HAAD/DHA/Prometric
Final Exam
Fundamentals of Care
1. The nurse walks into the room of a client who has
had surgery for testicular cancer The client says that
he’ll be undesirable to his wife and becomes tearful
He expresses that he’s 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
b. Unilateral neglect
c. Social isolation
d. Risk for loneliness
2. When auscultating a client’s abdomen, the nurse
detects high-pitched gurgles over the lower right
quadrant. Based on this finding, the nurse suspects:
a. decreased bowel motility.
b. increased bowel motility.
c. nothing abnormal.
d. abdominal cramping.
3. To help assess a client’s cerebral function, the nurse
should ask:
a. “Have you noticed 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?”
4. To evaluate a client’s posterior tibial pulse. Where
should the nurse palpate?
a. Medially in the antecubital space
b. Midway between the superior iliac spine and
symphysis pubis
c. On the inner aspect of the ankle, below the medial
malleolus
d. Along the top of the foot, over the instep
5. The nurse plans to obtain client information from a
primary source. Which is a primary information
source?
a. A family member
b. The physician
c. The client
d. Previous medical records
6. A nurse is assisting a physician with the insertion of
a subclavian central line After the physician has gained
access to the subclavian vein, he connects a 10-ml
syringe to the catheter and withdraws a sample of
blood He then disconnects the syringe from the port.
Suddenly. the client becomes confused, disoriented,
and pale The nurse suspects an air embolus The
appropriate response from the nurse should be to:
a. lie the client supine and prepare for
cardiopulmonary resuscitation
b. place the client in high-Fowlers position and give
supplemental oxygen.
c. turn the client on his left side and place the bed in
Trendelenburg’s position
d. position the client in the shock position with his legs
elevated
7. On admission, a client has the following arterial
blood gas (ABG) values: Pao2. 50 mm Hg: Paco2. 70
mm Hg: pH. 7.20: HC03. 28 mEq/L. Based on these
values, the nurse should formulate which nursing
diagnosis for this client?
a. Risk for deficient fluid volume
b. Deficient fluid volume
c. Impaired gas exchange
d. Metabolic acidosis
8. A client with newly diagnosed breast cancer asks
the nurse, ‘Why me? I’ve always been a good person.
What have I done to deserve this?’ Which response by
the nurse would be most therapeutic?
a. “Don’t worry. You’ll probably live longer than I wilL”
b. “rm sure a cure will be found soon”
c. “You seem upset. Let’s talk about something happy”
d. ‘Would you like to talk about this?”
9. A client complains of severe abdominal pain To elicit
as much information as possible about the pain, the
nurse should ask:
a. “Do you have the pain all the time?”
b. “Can you describe the pain?”
c. “Where does it hurt the most?”
d. “Is the pain stabbing like a knife?”
10. A client is being discharged after cataract surgery
After providing medication teaching. the nurse asks
the client to repeat the instructions- The nurse is
performing which professional role?
a. Manager
b. Educator
c. Caregiver
d. Client advocate
11. A client with a deficient fluid volume is receiving
an I.V. infusion of dextrose 5% in water and lactated
Ringer’s solution at 125 mL/hour. Which assessment
finding indicates the need for additional I.V. fluids?
a. Serum sodium level of 135 mEq/L
b. Temperature of 99.6° F (37.6° C)
c. Neck vein distention
d. Dark amber urine
12. The nurse is performing a preoperative
assessment- Which statement by the client would
alert the nurse to the presence of risk factors for
postoperative complications?
a. “I haven’t been able to eat anything solid for the
past 2 days”
b. “rye never had surgery before”
c. “I had an operation 2 years ago, and I don’t want to
have another one”
d. “I’ve cut my smoking down from two packs to one
pack a day”
13. All of the following components may be part of a
client’s medical record. Which one is the major source
of subjective data about the client’s health status?
a. Health history
b. Physical findings
c. Laboratory test results
d. Radiologic findings
14. While performing rounds, a nurse finds that a
client is receiving the wrong LV. solution The nurse’s
initial response should be to:
a. remove the LV. catheter and call the physician.
b. write up an incident report describing the mistake
c. slow the LV. flow rate and hang the appropriate
solution
d. wait until the next bottle is due and then change to
the proper solutions
15. A client who received general anesthesia returns
from surgery Post operatively, which nursing diagnosis
takes highest priority for this client?
a. Acute pain related to surgery
b. Deficient fluid volume related to blood and fluid loss
from surgery
c. Impaired physical mobility related to surgery
d. Ineffective airway clearance related to anesthesia
16. A nurse is caring for a client with a diagnosis of
Impaired gas exchange. Which outcome is most
appropriate based upon this nursing diagnosis?
a. The client maintains a reduced cough effort to
lessen fatigue.
b. The client restricts fluid intake to prevent over
hydration.
c. The client reduces daily activities to a minimum.
d. The client has normal breath sounds in all lung
fields.
17. Shortly after being admitted to the coronary care
unit with an acute myocardial infarction (Ml). a client
reports midsternal chest pain radiating down the left
arm The nurse notes that the client is restless and
slightly diaphoretic. and measures a temperature of
99.6° F (37.6° C); a heart rate of 102 beats/minute
regular, slightly labored respirations at 26
breaths/minute: and a blood pressure of 150/90
mmHg. Which nursing diagnosis takes highest priority?
a. Risk for imbalanced body temperature
b. Decreased cardiac output
c. Anxiety
d. Acute pain
18. The physician orders an l.V. infusion at 125
mI/hour for a client. To determine the I.V. drip rate,
the nurse must know the drip factor, which is:
a. the number of milliliters in one drop.
b. the number of drops in one milliliter.
c. the number of drops per minute to be infused.
d. the number of drops per hour to be infused.
RA11ONALES: The drip factor is the number of drops
in one milliliter, not the number of milliliters in one
drop. The drip rate refers to the number of drops
infused per minute. The flow rate is the number of
milliliters, not the number of drops infused per hour.
