NCLEX-PN Practice Questions Exam Cram: Practice Exam 3 and Rationales
This chapter is from the book
This chapter is from the book
This chapter is from the book
A client hospitalized with severe depression and suicidal ideation refuses to talk with the nurse. The nurse recognizes that the suicidal client has difficulty:
A. Expressing feelings of low self-worth- B. Discussing remorse and guilt for actions
- C. Displaying dependence on others
- D. Expressing anger toward others
Quick Answers: 187
Detailed Answer: 190
A client receiving HydroDIURIL (hydrochlorothiazide) is instructed to increase her dietary intake of potassium. The best snack for the client requiring increased potassium is:
- A. Pear
- B. Apple
- C. Orange
- D. Banana
Quick Answers: 187
Detailed Answer: 190
The nurse is caring for a client following removal of the thyroid. Immediately post-op, the nurse should:
- A. Maintain the client in a semi-Fowler’s position with the head and neck supported by pillows
- B. Encourage the client to turn her head side to side, to promote drainage of oral secretions
- C. Maintain the client in a supine position with sandbags placed on either side of the head and neck
- D. Encourage the client to cough and breathe deeply every 2 hours, with the neck in a flexed position
Quick Answers: 187
Detailed Answer: 190
A client hospitalized with chronic dyspepsia is diagnosed with gastric cancer. Which of the following is associated with an increased incidence of gastric cancer?
- A. Dairy products
- B. Carbonated beverages
- C. Refined sugars
- D. Luncheon meats
Quick Answers: 187
Detailed Answer: 190
A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing the client’s record, the nurse could expect to find:
- A. A history of consistent employment
- B. A below-average intelligence
- C. A history of cruelty to animals
- D. An expression of remorse for his actions
Quick Answers: 187
Detailed Answer: 190
The licensed vocational nurse may not assume the primary care for a client:
- A. In the fourth stage of labor
- B. Two days post-appendectomy
- C. With a venous access device
- D. With bipolar disorder
Quick Answers: 187
Detailed Answer: 190
The physician has ordered dressings with mafenide acetate (Sulfamylon) cream for a client with full-thickness burns of the hands and arms. Before dressing changes, the nurse should give priority to:
- A. Administering pain medication
- B. Checking the adequacy of urinary output
- C. Requesting a daily complete blood count
- D. Obtaining a blood glucose by finger stick
Quick Answers: 187
Detailed Answer: 190
The nurse is teaching a group of parents about gross motor development of the toddler. Which behavior is an example of the normal gross motor skill of a toddler?
- A. She can pull a toy behind her.
- B. She can copy a horizontal line.
- C. She can build a tower of eight blocks.
- D. She can broad-jump.
Quick Answers: 187
Detailed Answer: 190
A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible?
- A. Wire cutters
- B. Oral airway
- C. Pliers
- D. Tracheostomy set
Quick Answers: 187
Detailed Answer: 190
The nurse is to administer digoxin (Lanoxin) elixir to a 6-month-old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100. The nurse should:
- A. Record the heart rate and call the physician
- B. Record the heart rate and administer the medication
- C. Administer the medication and recheck the heart rate in 15 minutes
- D. Hold the medication and recheck the heart rate in 30 minutes
Quick Answers: 187
Detailed Answer: 190
A mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain the treatment for her daughter. The nurse’s explanation is based on the knowledge that lead poisoning is treated with:
- A. Gastric lavage
- B. Chelating agents
- C. Antiemetics
- D. Activated charcoal
Quick Answers: 187
Detailed Answer: 191
An 18-month-old is scheduled for a cleft palate repair. The usual type of restraints for the child with a cleft palate repair are:
- A. Elbow restraints
- B. Full arm restraints
- C. Wrist restraints
- D. Mummy restraints
Quick Answers: 187
Detailed Answer: 191
A client with glaucoma has been prescribed Timoptic (timolol) eyedrops. Timoptic should be used with caution in the client with a history of:
- A. Diabetes
- B. Gastric ulcers
- C. Emphysema
- D. Pancreatitis
Quick Answers: 187
Detailed Answer: 191
An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client’s confusion by:
- A. Assigning a nursing assistant to sit with him until he falls asleep
- B. Allowing the client to room with another elderly client
- C. Administering a bedtime sedative
- D. Leaving a nightlight on during the evening and night shifts
Quick Answers: 187
Detailed Answer: 191
Which of the following is a common complaint of the client with end-stage renal failure?
- A. Weight loss
- B. Itching
- C. Ringing in the ears
- D. Bruising
Quick Answers: 187
Detailed Answer: 191
Which of the following medication orders needs further clarification?
- A. Darvocet (propoxyphene) 65mg PO every 4–6 hrs. PRN
- B. Mysoline (primidone) 250mg PO TID
- C. Coumadin (warfarin sodium) 10mg PO
- D. Premarin (conjugated estrogen) .625mg PO daily
Quick Answers: 187
Detailed Answer: 191
The best diet for the client with Meniere’s syndrome is one that is:
- A. High in fiber
- B. Low in sodium
- C. High in iodine
- D. Low in fiber
Quick Answers: 187
Detailed Answer: 191
Which of the following findings is associated with right-sided heart failure?
- A. Shortness of breath
- B. Nocturnal polyuria
- C. Daytime oliguria
- D. Crackles in the lungs
Quick Answers: 187
Detailed Answer: 191
An 8-year-old admitted with an upper-respiratory infection has an order for O2 saturation via pulse oximeter. To ensure an accurate reading, the nurse should:
- A. Place the probe on the child’s abdomen
- B. Recalibrate the oximeter at the beginning of each shift
- C. Apply the probe and wait 15 minutes before obtaining a reading
- D. Place the probe on the child’s finger
Quick Answers: 187
Detailed Answer: 191
An infant with Tetralogy of Fallot is discharged with a prescription for lanoxin elixir. The nurse should instruct the mother to:
- A. Administer the medication using a nipple
- B. Administer the medication using the calibrated dropper in the bottle
- C. Administer the medication using a plastic baby spoon
- D. Administer the medication in a baby bottle with 1oz. of water
Quick Answers: 187
Detailed Answer: 191
The client scheduled for electroconvulsive therapy tells the nurse, “I’m so afraid. What will happen to me during the treatment?” Which of the following statements is most therapeutic for the nurse to make?
- A. “You will be given medicine to relax you during the treatment.”
- B. “The treatment will produce a controlled grand mal seizure.”
- C. “The treatment might produce nausea and headache.”
- D. “You can expect to be sleepy and confused for a time after the treatment.”
Quick Answers: 187
Detailed Answer: 191
Which of the following skin lesions is associated with Lyme’s disease?
- A. Bull’s eye rash
- B. Papular crusts
- C. Bullae
- D. Plaques
Quick Answers: 187
Detailed Answer: 191
Which of the following snacks would be suitable for the child with gluten-induced enteropathy?
- A. Soft oatmeal cookie
- B. Buttered popcorn
- C. Peanut butter and jelly sandwich
- D. Cheese pizza
Quick Answers: 187
Detailed Answer: 192
A client with schizophrenia is receiving chlorpromazine (Thorazine) 400mg twice a day. An adverse side effect of the medication is:
- A. Photosensitivity
- B. Elevated temperature
- C. Weight gain
- D. Elevated blood pressure
Quick Answers: 187
Detailed Answer: 192
Which information should be given to the client taking phenytoin (Dilantin)?
- A. Taking the medication with meals will increase its effectiveness.
- B. The medication can cause sleep disturbances.
- C. More frequent dental appointments will be needed for special gum care.
- D. The medication decreases the effects of oral contraceptives.
