Exit HESI Test Bank (answered) spring 2022.

1. A nurse is providing information to a group of pregnant clients and their partners

about the psychosocial development of an infant. Using Erikson's theory of
psychosocial development, what should the nurse tell the group about the
infants?

A. Rely on the fact that their needs will be met

B. Need to tolerate a great deal of frustration and discomfort to develop a
healthy personality
C. Must have needs ignored for short periods to develop a healthy
personality
D. Need to experience frustration, so it is best to allow an infant to cry for a
while before meeting his or her needs - A. Rely on the fact that their needs
will be met

2. A nurse is weighing a breastfed 6-month-old infant who has been brought to the
pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8
oz. The nurse notes that the infant now weighs 13 lb. Which action should the
nurse take?

A. Tell the mother that the infant's weight is increasing as expected

B. Tell the mother to decrease the daily number of feedings because the
weight gain is excessive
C. Tell the mother that semisolid foods should not be introduced until the
infant's weight stabilizes
D. Tell the mother that the infant should be switched from breast milk to
formula because the weight gain is inadequate - A. Tell the mother that
the infant's weight is increasing as expected

3. A nurse performing a physical assessment of a 12-month-old infant notes that

the infant's head circumference is the same as the chest circumference. Based
on this finding, what should the nurse do?

A. Suspect the presence of hydrocephalus

B. Suggest to the pediatrician that a skull x-ray be performed
C. Tell the mother that the infant is growing faster than expected
D. Document these measurements in the infant's health-care record - D.
Document these measurements in the infant's health-care record

4. A new mother asks the nurse, "I was told that my infant received my antibodies
during pregnancy. Does that mean that my infant is protected against infections?"
Which statement should the nurse make in response to the mother?

A. "Yes, your infant is protected from all infections."

B. "If you breastfeed, your infant is protected from infection."
 C. "The transfer of your antibodies protects your infant until the infant is 12
months old."
D. "The immune system of an infant is immature, and the infant is at risk for
infection." - D. "The immune system of an infant is immature, and the
infant is at risk for infection."

5. A nurse is assessing the language development of a 9-month-old infant. Which

developmental milestone does the nurse expect to note in an infant of this age?

A. The infant babbles.

B. The infant says "Mama."
C. The infant smiles and coos.
6. D .The infant babbles single consonants. - B. The infant says "Mama."

7. The mother of a 9-month-old infant calls the nurse at the pediatrician's office, tells
the nurse that her infant is teething, and asks what can be done to relieve the
infant's discomfort. What should the nurse instruct the mother to do?

A. Schedule an appointment with a dentist for a dental evaluation

B. Rub the infant's gums with baby aspirin that has been dissolved in water
C. Obtain an over-the-counter (OTC) topical medication for gum-pain relief
D. Give the infant cool liquids or a Popsicle and hard foods such as dry toast
- D. Give the infant cool liquids or a Popsicle and hard foods such as dry
toast

8. A nurse is teaching the mother of an 11-month-old infant how to clean the infant's
teeth. What should the nurse tell the mother to do?

A. Use water and a cotton swab and rub the teeth

B. Use diluted fluoride and rub the teeth with a soft washcloth
C. Use a small amount of toothpaste and a soft-bristle toothbrush
D. Dip the infant's pacifier in maple syrup so that the infant will suck - A. Use
water and a cotton swab and rub the teeth

9. A nurse provides information about feeding to the mother of a 6-month-old infant.

Which statement by the mother indicates an understanding of the information?

A. "I can mix the food in the my infant's bottle if he won't eat it."
B. "Fluoride supplementation is not necessary until permanent teeth come
in."
C. "Egg white should not be given to my infant because of the risk for an
allergy."
10. D "Meats are really important for iron, and I should start feeding meats to my
infant right away." - C. "Egg white should not be given to my infant because of
the risk for an allergy."
11. A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2
oz about car safety. What should the nurse tell the mother?