19. The physician orders morphine. 4 mg I.V. every
hour as needed to relieve a client’s pain The nurse
knows that morphine belongs to which schedule of
opioids?
a. Schedule I
b. Schedule II
c. Schedule Ill
d. Schedule IV
20. The nurse is preparing to administer a sustained-
release tablet to a client. Which statement about
sustained-release tablets is true?
a. They should never be split, crushed, or chewed
b. They should never be split or crushed, but they may
be chewed
c. They should never be chewed, but they may be split
or crushed
d. They may be split, crushed, or chewed, depending
on the clients condition
Ethical and Legal Aspects in Nursing/Prioritization
and Delegation/Infection Control
21. Which member of the health care team is
responsible for obtaining informed consent from a
client?
a. The primary nurse
b. The physician
c. The nurse working with the physician
d. The physician’s assistant
22. A nurse gives a client the wrong medication. After
assessing the client, the nurse completes an incident
report. Which statement describes what will occur
next?
a. The incident will be reported to the state board of
nursing for disciplinary action
b. The incident will be documented in the nurse’s
personnel file.
c. The medication error will result in the nurse being
suspended and, possibly, terminated from
employment at the facility
d. The incident report is a method of promoting
quality care and risk management
23. The staff of an outpatient clinic has formed a task
force to develop new procedures for swift, safe
evacuation of the unit. The new procedures haven’t
been reviewed, approved, or shared with all personnel
When the nurse-manager receives word of a bomb
threat, the task force members push for evacuating
the unit using the new procedures. Which action
should the nurse-manager take?
a. Determine that the procedures currently in place
must be followed and direct staff to follow them
without question
b. Tell staff members to use whatever procedures they
feel are best
c. I ask staff members to quickly meet among
themselves and decide what procedures to follow
d. 4 Tell staff members to assemble in the staff lounge:
there the nurse-manager will quickly gather opinions
about evacuation procedures before deciding what to
do
24. 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
25. The nurse-manager in the office of a group of
surgeons has received complaints from discharged
clients about inadequate instructions for performing
home care. Knowing the importance of good, timely
client education, the nurse should take which steps?
a. Contact the nurses who work in the facility and tell
them that client education should be implemented as
soon as the clients are admitted to either the hospital
or the outpatient surgical center
b. Review and revise the way client education is
conducted in the surgeons’ office.
c. Because no serious damage was done to any of the
clients, the nurse-manager can safely ignore their
complaints
d. Work with both surgeons staff and the nursing staff
in the hospital and outpatient surgical center to
evaluate current client education practices and make
revisions as needed
26. The client’s rights to information, informed
consent, and treatment refusal are addressed in the:
a. standards of nursing practice
b. client’s bill of rights
c. nurse practice act
d. code for nurses
27. A nurse-manager has decided to delegate
responsibility for the review and revision of the
surgical unit’s client education material. Which
statement illustrates the best method of delegation?
a. Tell the nursing staff they’re responsible for the
review and revision and that their recommendations
for improving the materials are welcome
b. Ask the two best staff nurses to form a task force to
review and revise client education materials within the
next 6 weeks Have them solicit input from clients and
staff members
c. Tell the nursing staff that the client education
materials need revision Ask the staff to select people
to review the materials and make suggestions for
change.
d. Ask the assistant manager to develop a plan for the
review and revision of client education material&
28. A nurse-manager has decided to delegate
responsibility for the review and revision of the
surgical units client education materials. Which
statement illustrates the best method of delegation?
a. Tell the nursing staff they’re responsible for the
review and revision and that their recommendations
for improving the materials are welcome
b. Ask the two best staff nurses to form a task force to
review and revise client education materials within the
next 6 weeks. Have them solicit input from clients and
staff members.
c. Tell the nursing staff that the client education
materials need revisions. Ask the staff to select people
to review the materials and make suggestions for
change.
d. Ask the assistant manager to develop a plan for the
review and revision of client education materials
29. Which guidelines define and regulate the scope of
the nursing professional practice (that is. set rules on
what the nurse can and can’t do as a professional)?
a. State Legislature
b. Facilities policies and procedures
c. Standards of Care
d. Nurse Practice Act
30. A hospitalized client who has a living will is being
fed through a nasogastric (NG) tubes. 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 client’s airway.
b. Make the client comfortable
c. Start cardiopulmonary resuscitation
d. Stop the feeding and remove the NG tubes
31. A client has suffered an extensive brain injury and
can’t make his own treatment choices Which written
document is recognized by state law and provides
directions for provision of care at a time when the
client can’t make his own choices?
a. Advance directive
b. Living will
c. Durable power of attorney
d. Patient self-determination
32. Standard precautions were designed for the care
of all clients in hospitals, regardless of their diagnosis
or infection status Guidelines for standard precautions
include:
a. Immediately recapping used needles.
b. disposing of sharp instruments in an impervious
container.
c. wearing gloves only for sterile procedures
d. substituting regular eyeglasses for eye protections.
33. A mother calls a neighbor who is a nurse and tells
the nurse that her 3-year-old child has just ingested
liquid furniture polish. The nurse would direct the
mother immediately to:
a. Induce vomiting.
b. Call an ambulance.
c. Call the Poison Control Center.
d. Bring the child to the emergency department.
34. The nurse is caring for a client experiencing
neutropenia as a result of chemotherapy and develops
a plan of care for the client. The nurse plans to:
1. Restrict all visitors.
2. Restrict fluid intake
3. Teach the dent and family about the need for hand
hygiene.
4. Insert an Indwelling urinary catheter to prevent skin
breakdown.
35. A client who is intubated and receiving mechanical
ventilation has a nursing diagnosis of Risk for infection.
The nurse should include which of the following in the
care of this client? Select all that apply
1. Monitor the client’s temperature.
2. Monitor sputum characteristics and amounts.
3. Use the closed-system method of suctioning.
4. Drain water from the ventilator tubing into the
humidifier bottle.
5. Use sterile technique when suctioning.
36. A nurse is planning the client assignments for the
shift. Which client would the nurse assign to the
nursing assistant?
a. a client requiring dressing changes
b. a client requiring frequent ambulation
c. a client on a bowel management program requiring
rectal suppositories and a daily enema
d. a client with diabetes mellitus requiring daily insulin
and reinforcement of dietary measures
37. The nursing team consists of one RN, two
LPNs/LVNs, and three nursing assistants. The RN
should care for which of the following patients?
a. A patient with a chest tube who is ambulating in the
hall.
b. A patient with a colostomy who requires assistance
with an irrigation.
c. A patient with a right-sided cerebral vascular
accident (CVA) who requires assistance with bathing.
d. A patient who is refusing medication to treat cancer
of the colon.
38. A 60-year-old man with a diagnosis of pneumonia
is being admitted to the medical/surgical unit.
The nurse should place the patient in a room with
which of the following patients?
a. A 20-year-old in traction for multiple fractures of
the left lower leg.
b. A 35-year-old with recurrent fever of unknown
origin.
c. A 50-year-old recovering alcoholic with cellulitis of
the right foot.
d. An 89-year-old with Alzheimer’s disease awaiting
nursing home placement.