Quick Answers: 187
Detailed Answer: 192
A client has returned to his room following an esophagoscopy. Before offering fluids, the nurse should give priority to assessing the client’s:
- A. Level of consciousness
- B. Gag reflex
- C. Urinary output
- D. Movement of extremities
Quick Answers: 187
Detailed Answer: 192
Which instruction should be included in the discharge teaching for the client with cataract surgery?
- A. Over-the-counter eyedrops can be used to treat redness and irritation.
- B. The eye shield should be worn at night.
- C. It will be necessary to wear special cataract glasses.
- D. A prescription for medication to control post-operative pain will be needed.
Quick Answers: 187
Detailed Answer: 192
An 8-year-old is admitted with drooling, muffled phonation, and a temperature of 102°F. The nurse should immediately notify the doctor because the child’s symptoms are suggestive of:
- A. Strep throat
- B. Epiglottitis
- C. Laryngotracheobronchitis
- D. Bronchiolitis
Quick Answers: 187
Detailed Answer: 192
Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should:
- A. Offer the baby sterile water between feedings of formula
- B. Apply an emollient to the baby’s skin to prevent drying
- C. Wear a gown, gloves, and a mask while caring for the infant
- D. Place the baby on enteric isolation
Quick Answers: 187
Detailed Answer: 192
A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client’s plan of care?
- A. Weighing the client after she eats
- B. Having a staff member remain with her for 1 hour after she eats
- C. Placing high-protein foods in the center of the client’s plate
- D. Providing the client with child-size utensils
Quick Answers: 187
Detailed Answer: 192
According to Erickson’s stage of growth and development, the developmental task associated with middle childhood is:
- A. Trust
- B. Initiative
- C. Independence
- D. Industry
Quick Answers: 187
Detailed Answer: 192
The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is:
- A. Tinnitus
- B. Nausea
- C. Ataxia
- D. Hypotension
Quick Answers: 187
Detailed Answer: 192
The 5-minute Apgar of a baby delivered by C-section is recorded as 9. The most likely reason for this score is:
- A. The mottled appearance of the trunk
- B. The presence of conjunctival hemorrhages
- C. Cyanosis of the hands and feet
- D. Respiratory rate of 20–28 per minute
Quick Answers: 187
Detailed Answer: 193
A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Quick Answers: 187
Detailed Answer: 193
A client with a bowel resection and anastamosis returns to his room with an NG tube attached to intermittent suction. Which of the following observations indicates that the nasogastric suction is working properly?
- A. The client’s abdomen is soft.
- B. The client is able to swallow.
- C. The client has active bowel sounds.
- D. The client’s abdominal dressing is dry and intact.
Quick Answers: 187
Detailed Answer: 193
The nurse is teaching the client with insulin-dependent diabetes the signs of hypoglycemia. Which of the following signs is associated with hypoglycemia?
- A. Tremulousness
- B. Slow pulse
- C. Nausea
- D. Flushed skin
Quick Answers: 187
Detailed Answer: 193
Which of the following symptoms is associated with exacerbation of multiple sclerosis?
- A. Anorexia
- B. Seizures
- C. Diplopia
- D. Insomnia
Quick Answers: 187
Detailed Answer: 193
Which of the following conditions is most likely related to the development of renal calculi?
- A. Gout
- B. Pancreatitis
- C. Fractured femur
- D. Disc disease
Quick Answers: 187
Detailed Answer: 193
A client with AIDS is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract?
- A. Thoroughly cooking all foods
- B. Offering yogurt and buttermilk between meals
- C. Forcing fluids
- D. Providing small, frequent meals
Quick Answers: 187
Detailed Answer: 193
The treatment protocol for a client with acute lymphocytic leukemia includes prednisone, methotrexate, and cimetadine. The purpose of the cimetadine is to:
- A. Decrease the secretion of pancreatic enzymes
- B. Enhance the effectiveness of methotrexate
- C. Promote peristalsis
- D. Prevent a common side effect of prednisone
Quick Answers: 187
Detailed Answer: 193
Which of the following meal choices is suitable for a 6-month-old infant?
- A. Egg white, formula, and orange juice
- B. Apple juice, carrots, whole milk
- C. Rice cereal, apple juice, formula
- D. Melba toast, egg yolk, whole milk
Quick Answers: 187
Detailed Answer: 193
The LPN is preparing to administer an injection of vitamin K to the newborn. The nurse should administer the injection in the:
- A. Rectus femoris muscle
- B. Vastus lateralis muscle
- C. Deltoid muscle
- D. Dorsogluteal muscle
Quick Answers: 187
Detailed Answer: 193
The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephotic syndrome. The nurse should:
- A. Encourage the client to drink extra fluids
- B. Request a low-protein diet for the client
- C. Bathe the client using only mild soap and water
- D. Provide additional warmth for swollen, inflamed joints
Quick Answers: 187
Detailed Answer: 193
The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal?
- A. Antabuse (disulfiram)
- B. Romazicon (flumazenil)
- C. Dolophine (methodone)
- D. Ativan (lorazepam)
Quick Answers: 187
Detailed Answer: 194
A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:
- A. 8 a.m.
- B. 10 a.m.
- C. 3 p.m.
- D. 5 a.m.
Quick Answers: 187
Detailed Answer: 194
The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?
- A. Alteration in comfort
- B. Alteration in mobility
- C. Alteration in skin integrity
- D. Alteration in O2 perfusion
Quick Answers: 187
Detailed Answer: 194
The primary purpose for using a CPM machine for the client with a total knee repair is to help:
- A. Prevent contractures
- B. Promote flexion of the artificial joint
- C. Decrease the pain associated with early ambulation
- D. Alleviate lactic acid production in the leg muscles
Quick Answers: 187
Detailed Answer: 194
Which of the following statements reflects Kohlberg’s theory of the moral development of the preschool-age child?
- A. Obeying adults is seen as correct behavior.
- B. Showing respect for parents is seen as important.
- C. Pleasing others is viewed as good behavior.
- D. Behavior is determined by consequences.
Quick Answers: 187
Detailed Answer: 194
A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:
- A. Determine whether the ear infection has affected her hearing
- B. Make sure that she has taken all the antibiotic
- C. Document that the infection has completely cleared
- D. Obtain a new prescription in case the infection recurs
Quick Answers: 187
Detailed Answer: 194
A factory worker is brought to the nurse’s office after a metal fragment enters his right eye. The nurse should:
- A. Cover the right eye with a sterile 4×4
- B. Attempt to remove the metal with a cotton-tipped applicator
- C. Flush the eye for 10 minutes with running water
- D. Cover both eyes and transport the client to the ER
Quick Answers: 187
Detailed Answer: 194
The nurse is caring for a client with systemic lupus erythematosis (SLE). The major complication associated with systemic lupus erythematosis is:
- A. Nephritis
- B. Cardiomegaly
- C. Desquamation
- D. Meningitis
Quick Answers: 187
Detailed Answer: 194
Which diet is associated with an increased risk of colorectal cancer?
- A. Low protein, complex carbohydrates
- B. High protein, simple carbohydrates
- C. High fat, refined carbohydrates
- D. Low carbohydrates, complex proteins
Quick Answers: 187
Detailed Answer: 194
The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:
- A. Holding the infant
- B. Offering a pacifier
- C. Providing a mobile
- D. Offering sterile water
Quick Answers: 187
Detailed Answer: 194
The physician has ordered Amoxil (amoxicillin) 500mg capsules for a client with esophageal varices. The nurse can best care for the client’s needs by:
- A. Giving the medication as ordered
- B. Providing extra water with the medication
- C. Giving the medication with an antacid
- D. Requesting an alternate form of the medication
Quick Answers: 187
Detailed Answer: 195
The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron?