A. To secure the infant in the middle of the back seat in a rear-facing infant
safety seat
B. To place the infant in a booster seat in the front seat of the car with the
shoulder and lap belts secured around the infant
C. That it is acceptable to place the infant in the front seat in a rear-facing
infant safety seat as long as the car has passenger-side air bags
D. That because of the infant's weight it is acceptable to hold the infant as
long as the mother and infant are sitting in the middle of the back seat of
the car - A. To secure the infant in the middle of the back seat in a rear-
facing infant safety seat

12. A nurse provides instructions to a mother about crib safety for her infant. Which
statement by the mother indicates a need for further instructions?

A. "I need to keep large toys out of the crib."

B. "The drop side needs to be impossible for my infant to release."
C. "Wood surfaces on the crib need to be free of splinters and cracks."
D. "The distance between the slats needs to be no more than 4 inches wide
to prevent entrapment of my infant's head or body." - D. "The distance
between the slats needs to be no more than 4 inches wide to prevent
entrapment of my infant's head or body."

13. The mother of a 2-year-old tells the nurse that she is very concerned about her
child because he has developed "a will of his own" and "acts as if he can control
others." The nurse provides information to the mother to alleviate her concern,
recalling that, according to Erikson, a toddler is confronting which developmental
task?

A. Initiative versus guilt

B. Trust versus mistrust
C. Industry versus inferiority
D. Autonomy versus doubt and shame - D. Autonomy versus doubt and
shame

14. A nurse is planning care for a hospitalized toddler. To best maintain the toddler's
sense of control and security and ease feelings of helplessness and fear, which
action should the nurse take?

A. Spend as much time as possible with the toddler

B. Keep hospital routines as similar as possible to those at home
C. Allow the toddler to play with other children in the nursing unit playroom
 D. Allow the toddler to select toys from the nursing unit playroom that can be
brought into the toddler's hospital room - B. Keep hospital routines as
similar as possible to those at home

15. A nurse in a daycare setting is planning play activities for 2- and 3-year-old
children. Which toy is most appropriate for these activities?

A. Blocks and push-pull toys

B. Finger paints and card games
C. Simple board games and puzzles
D. Videos and cutting-and-pasting toys - A. Blocks and push-pull toys

16. A mother of twin toddlers tells the nurse that she is concerned because she
found her children involved in sex play and didn't know what to do. What should
the nurse tell the mother?

A. To separate her children during playtime

B. That if the behavior continues, she will need to bring her children to a child
psychologist
C. That if she notes the behavior again she should casually tell her children
to dress and to direct them to another activity
D. To tell her children that what they are doing is bad and that they will be
punished if they are caught doing it again - C. That if she notes the
behavior again she should casually tell her children to dress and to direct
them to another activity

17. A nurse is assessing the motor development of a 24-month-old child. Which

activities would the nurse expect the mother to report that the child can perform?
Select all that apply.

A. Put on and tie his shoes

B. Align two or more blocks
C. Dress himself appropriately
D. Go to the bathroom without help
E. Turn the pages of a book one at a time - B. Align two or more blocks
F. Turn the pages of a book one at a time

18. AA nurse is assessing language development in a toddler from a bilingual

family. What should the nurse expect about the child's language development?

A. Is slower than expected

B. Is developing as expected
C. Is more advanced than expected
D. Will require assistance from a speech therapist - A. Is slower than
expected
19.AA mother asks the nurse when her child should have his first dentist visit.
What should the nurse tell the mother?

A. At age 3
B. Just before beginning kindergarten
C. Twelve months after the first primary tooth erupts
D. Soon after the first primary tooth erupts, usually around 1 year of age - D.
Soon after the first primary tooth erupts, usually around 1 year of age

20. The mother of a toddler asks the nurse when she will know that her child is ready
to start toilet training. The nurse should tell the mother that which observation is a
sign of physical readiness?

A. The child has been walking for 2 years.

B. The child can eat using a fork and knife.
C. The child no longer has temper tantrums.
D. The child can remove his or her own clothing. - D. The child can remove
his or her own clothing.

21. The mother of a 9 year old child who is 5 feet 1 inch in height asks a nurse about
car safety seats. What should the nurse tell the mother to use?