39. nurse is supervising care given to clients on a
medical/surgical unit. The nurse should intervene
if which of the following is observed?
a. A nurse and client wear masks during a dressing
change for the central catheter used for total
parenteral nutrition.
b. A nurse injects insulin through a single-lumen
percutaneous central catheter for client receiving
total parenteral nutrition.
c. A nurse applies lip balm to his/her lips immediately
after performing a blood draw to obtain a specimen.
d. A nurse wears a disposable particulate respirator
when administering rifampin to a client with
tuberculosis.
40. The nurse is assigned a team with another
registered nurse and an LPN. Which of the following
patients should the nurse assign to the LPN?
a. A 67-year-old man who is NPO and scheduled for a
transurethral resection of the prostate (TURP) in 3
hours.
b. A 53-year-old woman with an IV of 0.9% NaCl at 100
cc/hr who had a lumbar laminectomy two days ago.
c. A 40-year-old woman with a Hemovac drain and a
large surgical dressing from a mastectomy 2 days ago
who is showing signs of depression.
d. A 27-year-old woman scheduled for discharge later
today after receiving chemotherapy through a
portacath for treatment of leukemia.
41. A nursing team consists of an RN, an LPN/LVN, and
a nursing assistant. The nurse should assign which of
the following patients to the LPN/LVN?
a. A 72-year-old patient with diabetes who
requires a dressing change for a stasis ulcer.
b. A 55-year-old patient with terminal cancer
being transferred to hospice homecare.
c. A 42-year-old patient with cancer of the bone
complaining of pain.
d. A 23-year-old patient with a fracture of the
right leg who asks to use the urinal.
42. A nurse is reading the history and physical
examination of an older client admitted to the
hospital. Which findings documented in the history
place the client at risk for accidents? Select all that
apply.
1. Range of motion is limited.
2. PerIpheral vision is decreased.
3. No client complaints of nocturia.
4. TransmIssion of hot Impulses is delayed.
5. High-frequency hearing tones are perceptible.
6. Voluntary and autonomic reflexes are slowed.
43. Nursing staff members are sitting in the lounge
taking their morning break. A nursing assistant tells
the group that she thinks that the unit secretary has
acquired immunodeficiency syndrome (AIDS) and
proceeds to tell the nursing staff that the secretary
probably contracted the disease from her husband,
who is supposedly a drug addict. Which legal tort has
the nursing assistant violated?
a. Libel
b. Slander
c. Assault
d. Negligence
44. An 87-year-old woman is brought to the
emergency department for treatment of a fractured
arm. On physical assessment, the nurse notes old and
new ecchymotic areas on the clients chest and legs
and asks the client how the bruises were sustained.
The client, although reluctant, tells the nurse in
confidence that her son frequently hits her if supper is
not prepared on time when he arrives home from
work. Which of the following is the appropriate
nursing response?
a. “Oh, really. I will discuss this situation with your
son”
b. “This is a legal issue, and I must tell you that I will
need to report it.
c. “Let’s talk about the ways you can manage your
time to prevent this from happening.”
d. “Do you have any friends that can help you out until
you resolve these important issues with your son?”
Critical Care
45. A nurse calls the physician regarding a new
medication prescription because the dosage
prescribed is higher than the recommended dosage.
The nurse is unable to locate the physician, and the
medication is due to be administered. Which action
should the nurse implement?
a. Contact the nursing supervisor.
b, Administer the dose prescribed.
c. Hold the medication until the physician can be
contacted.
d. Administer the recommended dose until the
physician can be located.
46. The nurse is preparing to care for a bum client
scheduled for an escharotomy procedure being
performed for a third-degree circumferential arm
burn. The nurse understands that the anticipated
therapeutic outcome of the escharotomy is:
a. Return of distal pulses
b. Brisk bleeding from the site
c. Decreasing edema formation
d. Formation of granulation tissue
47. The nurse is caring for a client who suffered an
inhalation injury from a wood stove. The carbon
monoxide blood report reveals a level of 12%. Based
on this level, the nurse would anticipate which of the
following signs in the client?
a. Coma
b. Flushing
c. Dizziness
d. Tachycardia
48. A nurse is preparing to administer a dose of
naloxone hydrochlorìde (Narcan) intravenously to a
client with an intravenous opioid overdose. Which
supportive medical equipment would the nurse plan
to have at the clients bedside if needed?
a. Nasogastric tube
b. Paracentesis tray
c. Resuscitation equipment
d. Central line insertion tray
49. A client is in sinus bradycardia with a heart rate of
45 beats/min, complains of dizziness, and has a blood
pressure of 82/60 mm Hg. Which of the following
should the nurse anticipate will be prescribed?
a. Defibrillate the client.
b. Administer digoxin (Lanoxin).
c. Continue to monitor the client.
d. Prepare for transcutaneous pacing.
50. A nurse notes that a client with sinus rhythm has a
premature ventricular contraction that falls on the T
wave of the preceding beat. The client’s rhythm
suddenly changes to one with no P waves, no
definable QRS complexes, and coarse wavy lines of
varying amplitude. How would the nurse correctly
interpret this rhythm?
a. Asystole
b. Atrial fibrillation
c. Ventricular fibrillation
d. Ventricular tachycardia
51. A nurse is watching the cardiac monitor and
notices that the rhythm suddenly changes. There are
no P waves, the QRS complexes are wide, and the
ventricular rate is regular but more than loo
beats/mm. The nurse determines that the client is
experiencing which of the following dysrhythmias?
a. Sinus tachycardia
b. Ventricular fibrillation
c. Ventricular tachycardia
d. Premature ventricular contractions
52. A nurse is preparing to defibrillate a client in
ventricular fibrillation. After placing the paddles on the
client’s chest and before discharging them, which of
the following should be done?
a. Ensure that the client has been intubated.
b. Set the defibrillator to the synchronize’ mode.
c. Administer lidocaine hydrochloride (Xylocaine).
d. Confirm that the rhythm is actually ventricular
fibrillation,
53. A client in ventricular fibrillation is about to be
defibrillated. A nurse knows that to convert this
rhythm effectively, the biphasic defibrillator should be
set at which of the following energy levels (in joules.