- A. Tomatoes
- B. Legumes
- C. Dried fruits
- D. Nuts
Quick Answers: 187
Detailed Answer: 195
The nurse is teaching a client with Parkinson’s disease ways to prevent curvatures of the spine associated with the disease. To prevent spinal flexion, the nurse should tell the client to:
- A. Periodically lie prone without a neck pillow
- B. Sleep only in dorsal recumbent position
- C. Rest in supine position with his head elevated
- D. Sleep on either side but keep his back straight
Quick Answers: 187
Detailed Answer: 195
The nurse is planning dietary changes for a client following an episode of pancreatitis. Which diet is suitable for the client?
- A. Low calorie, low carbohydrate
- B. High calorie, low fat
- C. High protein, high fat
- D. Low protein, high carbohydrate
Quick Answers: 187
Detailed Answer: 195
A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:
- A. Uses an electric blanket at night
- B. Dresses in extra layers of clothing
- C. Applies a heating pad to her feet
- D. Takes a hot bath morning and evening
Quick Answers: 187
Detailed Answer: 195
A client has been hospitalized with a diagnosis of laryngeal cancer. Which factor is most significant in the development of laryngeal cancer?
- A. A family history of laryngeal cancer
- B. Chronic inhalation of noxious fumes
- C. Frequent straining of the vocal cords
- D. A history of alcohol and tobacco use
Quick Answers: 187
Detailed Answer: 195
The nurse is completing an assessment history of a client with pernicious anemia. Which complaint differentiates pernicious anemia from other types of anemia?
- A. Difficulty in breathing after exertion
- B. Numbness and tingling in the extremities
- C. A faster-than-usual heart rate
- D. Feelings of lightheadedness
Quick Answers: 187
Detailed Answer: 195
The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to:
- A. Speak using words that rhyme
- B. Repeat words or phrases used by others
- C. Include irrelevant details in conversation
- D. Make up new words with new meanings
Quick Answers: 187
Detailed Answer: 195
Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?
- A. Brushing the teeth
- B. Drinking a glass of juice
- C. Drinking a cup of coffee
- D. Brushing the hair
Quick Answers: 187
Detailed Answer: 195
A newborn weighed 7 pounds at birth. At 6 months of age, the infant could be expected to weigh:
- A. 14 pounds
- B. 18 pounds
- C. 25 pounds
- D. 30 pounds
Quick Answers: 187
Detailed Answer: 195
A client with nontropical sprue has an exacerbation of symptoms. Which meal selection is responsible for the recurrence of the client’s symptoms?
- A. Tossed salad with oil and vinegar dressing
- B. Baked potato with sour cream and chives
- C. Cream of tomato soup and crackers
- D. Mixed fruit and yogurt
Quick Answers: 187
Detailed Answer: 196
A client with congestive heart failure has been receiving Digoxin (lanoxin). Which finding indicates that the medication is having a desired effect?
- A. Increased urinary output
- B. Stabilized weight
- C. Improved appetite
- D. Increased pedal edema
Quick Answers: 187
Detailed Answer: 196
Which play activity is best suited to the gross motor skills of the toddler?
- A. Coloring book and crayons
- B. Ball
- C. Building cubes
- D. Swing set
Quick Answers: 187
Detailed Answer: 196
The physician has ordered Basalgel (aluminum carbonate gel) for a client with recurrent indigestion. The nurse should teach the client common side effects of the medication, which include:
- A. Constipation
- B. Urinary retention
- C. Diarrhea
- D. Confusion
Quick Answers: 187
Detailed Answer: 196
A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is:
- A. Loss of sensation in the lower extremities
- B. Back pain that lessens when standing
- C. Decreased urinary output
- D. Pulsations in the periumbilical area
Quick Answers: 187
Detailed Answer: 196
A client is admitted with acute adrenal crisis. During the intake assessment, the nurse can expect to find that the client has:
- A. Low blood pressure
- B. Slow, regular pulse
- C. Warm, flushed skin
- D. Increased urination
Quick Answers: 187
Detailed Answer: 196
An elderly client is hospitalized for a transurethral prostatectomy. Which finding should be reported to the doctor immediately?
- A. Hourly urinary output of 40–50cc
- B. Bright red urine with many clots
- C. Dark red urine with few clots
- D. Requests for pain med q 4 hrs.
Quick Answers: 187
Detailed Answer: 196
A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of polymigratory arthritis?
- A. Irregular movements of the extremities and facial grimacing
- B. Painless swelling over the extensor surfaces of the joints
- C. Faint areas of red demarcation over the back and abdomen
- D. Swelling, inflammation, and effusion of the joints
Quick Answers: 187
Detailed Answer: 196
A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the tent is to:
- A. Prevent insensible water loss
- B. Provide a moist environment with oxygen at 30%
- C. Prevent dehydration and reduce fever
- D. Liquefy secretions and relieve laryngeal spasm
Quick Answers: 187
Detailed Answer: 196
A client is admitted with a diagnosis of hypothyroidism. An initial assessment of the client would reveal:
- A. Slow pulse rate, weight loss, diarrhea, and cardiac failure
- B. Weight gain, lethargy, slowed speech, and decreased respiratory rate
- C. Rapid pulse, constipation, and bulging eyes
- D. Decreased body temperature, weight loss, and increased respirations
Quick Answers: 187
Detailed Answer: 196
Which statement describes the contagious stage of varicella?
- A. The contagious stage is 1 day before the onset of the rash until the appearance of vesicles.
- B. The contagious stage lasts during the vesicular and crusting stages of the lesions.
- C. The contagious stage is from the onset of the rash until the rash disappears.
- D. The contagious stage is 1 day before the onset of the rash until all the lesions are crusted.
Quick Answers: 187
Detailed Answer: 197
A client admitted to the psychiatric unit claims to be the Son of God and insists that he will not be kept away from his followers. The most likely explanation for the client’s delusion is:
- A. A religious experience
- B. A stressful event
- C. Low self-esteem
- D. Overwhelming anxiety
Quick Answers: 187
Detailed Answer: 197
The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?
- A. Reluctance to swallow
- B. Drooling of blood-tinged saliva
- C. An axillary temperature of 99°F
- D. Respiratory stridor
Quick Answers: 187
Detailed Answer: 197
The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort lessens when he:
- A. Skips a meal
- B. Rests in recumbent position
- C. Eats a meal
- D. Sits upright after eating
Quick Answers: 187
Detailed Answer: 197
Which of the following meal selections is appropriate for the client with celiac disease?
- A. Toast, jam, and apple juice
- B. Peanut butter cookies and milk
- C. Rice Krispies bar and milk
- D. Cheese pizza and Kool-Aid
Quick Answers: 187
Detailed Answer: 197
A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client’s medication?
- A. The client complains of blurred vision.
- B. The client complains of increased thirst and increased urination.
- C. The client complains of increased weight gain over the past year.
- D. The client complains of changes in taste.
Quick Answers: 187
Detailed Answer: 197
A 2-month-old infant has just received her first Tetraimmune injection. The nurse should tell the mother that the immunization:
- A. Will need to be repeated when the child is 4 years of age
- B. Is given to determine whether the child is susceptible to pertussis
- C. Is one of a series of injections that protects against dpt and Hib
- D. Is a one-time injection that protects against MMR and varicella
Quick Answers: 187
Detailed Answer: 197
The nurse is caring for a client hospitalized with bipolar disorder, manic phase. Which of the following snacks would be best for the client with mania?
- A. Potato chips
- B. Diet cola
- C. Apple
- D. Milkshake
Quick Answers: 187
Detailed Answer: 197
A 2-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?
