NCLEX-RN/PN

LIVE REVIEW COURSE

ORTIGAS * TAFT * SUCAT

BASIC CARE AND

COMFORT
1. After a computed tomography scan with intravenous
contrast medium, a client returns to the unit
complaining of shortness of breath and itching. The
nurse should be prepared to treat the client for

1.
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inflammation from the extravasation of fluid
during injection
2. an anaphylactic reaction to the dye
3. fluid overload from the volume of infusions
4. a normal reaction to the stress of the diagnostic
procedure
2. A nurse has given instructions to a client returning
home after arthroscopy of a knee. The nurse would
evaluate that the client understands the instructions if
the client states to

1. Complete bed rest for the rest of the day

2. Resume regular exercise the following day
3. Refrain from eating food for the remainder of the
day
4. Report fever or site inflammation to the physician
3. A client has had a bone scan done. The nurse would
evaluate that the client understands the elements of
follow-up care if the client states that he or she should

1. Report any feelings of nausea or flushing

2. Ambulate at least 3 times before the end of the
day Loading...
3. Eat only small meals for the remainder of the day
4. Drink plenty of water for 1 to 2 days following
the procedure
4. A client with possible rib fracture has never had a
chest radiograph. The nurse would plan to tell the
client which of the following items about the
procedure?
1. The x-rays stimulate a small amount of pain
2. Removal of jewelry and any other metal objects is
necessary
3. The client will be asked to breathe in and out as
the radiograph is taken
4. The x-ray technologist will stand next to the client
during the procedure
 5. The nurse is caring for a client for
Electromyography (EMG). Which of the following
is correct teaching regarding this procedure?

1) NPO for 6-8 hrs before the test

2) Needs to sleep 6-8 hrs before the test
3) There is pain when needle is inserted
4) No discomfort
 6. The nurse is caring for a client for Electromyography
(EMG). Which of the following is correct intervention
regarding this procedure?

1) Ask the patient for allergies to seafood

2) Tell the patient that he may experience
discomfort because of the needles to be used
3) Put the patient on NPO 6-8 hours.
4) Ask the patient to empty the bladder
7. When caring for a client with a fractured extremity,
the nurse would focus the assessment on which of the
following?

1. The area proximal to the fracture

2. The actual fracture site
3. The area distal to the fracture
4. The opposite extremity for baseline comparison
8. Which of the following would the nurse assess in a
client with an intracapsular hip fracture?

1. Internal rotation
2. Muscle flaccidity
3. Shortening of affected leg
4. Absence of pain in the fracture area
9. When assessing a client who has just received a
femoral head prosthesis, which of the following would
alert the nurse to the possibility of neurologic
impairment in the affected extremity?

1.
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Decreased distal pulse
2. Inability to move
3. Diminished capillary refill
4. Coolness to the touch
10. A client has fiberglass (nonplaster) cast applied to
the lower leg. The client asks the nurse when the client
will be able to walk on the cast. The nurse replies that
the client will be able to bear weight on the cast

1. Within 20 to 30 minutes of application

2. In about 8 hours
3. In 24 hours
4. In 48 hours
 11. Which of the following complaints from a client
after cast application 2 hours ago needs immediate
attention?

1) Has musty odor

2) There is slight swelling of my feet
3) My toes hurt when I wiggled it, not relieved by
narcotic I took 1 hour ago.
4) My skin itches
 12. The nurse is caring for clients with cast. Which of
the following clients should the nurse see first?

1) Client complaining of mild edema when the

affected limb is in dependent position.
2) Client telling the nurse that the cast feels loose.
3) Client telling the nurse that the skin under cast
feels warm.
4) Client telling the nurse that the cast feels cold.
 13. 24 hrs after plaster of Paris cast was applied, which
of the following health teachings is correct?

1) Apply adhesive tape to edges of cast

2) Cover the cast with water protector
3) Hold the cast with flat surface of hand
4) Blow dry in warm setting to facilitate drying of
the cast
14. Regardless of the type of cast material used, the
nurse identifies a knowledge deficit when the client
makes which of the following statements about the
care of his cast?

