnar surface
A client who has been admitted for surgery seems preoccupied and anxious the night before the operation.
Which comment by the nurse would promote therapeutic communication?
A. Are you worried about your surgery tomorrow?
B. Would you like me to call a chaplain to talk with you about your concerns you may have about
surgery?
C. You seem worried about something. Would you want to talk about it?
D. It isnt unusual to worry about surgery. If youd like Ill ask the physician for something to help you
sleep.
A 74-year-old client had three grown children who each have families of their own. The client is retired and
looks back on his life with satisfaction. According to Erikson, the nurse assesses that the client is in a stage
of:
A. Generativity
C. Ego identity
B. Ego integrity
D. Industry
The nurse is caring for a client who has had an above-the-knee amputation. The client refuses to look in the
stump. When the nurse attempts to speak with the client about his surgery, he tells her that he doesnt wish
to discuss it. The client also refuses to have his family visit. The nursing diagnosis that best describes the
clients problem is?
A. Hopelessness
C. Disturbed body image
B. Powerlessness
D. Fear
During an admission assessment, the nurse asks a client why hes being admitted to the facility. The client
responds, The physician found a lump in my prostate gland. I guess I have cancer. Which response by the
nurse would be most therapeutic?
A. There is no way to know whether you have cancer until a biopsy is done.
B. It isnt unusual for a man your age to have an enlarged prostate. Try not to worry.
C. Its important to keep a positive attitude. There is a good chance it isnt cancer.
D. You think you have cancer?
The nurse is trying to establish rapport with a newly admitted client. Which technique blocks effective
communication with a client?
A. Using silence
C. Giving advice
B. Asking open-ended questions
D. Reflecting
A client exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the
clients anxiety?
A. Everything will be fine. Dont worry.
B. Read this manual and then ask me any questions you may have.
C. Why dont you listen to the radio?
D. Lets talk about what is bothering you?
After receiving a visit from the spouse, a client begins crying and saying that the spouse is a mean person.
When the client starts pounding on the overbed table and using incomprehensible language, the nurse feels
unable to handle the situation. What should the nurse do at this time?
A. Tell the client that the spouse is probably under a lot of stress.
B. Instruct the client to stop pounding on the overbed table.
C. Call facility security to control the situation.
D. Request assistance by using the call system.
A client is admitted completely immobilized by an acute exacerbation of multiple sclerosis. Two days later,
the client cries frequently and refuses to see family members. The nurse formulates a nursing diagnosis of
Hopelessness. To address this diagnosis, the nurse should include which intervention in the plan of care?
A. Obtaining on order for tranquilizer.
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B. Limiting visitors to 15 minutes per day.

C. Encouraging the client to verbalize feelings.
D. Reinforcing the clients responsibility to the family.
As a client is being admitted to the facility. Her husband asks the nurse why she must sign a statement
confirming that she has been told of her rights to communicate her wishes about life support and
resuscitation. How should the nurse respond?
A. Everyone has to sign this. We need to know that we should do incase something unexpected
happens.
B. I hate talking about this because it may upset you, but federal law requires her to sign this and there
is nothing we can do.
C. We make sure our clients know they have the right to specify advance directives and
appoint someone to speak for them.
D. Hospital policy requires us to have your wife sign this. It doesnt mean we think anything will go
wrong.
A 49-year-old client with acute respiratory distress watches everything the staff does and demands full
explanations of all procedures and medications. Which of the following actions would best indicate that the
client has achieved an increased level of psychological comfort?
A. Making decreased eye contact
C. Joking about the present condition
B. Asking to see family members
D. Sleeping undisturbed for 3 hours
The Client Self-Determination Act of 1990 requires all hospitals to inform clients of advance directives. What
should the nurse tell the client about such advance directives as living wills and health care power of
attorney?
A. They guide the clients treatment in certain health care situations.
B. They cant provide do-not-resuscitate (DNR) orders for clients with terminal illnesses.
C. They allow physicians to make decisions about treatment.
D. They permit physicians to give verbal DNR orders.
The nurse is preparing a client for chemotherapy to treat colon cancer. The client says, I dont know about
this treatment. After everything is said and done, it may not do a bit of good. This thing may get me anyway.
Which response by the nurse would be most therapeutic?