- A. “Currant jelly” stools
- B. Projectile vomiting
- C. “Ribbonlike” stools
- D. Palpable mass over the flank
Quick Answers: 187
Detailed Answer: 197
A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:
- A. Remove the unsightly markings with acetone or alcohol
- B. Cover the radiation site with loose gauze dressing
- C. Sprinkle baby powder over the radiated area
- D. Refrain from using soap or lotion on the marked area
Quick Answers: 187
Detailed Answer: 197
The nurse is caring for a client with acromegaly. Following a transphenoidal hypophysectomy, the nurse should:
- A. Monitor the client’s blood sugar
- B. Suction the mouth and pharynx every hour
- C. Place the client in low Trendelenburg position
- D. Encourage the client to cough
Quick Answers: 187
Detailed Answer: 197
A client newly diagnosed with diabetes is started on Precose (acarbose). The nurse should tell the client that the medication should be taken:
- A. 1 hour before meals
- B. 30 minutes after meals
- C. With the first bite of a meal
- D. Daily at bedtime
Quick Answers: 187
Detailed Answer: 198
A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:
- A. Apply a lanolin-based lotion to the skin
- B. Wash the skin with water and pat dry
- C. Cover the area with a petroleum gauze
- D. Apply an occlusive dressing to the site
Quick Answers: 187
Detailed Answer: 198
A client with a laryngectomy returns from surgery with a nasogastric tube in place. The primary reason for placement of the nasogastric tube is to:
- A. Prevent swelling and dysphagia
- B. Decompress the stomach via suction
- C. Prevent contamination of the suture line
- D. Promote healing of the oral mucosa
Quick Answers: 187
Detailed Answer: 198
The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with:
- A. Speaking and writing
- B. Comprehending spoken words
- C. Carrying out purposeful motor activity
- D. Recognizing and using an object correctly
Quick Answers: 188
Detailed Answer: 198
A camp nurse is applying sunscreen to a group of children enrolled in swim classes. Chemical sunscreens are most effective when applied:
- A. Just before sun exposure
- B. 5 minutes before sun exposure
- C. 15 minutes before sun exposure
- D. 30 minutes before sun exposure
Quick Answers: 188
Detailed Answer: 198
A post-operative client has an order for Demerol (meperidine) 75mg and Phenergan (promethazine) 25mg IM every 3–4 hours as needed for pain. The combination of the two medications produces a/an:
- A. Agonist effect
- B. Synergistic effect
- C. Antagonist effect
- D. Excitatory effect
Quick Answers: 188
Detailed Answer: 198
Before administering a client’s morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
- A. Record the pulse rate and administer the medication
- B. Administer the medication and monitor the heart rate
- C. Withhold the medication and notify the doctor
- D. Withhold the medication until the heart rate increases
Quick Answers: 188
Detailed Answer: 198
What information should the nurse give a new mother regarding the introduction of solid foods for her infant?
- A. Solid foods should not be given until the extrusion reflex disappears, at 8–10 months of age.
- B. Solid foods should be introduced one at a time, with 4- to 7-day intervals.
- C. Solid foods can be mixed in a bottle or infant feeder to make feeding easier.
- D. Solid foods should begin with fruits and vegetables.
Quick Answers: 188
Detailed Answer: 198
A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:
- A. Withholding all morning medications
- B. Ordering a CBC and CPK
- C. Administering prescribed anti-Parkinsonian medication
- D. Transferring the client to a medical unit
Quick Answers: 188
Detailed Answer: 198
A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid:
- A. Calcium-rich foods
- B. Canned or frozen vegetables
- C. Processed meat
- D. Raw fruits and vegetables
Quick Answers: 188
Detailed Answer: 198
A 4-year-old is admitted with acute leukemia. It will be most important to monitor the child for:
- A. Abdominal pain and anorexia
- B. Fatigue and bruising
- C. Bleeding and pallor
- D. Petechiae and mucosal ulcers
Quick Answers: 188
Detailed Answer: 199
A 5-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:
- A. Preventing infection
- B. Administering antipyretics
- C. Keeping the skin free of moisture
- D. Limiting oral fluid intake
Quick Answers: 188
Detailed Answer: 199
The nurse is caring for a client with a history of diverticulitis. The client complains of abdominal pain, fever, and diarrhea. Which food was responsible for the client’s symptoms?
- A. Mashed potatoes
- B. Steamed carrots
- C. Baked fish
- D. Whole-grain cereal
Quick Answers: 188
Detailed Answer: 199
The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client’s cancer is located in:
- A. The tail of the pancreas
- B. The head of the pancreas
- C. The body of the pancreas
- D. The entire pancreas
Quick Answers: 188
Detailed Answer: 199
A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is:
- A. Weight gain
- B. Hair loss
- C. Sore throat
- D. Brittle nails
Quick Answers: 188
Detailed Answer: 199
The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is to:
- A. Prevent addiction
- B. Alleviate pain
- C. Facilitate mobility
- D. Prevent nausea
Quick Answers: 188
Detailed Answer: 199
Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
- A. Oxygen saturation
- B. Respiratory rate
- C. Breath sounds
- D. Arterial blood gases
Quick Answers: 188
Detailed Answer: 199
A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices:
- A. Gastric distress
- B. Changes in hearing
- C. Red discoloration of bodily fluids
- D. Changes in color vision
Quick Answers: 188
Detailed Answer: 199
The primary cause of anemia in a client with chronic renal failure is:
- A. Poor iron absorption
- B. Destruction of red blood cells
- C. Lack of intrinsic factor
- D. Insufficient erythropoietin
Quick Answers: 188
Detailed Answer: 199
Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram?
- A. Providing the client with a favorite meal for dinner
- B. Asking if the client has allergies to shellfish
- C. Encouraging fluids the evening before the test
- D. Telling the client what to expect during the test
Quick Answers: 188
Detailed Answer: 199
The doctor has prescribed aspirin 325mg daily for a client with transient ischemic attacks. The nurse knows that aspirin was prescribed to:
- A. Prevent headaches
- B. Boost coagulation
- C. Prevent cerebral anoxia
- D. Keep platelets from clumping together
Quick Answers: 188
Detailed Answer: 199
A client with tuberculosis who has been receiving combined therapy with INH and Rifampin asks the nurse how long he will have to take medication. The nurse should tell the client that:
- A. Medication is rarely needed after 2 weeks.
- B. He will need to take medication the rest of his life.
- C. The course of combined therapy is usually 6 months.
- D. He will be re-evaluated in 1 month to see if further medication is needed.
Quick Answers: 188
Detailed Answer: 199
Which development milestone puts the 4-month-old infant at greatest risk for injury?
- A. Switching objects from one hand to another
- B. Crawling
- C. Standing
- D. Rolling over
Quick Answers: 188
Detailed Answer: 199
A client taking Dilantin (phenytoin) for tonic-clonic seizures is preparing for discharge. Which information should be included in the client’s discharge care plan?
- A. The medication can cause dental staining.
- B. The client will need to avoid a high-carbohydrate diet.
- C. The client will need a regularly scheduled CBC.
- D. The medication can cause problems with drowsiness.
Quick Answers: 188
Detailed Answer: 200
Assessment of a newborn male reveals that the infant has hypospadias. The nurse knows that:
- A. The infant should not be circumcised.
- B. Surgical correction will be done by 6 months of age.
- C. Surgical correction is delayed until 6 years of age.
- D. The infant should be circumcised to facilitate voiding.
Quick Answers: 188
Detailed Answer: 200
The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a low-cholesterol diet?