J)?
a. 50J
b. 80J
c. 200J
d. 360J
54. A nurse would evaluate that defibrillation of a
client was most successful if which of the following
observations was made?
a. Arousable, sinus rhythm, BP 116/72mmHg
b. Arousable, marked bradycardia, BP 86154 mmHg
c, Nonarousable, supraventricular tachycardia, BP
122)60 mmHg
d. Nonarousable, sinus rhythm, BP 88/60 mmHg
55. A nurse has an order to give amiodarone
(Cordarone) intravenously to a client. During
administration of this medication, the nurse includes
monitoring which of the following as the priority
nursing action?
a. Skin color and dryness
b. Cardiac rhythm
c. Oxygen saturation level
d. Blood pressure
Obstetric Nursing
56. The nurse is teaching a postpartum client how to
perform Kegel exercises. What is the primary purpose
of these exercises?
a. To prevent urine retention
b. To relieve lower back pain
c. To strengthen the abdominal muscles
d. To strengthen the perineal muscles
57. Which of the following would the nurse expect to
assess as presumptive signs of pregnancy ?
a. Amenorrhea and quickening
b. Uterine enlargement and Chadwicks sign
c. A positive pregnancy test and a fetal outline
d. Braxton Hicks contractions and Hegar’s sign
58. Which of the following would be an inappropriate
indication of placental detachment?
a. An abrupt lengthening of the cord
b. An increase in the number of contractions
c. Relaxation of the uterus
d. Increased vaginal bleeding
57. During a prenatal visit at 20 week& gestation, a
pregnant client asks whether tests can be done to
identify fetal abnormalities. Between 18 and 40 weeks
of gestation. Which procedure is used to detect fetal
anomalies?
a. Amniocentesis
b. Chorionic villi sampling
c. Fetoscopy
d. Ultrasound
58. The nurse is caring for a postpartum client who
had a vaginal delivery with a midline episiotomy.
Which nursing diagnosis takes priority for this client?
a. Risk for deficient fluid volume related to
hemorrhage
b. Risk for infection related to the type of delivery
c. Acute pain related to the type of incision
d. Urinary retention related to periurethral edema
59. During the fourth stage of labor, the nurse notes
that the client’s fundus is boggy and located above the
umbilicus. How should the nurse intervene?
a. Let the condition resolve spontaneously.
b. Massage the clients fund us.
c. Instruct the client to bear down.
d. Notify the physician or nurse-midwife.
60. The nurse is obtaining a prenatal history from a
client who’s 8 weeks pregnant. To help determine
whether the client is at risk for a TORCH infection, the
nurse should ask:
a. “Have you ever had osteomyelitis?”
b. “Do you have any cats at home?”
c. “Do you have any birds at home?”
d. “Have you recently had a rubeola vaccination?”
61. The nurse is evaluating the external fetal
monitoring strip of a client who is in labor She notes
decreases in the fetal heart rate (FHR) that coincide
with the client’s contractions What term does the
nurse use to document this finding?
a. Prolonged decelerations
b. Early decelerations
c. Late decelerations
d. Accelerations
62. Which client is most appropriate for the registered
nurse to assign to the licensed practical nurse (LPN)?
a. Multiparous woman who just received ergonovine
maleate (Ergot)
b. Multiparous woman with Kiebsielia pneumoniae
cystitis
c. Multiparous woman with Enterobactercystitis and
sickle cell crisis
d. Multiparous woman with polymicrobial necrotizing
fasciitis
63. A client is admitted to the facility in preterm labor
To halt her uterine contractions, the nurse expects the
physician to prescribe:
a. betamethasone (Celestone)
b. dinoprostone (PrepidiI)
c. ergonovine (Ergotrate Maleate).
d. ritodrine (Yutopar)
64. Because cervical effacement and dilation aren’t
progressing in a client in labor, the physician orders
I.V. administration of oxytocin (Pitocin). Why must the
nurse monitor the client’s fluid intake and output
closely during oxytocin administration?
a. Oxytocin causes water intoxication
b. Oxytocin causes excessive thirst
c. Oxytocin is toxic to the kidneys.
d. Oxytocin has a diuretic effect
65. A 32-year-old multipara is admitted to the birthing
room after her initial examination reveals her cervix to
be at 8 cm, completely effaced (100%). and at O
station What phase of labor is she in?
a. Active phase
b. Latent phase
c. Expulsive phase
d. Transitional phase
Pediatric Nursing
66. A child. age 4. is admitted with a tentative
diagnosis of congenital heart disease When
assessment reveals a bounding radial pulse coupled
with a weak femoral pulse. the nurse suspects that the
child has:
a. patent ductus arteriosus.
b. coarctation of the aorta.
c. a ventricular septal defect.
d. truncus arteriosus.
67. The nurse is caring for a 2-year-old child with
tetralogy of Fallot (TOF) Which abnormalities are
associated with TOF?
a. Aortic stenosis, atrial septal defect, overriding aorta,
and left ventricular hypertrophy
b. Pulmonic stenosis. intraventricular septal defect,
overriding aorta, and right ventricular hypertrophy
c. Pulmonic stenosis. patent ductus arteriosus.
overriding aorta, and right ventricular hypertrophy
d. Transposition of the great vessels. intraventricular
septal defect, right ventricular hypertrophy and patent
ductus arteriosus
68. A preschooler goes into cardiac arrest. When
performing cardiopulmonary resuscitation (CPR) on a
child, how should the nurse deliver chest
compressions?
a. With two hands
b. With two fingertips
c. With the palm of one hand
d. With the heel of one hand
69. A 15-month-old child is being discharged after
treatment for severe otitis media and bacterial
meningitis. Which statement by the parents indicates
effective discharge teaching?
a. We should have gone to the physician sooner Next
time, we will-”
b. ‘We’ll take our child to the physician’s office every
week until everything is okay”
c. Well go to the physician if our child pulls on the ears
or won’t lie down”
d. ‘We’re just so glad this is all behind us”
70. A child is diagnosed with nephrotic syndrome.
When planning the child’s care, the nurse understands
that the primary goal of treatment is to:
a. manage urinary changes by monitoring fluid intake
and output and observing for hematuria
b. reduce the excretion of urinary protein
c. help prevent cardiac or renal failure by carefully
monitoring fluid and electrolyte balance
d. decrease edema and hypertension through bed rest
and fluid restriction
71. When teaching parents about fifth disease
(erythema infectiosum) and its transmission, the nurse
should provide which information?
a. Fifth disease is transmitted by respiratory
secretions.
b. Fifth disease has an unknown transmission mode
c. Fifth disease is transmitted by respiratory
secretions, stool, and urine
d. Fifth disease is transmitted by stool.