A. Youre wondering whether youve made the right decision about treatment.
B. Many people beat cancer. You need to keep a positive attitude.
C. Colon cancer can now be cured in many cases. Lets hope youll be one of your lucky ones.
D. Everyone with cancer worries, but you have every reason to be hopeful.
A client in her first postpartum month has developed mastitis secondary to breast-feeding. Her nurse, a
mother who developed and recovered from mastitis after her third child, says, I remember the discomfort I
had and how quickly it resolved when I began getting treatment. The therapeutic communication being used
by the nurse is:
A. Clarification
C. Restating
B. Reflection
D. Self-disclosure
The nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive
development?
A. Has perceptions based on reality
D. Has maximum ability to solve problems
B. Assumes responsibility for actions
and learn new skills
C. Generates new levels of awareness
Which of the following factors would have the most influence on the outcome of a crisis situation?
A. Age
C. Self-esteem
B. Previous coping skills
D. Perception of the problem
The nurse is caring for a young adult with hepatitis A. The client is crying and saying that she hates the way
she looks with yellow skin. Which of the following would be the nurses best response?
A. Ill leave you alone for awhile until you feel better.
B. Dont cry, it doesnt look as bad as you think.
C. Try covering your face with a little make-up; it will hardly be noticeable.
D. I know youre upset; your skin will return to its normal color as you get well.
Two days after undergoing a modified radical mastectomy, a client tells the nurse, Now I wont be sexually
attractive to my husband. Based on this statement, which nursing diagnosis is most appropriate?
A. Anxiety
C. Ineffective sexuality patterns
B. Disturbed body image
D. Ineffective individual coping
Which of the following strategies should the nurse use to help assess a clients orientation?
A. Ask the clients name and city of residence and the time of the day.
B. Ask the client to repeat a series of three digits spoken slowly.
C. Point to common objects and ask the client to name them.
D. Use the Glasgow Coma Scale and compute the score.
As the nurse helps a client to the bathroom, the client says, When you get to the point where you cant even
go to the bathroom by yourself, you might as well be dead. Which response by the nurse would be most
therapeutic?
A. Keep your chin up. Things will look better tomorrow.
B. Youre making great progress. A week ago, you couldnt even get out of bed.
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C. Why are you feeling so down today? This isnt like you.
D. You sound really discouraged today.
The nurse walks into the room of a client who has had surgery for testicular cancer. The client says that hell
be undesirable to his wife and becomes tearful. He expresses that hes been spoiled by a happy, satisfying
sex life with his wife and says he thinks it might be best if he would just die. Based on these signs and
symptoms, which nursing diagnosis would be most appropriate for planning purposes?
A. Risk for situational low self-esteem
C. Social isolation
B. Unilateral neglect
D. Risk for loneliness
The nurse writes the following note in the clients chart: The physician is incompetent because he ordered
the wrong drug dosage. This statement may lead to a charge of:
A. Assault
C. Battery
B. Slander
D. Libel
Before preparing a client for surgery, the nurse assists in developing a teaching plan. What is the primary
purpose of preoperative teaching?
A. To determine whether the client is psychologically ready for surgery
B. To express concerns to the client about surgery
C. To reduce the risk of postoperative complications
D. To explain the risks and obtain informed consent
A client says to the nurse I know that Im going to die. Which of the following responses by the nurse would
be best?
A. We have special equipment to monitor you and your problem.
B. Dont worry we know what were doing and you arent going to die.
C. Why do you think youre going to die?
D. Oh no, youre doing quite well considering your condition.
Which of the following changes is demonstrated when a nurse helps a young mother adjust to the birth of
her child?
A. Unplanned
C. Maturational
B. Situational
D. Physiologic
A client in the intensive care unit has a nursing diagnosis of Social isolation. Which action should the nurse
include in the plan of care?
A. Prohibiting personal belongings at the bedside.
B. Involving the family and client in planning care.
C. Providing detailed explanations of conditions and treatment.
D. Allowing the family to visit only when the client asks to see them.
A 40 year old client is admitted for treatment of a breast tumor. She asks the nurse, Do you think I have
cancer? Which response by the nurse would be most therapeutic?
A. Your physician can tell you more about it.
B. Most women your age have some kind of breast problem.
C. We wont know for sure until you undergo some tests.
D. You sound concerned about what the physician will tell you.
A client scheduled for cardiac catheterization tells the nurse she is nervous because she has heard of
people dying during this procedure. Which response by the nurse would be best?
A. I dont blame you for being nervous. We all worry sometimes.
B. Dont worry. Youre in excellent hands.
C. Why do you feel this way? Do you know someone who had a problem?
D. You sound really upset. Would you like to talk about it?
An obese client is admitted to the facility for abusing amphetamines in an attempt to lose weight. Which
nursing intervention is appropriate for this client?