- A. Safflower oil
- B. Sunflower oil
- C. Coconut oil
- D. Canola oil
Quick Answers: 188
Detailed Answer: 200
The nurse is caring for a client with stage III Alzheimer’s disease. A characteristic of this stage is:
- A. Memory loss
- B. Failing to recognize familiar objects
- C. Wandering at night
- D. Failing to communicate
Quick Answers: 188
Detailed Answer: 200
The doctor has prescribed Cortone (cortisone) for a client with systemic lupus erythematosis. Which instruction should be given to the client?
- A. Take the medication 30 minutes before eating.
- B. Report changes in appetite and weight.
- C. Wear sunglasses to prevent cataracts.
- D. Schedule a time to take the influenza vaccine.
Quick Answers: 188
Detailed Answer: 200
The nurse is caring for a client with an above-the-knee amputation (AKA). To prevent contractures, the nurse should:
- A. Place the client in a prone position 15–30 minutes twice a day
- B. Keep the foot of the bed elevated on shock blocks
- C. Place trochanter rolls on either side of the affected leg
- D. Keep the client’s leg elevated on two pillows
Quick Answers: 188
Detailed Answer: 200
The mother of a 6-month-old asks when her child will have all his baby teeth. The nurse knows that most children have all their primary teeth by age:
- A. 12 months
- B. 18 months
- C. 24 months
- D. 30 months
Quick Answers: 188
Detailed Answer: 200
While caring for a client with cervical cancer, the nurse notes that the radioactive implant is lying in the bed. The nurse should:
- A. Place the implant in a biohazard bag and return it to the lab
- B. Give the client a pair of gloves and ask her to reinsert the implant
- C. Use tongs to pick up the implant and return it to a lead-lined container
- D. Discard the implant in the commode and double-flush
Quick Answers: 188
Detailed Answer: 200
The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should:
- A. Tell the client to avoid a tub bath for 5 to 7 days
- B. Tell the client to expect clay-colored stools
- C. Tell the client that she can expect lower abdominal pain for the next week
- D. Tell the client that she can resume a regular diet immediately
Quick Answers: 188
Detailed Answer: 200
A high school student returns to school following a 3-week absence due to mononucleosis. The school nurse knows it will be important for the client:
- A. To drink additional fluids throughout the day
- B. To avoid contact sports for 1–2 months
- C. To have a snack twice a day to prevent hypoglycemia
- D. To continue antibiotic therapy for 6 months
Quick Answers: 188
Detailed Answer: 200
A 6-year-old with cystic fibrosis has an order for pancreatic replacement. The nurse knows that the medication will be given:
- A. At bedtime
- B. With meals and snacks
- C. Twice daily
- D. Daily in the morning
Quick Answers: 188
Detailed Answer: 201
The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia. Which foods are highest in B12?
- A. Meat, eggs, dairy products
- B. Peanut butter, raisins, molasses
- C. Broccoli, cauliflower, cabbage
- D. Shrimp, legumes, bran cereals
Quick Answers: 188
Detailed Answer: 201
A client with hypertension has begun an aerobic exercise program. The nurse should tell the client that the recommended exercise regimen should begin slowly and build up to:
- A. 20–30 minutes three times a week
- B. 45 minutes two times a week
- C. 1 hour four times a week
- D. 1 hour two times a week
Quick Answers: 188
Detailed Answer: 201
A client with breast cancer is returned to the room following a right total mastectomy. The nurse should:
- A. Elevate the client’s right arm on pillows
- B. Place the client’s right arm in a dependent sling
- C. Keep the client’s right arm on the bed beside her
- D. Place the client’s right arm across her body
Quick Answers: 188
Detailed Answer: 201
A neurological consult has been ordered for a pediatric client with suspected absence seizures. The client with absence seizures can be expected to have:
- A. Short, abrupt muscle contraction
- B. Quick, bilateral severe jerking movements
- C. Abrupt loss of muscle tone
- D. A brief lapse in consciousness
Quick Answers: 188
Detailed Answer: 201
A client with schizoaffective disorder is exhibiting Parkinsonian symptoms. Which medication is responsible for the development of Parkinsonian symptoms?
- A. Zyprexa (olanzapine)
- B. Cogentin (benzatropine mesylate)
- C. Benadryl (diphenhydramine)
- D. Depakote (divalproex sodium)
Quick Answers: 188
Detailed Answer: 201
Which activity is best suited to the 12-year-old with juvenile rheumatoid arthritis?
- A. Playing video games
- B. Swimming
- C. Working crossword puzzles
- D. Playing slow-pitch softball
Quick Answers: 188
Detailed Answer: 201
The glycosylated hemoglobin of a 40-year-old client with diabetes mellitus is 2.5%. The nurse understands that:
- A. The client can have a higher-calorie diet.
- B. The client has good control of her diabetes.
- C. The client requires adjustment in her insulin dose.
- D. The client has poor control of her diabetes.
Quick Answers: 188
Detailed Answer: 201
The physician has ordered Stadol (butorphanol) for a post-operative client. The nurse knows that the medication is having its intended effect if the client:
- A. Is asleep 30 minutes after the injection
- B. Asks for extra servings on his meal tray
- C. Has an increased urinary output
- D. States that he is feeling less nauseated
Quick Answers: 188
Detailed Answer: 201
The mother of a child with cystic fibrosis tells the nurse that her child makes “snoring” sounds when breathing. The nurse is aware that many children with cystic fibrosis have:
- A. Choanal atresia
- B. Nasal polyps
- C. Septal deviations
- D. Enlarged adenoids
Quick Answers: 188
Detailed Answer: 202
A client is hospitalized with hepatitis A. Which of the client’s regular medications is contraindicated due to the current illness?
- A. Prilosec (omeprazole)
- B. Synthroid (levothyroxine)
- C. Premarin (conjugated estrogens)
- D. Lipitor (atorvastatin)
Quick Answers: 188
Detailed Answer: 202
The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates that the client understands his new diet?
- A. Cornflakes, whole milk, banana, and coffee
- B. Scrambled eggs, bacon, toast, and coffee
- C. Oatmeal, apple juice, dry toast, and coffee
- D. Pancakes, ham, tomato juice, and coffee
Quick Answers: 188
Detailed Answer: 202
An 18-month-old is being discharged following hypospadias repair. Which instruction should be included in the nurse’s discharge teaching?
- A. The child should not play on his rocking horse.
- B. Applying warm compresses to decrease pain.
- C. Diapering should be avoided for 1–2 weeks.
- D. The child will need a special diet to promote healing.
Quick Answers: 188
Detailed Answer: 202
An obstetrical client calls the clinic with complaints of morning sickness. The nurse should tell the client to:
- A. Keep crackers at the bedside for eating before she arises
- B. Drink a glass of whole milk before going to sleep at night
- C. Skip breakfast but eat a larger lunch and dinner
- D. Drink a glass of orange juice after adding a couple of teaspoons of sugar
Quick Answers: 188
Detailed Answer: 202
The nurse has taken the blood pressure of a client hospitalized with methicillin-resistant staphylococcus aureus. Which action by the nurse indicates an understanding regarding the care of clients with MRSA?
- A. The nurse leaves the stethoscope in the client’s room for future use.
- B. The nurse cleans the stethoscope with alcohol and returns it to the exam room.
- C. The nurse uses the stethoscope to assess the blood pressure of other assigned clients.
- D. The nurse cleans the stethoscope with water, dries it, and returns it to the nurse’s station.
Quick Answers: 188
Detailed Answer: 202
The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician’s teaching by telling the parents that:
- A. The medication will be needed only during times of rapid growth.
- B. The medication will be needed throughout the child’s lifetime.