72. A child with asthma is receiving theophyIline The
nurse knows that theophylline is administered
primarily to:
a. decrease coughing induced by postnasal drip
b. dilate the bronchioles
c. reduce airway inflammation
d. eradicate the infection
73. 8-year-old child has just returned from the
operating room after having a tonsillectomy. The
nurse is preparing to do a postoperative assessment
The nurse should be alert for which signs and
symptoms of bleeding? Select all that apply:
1. Frequent clearing of the throat
2. Breathing through the mouth
3. Frequent swallowing
4. Sleeping for long intervals
5. Pulse rate of 98 beats/minute
6. Blood red vomitus
74. The physician diagnoses leukemia in a child, age 4.
who complains of being tired and sleeps most of the
day Which nursing diagnosis reflects the nurses
understanding of the physiologic effects of leukemia?
a. Ineffective airway clearance related to fatigue
b. Activity intolerance related to anemia
c. Imbalanced nutrition: More than body requirements
related to lack of activity
d. Ineffective cerebral tissue perfusion related to
central nervous system infiltration by leukemic cells
75. A nurse Is caring for a 3-year-old child with viral
meningitis. Which signs and symptoms would the
nurse expected to find during the initial assessment?
Select all that apply
1. Bulging anterior fontanel
2. Fever
3. Nuchal rigidity
4. Petechiae
5. Irritability
6. Photophobia
7. Hypothermia
Medical-Surgical Nursing
Neurosensory Problems
76. A client who has been severely beaten is admitted
to the emergency department. The nurse suspects a
basilar skull fracture after assessing:
a. raccoon’s eyes and Battle’s sign
b. nuchal rigidity and Kernig’s signs
c. motor loss in the legs that exceeds that in the arms
d. pupillary changes
77. What should the nurse do when administering
pilocarpine (Pilocar)?
a. Apply pressure on the inner canthus to prevent
systemic absorption.
b. Administer at bedtime to prevent night blindness.
c. Apply pressure on the outer canthus to prevent
adverse reactions.
d. Flush the client’s eye with normal saline solution to
prevent burning.
78. A client is receiving an LV. infusion of mannitol
(Osmitrol) after undergoing intracranial surgery to
remove a brain tumor. To determine whether this
drug is producing its therapeutic effect, the nurse
should consider which finding most significant?
a. Decreased level of consciousness (LOC)
b. Elevated blood pressure
c. Increased urine output
d. Decreased heart rate
79. Which nursing diagnosis takes highest priority for a
client admitted for evaluation for Ménière’s disease?
a. Acute pain related to vertigo
b. Imbalanced nutrition: Less than body requirements
related to nausea and vomiting
c. Rïsk for deficient fluid volume related to vomiting
d. Risk for injury related to vertigo
80. To assess a client’s cranial nerve function, the
nurse should:
a. assess hand grip.
b. assess orientation to person, time, and place
c. assess arm drifting
d. assess gag reflex
81. When caring for a client with a head injury, the
nurse must stay alert for signs and symptoms of
increased intracranial pressure (ICP) Which
cardiovascular findings are late indicators of increased
ICP?
a. Rising blood pressure and bradycardia
b. Hypotension and bradycardia
c. Hypotension and tachycardia
d. Hypertension and narrowing pulse pressure
82. A client with respiratory complications of multiple
sclerosis (MS) is admitted to the medical-surgical unit.
Which equipment is most important for the nurse to
keep at the clients bedside?
a. Sphygmomanometer
b. Padded tongue blade
c. Nasal cannula and oxygen
d. Suction machine with catheters
83. A client with epilepsy is having a seizure During the
active seizure phase, the nurse should:
a. place the client on his back, remove dangerous
objects, and insert a bite block
b. place the client on his side, remove dangerous
objects, and insert a bite block.
c. place the client on his back, remove dangerous
objects, and hold down his arms
d. place the client on his side, remove dangerous
objects, and protect his head
84. The nurse is caring for a client with a complete T5
spinal cord injury. Upon assessment the nurse notes
flushed skin, diaphoresis above T5, and a blood
pressure of 162196 mm Hg. The client reports a
severe, pounding headache. Which nursing
interventions would be appropriate for this client’?
Select all that apply:
1. Elevating the head of the bed 90 degrees
2. Loosening constrictive clothing
3. Using a fan to reduce diaphoresis
4. Assessing for bladder distention and bowel
impaction
5. Administering antihypertensive medication
6. Placing the client in a supine position with legs
elevated
85. The nurse is administering neostigmine to a client
with myasthenia gravis. Which nursing intervention
should the nurse implement?
a. Give the medication on an empty stomach.
b. Warn the client that hell experience mouth dryness.
c. Schedule the medication before meals
d. Administer the medication for complaints of muscle
weakness or difficulty swallowing
86. A client is admitted for investigation of balance
and coordination problems, including possible
Ménière’s disease. When assessing this client, the
nurse expects to note:
a. vertigo, Tinnitus, and hearing loss.
b. vertigo, vomiting, and nystagmus.
c. vertigo, pain, and hearing impairment.
d. vertigo, blurred vision, and fever
87. A client, age 21, is admitted with bacterial
meningitis. Which hospital room would be the best
choice for this client?
a. A private room down the hall from the nurses’
station
b. An isolation room three doors from the nurses’
station
c. A semiprivate room with a 32-year-old client who
has viral meningitis
d. A two-bed room with a client who previously had
bacterial meningitis
88. When obtaining the health history from a client
with retinal detachment, the nurse expects the client
to report:
a. light flashes and floaters in front of the eyes
b. a recent driving accident while changing lanes
c. headaches, nausea, and redness of the eye&
d. frequent episodes of double vision.
89. A client with quadriplegia is in spinal shock. What
should the nurse expect?
a. Absence of reflexes along with flaccid extremities
b. Positive Babinski’s reflex along with spastic
extremities
c. Hyperreflexia along with spastic extremities
d. Spasticity of all four extremities
90. The nurse is teaching a client with multiple
sclerosis. When teaching the client how to reduce
fatigue, the nurse should tell the client to:
a. take a hot bath
b. rest in an air-conditioned room.
c. increase the dose of muscle relaxants
d. avoid naps during the day.