A. Encouraging the client to suppress his feelings regarding obesity.
B. Reinforcing the clients concerns over physical appearance
C. Using an abrupt, forceful manner to communicate with the client
D. Teaching the client alternative ways to lose weight
The nurse is assessing an adults developmental stage. The nurse should consider:
A. Height and weight
C. Previous problem-solving strategies.
B. Blood pressure
D. Pulse rate
A client with terminal illness has just been informed of his diagnosis. Indicators of the first stage of grieving
include which of the following?
A. Shock and dismay
C. Stoicism
B. Numbness
D. Preparatory grief
A client with an infected abdominal wound must be placed in strict isolation for 10 days. To help meet the
clients emotional needs, what should the nurse do?
A. Tell the client that family members and significant others cant visit but may telephone at any time.
B. Gently explain that the clients movements must be limited while in the isolation room.
C. Describe the reasons for isolation and how its carried out, and provide reassurance.
D. Tell the client to bring whatever personal items are desired into the isolation unit.
The nurse is caring for a client on a regimen of four medications to treat tuberculosis. The nurse discovers
that the client is taking all of his medications. What is appropriate for the nurse to say to the client?
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A. Dont you realize that resistance can develop if you dont take your medications properly?
B. You need to take your medications as you were instructed. Do you need supervision?
C. Why arent you taking your medications? Dont you want to get better?
D. Taking many medications can be difficult. Tell me about the difficulties youre having.
Upon entering a clients room, the client frowns and states, Ive had my damn light on for 20 minutes. Its
about time you got here. Im sick of this place and the staff. The nurses best response would be:
A. My name is Mary and Im your nurse for today.
B. Im sorry; I was busy with another client.
C. You seem upset this morning.
D. Youve had your light on for 20 minutes?
A client, age 68, admitted for the treatment of colon tumor, asks the nurse, Do I have cancer? Which
response by the nurse would be best?
A. Most people your age develop some type of colon problem.
B. Your physician can discuss this in more detail.
C. You sound concerned about what is happening.
D. Youll have to have some tests before cancer can be ruled out.
A female client who recently had a colostomy expresses concerns about her sexual relationship with her
husband. Which of the following interventions should the nurse implement?
A. Discuss the clients concern with the husband.
B. Refer the client to a psychiatrist.
C. Invite a client with similar experience to speak with the client.
D. Refer the client to a sex therapist
For a client with sleep pattern disturbance, the nurse could use which of the following measures to promote
sleep?
A. Play soft or soothing music.
B. Encourage less activity during the day.
C. Provide a cup of coffee and snack in the evening.
D. Increase the clients activity 2 hours before bedtime.
Six months after undergoing a radical modified mastectomy to treat breast cancer, a client is admitted for
chemotherapy. When the nurse enters the clients room, the client is sobbing and states, I thought the
chemotherapy would help, but now I feel worse. Which response by the nurse would be most therapeutic?
A. Ill bring you a sedative to calm you down.
B. Ill sit here with you for a while. Would it help you to talk about it?
C. Dont worry. Im sure everything will be ok if you just give it time.
D. You probably should have had surgery sooner so the tumor could have been caught earlier.
A client with newly diagnosed breast cancer asks the nurse, Why me? Ive always been a good person.
What have I done to deserve this? Which response by the nurse would be most therapeutic?
A. Dont worry. Youll probably live longer than I will.
B. Im sure a cure will be found soon.
C. You seem upset. Lets talk about something happy.
D. Would you like to talk about this?
A client is admitted with fatigue, anorexia, weight loss, and inability to sleep, which started 1 month after the
death of the clients spouse. Which nursing diagnosis is most appropriate for this client?
A. Activity intolerance
C. Ineffective role performance
B. Dysfunctional grieving
D. Impaired physical mobility
A home care nurse is assessing a geriatric client. What is the most common cause of medication errors in
noninstitutionalized geriatric clients?
A. Knowledge deficit
C. Dementia
B. Poor vision
D. Confusion
Which I.M. injection site is appropriate for a 6-month-old infant?
A. Vastus lateralis muscle
C. Deltoid muscle
B. Ventrogluteal area
D. Gluteus maximus muscle
The nurse is monitoring the effectiveness of clients drug therapy. When should the nurse obtain a blood
sample to measure the trough drug level?
A. 1 hour before administering the next dose
B. Immediately before administering the next dose
C. Immediately after administering the next dose
D. 30 minutes after administering the next dose
The physician prescribes 250mg of a drug. The drug vial reads 500mg/ml. How much of drug should the
nurse give?
