Question Number 1 of 25

A client is waiting to have an intravenous pyelogram (IVP). The most important information to
be obtained by the nurse prior to the procedure is

A) time of the client's last meal

B) client's allergy history
C) assessment of the peripheral pulses
D) results of the blood coagulation studies

The correct answer is B: client''s allergy history

Intravenous Pyelogram is a dye study that uses an iodine-based contract. Therefore, the study
is contraindicated in clients with allergy to iodine. Cavanaugh, B.M. (2003). Nurses manual of
laboratory and diagnostic tests, 4th ed. Philadelphia: F.A. Davis. Schnell, Z.B., Van Leeuwen,
A.M., Kranpitz, T.R. (2003). Comprehensive handbook of laboratory and diagnostic tests with
nursing implications. Philadelphia: F.A. Davis.

Question Number 2 of 25
The nurse is caring for a client several days following a cerebral vascular accident. Coumadin
(warfarin) has been prescribed. Today's prothrombin level is 40 seconds (normal range 10-14
seconds). Which of the following findings requires priority follow-up?

A) Gum bleeding
B) Lung sounds
C) Homan's sign
D) Generalized weakness

The correct answer is A: Gum bleeding

The prothrombin time is elevated, indicating a high risk for bleeding. Neurological assessments
remain important for post-CVA clients. Deglin, J.D. and Vallerand, A.H. (2001). Davis drug
guide for nurses. (7th edition). Philadelphia: F.A. Davis Company. Wilson, B.A., Shannon, M.T.,
and Stang, C.L. (2004). Nurses drug guide. Upper Saddle River, New Jersey: Pearson Prentice
Hall.

Question Number 3 of 25
A client with a fracture of the radius had a plaster cast applied 2 days ago. The client
complains of constant pain and swelling of the fingers. The first action of the nurse should be

A) elevate the arm no higher than heart level

B) remove the cast
C) assess capillary refill of the exposed hand and fingers
D) apply a warm soak to the hand

The correct answer is C: assess capillary refill of the exposed hand and fingers
A deterioration in neurovascular status indicates the development of compartment syndrome
(elevated tissue pressure within a confined area) which requires immediate pressure-reducing
interventions. Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins. Lewis, S.M., Heitkemper, M.M., & Dirksen, S.
R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis:
Mosby.

Question Number 4 of 25
The nurse performs an assessment during a fluid exchange for the client who is 48 hours post-
insertion of an abdominal Tenckhoff catheter for peritoneal dialysis. The nurse knows that the
appearance of which of the following needs to be reported to the provider immediately?

A) slight pink-tinged drainage

B) abdominal discomfort
C) muscle weakness
D) cloudy drainage

The correct answer is D: cloudy drainage

Cloudy drainage is a sign of infection that can lead to peritonitis (inflammation of the
peritoneum). The other options are expected side effects of peritoneal dialysis. Altman, G.
(2004). Delmars Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.
Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric,
Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

Question Number 5 of 25
The nurse is caring for a pregnant woman with pregnancy induced hypertension (PIH) receiving
magnesium sulfate intravenously. In assessing the client, it is noted that respirations are 12,
pulse and blood pressure have dropped significantly, and 8 hour output is 200 ml. What should
the nurse do first?

A) Administer calcium gluconate

B) Call the provider immediately
C) Discontinue the magnesium sulfate
D) Perform additional assessments

The correct answer is C: Discontinue the magnesium sulfate

The assessments strongly suggest magnesium sulfate toxicity. The nurse must discontinue the
IV immediately and take measures to ensure the safety of the client.Deglin, J.D. and Vallerand,
A.H. (2001). Davis drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.
Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition).
Mosby: St. Louis, Missouri.

Question Number 6 of 25
Before administering a feeding through a gastrostomy tube, what is the priority nursing
assessment?
 A) Measure the vital signs
B) Palpate the abdomen
C) Assess for breath sounds
D) Verify tube patency

The correct answer is D: Verify tube patency

Tube patency should be checked prior to all feedings. The feeding should not be attempted if
the tube is not patent. Altman, G. (2004). Delmars Fundamental and Advanced Nursing Skills,
2nd ed. Albany, NY: Delmar. Delaune, S & Lander, P. (2002). Fundamentals in Nursing:
Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Question Number 7 of 25
A client has been on antibiotics for 72 hours for cystitis. Which report from the client requires
priority attention by the nurse?
A) foul smelling urine
B) burning on urination
C) elevated temperature
D) nausea and anorexia

The correct answer is C: elevated temperature

Elevated temperature after 72 hours on an antibiotic indicates the antibiotic has not been
effective in eradicating the offending organism. The provider should be informed immediately
so that an appropriate medication can be prescribed, and complications such as pyelonephritis
are prevented. Options A and B are expected with cystitis. Option D may be related to the
antibiotics as a side effect and should also be reported to the provider. Altman, G. (2004).
Delmars Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar. Swearingen,
P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and
Psychiatric Nursing Care Plans. St. Louis: Mosby.