Endocrine and Metabolic Disorders
91. The nurse is assessing a client with
hyperthyroidism. What findings should the nurse
expect?
a. Weight gain, constipation, and lethargy
b. Weight loss, nervousness, and tachycardia
c Exophthalmos, diarrhea, and cold intolerance
d. Diaphoresis, fever, and decreased sweating
92. The nurse is caring for a client in acute addisonian
crisis. Which laboratory data would the nurse expect
to find?
a. Hyperkalemia
b. Reduced blood urea nitrogen (BUN)
c. Hypernatremia
d. Hyperglycemia
93. In a 28-year-old female client who is being
successfully treated for Cushing’s syndrome. The nurse
would expect a decline in:
a. serum glucose level
b. hair loss
c. bone mineralization
d. menstrual flow
94. The nurse should expect a client with
hypothyroidism to report which health concern(s)?
a. Increased appetite and weight loss
b. Puffiness of the face and hands
c. Nervousness and tremors
d. Thyroid gland swelling
95. Which sign suggests that a client with the
syndrome of inappropriate antidiuretic hormone
(SIADH) secretion is
experiencing complications?
a. Tetanic contractions
b. Neck vein distention
c. Weight loss
d. Polyuria
96. A client with type 1 diabetes mellitus has a highly
elevated glycosylated hemoglobin (Hb) test results. In
discussing the result with the client, the nurse would
be most accurate in stating:
a. “The test needs to be repeated following a 12-hour
fast.”
b. “It looks like you aren’t following the prescribed
diabetic diet.’
c. “It tells us about your sugar control for the last 3
months.”
d. “Your insulin regimen needs to be altered
significantly.”
97. The nurse is caring for a client with diabetes
insipidus. The nurse should anticipate the
administration of:
a. insulin
b. furosemide (Lasix).
c. potassium chloride.
d. vasopressin (Pitressin).
98. A 55-year-old diabetic client is admitted with
hypoglycemia. Which information should the nurse
include in her client teaching? Select all that apply:
1. Hypoglycemia can result from excessive alcohol
consumption.
2. “Skipping meals can cause hypoglycemic
3. “Symptoms of hypoglycemia include thirst and
excessive urinary output,”
4. “Strenuous activity may result in hypoglycemia.”
5. “Symptoms of hypoglycemia include shakiness,
contusion, and headache.”
6. “Hypoglycemia is a relatively harmless situation.”
99. A female client who weighs 210 lbs (95 kg) and has
been diagnosed with hyperglycemia tells the nurse
that her husband sleeps in another room because her
snoring keeps him awake The nurse notices that she
has large hands and a hoarse voice. Which disorder
would the nurse suspect as a possible cause of the
client’s hyperglycemia?
a. Acromegaly
b. Type 1 diabetes mellitus
c. Hypothyroidism
d. Deficient growth hormone
100. Which intervention is essential when performing
dressing changes on a client with a diabetic foot ulcer?
a. Applying a heating pad
b. Debriding the wound three times per day
c. Using sterile technique during the dressing change
d. Cleaning the wound with a povidone-iodine solution
Cardiovascular Disorders
101. A client is receiving nitroglycerin ointment (Nitrol)
to treat angina pectoris. The nurse evaluates the
therapeutic effectiveness of this drug by assessing the
client’s response and checking for adverse effects-
Which vital sign is most likely to reflect an adverse
effect of nitroglycerin?
a. Heart rate
b. Respiratory rate
c. Blood pressure
d. Temperature
102. When assessing a client who reports recent chest
pain, the nurse obtains a thorough history. Which
statement by the client most strongly suggests angina
pectoris?
a. ‘The pain lasted about 45 minutes”
b. ‘The pain resolved after I ate a sandwich-”
c. ‘The pain got worse when I took a deep breath”
d. ‘The pain occurred while I was mowing the lawn”
103. To check for arterial insufficiency when a client is
in a supine position. The nurse should elevate the
extremity at a 45-degree angle and then have the
client sit up. The nurse suspects arterial insufficiency if
the assessment reveals:
a. elevational rubor.
b. no rubor for 10 seconds after the maneuver.
c. dependent pallor
d. a 30-second filling time for the veins.
104. A client in the emergency department complains
of squeezing substernal pain that radiates to the left
shoulder and jaw. He also complains of nausea,
diaphoresis, and shortness of breath. What should the
nurse do?
a. Complete the client’s registration information,
perform an electrocardiogram gain l.V. access, and
take vital signs.
b. Alert the cardiac catheterization team, administer
oxygen, attach a cardiac monitor, and notify the
physician.
c. Gain l.V. access, give sublingual nitroglycerin, and
alert the cardiac catheterization team.
d. Administer oxygen attach a cardiac monitor, take
vital signs and administer sublingual nitroglycerin.
105. A client with high blood pressure is receiving an
antihypertensive drug The nurse knows that
antihypertensive drugs commonly cause fatigue and
dizziness, especially on rising When developing a client
teaching plan to minimize orthostatic hypotension.
The nurse should include which instruction?
a. “Avoid drinking alcohol and straining at stool. and
eat a low-protein snack at night.”
b. “Wear elastic stockings, change positions quickly,
and hold onto a stationary object when rising.”
c. “Flex your calf muscles, avoid alcohol, and change
positions slowly.”
d. “Rest between demanding activities, eat plenty of
fruits and vegetables, and drink 6to 8 cups of fluid
daily.”
106. A client is experiencing an acute myocardial
infarction (Ml) and l.V. morphine is prescribed
Morphine is given because it:
a. eliminates pain, reduces cardiac workload, and
increases myocardial contractility
b. lowers resistance, reduces cardiac workload, and
decreases myocardial oxygen demand
c. raises the blood pressure, lowers myocardial oxygen
demand, and eliminates pain.
d. increases venous return, lowers resistance, and
reduces cardiac workload.
107. A client with chronic heart failure is receiving
digoxin (Lanoxin). 0.25 mg by mouth (PO.) daily, and
furosemide (Lasix) 20 mg P.O. twice daily. The nurse
instructs the client to notify the physician if nausea,
vomiting, diarrhea, or abdominal cramps occur
because these signs and symptoms may signal digitalis
toxicity. Digitalis toxicity also may cause:
a. visual disturbances
b. taste and smell alterations
c. dry mouth and urine retention.
d. nocturia and sleep disturbances.
108. The physician prescribes digoxin (Lanoxin) for a
client with heart failure. During digoxin therapy.
Which electrolyte imbalance may predispose the client
to digitalis toxicity?
a. Hypermagnesemia
b. Hypercalcemia
c. Hypernatremia
d. Hypokalemia
109. After experiencing a transient ischemic attack
(TIA), a client is prescribed aspirin 325 mg PO daily.
The nurse should teach the client that this medication
has been prescribed to:
a. control headache pain
b. enhance the immune response
c. prevent intracranial bleeding
d. reduce the chance of blood clot formation.