A. 2ml
B. 1ml
C. ml
D. ml
The nurse is preparing to discharge a child who has rheumatic fever. Which of the following medications is
prescribed to prevent recurrence of rheumatic fever?
A. Glucocorticoid
C. Antibiotics
B. Digoxin
D. Anti-inflammatory medications
E.
F.
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G.
88. When assessing a clients I.V. insertion site, the nurses notes normal color and temperature at the site and no
swelling. However, the IV solutions havent infused at the ordered rate; the flow rate is slow even with the roller
clamp wide open. When the nurse lowers the I.V. fluid bag, no blood returns to the tubing. What should the nurse
do first?
A.
Discontinue the I.V. infusion at the site and restart in the other arm.
B.
Irrigate the I.V. tubing with 1 ml of normal saline solution.
C.
Check the tubing for kinks and reposition the clients wrist and elbow.
D.
Elevate the I.V. fluid bag.
89. The nurse is to administer an I.M. injection into a clients vastus lateralis muscle. How should the nurse position
the client?
A.
Lying supine
C. Lying on the left side
B.
Lying on the stomach
D. Lying on the right side
90. The nurse is developing a teaching plan for a client who has just been diagnosed with breast cancer. The nurse
should include information about which medication?
A.
Acetaminophen (Tylenol)
C.
Tamoxifen (Nolvadex)
B.
Dopamine (Intropin)
D.
Progesterone (Gesterol 50)
91. The client is to receive an I.V. infusion of 3, 000 ml of dextrose and normal saline solution over 24 hours. The
nurse observes that the rate is 150 ml/hour. If the solution runs continuously at this rate, the infusion will be
completed in:
A. 12 hours
C. 24 hours
B. 20 hours
D. 50 hours
92. Which type of medication order might read Vitamin K 10mg I.M. daily x 3 days?
A. Single order
C. Standing order
B. Stat order
D. Standard written order
93. A client comes to the emergency department complaining of a fast and irregular heartbeat. After examining the
client, the physician gives a verbal order for digoxin (Lanoxin), 1mg I.V. in four divided doses over the next 24
hours, starting with the first dose stat. How should the nurse respond to this order?
A. Write and sign the order as dictated, and then repeat it aloud for the physicians verification.
B. Verbally repeat the order to the physician for verification.
C. Insist that the physician write the order, and then administer the drug.
D. Refuse to carry out the order.
94. The nurse administers racemic epinephrine to an 8-year-old boy. Ten minutes after administration, the nurse
should be alert for:
A.
Respiratory distress.
C.
Signs of improved oxygenation.
B.
Profound tachycardia.
D.
Diminished cyanosis.
95. Which detail of a clients drug therapy is the nurse legally responsible for documenting?
A.
Peak concentration time of the drug.
C.
Clients socioeconomic data
B.
Safe ranges of the drug.
D.
Clients reaction to the drug
96. Which statement about concurrent administration of piperacillin-tazobactam and gentamicin is correct?
A. These drugs should be mixed and given together via continuous I.V. infusion to promote bacteria cell
penetration.
B. The doses should be separated by at least 1 hour to prevent inactivation of gentamicin.
C. These drugs should be administered at the same time via I.V. bolus for maximum effectiveness.
D. These drugs should be separated by at least 15 minutes to prevent inactivation of piperacillin.
97. The nurse has an order to administer iron dextran, 50 mg I.M. injection. When carrying out this order, the nurse
should:
A.
Insert the needle at a 45-degree angle
C.
Pull the skin literally toward the injection site.
B.
Wipe the needle immediately after injection
D.
Use the Z-track technique
98. The nurse is teaching a client how to rotate insulin injection sites. What is the purpose of rotating injection sites?
A.
To prevent bruising
C.
To prevent erratic drug distribution.
B.
To prevent medication leakage from the tissue
D.
To prevent the distribution of hard nodules.
or muscle.

16

99. When preparing to give a client a prescribed drug, the nurse realizes that the drug is one the nurse
administered has never administered before. No drug references on the nursing unit contain
information about the drug in question. What should the nurse do?
A. Contact a pharmacist to obtain information about the drug.
B. Consult the physician for information about the drug.
C. Ask other nurses on the unit for information about the drug.
D. Refuse to give the drug because no written information exists.
100.
101.
A client to be discharged on daily medication delivered by a transdermal disk. Which statement
indicates the need for further medication teaching?
A. Ill place the disk on the same spot each day.
B. Ill wash my hands after applying the disk.
C. Ill change the disk at the same time every day.
102. Ill avoid touching the gel in the disk.