A. Front booster seat

B. Rear convertible seat
C. Forward-facing car seat
D. Rear seat using lap and shoulder seat belts - D. Rear seat using lap and
shoulder seat belts

22. The mother of a 5-year-old asks the nurse how often her child should undergo a
dental examination. When should the nurse tell the mother the child should have
dental examinations?

A. Once a year
B. Every 3 months
C. Every 6 months
D. Whenever a new primary tooth erupts - C. Every 6 months

23. AA nurse, planning play activities for a hospitalized school-age child, uses
Erikson's theory of psychosocial development to select an appropriate activity.
The nurse should select an activity that will assist is developing which
psychosocial stage?

A. Initiative
B. Autonomy
C.A sense of trust
D. A sense of industry - D. A sense of industry
24. AA nurse, assigned to care for a hospitalized child who is 8 years old, plans
care, taking into account Erik Erikson's theory of psychosocial development.
According to Erikson's theory, which task represents the primary developmental
task of this child?

A. Mastering useful skills and tools

B. Gaining independence from parents
C. Developing a sense of trust in the world
D. Developing a sense of control over self and body functions - A. Mastering
useful skills and tools

25. AA school nurse provides information to the parents of school-age children

regarding appropriate dental care. What should the nurse tell the parents their
children should do?

A. Brush their teeth every morning and at bedtime

B. Brush and floss their teeth after meals and at bedtime
C. Brush and floss their teeth every morning and at bedtime
D. Brush their teeth every morning and at bedtime and floss the teeth once a
day, preferably at bedtime - B. Brush and floss their teeth after meals and
at bedtime

26. The parents of an adolescent tell the school nurse that they are frustrated
because their daughter has become self-centered, lazy, and irresponsible. What
should the nurse tell the parents?

A. That this is normal behavior for an adolescent

B. To restrict any social privileges until the behavior stops
C. That this type of behavior is usually the result of parents' spoiling a child
D. That their daughter will need to see a child psychologist if the behavior
continues - A. That this is normal behavior for an adolescent

27. AA nurse is preparing to care for a hospitalized teenage girl who is in skeletal
traction. The nurse plans care knowing that the most likely primary concern of the
teenager is which?

A. Body image
B. Obtaining adequate nutrition
C. Keeping up with schoolwork
D. Obtaining adequate rest and sleep - A. Body image

28. The mother of an adolescent calls the clinic nurse and reports that her daughter
wants to have her navel pierced. The mother asks the nurse about the dangers
associated with body piercing. What should the nurse tell the mother?
 A. Hepatitis B is a concern with body piercing
B. Infection always occurs when body piercing is done
C. Body piercing is generally harmless as long as it is performed under sterile
conditions
D. It is important to discourage body piercing because of the risk of
contracting human immunodeficiency virus (HIV) - C. Body piercing is
generally harmless as long as it is performed under sterile conditions

29. AA sexually active adolescent asks the school nurse about the use of latex
condoms and the prevention of sexually transmitted infections (STIs). What
should the nurse tell the adolescent?

A. Use of a latex condom can prevent transmission of STIs

B. The only way to prevent transmission of STIs is abstinence
C. Use of a latex condom is a good method for preventing pregnancy
D. A spermicide needs to be used along with a condom to prevent
transmission of STIs - A. Use of a latex condom can prevent transmission
of STIs

30. AA nurse helps a young adult conduct a personal lifestyle assessment.

Why should the nurse carefully review the assessment with the young
adult?

A. Young adults ignore their risk for a serious illness

B. Young adults are unable to afford health insurance
C. Young adults are exposed to hazardous substances
D. Young adults ignore physical symptoms and postpone seeking health care
- D. Young adults ignore physical symptoms and postpone seeking health
care

31. AA nurse is conducting a psychosocial assessment of a young adult. Which

observations would lead the nurse to determine that the client is demonstrating a
sign of emotional health? Select all that apply.

A. The young adult is sensitive to criticism.

B. The young adult verbalizes unrealistic fears.
C. The young adult verbalizes disappointment with life.
D. The young adult verbalizes satisfaction with friendships.
E. The young adult has a sense of meaning and direction in life. - D. The
young adult verbalizes satisfaction with friendship.
F. The young adult has a sense of meaning and direction in life.