110. When administering dobutamine (Dobutrex). The
nurse knows that its major clinical use is to:
a. increase cardiac output
b. prevent sinus bradycardia
c. treat hypotension
d. treat hypertension.
Respiratory Disorders
111. When caring for a client with acute respiratory
failure, the nurse should expect to focus on resolving
which set of problems?
a. Hypotension, hyperoxemia, and hypercapnia
b. Hyperventilation, hypertension, and hypocapnia
c. Hyperoxemia, hypocapnia, and hyperventilation
d. Hypercapnia, hypoventilation, and hypoxemia
112. At 11 p.m., a client is admitted to the emergency
department. He has a respiratory rate of 44
breaths/min. He’s anxious, and wheezes are audible.
The client is immediately given oxygen by face mask
and methylprednisolone (Depo-medrol) l.V. At 11:30
p.m. The client’s arterial blood oxygen saturation is
86%, and he’s still wheezing. The nurse should plan to
administer
a. alprazolam (Xanax).
b. propranolol (Inderal).
c. morphine.
d. albuterol (Proventil).
113. A client has undergone a left hemicolectomy for
bowel cancer. Which activities prevent the occurrence
of postoperative pneumonia in this client?
a. Administering oxygen, coughing, breathing deeply,
and maintaining bed rest
b. Coughing, breathing deeply, maintaining bed rest,
and using an incentive spirometer
c. Coughing, breathing deeply, frequent repositioning.
and using an incentive spirometer
d. Administering pain medications, frequent
114. A client with suspected severe acute respiratory
syndrome (SARS) comes to the emergency
department. Which physician order should the nurse
implement first?
a. Institute isolation precautions
b. Begin an LV. infusion of dextrose 5% in half-normal
saline solution at 100 mI/hour
c. Obtain a nasopharyngeal specimen for reverse-
transcription polymerase chain reaction testing.
d. Obtain a sputum specimen for enzyme immuno
assay testing
115. The nurse prepares to perform postural drainage.
How should the nurse ascertain the best position to
facilitate clearing the lungs?
a. Inspection
b. Chest X-ray
c. Arterial blood gas (ABG) levels
d. Auscultation
Gastrointestinal Disorders
116. A client is admitted to the health care facility with
abdominal pain, a low-grade fever, abdominal
distention, and weight loss. The physician diagnoses
acute pancreatitis. What is the primary goal of nursing
care for this client?
a. Relieving abdominal pain
b. Preventing fluid volume overload
c. Maintaining adequate nutritional status
d. Teaching about the disease and its treatment
117. Which laboratory finding is the primary diagnostic
indicator for pancreatitis?
a. Elevated blood urea nitrogen (BUN)
b. Elevated serum lipase
c. Elevated aspartate aminotransferase (AST)
d. Increased lactate dehydrogenase (LD)
118. The physician prescribes lactulose (Cephulac), 30
ml three times daily, when a client with cirrhosis
develops an increased serum ammonia level. To
evaluate the effectiveness of lactulose, the nurse
should monitor
a. urine output.
b. abdominal girth
c. stool frequency.
d. level of consciousness (LOC)
119. During clindamycin (Cleocin) therapy, the nurse
monitors a client for pseudomembranous colitis This
serious adverse reaction to clindamycin results from
superinfection with which organism?
a. Staphylococcus aureus
b. Bacteroides fragilis
c. Escherichia coli
d. Clostridium difficile
120. The nurse is teaching an elderly client about good
bowel habits. Which statement by the client would
indicate to the nurse that additional teaching is
required?
a. “1 should eat a fiber-rich diet with raw, leafy
vegetables, unpeeled fruit, and whole grain bread.”
b. “I need to use laxatives regularly to prevent
constipation”
c. “I need to drink 2 to 3 liters of fluid every day”
d. “I should exercise four times per week.”
Genitourinary Disorders
121. A client with decreased urine output refractory to
fluid challenges is evaluated for renal failure. Which
condition may cause the intrinsic (intrarenal) form of
acute renal failure?
a. Poor perfusion to the kidneys
b. Damage to cells in the adrenal cortex
c. Obstruction of the urinary collecting system
d. Nephrotoxic injury secondary to use of contrast
media
122. A client who has been treated for chronic renal
failure (CRF) is ready for discharge. The nurse should
reinforce which dietary instruction?
a. “Be sure to eat meat at every meal”
b. “Eat plenty of bananas”
c. “Increase your carbohydrate intake”
d. “Drink plenty of fluids, and use a salt substitute”
123. A client is admitted for treatment of
glomerulonephritis On initial assessment, the nurse
detects one of the classic signs of acute
glomerulonephritis of sudden onset- Such signs
include:
a. generalized edema, especially of the face and
periorbital area
b. green-tinged urine
c. moderate to severe hypotension
d. polyuria
124. A client with renal dysfunction of acute onset
comes to the emergency department complaining of
fatigue, oliguria, and coffee-colored urine. When
obtaining the clients history to check for significant
findings, the nurse should ask about:
a. chronic, excessive acetaminophen use.
b. recent streptococcal infection
c. childhood asthma.
d. family history of pernicious anemia.
125. The nurse is caring for a male client with
gonorrhea who’s receiving ceftriaxone and
doxycycline. The client asks the nurse why he’s
receiving two antibiotics. How should the nurse
respond?
a. “Because there are many resistant strains of
gonorrhea, more than one antibiotic may be required
for successful treatment”
b. ‘The combination of these two antibiotics reduces
the risk of reinfection”
c. “Many people infected with gonorrhea are infected
with chlamydia as well”
d. ‘This combination of medications will eradicate the
infection faster than a single antibiotic”
Integumentary Problems
126. When developing a care plan for a client
recovering from a serious thermal burn, the nurse
knows that the most important immediate goal of
therapy is:
a. planning for the clients rehabilitation and discharge
b. providing emotional support to the client and family
c. maintaining the clients fluid, electrolyte, and acid-
base balances.
d. preserving full range of motion in all affected joints
127. When planning care for a client with burns on the
upper torso, which nursing diagnosis should take the
highest priority?
a. Ineffective airway clearance related to edema of the
respiratory passages
b. Impaired physical mobility related to the disease
process
c. Disturbed sleep pattern related to facility
environment
d. Risk for infection related to breaks in the skin
128. When assessing a client with partial thickness
bums ever 60% of the body, which finding should the
nurse report immediately?
a. Complaints of intense thirst
b. Moderate to severe pain
c. Urine output of 70ml the first hour
d. Hoarseness of the voice
129. A client presents with blistering wounds caused
from an unknown chemical agent. How should the
nurse intervene?
a. Do nothing until the chemical agent is identified
b. Irrigate the wounds with water
c. Wash the wounds with soap and water and apply a
barrier cream
d. Insert a 20-gauge LV. catheter and infuse normal
saline solution at 150 mI/hour.