1. “I’ll elevate the cast above my heart initially.”

2. “”I’ll exercise my joints above and below the
cast.”
3. “I can pull out cast padding to scratch inside the
cast.”
4. “I’ll apply ice for 10 minutes to control edema for
the first 24 hours.”
 15. A client has suffered an injury to the radial bone 48
hours ago and has an arm cast. Which of the following
will you include in the health teaching for this client?

1) Use sling when ambulating

2) Use hot compress
3) Use cotton-tipped swab when itchy
4) Use cold compress
 16. A client has a fracture with radial cast applied two
hours ago using Plaster of Paris. Which of the following
should be the appropriate intervention/s for this client?
Select all that apply.

1) Assess fingers for movement.

2) Use flat portion of the hand when caring for the
cast.
3) Elevate the affected arm in two pillows.
4) Perform range of motion exercises.
5) Do not move fingers
6) Use hair dryer to facilitate drying of the cast.
 17. The nurse is caring for a client who just returned from
surgery with a long leg cast. Which of the following
interventions is the priority in the first 24 hours?

1) Position the client supine to facilitate drying of the

cast
2) Dangle the client on the side of the bed in the
evening
3) Elevate the leg on a pillow above heart level
4) Assess the cast for rough edges and smoothness
 18. Immediately after application of a plaster of paris cast,
the client asks the nurse when weight bearing may begin.
The most appropriate response by the nurse is

1) “I do not know. I will ask your physician.”

2) “It is all individualized based on how you feel.”
3) “Within 8 hours, you will be standing next to the
bed.”
4) “Generally after 24 to 48 hours.”
 19. Which of the following dietary guidelines should the
nurse provide to a client with a fracture?

1) Three large, high-calorie meals

2) High-fiber foods and 2000 to 3000 mL of fluids
daily
3) Low-protein and low-fat foods
4) Limit milk and milk products to two servings
daily
 20. Which of the following changes in a client’s
neurovascular assessment should be reported as a
critical sign of arterial insufficiency?

1)Pale extremity that is cool to touch

2)Hypersensation below the injury
3)Pain unrelieved by analgesic
4)Reduced motion in affected extremity
 21. In planning the postoperative care for a client with a
cast, the nurse would select which of the following as an
appropriate nursing diagnosis?

1) Risk for deficient fluid volume related to excess

fluid loss
2) Total urinary incontinence: related to aging
process
3) Constipation related to decreased mobility
4) Imbalanced nutrition: less than body
requirements related to lack of knowledge of
appropriate food choices
22. Which of the following neurovascular complications
should the nurse assess for after a fracture?

Select all that apply:

1. Petechiae over all extremities
2. Pallor
3. Exaggerated extremity movement
4. Deceased sensation distal to the fracture
5. Purulent drainage at the site of an open fracture
6. Pulselessness
23. A client who has had a plaster of Paris cast applied
to his forearm is receiving pain medication. To detect
early manifestations of compartment syndrome, which
of these assessments should the nurse make?

1. Observe the color of the fingers

2. Palpate the radial pulse under the cast
3. Check the cast for odor and drainage
4. Evaluate the response to analgesics
24. A client who crashed her motorcycle suffered a tibial
fracture that required casting. Approximately 5 hours later,
the client begins to complain of increasing pain distal to the
left tibial fracture despite the morphine injection
administered 30 minutes previously. The nurse’s next
action should be to assess for which of the following?

1. Presence of a distal pulse.

2. Pain with a pain rating scale.
3. Vital sign changes.
4. Potential for drug tolerance
25. A nurse has conducted teaching with a client in an arm
cast about signs and symptoms of compartment syndrome.
The nurse determines that the client understands the
information if the client stated that he or she should report
which of the following early symptoms of compartment
syndrome?

1. Pain that is relieved only by oxycodone and

aspirin (Percodan)
2. Pain that increases when the arm is dependent
3. Cold, bluish colored fingers
4. Numbness and tingling in the fingers
26. Which nursing intervention is appropriate for a
client with skeletal traction?