32. According to Erik Erikson's developmental theory, which is a developmental task

of the middle adult?

A. Redefining self-perception and capacity for intimacy

B. Providing guidance during interactions with his children
 C. Verbalizing readiness to assume parental responsibilities
D. Making decisions concerning career, marriage, and parenthood - B.
Providing guidance during interactions with his children

33. AA nurse is planning dietary measures for an older client who is

experiencing dysphagia. Which action should the nurse include in the plan
of care?

A. Encouraging the client to feed herself

B. Ensuring that most of the diet consists of liquids
C. Monitoring the client during meals to ensure that food is swallowed
D. Consulting with the health care provider regarding feeding through an
enteral tube - C. Monitoring the client during meals to ensure that food is
swallowed

34.AA nurse is obtaining assessment data from an older client about sleep patterns.
The client reports that she has been awakening during the night, awakens
early in the morning and is unable to fall back to sleep, and feels sleepy during
the daytime. Based on the data, which action should the nurse take?

A. Report the findings to the health care provider

B. Document the findings in the medical record
C. Ask the health care provider for a prescription for a nighttime sedative
D. Encourage the client to consume stimulants such as caffeinated coffee or
tea during the daytime hours - B. Document the findings in the medical
record

35. AA nurse is developing a plan of care for an older client that will help maintain
an adequate sleep pattern. Which action should the nurse include in the plan?

A. Encouraging at least one daytime nap

B. Discouraging the use of a night light at bedtime
C. Encouraging bedtime reading or listening to music
D. Discouraging social interaction, particularly at bedtime - C. Encouraging
bedtime reading or listening to music

36. AA nurse is performing an admission assessment on an older client who will be

seen by a health care provider in a health care clinic. When the nurse asksthe
client about sexual and reproductive function, he reports concern about sexual
dysfunction. What is the next action the nurse should take?

A. Report the client's concern to the health care provider

B. Ask the client about medications he is taking
C. Document the client's concern in the medical record
D. Tell the client that sexual dysfunction is a normal age-related change - B.
Ask the client about medications he is taking
37.A
A community health nurse is providing information to a group of older
clients about measures to decrease the risk of contracting influenza during
peak flu season. What should the nurse tell the clients?

A. It is best to do grocery shopping and other errands late in the day

B. They must stay in the house and ask a neighbor or family member to run
their errands
C. Drinking eight 8-oz glasses of fluid each day will reduce the risk of
contracting influenza
D. Wearing a scarf around the nose and mouth will help reduce the
transmission of airborne viruses - D. Wearing a scarf around the nose and
mouth will help reduce the transmission of airborne viruses

38. AA nurse is caring for an older client who has a bronchopulmonary infection.
Why should the nurse monitor the client's ability to maintain a patent airway?

A. The normal aging process increases the production of surfactant

B. The normal aging process increases respiratory system compliance
C. The normal aging process decreases an older client's ability to clear
secretions
D. The normal aging process decreases the number of alveoli and increases
the function of those remaining - C. The normal aging process decreases
an older client's ability to clear secretions

39. An older female client asks a nurse why her hair has turned gray. Which
response is most appropriate for the nurse to make to the client?

A. "It is caused by hereditary factors."

B. "A loss of melanin occurs in the normal aging process."
C. "The skin on the scalp becomes thin, causing moisture to escape."
D. "The number of sweat glands and blood vessels decreases in the normal
aging process." - B. "A loss of melanin occurs in the normal aging
process."

40. AA nurse provides instructions to an older adult about measures to prevent

heatstroke. Which statement by the client indicates a need for further instruction?

A. "I should drink extra fluids during the summer."

B. "I should wear cool, light clothing in warm weather."
C. "I need to wear a hat with a wide brim when I go outdoors."
D. "I need to wear additional antiperspirant and deodorant in warm weather."
- D. "I need to wear additional antiperspirant and deodorant in warm
weather."