130. A nurse is seen in the employee health
department for mild itching and rash on both hands
During the assessment interview, the employee health
nurse should focus on:
a. medication allergies
b. life stressors the nurse may be experiencing
c. chemical and latex glove use
d. laundry detergent or bath soap changes
Psychiatric Nursing
131. Every day for the past 2 weeks, a client with
schizophrenia stands up during group therapy and
screams. “Get out of here right now! The elevator
bombs are going to explode in 3 minutes!” The next
time this happens. How should the nurse respond?
a. ‘Why do you think there is a bomb in the elevator?”
b. ‘That is the same thing you said in yesterday’s
session”
c. “I know you think there are bombs in the elevator,
but there aren’t”
d. “If you have something to say, you must do it
according to our group rules”
132. The nurse must administer a medication to
reverse or prevent Parkinson-type symptoms in a
client receiving an antipsychotic The medication the
client will likely receive is:
a. Benztropine (Cogentin).
b. Diphenhydramine (Benadryl)
c. Propranolol (Inderal).
d. Haloperidol (Haldol)
133. Which medications have been found to help
reduce or eliminate panic attacks?
a. Antidepressants
b. Anticholinergics
c. Antipsychotics
d. Mood stabilizers
134. An adolescent becomes increasingly withdrawn,
is irritable with family members. and has been getting
lower grades in school. After giving away a stereo and
some favorite clothes, the adolescent is brought to the
community mental health agency for evaluation. This
adolescent is at risk for:
a. suicide.
b. anorexia nervosa.
c. school phobia.
d. psychotic break.
135. The nurse is monitoring a client receiving
tranylcypromine sulfate (Pamate) Which serious
adverse reaction can occur with high dosages of this
monoamine oxidase (MAO) inhibitor?
a. Hypotensive episodes
b. Hypertensive crisis
c. Muscle flaccidity
d. Hypoglycemia
136. The nurse notices that a depressed client taking
amitriptyline (Elavil) for 2 weeks has become very
outgoing, cheerful, and talkative The nurse suspects
that the client:
a. is responding to the antipsychotic
b. may be experiencing increased energy and is at an
increased risk for suicide
c. is ready to be discharged from treatment
d. is experiencing a split personality
137. Which nursing intervention would be most
appropriate if a client were to develop orthostatic
hypotension while taking amitriptyline (Elavil)?
a. Consulting the physician about substituting a
different type of antidepressant
b. Advising the client to sit up for 1 minute before
getting out of bed
c. Instructing the client to double the dosage until the
problem resolves
d. Informing the client that this adverse reaction
should disappear within 1 week
138. A client is admitted to the substance abuse unit
for alcohol detoxification. Which of the following
medications is the nurse most likely to administer to
reduce the symptoms of alcohol withdrawal?
a. Naloxone (Narcan)
b. Haloperidol (Haldol)
c. Magnesium sulfate
d. Chlordiazepoxide (Librium)
139. Which medication can control the extrapyramidal
effects associated with antipsychotic agents?
a. Perphenazine (Trilafon)
b. Doxe pin (Sine quan)
c. Amantadine (Symmetrel)
d. Clorazepate (Tranxene)
140. A client with manic episodes is taking lithium.
Which electrolyte level should the nurse check before
administering this medication?
a. Calcium
b. Sodium
c. Chloride
d. Potassium
Nutrition
141. The nurse is teaching a client who has iron
deficiency anemia about foods she should include in
her diet. The nurse determines that the client
understands the dietary modifications if she selects
which of the following from her menu?
a. Nuts and milk
b. Coffee and lea
c. Cooked rolled oats and fish
d. Oranges and dark green leafy vegetables
142. The nurse instructs a client with renal failure who
is receiving hemodialysis about dietary modifications.
The nurse determines that the client understands
these dietary modifications if the client selects which
items from the dietary menu?
a. Cream of wheat, blueberries, coffee
b. Sausage and eggs, banana, orange juice
c. Bacon, cantaloupe melon, tomato juice
d. Cured pork, grits, strawberries, orange juice
144. The nurse is conducting a dietary assessment on a
client who is on a vegan diet. The nurse provides
dietary teaching focusing on foods high in which
vitamin that may be lacking in a vegan diet?
a. Vitamin A
b. Vitamin B12
c. Vitamin C
d. Vitamin E
145. The nurse is instructing a client with hypertension
on the importance of choosing foods low in sodium.
The nurse should teach the client to limit which of the
following foods?
a. Apples
b. Bananas
c. Smoked sausage
d. Steamed vegetables
146. A Client who is recovering from surgery has been
advanced from a clear liquid diet to a full liquid diet.
The client is looking forward to the diet change
because he has been “bored” with the clear liquid
diet. The nurse would offer which full liquid item to
the client?
a. Tea
b. Gelatin
c. Custard
d. Popsicle
147. A nurse is caring for a group of adult clients on an
acute care medical-surgical nursing unit. The nurse
understands that which of the following clients would
be the least likely candidate for parenteral nutrition
(PN)?
a. A 66-year-old client with extensive burns
b. A 42-year-old client who has had an open
cholecystectomy
c. A 27-year-old client with severe exacerbation of
Crohn’s disease
d. A 35-year-old client with persistent nausea and
vomiting from chemotherapy

148. A client has been on parenteral nutrition (PN) for

8 weeks at home. The physician prescribes that the PN
be weaned by 50 mL per hour per day until
discontinued. The client asks the nurse why the PN
cannot just be stopped. The nurse explains that unless
the PN infusions are tapered gradually, the client is at
risk for development of which of the following?
a. Dehydration
b. Hypokalemia
c. Hypernatremia
d. Hypoglycemia

149. A nurse is teaching a client with tuberculosis (TB)

about elements that should be increased in the diet.
The nurse suggests that the client increase intake of:
a. Potatoes and fish
b. Eggs and spinach
c. Grains and broccoli
d. Meats and citrus fruits

150. A nurse is evaluating the effect of dietary

counseling on the client with cholecystitis. The nurse
determines that the client understands the
instructions given if the client states that which of the
following food items is acceptable in the diet?
a. Baked fish
b. Fried chicken
c. Sauces and gravies
d. Fresh whipped cream