1. Pin care
2. Prone positioning
3. Intermittent weights
4. 5-lb weight limit
27. A client has Buck’s extension traction applied to
the right leg. The nurse would plan which of the
following interventions to prevent complications of the
device?

1. Massage the skin of the right leg with lotion every

8 hours.
2. Give pin care once a shift.
3. Loading...
Inspect the skin on the right leg at least once every
8 hours.
4. Release the weights on the right leg for range of
motion exercises daily.
28. A client with a hip fracture has undergone surgery
for insertion of a femoral head prosthesis. Which of the
following activities would the nurse instruct the client
to avoid?

1. Using an abductor splint while lying on the side

2. Crossing the legs while sitting down
3. Sitting on a raised commode seat
4. Rising straight from a chair to a standing position
 29. Before a client has skin traction applied, which of the
following should the nurse include in the instructions
given to the client?

1) Skin traction may be used for long periods of

time
2) Skin traction is applied until surgery can be
performed
3) A pin will be put in the bone
4) Weights up to 45 pounds will be applied
30. A nurse is evaluating a client’s use of a cane for
left-sided weakness. The nurse would intervene and
correct the client if the nurse observed that the client

1. holds the cane on the right side

2. keeps the cane 6 inches out to the side of the right
foot
3. moves the cane when the right leg is moved
4. leans on the cane when the right leg swings
through
 wq
31. The nurse is assisting a client to walk with a crutch for
the first time after an amputation. Which of the following
indicates the nurse correctly understands the principles of
crutch walking after an amputation?
1) Instruct the client to remove the compression
dressing before crutch walking
2) Encourage the client to place the weight of the body
on the axilla
3) Administer an analgesic 30 minutes prior to crutch
walking
4) Assist the client to crutch walk for no more than 5
minutes
 32. A client is scheduled for an open reduction internal fixation
(ORIF) of a fracture. The nurse is explaining to the client why this
procedure is necessary. Which of the following is the primary
reason for the nurse to give a client that best describes the purpose
of the ORIF?

1) “It is used when the client is in too much pain to do a

closed reduction.”
2) “It is completed whenever client cannot maintain long-
term immobility.”
3) “It is necessary when no other realignment method can be
completed.”
4) “It is necessary when a cast would be too large to provide
adequate mobility.”
 33. The nurse assesses that a client has lower-extremity weakness on the left.
What should the nurse observe the client doing to evaluate the client’s ability to
use a walker?

1) Moving both the walker and the left leg forward 6 inches, then
moving the right leg while the body weight is supported by the arms
and the left leg
2) Moving both the walker and the right leg forward 6 inches, then
moving the left leg while the body weight is supported by the arms and
the right leg
3) Moving the walker forward 12 inches, bearing the body weight on
the arms and extremities, then walking up to the walker
4) Moving both the walker and the left leg forward 12 inches, then
moving the right leg while the body weight is supported by the arms
and the left leg
 34. A client has received teaching on the use of a cane to
assist with ambulation. Which of the following statements by
the client would indicate to the nurse that further teaching is
needed?

1)“My elbows should be slightly bent when I use the cane.”

2)“I should hold the cane on my unaffected side.”
3)“A walker would be more difficult to use than a cane.”
4)“While walking, I should have shoes and socks on at all
times.”
 35. Which of the following crutch gaits should the nurse
instruct the client to use who has bilateral paralysis of
the hips and legs?

1) Swing-to gait
2) Four-point gait
3) Three-point gait
4) Two-point gait
 3
36. Which of the following should the nurse include when
instructing a client with crutches on the two-point gait?

1) Move the right crutch followed by the left foot, then

move the left crutch forward followed by the right foot
2) Move both crutches forward together and bring the legs
through beyond the crutches
3) Move the left crutch and right foot forward together,
followed by moving the right crutch and the left foot
forward together
4) Move both crutches and the weaker leg forward,
followed by moving the stronger leg forward
 37. The nurse should include which of the following in the
teaching plan for a client who has a cane prescribed?