41. AA nurse is reviewing the medical record of an older client with

presbycusis. Which finding should the nurse expect to note in the client's
record?
 A. Unilateral conductive hearing loss
B. Difficulty hearing low-pitched tones
C. Difficulty hearing whispered words in the voice test
D. Improved hearing ability during conversational speech - C. Difficulty
hearing whispered words in the voice test

42. AA nurse is performing a skin and peripheral vascular assessment on a client

in later adulthood. Which observation should the nurse expect to note as
an age- related finding?

A. Thin, ridged toenails

B. Thick skin on the lower legs
C. Bounding dorsalis pedis pulse
D. Loss of hair on the lower legs - D. Loss of hair on the lower legs

43. AA nurse performing a neurological assessment of a client in later adulthood

notes that the client has tremors of the hands. Based on this finding, which action
should the nurse take?

A. Document the findings

B. Notify the health care provider immediately
C. Obtain a prescription for a muscle relaxant
D. Ask the health care provider about referring the client to a neurological
specialist - A. Document the findings

44. AA nurse observes an unlicensed assistive personnel (UAP) communicating with

a hearing-impaired client in later adulthood. The nurse should intervene if the
UAP performs which action?

A. Uses short sentences

B. Overarticulates words
C. Uses facial expressions or gestures
D. Speaks at a normal rate and volume - B. Overarticulates words

45. A nurse gathering subjective data from a client during a health assessment plans
to ask the client about the medical history of the client's extended family. About
which family members should the nurse ask the client?

46. A.Spouse and spouse's parents

47. B. Foster children and their parents
48. C. Spouse's children from a previous marriage
49. D. Aunts, uncles, grandparents, and cousins - D. Aunts, uncles, grandparents,
and cousins
50. AA home health care nurse is visiting a male African-American client who was
recently discharged from the hospital. Which family member does the the nurse
ensure is present when teaching the client about his prescribed medications?

A. The client's son

B. The client's father
C. The client's mother
D. The client's grandson - C. The client's mother

51. AA female client asks a nurse about the advantages of using a female
condom. Which should the nurse tell the client?

A. It can be used along with a male condom

B. That it is 100% safe in preventing pregnancy
C. That it offers protection against sexually transmitted infections (STIs)
D. That it does not have to be discarded after use and can be used several
times before a new one must be obtained - C. That it offers protection
against sexually transmitted infections (STIs)

52. AA nurse provides information to a client about the use of a diaphragm. Which
statement indicates to the nurse that the client needs further information on how
to use the diaphragm?

A. "I need to reapply spermicidal cream with repeated intercourse."

B. "The diaphragm needs to be filled with spermicidal cream before
insertion."
C. "The diaphragm can be inserted as long as 6 hours before intercourse."
D. "I can leave the diaphragm in place as long as I want after intercourse." -
D. "I can leave the diaphragm in place as long as I want after intercourse."

53. AA nurse is discussing birth control methods with a client who is trying to
decide which method to use. On which major factor that will provide the
motivation needed for consistent implementation of a birth control method
should the nurse focus?

A. Personal preference
B. Family planning goals
C. Work and home schedules
D. Desire to have children in the future - A. Personal preference

54. AA sexually active married couple, discussing birth control methods with the
nurse, express the need for a method that is convenient. Because the couple has
told the nurse that family-planning goals have been met, which method of birth
control does the nurse suggest?

A. Diaphragm
 B. Spermicide
C. Sterilization
D. Male condom - C. Sterilization

55. AA nurse is gathering subjective data from a client who is seeking a

prescription for an oral contraceptive. To identify risk factors associated with
the use of an oral contraceptive, which question should the nurse ask?

A. "Are you dieting?"

B. "Do you smoke cigarettes?"
C. "Do you engage in strenuous exercise such as jogging?"
D. "Do you normally have menstrual cramps with your periods?" - B. "Do you
smoke cigarettes?"

56. AA nurse reviews the health history of a client who will be seeing the health
care provider to obtain a prescription for a combination oral contraceptive
(estrogen and progestin). Which finding in the health history would cause the
nurse to determine that use of a combination oral contraceptive is
contraindicated?