- C. The medication schedule can be arranged to allow for drug holidays.
- D. The medication is given one time daily every other day.
Quick Answers: 188
Detailed Answer: 202
A client with diabetes mellitus has a prescription for Glucotrol XL (glipizide). The client should be instructed to take the medication:
- A. At bedtime
- B. With breakfast
- C. Before lunch
- D. After dinner
Quick Answers: 188
Detailed Answer: 202
The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis?
- A. Visual disturbances, including diplopia
- B. Ascending paralysis and loss of motor function
- C. Cogwheel rigidity and loss of coordination
- D. Progressive weakness that is worse at the day’s end
Quick Answers: 188
Detailed Answer: 202
The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should tell the parents:
- A. That the infant will need daily calcium supplements
- B. To lift the infant by the buttocks when diapering
- C. That the condition is a temporary one
- D. That only the bones are affected by the disease
Quick Answers: 188
Detailed Answer: 202
Physician’s orders for a client with acute pancreatitis include the following: strict NPO, NG tube to low intermittent suction. The nurse recognizes that these interventions will:
- A. Reduce the secretion of pancreatic enzymes
- B. Decrease the client’s need for insulin
- C. Prevent secretion of gastric acid
- D. Eliminate the need for analgesia
Quick Answers: 188
Detailed Answer: 203
A client with diverticulitis is admitted with nausea, vomiting, and dehydration. Which finding suggests a complication of diverticulitis?
- A. Pain in the left lower quadrant
- B. Boardlike abdomen
- C. Low-grade fever
- D. Abdominal distention
Quick Answers: 188
Detailed Answer: 203
The diagnostic work-up of a client hospitalized with complaints of progressive weakness and fatigue confirms a diagnosis of myasthenia gravis. The medication used to treat myasthenia gravis is:
- A. Prostigmin (neostigmine)
- B. Atropine (atropine sulfate)
- C. Didronel (etidronate)
- D. Tensilon (edrophonium)
Quick Answers: 188
Detailed Answer: 203
A client with AIDS complains of a weight loss of 20 pounds in the past month. Which diet is suggested for the client with AIDS?
- A. High calorie, high protein, high fat
- B. High calorie, high carbohydrate, low protein
- C. High calorie, low carbohydrate, high fat
- D. High calorie, high protein, low fat
Quick Answers: 188
Detailed Answer: 203
The nurse is caring for a 4-year-old with cerebral palsy. Which nursing intervention will help ready the child for rehabilitative services?
- A. Patching one of the eyes to strengthen the muscles
- B. Providing suckers and pinwheels to help strengthen tongue movement
- C. Providing musical tapes to provide auditory training
- D. Encouraging play with a video game to improve muscle coordination
Quick Answers: 188
Detailed Answer: 203
At the 6-week check-up, the mother asks when she can expect the baby to sleep all night. The nurse should tell the mother that most infants begin to sleep all night by age:
- A. 1 month
- B. 2 months
- C. 3–4 months
- D. 5–6 months
Quick Answers: 188
Detailed Answer: 203
Which of the following pediatric clients is at greatest risk for latex allergy?
- A. The child with a myelomeningocele
- B. The child with epispadias
- C. The child with coxa plana
- D. The child with rheumatic fever
Quick Answers: 188
Detailed Answer: 203
The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
- A. Use the heel of her hand during percussion
- B. Change the child’s position every 20 minutes
- C. Do percussion after the child eats and at bedtime
- D. Use cupped hands during percussion
Quick Answers: 188
Detailed Answer: 203
The nurse calculates the amount of an antibiotic for injection to be given to an infant. The amount of medication to be administered is 1.25mL. The nurse should:
- A. Divide the amount into two injections and administer in each vastus lateralis muscle
- B. Give the medication in one injection in the dorso-gluteal muscle
- C. Divide the amount in two injections and give one in the ventrogluteal muscle and one in the vastus lateralis muscle
- D. Give the medication in one injection in the ventro-gluteal muscle
Quick Answers: 188
Detailed Answer: 203
A client with schizophrenia is receiving depot injections of Haldol Deconate (haloperidol decanoate). The client should be told to return for his next injection in:
- A. 1 week
- B. 2 weeks
- C. 4 weeks
- D. 6 weeks
Quick Answers: 188
Detailed Answer: 203
A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?
- A. Keep the bed flat, with a small pillow beneath the cast
- B. Provide crayons and a coloring book for play activity
- C. Increase her intake of high-calorie foods for healing
- D. Tuck a disposable diaper beneath the cast at the perineal opening
Quick Answers: 188
Detailed Answer: 204
The nurse is caring for a client following the reimplantation of the thumb and index finger. Which finding should be reported to the physician immediately?
- A. Temperature of 100°F
- B. Coolness and discoloration of the digits
- C. Complaints of pain
- D. Difficulty moving the digits
Quick Answers: 188
Detailed Answer: 204
When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find:
- A. Cherry-red urine that gradually becomes clearer
- B. Orange-tinged urine containing particles of calculi
- C. Dark red urine that becomes cloudy in appearance
- D. Dark, smoky-colored urine with high specific gravity
Quick Answers: 188
Detailed Answer: 204
The physician has prescribed Cognex (tacrine) for a client with dementia. The nurse should monitor the client for adverse reactions, which include:
- A. Hypoglycemia
- B. Jaundice
- C. Urinary retention
- D. Tinnitus
Quick Answers: 188
Detailed Answer: 204
The physician has ordered a low-potassium diet for a child with acute glomerulonephritis. Which snack is suitable for the child with potassium restrictions?
- A. Raisins
- B. Oranges
- C. Apricots
- D. Bananas
Quick Answers: 188
Detailed Answer: 204
The physician has ordered a blood test for H. pylori. The nurse should prepare the client by:
- A. Withholding intake after midnight
- B. Telling the client that no special preparation is needed
- C. Explaining that a small dose of radioactive isotope will be used
- D. Giving an oral suspension of glucose 1 hour before the test
Quick Answers: 188
Detailed Answer: 204
The nurse is preparing to give an oral potassium supplement. The nurse should:
- A. Give the medication without diluting it
- B. Give the medication with 4oz. of juice
- C. Give the medication with water only
- D. Give the medication on an empty stomach
Quick Answers: 188
Detailed Answer: 204
The physician has ordered cultures for cytomegalovirus (CMV). Which statement is true regarding collection of cultures for cytomegalovirus?
- A. Stool cultures are preferred for definitive diagnosis.
- B. Pregnant caregivers may obtain cultures.
- C. Collection of one specimen is sufficient.
- D. Accurate diagnosis depends on fresh specimens.
Quick Answers: 188
Detailed Answer: 204
A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
- A. Will cause dark staining of the surrounding skin
- B. Produces a cooling sensation when applied
- C. Can alter the function of the thyroid
- D. Produces a burning sensation when applied
Quick Answers: 188
Detailed Answer: 204
The physician has ordered Dilantin (phenytoin) for a client with generalized seizures. When planning the client’s care, the nurse should:
- A. Maintain strict intake and output
- B. Check the pulse before giving the medication
- C. Administer the medication 30 minutes before meals
- D. Provide oral hygiene and gum care every shift
Quick Answers: 188
Detailed Answer: 204
A client receiving chemotherapy for breast cancer has an order for Zofran (ondansetron) to be given IV 30 minutes before induction of the chemotherapy. The purpose of the medication is to:
- A. Prevent anemia
- B. Promote relaxation
- C. Prevent nausea
- D. Increase neutrophil counts
Quick Answers: 188
Detailed Answer: 204
The physician has ordered Cortisporin ear drops for a 2-year-old. To administer the ear drops, the nurse should:
- A. Pull the ear down and back
- B. Pull the ear straight out
- C. Pull the ear up and back
- D. Leave the ear undisturbed
Quick Answers: 188
Detailed Answer: 205
A client with schizophrenia has been taking Thorazine (chlorpromazine) 200mg four times a day. Which finding should be reported to the doctor immediately?