1) Move the cane forward two feet to ensure that the

body weight is supported on both legs
2) Hold the cane with the hand on the weaker side of the
body
3) Position the arm holding the cane so the elbow is
completely straight to ensure maximum support
4) Position the cane six inches to the side and six inches
to the front of the strongest leg
38. A nurse is conducting health screening for
osteoporosis. The nurse would interpret that which of
the following clients is at greatest risk of developing
this disorder?

1. A 36-year-old man
2. A 25-year-old woman who jogs
3. A sedentary 65-year-old woman who smokes
cigarettes.
4. A 70-year-old man who consumes excess alcohol
39. A client has been admitted to the hospital with a diagnosis of
osteoporosis resulting in a compression fracture of the spine. The
physician has ordered complete bed rest and has ordered a dietitian
consultation. Which of the following is the priority for the
dietitician to include in the nutritional counseling?

1. Protein intake should be increased to 50% of the calorie

intake daily
2. Vitamin D should be taken in the diet as food, not as an oral
medication
3. Calcium intake should be 1500 mg daily
4. Calorie and fat intake should not exceed 1500 calories daily
 40. The nurse is discharging a client with rheumatoid arthritis who
complains of morning stiffness. Which of the following measures
should the nurse include in the discharge instructions?

1) Encourage the client to sleep with pillows under the knees

2) Instruct the client to apply ice packs to the joints before
getting out of bed
3) Instruct the client to take a warm shower in the morning
when getting up
4) Teach the client to perform all of the household chores at
one time
 41. The nurse is admitting a client with rheumatoid
arthritis. Which of the following laboratory test results
would the nurse evaluate as being elevated and used to
monitor disease activity?

1)Serum uric acid

2)Erythromycin sedimentation rate
3)Bence Jones protein
4)White blood cell count
42. The nurse is caring for a client with gout. Which of
the following dietary selections should the nurse include
in the dietary instructions?

Select all that apply:

1. Salmon
2. Macaroni
3. Sardines
4. Cheese
5. Lentils
6. Venison
 43. The nurse expects to find which of the characteristic
clinical manifestations in a client with osteoarthritis?

1) Loss of function from Bouchard’s and Heberden’s

nodes
2) Joint pain that is relieved by rest
3) Joint stiffness that is worse with activity
4) Pain and stiffness that improve with humidity and
low barometric pressure
 44. The nurse is to assist a patient going out of the bed to
a wheelchair. How should the nurse help the patient?
Patient is left hemiplegic.

1) The nurse should position the wheelchair on the

right side of the bed, on the foot part.
2) The nurse should use a transfer belt
3) The nurse should position the wheelchair on the
right side, head part.
4) The nurse should use the top sheet in turning
and lifting the patient out of bed.
 45. A patient is diagnosed with osteomalacia. The physician
prescribes vitamin D replacement 50,000 U/day for two
weeks, to be followed by a daily dose of 800 U/day. The
primary goal for this pharmacological treatment is that:

1) The patient will maintain normal serum and urine

calcium levels.
2) The patient will not demonstrate signs of tetany or
bone pain.
3) The patient will achieve effective remineralization of
bone structure.
4) The patient will have limited functional disabilities.
 46. The nurse has given discharge instructions to a client with
an above-the-knee amputation who will be fitted with a prosthesis
when healing is complete. Which of the following statements by
the client would indicate that the client has understood the
instructions?

1)“I should lie on my abdomen for 30 minutes three or four

times a day.”
2)“I should change the limb sock when it becomes soiled or
stretched out.”
3)“I should use lotion on the stump to prevent drying and
cracking of the skin.”
4)“I should elevate the residual limb on a pillow several times
a day to decrease edema.”
 47. The nurse is collecting a medication history for a client
who has meloxican (Mobic) prescribed. Which of the
following drugs that the client is taking should the nurse
question?

1) Atorvastatin calcium (Lipitor)

2) Alendronate sodium (Fosamax)
3) Omeprazole (Prilosec)
4) Diclofenac potassium (Cataflam)
 48. The client has been on treatment for rheumatoid
arthritis for 3 weeks. Prior to the administration of
etanercept (Enbrel), it is most important for the nurse to
assess:

1) The injection site for itching and edema.