Question Number 8 of 25
The nurse is caring for a client with a vascular access for hemodialysis. Which of these findings
necessitates immediate action by the nurse?
A) pruritic rash
B) dry, hacking cough
C) chronic fatigue
D) elevated temperature

The correct answer is D: elevated temperature

It is a priority to report this finding since clients on hemodialysis are prone to infection, and
the first sign is an elevated temperature. The other findings should be reported to the provider
as well. Altman, G. (2004). Delmars Fundamental and Advanced Nursing Skills, 2nd ed. Albany,
NY: Delmar. Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical,
Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.
Question Number 9 of 25
A client is placed on sulfamethoxazole-trimethoprim (Bactrim) for a recurrent urinary tract
infection. Which of the following is appropriate reinforcement of information by the nurse?
A) "Drink at least 8 glasses of water a day."
B) "Be sure to take the medication with food."
C) "It is safe to take with oral contraceptives."
D) "Stop the medication after 5 days."

The correct answer is A: "Drink at least 8 glasses of water a day."

Bactrim is a highly insoluble drug and requires a large volume of fluid intake. It is not necessary
to take it with food. Options C and D are incorrect instructions for those taking Bactrim.
Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurses drug guide. Upper Saddle River,
New Jersey: Pearson Prentice Hall. Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing
process approach. (4th edition). Philadelphia: Saunders.

Question Number 10 of 25
The nurse is caring for a client with a chest tube. On the second postoperative day, the chest
tube accidentally disconnects from the drainage tube. The first action the nurse should take is

A) reconnect the tube

B) raise the collection chamber above the client's chest
C) call the health care provider
D) clamp the chest tube

The correct answer is D: clamp the chest tube

Immediate steps should be taken to prevent air from entering the chest cavity. Lung collapse
may occur if air enters the chest cavity. Clamping the tube close to the clients chest is the
first action to take, followed by health care provider notification. Smeltzer, S.C. and Bare,
B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams &
Wilkins. Altman, G. (2004). Delmars Fundamental and Advanced Nursing Skills, 2nd ed. Albany,
NY: Delmar.

Question Number 11 of 25
The nurse is caring for a client on complete bed rest. Which action by the nurse is most
important in preventing the formation of deep vein thrombosis?

A) Elevate the foot of the bed

B) Apply knee high support stockings
C) Encourage passive exercises
D) Prevent pressure at back of knees

The correct answer is D: Prevent pressure at back of knees

Preventing popliteal pressure will prevent venous stasis and possibly deep vein thrombosis.
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed).
Clinton Park, New York: Delmar. Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing.
(10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Question Number 12 of 25
When caring for a client with urinary incontinence, which content should be reinforced by the
nurse?
A) hold the urine to increase bladder capacity
B) avoid eating foods high in sodium
C) restrict fluid to prevent elimination accidents
D) avoid taking antihistamines

The correct answer is D: avoid taking antihistamines

Antihistamines can aggravate urinary incontinence and should be avoided by these clients.
Holding the urine, avoiding sodium, and restricting fluids have not been shown to reduce
urinary incontinence. Altman, G. (2004). Delmars Fundamental and Advanced Nursing Skills,
2nd ed. Albany, NY: Delmar. Swearingen, P. (2004). All-in-One Care Planning Resource:
Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

QueStion Number 13 of 25
The nurse is caring for a client who is receiving total parenteral nutrition (TPN)
(hyperalimentation and lipids). What is the priority nursing action on every 8 hour shift?

A) Monitor blood pressure, temperature and weight

B) Change the tubing under sterile conditions
C) Check urine glucose, acetone and specific gravity
D) Adjust the infusion rate to provide for total volume

The correct answer is C: Check urine glucose, acetone and specific gravity
Because of the high dextrose and protein content in parenteral nutrition, the nurse should
assess the urine at least every 8 hours. Delaune, S & Lander, P. (2002). Fundamentals in
Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar. Lutz, C.A. and
Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis
Company.