A. The client has hyperlipidemia.

B. The client has type 2 diabetes mellitus.
C. The client is being treated for hypertension.
D. The client has been treated for breast cancer. - D. The client has been
treated for breast cancer.

57. Clomiphene (Clomid, Serophene) is prescribed for a female client to treat

infertility. The nurse is providing information to the client and her spouse about
the medication. What should the nurse tell the couple?

A. The couple should engage in coitus once a week during treatment

B. The health care provider should be notified immediately if breast
engorgement occurs
C. If the oral tablets are not successful, the medication will be administered
intravenously
D. Multiple births occur in a small percentage of clomiphene-facilitated
pregnancies - D. Multiple births occur in a small percentage of
clomiphene-facilitated pregnancies

58. AA nurse is reviewing the medical notes of a client seen by the health care
provider to determine whether the client is pregnant. The nurse determines that
pregnancy was confirmed if which finding is documented?

A. Amenorrhea
B. Palpable fetal movement
C. Thinning of the cervix
 D. Positive result on home urine test for pregnancy - B. Palpable fetal
movement

59. AA nurse is preparing to assess the fetal heart rate (FHR) of a client who is
14 weeks pregnant. Which piece of equipment does the nurse use to assess
the FHR?

A. Fetoscope
B. Stethoscope
C. Doppler transducer
D. Pulse oximetry on the client and a fetoscope - C. Doppler transducer

60. AA nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first
trimester of pregnancy notes that the FHR is 160 beats per minute. Which action
should the nurse take?

A. Document the findings

B. Notify the health care provider of the finding
C. Wait 15 minutes and then recheck the FHR
D. Tell the client that the FHR is faster than normal but that it is nothing to be
concerned about at this time - A. Document the findings

61. AA nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs
the Leopold maneuvers to determine the position of the fetus and then places the
fetoscope over which area?

A. Chest of the fetus

B. Back of the fetus
C. Carotid artery in the neck of the fetus
D. Brachial area of one extremity of the fetus - B. Back of the fetus

62. AA nurse is assessing a fetal heart rate (FHR) and places the fetoscope on
the mother's abdomen to count the FHR. The nurse simultaneously palpates
the mother's radial pulse and notes that it is synchronized with the sounds
heard through the fetoscope. Which action should the nurse take?

A. Asks the mother to lie still while both the FHR and the radial pulse rate are
counted.
B. Move the fetoscope to another area on the mother's abdomen to locate
the fetal heart.
C. Count the FHR for 30 seconds and then count the radial pulse rate of the
mother for 30 seconds.
D. Count the FHR for 60 seconds, ensuring that it is synchronized
consistently with the mother's radial pulse. - B. Move the fetoscope to
another area on the mother's abdomen to locate the fetal heart.
63. AA nurse is assessing a fetal heart rate (FHR) and notes accelerations from
the baseline rate when the fetus is moving. How should the nurse interpret
this finding?

A. A reassuring sign
B. A nonreassuring sign
C. An indication of fetal distress
D. An indication of the need to contact the health care provider - A. A
reassuring sign

64. AA nurse-midwife, performing a vaginal examination of a client who suspects

that she is pregnant, documents the presence of the Chadwick sign. The nurse
reads the client's record and interprets this sign as indicating which?

A. A thinning of the cervix

B. A positive sign of pregnancy
C. That cervical softening is present
D. That the cervix was seen to be violet - D. That the cervix was seen to be
violet

65. AA client is pregnant for the sixth time. She tells the nurse that she has had
three elective first-trimester abortions and that she has a son who was born at
40 weeks' gestation and a daughter who was born at 36 weeks' gestation. In
calculating the gravidity and para (parity), what does the nurse determine?

A. Gravida 6, para 2
B. Gravida 2, para 6
C. Gravida 2, para 2
D. Gravida 3, para 6 - A. Gravida 6, para 2

66. AA nurse is determining the estimated date of delivery for a pregnant client,
using Nägele's rule, and notes documentation that the date of the client's last
menstrual period was August 30, 2015. When does the nurse determine the
estimated date of delivery to be?