2) The white blood cell counts and platelet counts.
3) Whether the client is experiencing fatigue and
joint pain.
4) A metallic taste in the mouth, with a loss of
appetite.
 49. The nurse is caring for a client with fibromyalgia who
is experiencing pain and insomnia. Which of the following
prescribed drugs should the nurse administer to relieve
pain?

1) Cyclobenzaprine (Flexeril)
2) Acetaminophen (Tylenol)
3) Naproxen sodium (Naprosyn)
4) Clonazepam (Klonopin)
50. When providing care to a client who is on dexamethasone
(Decadron), the nurse should monitor the client for which of the
following adverse reactions?
Select all that apply:

1. Hyperglycemia
2. Acne
3. Hypotension
4. Dehydration
5. Moon face
6. Weight loss
51. The nurse should prepare to administer adalimumab
(Humira) by which route to a client who has rheumatoid
arthritis? ____________
 52. The nurse is caring for a client with a history of
chronic gout, The nurse should understand that the client
is to receive probenecid (Benemid) for which of the
following purposes?

1) Slows uric acid production

2) Decreases inflammation
3) Increases uric acid excretion
4) Reduces pain
 53. The nurse is discharging a client with osteoporosis
who is to begin on alendronate (Fosamax). Which of the
following should the nurse include in the medication
instructions?

1) Take with food or within 30 minutes of eating

2) Notify the physician if urinary retention
develops
3) Avoid taking within 20 minutes of food
4) Avoid driving while taking the medication
 54. After total hip replacement surgery, the nurse
should avoid placing the client in the:

1) Orthopneic position
2) Supine position
3) Lateral position
4) Standing position
55. Mrs. T. has had a total right hip replacement and asks the
nurse about “moving around in this bed.” The nurse’s best
response is based on the knowledge that

1)a side-lying position is undesirable, but the head of the bed

can be elevated 60–75° to shift weight off of back and buttocks.
2)although the client must remain supine, she can cross her legs
to change position for comfort.
3)the client should remain supine for 48 hours after surgery,
with affected leg in a slightly inward-rotation position.
4)the client will be repositioned using an abductor pillow
between the legs
 56. In order to avoid hip dislocation following total hip
replacement, the nurse teaches the patient which of the
following guidelines?

1) Never cross the affected leg when seated.

2) Keep the knees together at all times.
3) Avoid placing a pillow between the legs when
sleeping.
4) Bend forward only when seated in a chair.
 57. The recovery room nurse is caring for a client who
has just had a left BKA. Which intervention should the
nurse implement?

1) Assess the client’s surgical dressing every two

(2) hours.
2) Do not allow the client to see the residual limb.
3) Keep a large tourniquet at the client’s bedside.
4) Perform passive range-of-motion exercises to
the right leg.
58. The client is 3 hours postoperative left AKA. The

client tells the nurse, “My left foot is killing me. Please do
something.” Which intervention should the nurse
implement?

1)Explain to the client that his left leg has been

amputated.
2)Medicate the client with a prn narcotic analgesic
immediately.
3)Instruct the client on how to perform biofeedback
exercises.
4)Place the client’s residual limb in the dependent
position.
59. The nurse teaches an adult woman that because she has
osteoporosis, she must take safety precautions to prevent falls,
“because you could break a hip.” The client asks the nurse what
one has to do with the other, and the nurse’s best response is based
on the knowledge that

1)both osteoporosis and hip fractures are common in elderly

women.
2)hips are the primary sites of calcium loss in osteoporosis, making
them more susceptible to fracture.
3)osteoporosis causes changes in balance, which makes the client
more susceptible to falls that could lead to hip fractures.
4)osteoporosis yields brittle bones which break easily.
60. The nurse is teaching a class to pregnant teenagers.
Which information is most important when discussing
ways to prevent osteoporosis?

1)Take at least 1500 mg of calcium supplements a day.

2)Eat foods low in calcium and high in phosphorus.
3)Osteoporosis does not occur until around age 50
years.
4)Remain as active as possible until the baby is born.
 61. The nurse is discussing osteoporosis with a group of
women. Which factor will the nurse identify as a
nonmodifiable risk factor?