Question Number 14 of 25
The nurse reviews an order to administer Rh (D) immune globulin to an Rh negative woman
following the birth of an Rh positive baby. Which assessment is a priority before the nurse
gives the injection?

A) Newborn's blood type

B) Coombs' test results
C) Previous RhoGAM history
D) Gravida and parity
The correct answer is B: Coombs'' test results
Rh (D) immune globulin (RhoGAM) is given only if antibody formation has not occurred. A
negative Coombs'' test confirms this. Deglin, J.D. and Vallerand, A.H. (2001). Davis drug guide
for nurses. (7th edition). Philadelphia: F.A. Davis Company. Tierney, L.M., McPhee, S.J., and
Papadakis, M.A. (2004). Current medical Diagnosis and Treatment. (43rd edition). USA:McGraw-
Hill.

Question Number 15 of 25
The registered nurse (RN) is making decisions regarding client room assignments on a pediatric
unit. Which possible roommate would be most appropriate for a 3 year-old child with minimal
change nephrotic syndrome?
A) 2 year-old with respiratory infection
B) 3 year-old fracture whose sibling has chickenpox
C) 4 year-old with bilateral inguinal hernia repair
D) 6 year-old with a sickle cell anemia crisis

The correct answer is C: 4 year-old with bilateral inguinal hernia repair

The nurse must know that children with nephrotic syndrome are at high risk for development of
infections as a result of the standard use of immunosuppressant therapy, as well as from the
accumulation of fluid (edema). Therefore, these children must be protected from sources of
possible infection. D is incorrect because the sickle cell crisis is potentially due to an infectious
process. Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wongs Nursing
Care of Infants and Children, (7th ed). St. Louis: Mosby. Ball, J. & Bindler, R. (2003). Pediatric
Nursing. Upper Saddle River, N.J.: Pearson Education.

Question Number 16 of 25
A client returns from the operating room after a right orchiectomy. For the immediate post-
operative period the nursing priority would be to

A) maintain fluid and electrolyte balance

B) manage post-operative pain
C) ambulate the client within 1 hour of surgery
D) control bladder spasms

The correct answer is B: manage post-operative pain

Due to the location of the incision, pain management is the priority. Bladder spasms are more
related to prostate surgery. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-
Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby. Smeltzer,
S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA.
Lippincott Williams & Wilkins.

Question Number 17 of 25
A client is 2 days post operative. The vital signs are: BP - 120/70, HR -- 110 BPM, RR - 26, and
Temperature - 100.4 degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes
profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse
first to the client's change in condition?
 A) Heart rate
B) Respiratory rate
C) Blood pressure
D) Temperature

The correct answer is B: Respiratory rate

Tachypnea is one of the first clues that the client is not oxygenating appropriately. The
compensatory mechanism for decreased oxygenation is increased respiratory rate. Lewis, S.M.,
Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment &
management of clinical problems. St. Louis: Mosby. Swearingen, P. (2004). All-in-One Care
Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans.
St. Louis: Mosby.

Question Number 18 of 25
A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse question
first?

A) Repeat glycohemoglobin in 24 hours

B) Document Accu-checks, intake and output every 4 hours
C) Humulin N 20 units IV push
D) IV fluids of 0.9% normal saline at 125 ml per hour

The correct answer is C: Humulin N 20 units IV push

Regular insulin is the only insulin that can be given by the intravenous route. This is the initial
order to question. Option A should also be questioned, although it is not a priority since the
client would not be harmed by this action. This lab test gives the average glucose on the
hemoglobin molecule for the past 2 to 3 months. There would be no need to repeat it at this
time. A fasting glucose in the morning would be a more appropriate assessment. The other
orders are within expected actions in this situation. White, L., and Duncan, G,. (2002).
Medical-Surgical Nursing An Integrated Approach (2nd ed.). Australia: Delmar. Ignatavicius, D.,
and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th
ed.). Philadelphia: Saunders.

Question Number 19 of 25
What must the nurse emphasize when teaching a client with depression about a new
prescription for nortriptyline (Pamelor)?