- A. The client complains of thirst.
- B. The client has gained 4 pounds in the past 2 months.
- C. The client complains of a sore throat.
- D. The client naps throughout the day.
Quick Answers: 188
Detailed Answer: 205
A client with iron-deficiency anemia is taking an oral iron supplement. The nurse should tell the client to take the medication with:
- A. Orange juice
- B. Water only
- C. Milk
- D. Apple juice
Quick Answers: 188
Detailed Answer: 205
A client is admitted with burns of the right arm, chest, and head. According to the Rule of Nines, the percent of burn injury is:
- A. 18%
- B. 27%
- C. 36%
- D. 45%
Quick Answers: 188
Detailed Answer: 205
A client who was admitted with chest pain and shortness of breath has a standing order for oxygen via mask. Standing orders for oxygen mean that the nurse can apply oxygen at:
- A. 2L per minute
- B. 6L per minute
- C. 10L per minute
- D. 12L per minute
Quick Answers: 188
Detailed Answer: 205
The nurse is caring for a client with an ileostomy. The nurse should pay careful attention to care around the stoma because:
- A. Digestive enzymes cause skin breakdown.
- B. Stools are less watery and contain more solid matter.
- C. The stoma will heal more slowly than expected.
- D. It is difficult to fit the appliance to the stoma site.
Quick Answers: 188
Detailed Answer: 205
The physician has ordered aspirin therapy for a client with severe rheumatoid arthritis. A sign of acute aspirin toxicity is:
- A. Anorexia
- B. Diarrhea
- C. Tinnitus
- D. Pruritis
Quick Answers: 188
Detailed Answer: 205
A client is admitted to the emergency room with symptoms of delirium tremens. After admitting the client to a private room, the priority nursing intervention is to:
- A. Obtain a history of his alcohol use
- B. Provide seizure precautions
- C. Keep the room cool and dark
- D. Administer thiamine and zinc
Quick Answers: 188
Detailed Answer: 205
The nurse is providing dietary teaching for a client with gout. Which dietary selection is suitable for the client with gout?
- A. Broiled liver, macaroni and cheese, spinach
- B. Stuffed crab, steamed rice, peas
- C. Baked chicken, pasta salad, asparagus casserole
- D. Steak, baked potato, tossed salad
Quick Answers: 188
Detailed Answer: 205
A newborn has been diagnosed with exstrophy of the bladder. The nurse should position the newborn:
- A. Prone
- B. Supine
- C. On either side
- D. With the head elevated
Quick Answers: 188
Detailed Answer: 205
The mother of a 3-month-old with esophageal reflux asks the nurse what she can do to lessen the baby’s reflux. The nurse should tell the mother to:
- A. Feed the baby only when he is hungry
- B. Burp the baby after the feeding is completed
- C. Place the baby supine with head elevated
- D. Burp the baby frequently throughout the feeding
Quick Answers: 188
Detailed Answer: 205
A child is hospitalized with a fractured femur involving the epiphysis. Epiphyseal fractures are serious because:
- A. Bone marrow is lost through the fracture site.
- B. Normal bone growth is affected.
- C. Blood supply to the bone is obliterated.
- D. Callus formation prevents bone healing.
Quick Answers: 188
Detailed Answer: 206
Before administering a nasogastric feeding to a client hospitalized following a CVA, the nurse aspirates 40mL of residual. The nurse should:
- A. Replace the aspirate and administer the feeding
- B. Discard the aspirate and withhold the feeding
- C. Discard the aspirate and begin the feeding
- D. Replace the aspirate and withhold the feeding
Quick Answers: 188
Detailed Answer: 206
A client has an order for Dilantin (phenytoin) .2g orally twice a day. The medication is available in 100mg capsules. For the morning medication, the nurse should administer:
- A. 1 capsule
- B. 2 capsules
- C. 3 capsules
- D. 4 capsules
Quick Answers: 188
Detailed Answer: 206
The LPN is reviewing the lab results of an elderly client when she notes a specific gravity of 1.025. The nurse recognizes that:
- A. The client has impaired renal function.
- B. The client has a normal specific gravity.
- C. The client has mild to moderate dehydration.
- D. The client has diluted urine from fluid overload.
Quick Answers: 188
Detailed Answer: 206
A client with acute pancreatitis has requested pain medication. Which pain medication is indicated for the client with acute pancreatitis?
- A. Demerol (meperidine)
- B. Toradol (ketorolac)
- C. Morphine (morphine sulfate)
- D. Codeine (codeine)
Quick Answers: 188
Detailed Answer: 206
A client with a hiatal hernia has been taking magnesium hydroxide for relief of heartburn. Overuse of magnesium-based antacids can cause the client to have:
- A. Constipation
- B. Weight gain
- C. Anorexia
- D. Diarrhea
Quick Answers: 188
Detailed Answer: 206
When performing a newborn assessment, the nurse measures the circumference of the neonate’s head and chest. Which assessment finding is expected in the normal newborn?
- A. The head and chest circumference are the same.
- B. The head is 2cm larger than the chest.
- C. The head is 3cm smaller than the chest.
- D. The head is 4cm larger than the chest.
Quick Answers: 188
Detailed Answer: 206
A client with a history of clots is receiving Lovenox (enoxaparin). Which drug is given to counteract the effects of enoxaparin?
- A. Calcium gluconate
- B. Aquamephyton
- C. Methergine
- D. Protamine sulfate
Quick Answers: 188
Detailed Answer: 206
The nurse is formulating a plan of care for a client with a cognitive disorder. Which activity is most appropriate for the client with confusion and short attention span?
- A. Taking part in a reality-orientation group
- B. Participating in unit community goal setting
- C. Going on a field trip with a group of clients
- D. Meeting with an assertiveness training group
Quick Answers: 188
Detailed Answer: 206
The mother of a child with hemophilia asks the nurse which over-the-counter medication is suitable for her child’s joint discomfort. The nurse should tell the mother to purchase:
- A. Advil (ibuprofen)
- B. Tylenol (acetaminophen)
- C. Aspirin (acetylsalicytic acid)
- D. Naproxen (naprosyn)
Quick Answers: 188
Detailed Answer: 206
Which home remedy is suitable to relieve the itching associated with varicella?
- A. Dusting the lesions with baby powder
- B. Applying gauze saturated in hydrogen peroxide
- C. Using cool compresses of normal saline
- D. Applying a paste of baking soda and water
Quick Answers: 188
Detailed Answer: 206
The nurse is caring for a newborn with hypospadias. Which statement describes hypospadias?
- A. The urinary meatus is located on the underside of the penis rather than the tip.
- B. The ureters allow a reflux of urine into the kidneys.
- C. The urinary meatus is located on the topside of the penis rather than the tip.
- D. The bladder lies outside the abdominal cavity.
Quick Answers: 188
Detailed Answer: 207
The recommended time for daily administration of Tagamet (cimetidine) is:
- A. Before breakfast
- B. Mid-afternoon
- C. After dinner
- D. At bedtime
Quick Answers: 188
Detailed Answer: 207
Which statement best describes the difference between the pain of angina and the pain of myocardial infarction?
- A. Pain associated with angina is relieved by rest.
- B. Pain associated with myocardial infarction is always more severe.
- C. Pain associated with angina is confined to the chest area.
- D. Pain associated with myocardial infarction is referred to the left arm.