1) Calcium deficiency.
2) Tobacco use.
3) Female gender.
4) High alcohol intake.
 62. The nurse recognizes that a client understood the
demonstration of crutch walking when she places her
weight on:

1) The palms and axillary regions

2) Both feet placed wide apart

3) The palms of her hands
4) Her axillary regions
 63. A client is being discharged to home after application of
a plaster leg cast. The nurse determines that the client
understands proper care of the cast if the client states that he
or she should:

1) Avoid getting the cast wet.

2) Cover the casted leg with warm blankets.
3) Use the fingertips to lift and move the leg.
4) Use a padded coat hanger end to scratch under the
cast.
64. Seventeen-year-old Jack E. sprained his left ankle playing football. The emergency
nurse is teaching Jack ambulation with crutches using a four-point gait. Which sequence
correctly describes this gait?

1) Weight on both crutches and right foot; crutches and left foot move forward while
weight stays on right foot; all weight transferred to crutches, then to right foot; crutches
advanced forward for next step.
2) Weight on both crutches and both feet; right crutch advances forward, then left foot is
advanced as weight shifts to right foot and both crutches; weight is distributed to both
feet and right crutch as left crutch is advanced; right foot is advanced with weight on left
foot and both crutches.
3) Weight on both feet and crutches; both crutches are advanced while weight remains
on feet; weight transfers to crutches as feet swing forward and land with heels on line
with the crutches; both crutches are advanced and the pattern is continued.
4) Weight on both crutches and both feet; left foot and right crutch are advanced
simultaneously and weight transferred to them; right foot and left crutch are advanced
simultaneously and weight transferred to them; the pattern is continued.
65. The nurse is teaching a client with a broken left ankle how to
go up stairs when using crutches. Which statement by the nurse is
correct?

1)“Place the left crutch and right foot on the next step and push off
with both arms then lift the left foot up to the step.”
2)“Place both crutches on the next step, stand on the right foot and
place the left foot on the step next to the crutches.”
3)“Place the right foot on the next step, then move the crutches and
the left foot onto the step.”
4)“Place the right crutch and left foot on the next step; move the
right crutch up onto the step, then swing the right foot up.”
66. The nurse teaches the patient with a high risk for
osteoporosis about risk-lowering strategies including
which of the following statements?

1) Walk or perform weight-bearing exercises out of

doors.
2)Increase fiber in the diet.
3)Reduce stress.
4)Decrease the intake of vitamin A and D.
 67. A client has a fiberglass (nonplaster) cast applied
to the lower leg. The client asks the nurse when the
client will be able to walk using the casted leg. The
nurse replies that the client will be able to bear weight
on the casted leg:

1) In 48 hours
2) In 24 hours
3) In about 8 hours
4) Within 20 to 30 minutes of application
68. The nurse reads a physician’s order, which states
atropine sulfate 0.5 mg IM stat. The nurse has atropine
sulfate 0.3 mg/0.5 ml for injection available. What volume
of the atropine solution should the nurse administer IM?

1. 0.1 ml
2. 0.5 ml
3. 0.8 ml
4. 1.0 ml
69. A physician has ordered acetylsalicylic acid (aspirin) 10
gr every 4 hours p.r.n. The available dose for aspirin is 325
mg per tablet. What will the nurse administer?

1. 2 tabs
2. 1 tab
3. 6.6 tabs
4. 1.5 tabs
 70. Mr. Johnson, a 68 year old man with congestive
heart failure, has been prescribed a low-sodium diet.
In instructing him on appropriate food choices,
which would the nurse counsel him against eating?

1) Spinach salad
2) Canned chicken noodle soup
3) Whole wheat bread
4) Apples
 71. The nurse notes that the post operative patient has
been put on a clear diet. Which of the following items
would not be included?

1) Apple juice
2) Beef broth
3) Orange juice
4) Herbal tea
72. John A. is on coumadin therapy, which he takes
because he has an artificial heart valve. Which meal
plan would suggest the need for further teaching about
the effects of diet on this medication?