A) Symptom relief occurs in a few days

B) Alcohol use is to be avoided
C) Medication must be stored in the refrigerator
D) Episodes of diarrhea can be expected

The correct answer is B: Alcohol use is to be avoided

Alcohol potentiates the action of tricyclic antidepressants. Deglin, J.D. and Vallerand, A.H.
(2001). Davis drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company. Key, J.L.
and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia:
Saunders.

Question Number 20 of 25
A client calls the evening health clinic to state I know I have a severely low sugar since the
Lantus insulin was given 3 hours ago and it peaks in 2 hours. What should be the nurses initial
response to the client?
A) What else do you know about this type of insulin?
B) What are you feeling at this moment?
C) Have you eaten anything today?
D) Are you taking any other insulin or medication?

The correct answer is B: What are you feeling at this moment?

When a client has changed from stable to unstable, the nurses initial response should be to do
further assessment of the client. White, L., and Duncan, G,. (2002). Medical-Surgical Nursing
An Integrated Approach (2nd ed.). Australia: Delmar. Wilson, B.A., Shannon, M.T., and Stang,
C.L. (2004). Nurses drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

Question Number 21 of 25
A client arrives in the emergency department after a radiologic accident at a local factory. The
first action of the nurse would be to
A) begin decontamination procedures for the client
B) ensure physiologic stability of the client
C) wrap the client in blankets to minimize staff contamination
D) double bag the clients contaminated clothing

The correct answer is B: ensure physiologic stability of the client

The nurse must initially assist in stabilizing the patient prior to performing the other tasks
related to radiologic contamination. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004).
Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.
Veenema, T. & Karam, A. (2003). Radiation: Clinical responses to radiologic incidents and
emergencies. American Journal of Nursing, 103 (5), 32-40.

Question Number 22 of 25
If a very active two year-old client pulls his tunneled central venous catheter out, what initial
nursing action is appropriate?

A) Obtain emergency equipment

B) Assess heart rate, rhythm and all pulses
C) Apply pressure to the vessel insertion site
D) Use cold packs at the exit incision site

The correct answer is C: Apply pressure to the vessel insertion site

If a central venous catheter is accidentally removed, pressure should be applied to the vein
entry site. Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd
edition). Mosby: St. Louis, Missouri. Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing,
caring for children and their families. USA: Thompson, Delmar, Learning.

Question Number 23 of 25
The nurse must know that the most accurate oxygen delivery system available is

A) the Venturi mask

B) nasal cannula
C) partial non-rebreather mask
D) simple face mask

The correct answer is A: the Venturi mask

The most accurate way to deliver oxygen to the client is through a Venturi system such as the
Venti Mask. The Venti Mask is a high flow device that entrains room air into a reservoir device
on the mask and mixes the room air with 100% oxygen. The size of the opening to the reservoir
determines the concentration of oxygen. The clients respiratory rate and respiratory pattern
do not affect the concentration of oxygen delivered. The maximum amount of oxygen that can
be delivered by this system is 55%. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004).
Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis:
Mosby.Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
hiladelphia, PA. Lippincott Williams & Wilkins.

Question Number 24 of 25
The nurse is caring for a school-aged child with a diagnosis of secondary hyperparathyroidism
following treatment for chronic renal disease. Which of the following lab data should receive
priority attention?
A) Calcium and phosphorus levels
B) Blood sugar
C) Urine specific gravity
D) Blood urea nitrogen

The correct answer is A: Calcium and phosphorus levels

Calcium and phosphorous levels will be elevated until the client is stabilized. Hockenberry,
M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wongs Nursing Care of Infants and
Children, (7th ed). St. Louis: Mosby. Daniels, R. (2003). Delmars manual of laboratory and
diagnostic tests. USA: Thompson Delmar Learning.

Question Number 25 of 25
The nurse assesses several post partum women in the clinic. Which of the following women is
at highest risk for puerperal infection?

A) 12 hours post partum, temperature of 100.4 degrees Fahrenheit since delivery

B) 2 days post partum, temperature of 101.2 degrees Fahrenheit this morning
C) 3 days post partum, temperature of 100.8 degrees Fahrenheit the past 2 days
D) 4 days post partum, temperature of 100 degrees Fahrenheit since delivery
The correct answer is C: 3 days post partum, temperature of 100.8 degrees Fahrenheit the past
2 days
A temperature of 100.4 degrees Fahrenheit or higher on 2 successive days, not counting the
first 24 hours after birth, indicates a post partum infection. Wong, D.L., Perry, S.E., &
Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed).
Clinton Park, New York: Delmar.