Quick Answers: 188
Detailed Answer: 207
The nurse is developing a bowel-retraining plan for a client with multiple sclerosis. Which measure is likely to be least helpful to the client:
- A. Limiting fluid intake to 1000mL per day
- B. Providing a high-roughage diet
- C. Elevating the toilet seat for easy access
- D. Establishing a regular schedule for toileting
Quick Answers: 188
Detailed Answer: 207
The nurse is providing dietary teaching for a client with Meniere’s disease. Which statement indicates that the client understands the role of diet in triggering her symptoms?
- A. “I can expect to see more problems with tinnitus if I eat a lot of dairy products.”
- B. “I need to limit foods that taste salty or that contain a lot of sodium.”
- C. “I can help control problems with vertigo if I avoid breads and cereals.”
- D. “I need to eat fewer foods that are high in potassium, such as raisins and bananas.”
Quick Answers: 189
Detailed Answer: 207
The nurse is assessing a multigravida, 36 weeks gestation for symptoms of pregnancy-induced hypertension and preeclampsia. The nurse should give priority to assessing the client for:
- A. Facial swelling
- B. Pulse deficits
- C. Ankle edema
- D. Diminished reflexes
Quick Answers: 189
Detailed Answer: 207
An adolescent with borderline personality disorders is hospitalized with suicidal ideation and self-mutilation. Which goal is both therapeutic and realistic for this client?
- A. The client will remain in her room when feeling overwhelmed by sadness.
- B. The client will request medication when feeling loss of emotional control.
- C. The client will leave group activities to pace when feeling anxious.
- D. The client will seek out a staff member to verbalize feelings of anger and sadness.
Quick Answers: 189
Detailed Answer: 207
A client with angina has an order for nitroglycerin ointment. Before applying the medication, the nurse should:
- A. Apply the ointment to the previous application
- B. Obtain both a radial and an apical pulse
- C. Remove the previously applied ointment
- D. Tell the client he will experience pain relief in 15 minutes
Quick Answers: 189
Detailed Answer: 207
The nurse is caring for a client who is unconscious following a fall. Which comment by the nurse will help the client become reoriented when he regains consciousness?
- A. “I am your nurse and I will be taking care of you today.”
- B. “Can you tell me your name and where you are?”
- C. “I know you are confused right now, but everything will be alright.”
- D. “You were in an accident that hurt your head. You are in the hospital.”
Quick Answers: 189
Detailed Answer: 207
Following a generalized seizure, the nurse can expect the client to:
- A. Be unable to move the extremities
- B. Be drowsy and prone to sleep
- C. Remember events before the seizure
- D. Have a drop in blood pressure
Quick Answers: 189
Detailed Answer: 207
A client with oxylate renal calculi should be taught to limit his intake of foods such as:
- A. Strawberries
- B. Oranges
- C. Apples
- D. Pears
Quick Answers: 189
Detailed Answer: 208
A 6-year-old is diagnosed with Legg-Calve Perthes disease of the right femur. An important part of the child’s care includes instructing the parents:
- A. To increase the amount of dietary protein
- B. About exercises to strengthen affected muscles
- C. About relaxation exercises to minimize pain in the joints
- D. To prevent weight bearing on the affected leg
Quick Answers: 189
Detailed Answer: 208
The nurse is assessing an infant with Hirschsprung’s disease. The nurse can expect the infant to:
- A. Weigh less than expected for height and age
- B. Have infrequent bowel movements
- C. Exhibit clubbing of the fingers and toes
- D. Have hyperactive deep tendon reflexes
Quick Answers: 189
Detailed Answer: 208
The physician has prescribed supplemental iron for a prenatal client. The nurse should tell the client to take the medication with:
- A. Milk, to prevent stomach upset
- B. Tomato juice, to increase absorption
- C. Oatmeal, to prevent constipation
- D. Water, to increase serum iron levels
Quick Answers: 189
Detailed Answer: 208
The nurse is teaching a client with a history of obesity and hypertension regarding dietary requirements during pregnancy. Which statement indicates that the client needs further teaching?
- A. “I need to reduce my daily intake to 1,200 calories a day.”
- B. “I need to drink at least a quart of milk a day.”
- C. “I shouldn’t add salt when I am cooking.”
- D. “I need to eat more protein and fiber each day.”
Quick Answers: 189
Detailed Answer: 208
An elderly client is admitted to the psychiatric unit from the nursing home. Transfer information indicates that the client has become confused and disoriented, with behavioral problems. The client will also likely show a loss of ability in:
- A. Speech
- B. Judgment
- C. Endurance
- D. Balance
Quick Answers: 189
Detailed Answer: 208
The physician has ordered an external monitor for a laboring client. If the fetus is in the left occipital posterior (LOP) position, the nurse knows that the ultrasound transducer will be located:
- A. Near the symphysis pubis
- B. Near the umbilicus
- C. Over the fetal back
- D. Over the fetal abdomen
Quick Answers: 189
Detailed Answer: 208
A client develops tremors while withdrawing from alcohol. Which medication is routinely administered to lessen physiological effects of alcohol withdrawal?
- A. Dolophine (methodone)
- B. Klonopin (clonazepam)
- C. Narcan (naloxone)
- D. Antabuse (disulfiram)
Quick Answers: 189
Detailed Answer: 208
A client with Type II diabetes has an order for regular insulin 10 units SC each morning. The client’s breakfast should be served within:
- A. 15 minutes
- B. 20 minutes
- C. 30 minutes
- D. 45 minutes
Quick Answers: 189
Detailed Answer: 208
A 10-year-old has an order for Demerol (meperidine) 35mg IM for pain. The medication is available as Demerol 50mg per mL. How much should the nurse administer?
- A. .5mL
- B. .6mL
- C. .7mL
- D. .8mL
Quick Answers: 189
Detailed Answer: 208
Which antibiotic is contraindicated for the treatment of infections in infants and young children?
- A. Tetracyn (tetracycline)
- B. Amoxil (amoxicillin)
- C. Cefotan (cefotetan)
- D. E-Mycin (erythromycin)
Quick Answers: 189
Detailed Answer: 208
Quick Check Answer Key
- D
- D
- A
- D
- C
- C
- A
- A
- A
- B
- B
- A
- C
- D
- B
- C
- B
- B
- D
- B
- A
- A
- B
- B
- C
- B
- B
- B
- A
- B
- D
- B
- C
- B
- A
- A
- C
- A
- D
- D
- C
- B
- A
- D
- C
- B
- B
- D
- C
- D
- A
- C
- B
- D
- A
- A
- B
- B
- D
- B
- B
- C
- A
- C
- A
- B
- A
- D
- A
- B
- D
- D
- B
- D
- C
- D
- C
- C
- B
- C
- D
- A
- D
- A
- C
- B
- C
- A
- D
- B
- C
- B
- C
- D
- C
- A
- D
- B
- C
- B
- C
- D
- D
- C
- D
- C
- D
- C
- A
- C
- B
- D
- A
- D
- C
- A
- B
- B
- A
- A
- A
- D
- A
- B
- B
- A
- B
- D
- C
- A
- A
- A
- B
- B
- D
- B
- A
- B
- A
- D
- B
- C
- A
- D
- A
- C
- D
- B
- A
- B
- C
- B
- B
- D
- D
- D
- C
- A
- C
- A
- B
- B
- A
- C
- B
- D
- C
- D
- B
- A
- B
- B
- A
- D
- B
- D
- A
- B
- D
- A
- D
- A
- A
- B
- A
- D
- C
- D
- B
- A
- D
- B
- B
- A
- B
- C
- B
- C
- C
- A