(1) Caesar salad with a spinach frittata

(2) Steak, french fries, and a milkshake
(3) Chicken tettrazini and fresh fruit salad
(4) Chile con carne with garlic bread
73. The vegetarian presents with anemia, fatigue, and
loss of sensation in her hands and feet. The woman states
that she does not eat any meat, chicken, or fish. The
nurse, suspecting a vitamin B12 deficiency, asks if she
includes the following in her diet:

(1) Green, leafy vegetables

(2) Fresh fruits
(3) Nuts, seeds, and dried fruits
(4) Eggs and milk
74. The nurse is counseling the 58-year-old male whose
cholesterol reading was 250. She is instructing him in diet,
exercise, and the avoidance of high cholesterol foods. Which
of the following food choices would indicate the need for
further teaching?

(1) Pasta primavera

(2) Large salad with lowfat dressing
(3) Turkey sandwich on whole-grain bread
(4) Cheese omelet
75. The nurse is caring for an overweight 65-year-old man
with gout. After discussion of the need to avoid high purine foods
since they promote uric acid formation,
which comment by the man indicates he has understood the
material?

(1) “I will try to avoid high-carbohydrate and sugary

foods.”
(2) “I will eat more foods with high fiber such as beans,
oatmeal, and whole grains.”
(3) “I will avoid organ meats, alcohol, fat, beans, lentils,
and bran.”
(4) “I will eat more low-fat protein and vegetables.”
76. Mary J. has had a gastrectomy because of stomach
cancer. In order to prevent anemia, the nurse will
administer a(n)

(1) iron supplement.

(2) folic acid supplement.
(3) list of foods to eat.
(4) vitamin B12 injection.
77. The nurse needs to perform the following
procedures on her elderly patient. For which
procedure is it essential that she use surgical
asepsis?

(1) Intramuscular injection

(2) Removal of an indwelling catheter
(3) Colostomy irrigation
(4) Gastric tube feeding
 78. The nurse is correct in saying that generally, a bottle
of TPN should run for

1) 48 hours
2) 24 hours
3) 12 hours
4) 8 hours
79. The nurse must obtain a clean catch urine specimen.
She is responsible for all EXCEPT

(1) Instructing the client in the proper technique to

obtain a clean catch specimen.
(2) Determining if the test is necessary.
(3) Preventing contamination of the specimen.
(4) Labeling the specimen and sending it to the lab.
 80. When preparing to administer a tapwater
enema, the nurse should place the client in which
position?

1) Left Sims’
2) High Fowler’s
3) Right lateral
4) Prone
 81. Where should the nurse tape the female client’s
Foley catheter to reduce urethral irritation?

1) Groin area
2) Lower thigh
3) Inner thigh
4) Loading...
Upper abdomen
 82. The nurse is assessing a client and notes that
he has confusion and decreased memory, polyuria,
nausea, vomiting, and constipation. These
findings are indicative of which electrolyte
imbalance?

1) Hypercalcemia
2) Hyperkalemia
3) Hypernatremia
4) Hypermagnesemia
83. The nurse knows to maintain medical asepsis when
performing the following procedure:

(1) Insertion of an IV catheter

(2) Endotracheal suctioning
(3) Gastric tube feeding
(4) Foley catheter insertion
 84. The nurse is caring for a client who is on
TPN. The solution is to infuse at 125 ml per
hour. The nurse should set the drip at which
rate if the infusion equipment will deliver 15
drops per ml?

1) 32 gtts/min
2) 50 gtts/min

3) 80 gtts/min
4) 125 gtts/min
85. The nurse is caring for a client who is prescribed a
subcutaneous administration of medication. Which of the
following factors would be the most important consideration
in selecting the needle length to use for subcutaneous injection
of the drug?

1)The diameter of the needle

2)The amount of medication to be administered
3)The amount of adipose tissue at the administration site
4)The viscosity of the solution to be injected
 86. The physician orders normal saline solution to
replace the fluid losses of a client. While the
solution is infusing, the nurse should assess for
which of the following symptoms that might
indicate fluid overload is developing?