A. July 6, 2016
B. May 6, 2016
C. June 6, 2016
D. May 30, 2016 - C. June 6, 2016

67. AA rubella titer is performed on a pregnant client, and the results indicate a
titerof less than 1:8. What should the nurse tell the client?

A. The test results are normal

B. She has developed immunity to the rubella virus
C. The test will need to be repeated during the pregnancy
 D. She must have been exposed to the rubella virus at some point in her life -
C. The test will need to be repeated during the pregnancy

68. AA hepatitis B screen is performed on a pregnant client, and the results

indicate the presence of antigens in the client's blood. Based on this
finding, what does the nurse determine?

A. The results are negative

B. The client needs to receive the hepatitis B series of vaccines
C. The results indicate that the mother does not have hepatitis B
D. Hepatitis immune globulin and vaccine will be administered to the
newborn infant soon after birth - D. Hepatitis immune globulin and vaccine
will be administered to the newborn infant soon after birth

69. AA multigravida pregnant woman asks the nurse when she will start to feel fetal
movements. Around which week of gestation does the nurse tell the mother that
fetal movements are first noticed?

A. 6 weeks
B. 8 weeks
C. 12 weeks
D. 16 weeks - D. 16 weeks

70. The nurse provides information to a pregnant client who is experiencing nausea
and vomiting about measures to relieve the discomfort. Which statement by the
mother indicates the need for further information?

A. "I need to avoid eating fried or greasy foods."

B. "I need to be sure to drink adequate fluids with my meals."
C. "I should eat five or six small meals a day rather than three full meals."
D. "I should keep dry crackers at my bedside and eat them before I get out of
bed in the morning." - B. "I need to be sure to drink adequate fluids with
my meals."

71. AA nurse provides information to a pregnant client with hemorrhoids about

measures that will alleviate her discomfort. Which actions does the nurse tell the
client to take? Select all that apply.

A. Sleep lying on her back

B. Shower daily but avoid sitting in a bathtub
C. Apply cool compresses to the hemorrhoids
D. Contact the nurse-midwife if any bleeding occurs
E. Elevate her hips on a pillow when resting or during sleep - C. Apply cool
compresses to the hemorrhoids
F. Elevate her hips on a pillow when resting or during sleep
72. AA pregnant client asks a nurse about the use of noninvasive acupressure as a
complementary alternative therapy to relieve nausea. What should the nurse tell
the client?

A. Complementary alternative therapies should not be used during

pregnancy
B. Devices that apply pressure alone are available over the counter
C. The health care provider or nurse-midwife needs to provide a prescription
for acupressure
D. It is all right to try any type of complementary alternative therapy to relieve
the nausea - B. Devices that apply pressure alone are available over the
counter

73. AA nurse is telling a pregnant client about the signs that must be reported
to the health care provider or nurse-midwife. The nurse tells the client that
the health care provider or nurse-midwife should be contacted if which occurs?

A. Morning sickness
B. Breast tenderness
74. C.Urinary frequency
75. D. Puffiness of the face - D. Puffiness of the face

76. AA pregnant client tells the nurse that she has a 2-year-old child at home and
expresses concern about how the toddler will adapt to a newborn infant being
brought into the home. Which statement is the most appropriate response for the
nurse to make to the client?

A. "Don't be concerned; any 2-year-old would welcome a newborn."

B. "If your 2-year-old becomes angry or jealous, you should have the child
seen by a child psychologist."
C. "A 2-year-old toddler will be more concerned about exploring the
environment, so there's no reason to be concerned."
D. "Even though a 2-year-old may have little perception of time, if any
changes in sleeping arrangements need to be made for the newborn they
should be carried out several weeks before birth." - D. "Even though a 2-
year-old may have little perception of time, if any changes in sleeping
arrangements need to be made for the newborn they should be carried out
several weeks before birth."

77. AA Muslim woman and her husband are seen in the health care clinic because
the woman suspects that she is pregnant. When planning for the physical
assessment of the woman, which should the nurse ensure?