1) Hypotension
2) Weak pulse
3) Tachypnea
4) Clear breath sounds
 87. The physician’s order reads “Administer 0.02
grams of furosemide (Lasix) I.M.” Available stock
is 20mg/1mL ampule. How many mL should the
nurse prepare?

1) 0.5 mL
2) 1.0 mL
3) 1.5 mL
4) 2.0 mL
 88. The client is scheduled for a lower abdominal surgery.
As the nurse administers a tapwater enema prior to the
procedure, the client begins to complain of abdominal
cramping. Which of the following actions should the nurse
implement first?

1) Tell the client to relax, and continue infusing the

enema
2) Stop infusing the enema, and allow the client to
evacuate the fluid
3) Temporarily stop the infusion until the cramping
subsides
4) Turn the client onto the other side, and continue
infusing the enema
 89. A client with hypertension has been placed on a
low-cholesterol diet. The nurse should advise the
client to reduce intake of which of the following
food?

1) Eggs
2) Chicken
3) Vegetables
4) Veal
90. A client with peritonitis has a Salem sump that is
connected to low suction. Nursing plan for this client
should include

1. Irrigating the nasogastric tube with sterile water

through the blue opening
2. Measuring nasogastric drainage daily
3. Turning the client from side to side every 4 hours
4. Increasing the suction control to high if no
drainage appears
 91. Vitamins are needed daily in small quantities to
sustain growth and health. Which of the following
vitamin deficiency should the nurse identify in
relation to night blindness?

1) Retinol
2) Riboflavin
3) Vitamin C
4) Vitamin E
 92. The nurse is assessing a client complaining of
leg cramps. Deficiency of which vitamin is
commonly associated with the client’s disorder?

1) Ascorbic acid
2) Folic acid
3) Thiamine
4) Vitamin A
 93. The nurse is about to administer a continuous
infusion of 25,000 units of heparin in 250 mL of
D5W. If the patient is to receive 600 units/hour, what
would be the flow rate in milliliters per hour?

1) 3 mL/hour
2) 6 mL/hour
3) 9 mL/hour
4) 12 mL/hour
 94. Place these steps for eye drop administration in the correct
order:

1) Gently press on the lacrimal duct for 1 minute

2) Gently pull downward to expose the lower conjunctival
sac
3) Have the client gently close the eye and move it around
4) Have the client look up while you instill the number of
prescribed drops.
5) Hold the dropper and stabilize your hand on the client’s
forehead
6) Have the client sit down with head slightly
hyperextended.
 95. The nurse needs to infuse 2 liters of D5W over 10
hours. What would be the flow rate in milliliter per
hour?

1) 100 mL/hour
2) 200 mL/hour
3) 300 mL/hour
4) 400 mL/hour
 96. The nurse assesses a client who opens his eyes

only in response to pain, moans incomprehensively,

and flexes in response to pain. The Glasgow Coma
Scale score for this patient is

1) 5
2) 6
3) 7
4) 8
 97. Place these steps for proper donning of PPE:

1) Mask
2) Gown
3) Gloves
4) Goggles
 98. The nurse finds a client who is unresponsive. She
sends a colleague to phone the emergency response
number. The nurse performs a head tilt-chin lift and
looks, listens, and feels for breathing. The client is not
breathing. What should the nurse do next?

1) Give 2 rapid breaths

2) Give 1 slow breath
3) Give 1 rapid breath
4) Give 2 slow breaths
 99. After surgery, Gina returns from the Post-anesthesia Care
Unit (Recovery Room) with a nasogastric tube in place following
a gall bladder surgery. She continues to complain of nausea.
Which action would the nurse take?

1) Call the physician immediately.

2) Administer the prescribed antiemetic.
3) Check the patency of the nasogastric tube for any
obstruction.
4) Change the patient’s position.
 100. When caring for a client with total parenteral
nutrition (TPN), what is the most important action on
the part of the nurse?

1) Record the number of stools per day

2) Maintain strict intake and output records
3) Sterile technique for dressing change at IV
site
4) Monitor for cardiac arrhythmias
THE
END