A. A female health care provider examines the woman

B. The woman's husband remains in the examining room at all times
C. The woman is examined without any other people in the examining room
 D. Written permission is obtained from the woman to obtain subjective health
data - A. A female health care provider examines the woman

78. AA nurse is teaching a pregnant client about nutrition and food sources that
are high in folic acid. Which food item does the nurse tell the client contains
the highest amount of folic acid?

A. Lettuce
B. Oranges
C. Broccoli
D. Pinto beans - D. Pinto beans

79. AA pregnant client is scheduled to undergo a transabdominal ultrasound, and

the nurse provides information to the client about the procedure. What should
the nurse tell the client?

A. The procedure takes about 2 hours

B. She will be positioned on her back for the procedure
C. A probe coated with gel will be inserted into the vagina
D. That she may need to drink fluids before the test and may not void until
the test has been completed - D. That she may need to drink fluids before
the test and may not void until the test has been completed

80. An amniocentesis is scheduled for a pregnant client who is in the third trimester
of pregnancy. The nurse tells the client that the most common indication for
amniocentesis during the third trimester is which?

A. Determination of fetal lung maturity

B. Checking the amniotic fluid for intrauterine infection
C. Checking the fetal cells for chromosomal abnormalities
D. Determination of whether alpha-fetoprotein (AFP) is present in the
amniotic fluid - A. Determination of fetal lung maturity

81. AA nurse performs a nonstress test on a pregnant client. The nurse

determines that the results are nonreactive if which finding is noted on the
electronic monitoring recording strip?

A. Absence of accelerations after fetal movement

B. Accelerations without fetal movement with fetal heart rate (FHR) increases
of 15 beats per minute for 15 seconds
C. Acceleration of the FHR by 25 to 30 beats per minute for at least 15
seconds in response to fetal movement
D. Two fetal heart accelerations within a 20-minute period, peaking at 15
beats per minute above baseline and lasting 15 seconds from baseline to
baseline - A. Absence of accelerations after fetal movement
82. A nurse is assisting a nurse-midwife in performing an amniotomy. After the
procedure, the nurse should perform the following actions. Arrange the actions in
the order that they should be performed. All options must be used. - The correct
order is:

83. Assess the fetal heart rate

84. Assess the color, odor, and other characteristics of the amniotic fluid
85. Check the woman's heart rate and blood pressure
86. Assist the woman in cleaning the perineal area
87. Ask the woman about the need to void

88. AA nurse is taking the vital signs of a pregnant client who has been admitted to
the labor unit. The nurse notes that the client's temperature is 100.6° F, the pulse
rate is 100 beats per minute, and respirations are 24 breaths per minute. Based
on these findings, what is the most appropriate nursing action?

A. Recheck the vital signs in 1 hour

B. Notify the nurse-midwife of the findings
C. Continue collecting subjective and objective data
D. Document the findings in the client's medical record - B. Notify the nurse-
midwife of the findings

89. AA nurse is caring for a pregnant client in the labor unit who suddenly
experiences spontaneous rupture of the membranes. On inspecting the amniotic
fluid, the nurse notes that it is clear, with creamy white flecks. What is the most
appropriate action for the nurse to take based on this finding?

A. Document the findings.

B. Check the client's temperature.
C. Report the findings to the nurse-midwife.
D. Obtain a sample of the amniotic fluid for laboratory analysis. - A.
Document the findings.

90. AA client in labor complains of back discomfort. Which position will best
aidin relieving the discomfort?

A. Prone
B. Supine
C. Standing
D. Hands and knees - D. Hands and knees

91. AA nurse monitoring a client in labor notes this fetal heart rate pattern
(referto figure) on the electronic fetal monitoring strip. Which is the most
appropriate nursing action?

A. Stop the oxytocin (Pitocin) infusion

 B. Notify the nurse-midwife or health care provider
C. Administer oxygen with a face mask at 8 to 10 L/min
D. Continue to monitor the client and fetal heart rate patterns - D. Continue to
monitor the client and fetal heart rate patterns

92. AA nurse notes the presence of variable decelerations on the fetal heart rate
monitor strip and suspects cord compression. Which action should the nurse take
immediately?

A. Notify the nurse-midwife or health care provider

B. Perform a vaginal examination on the mother
C. Position the mother so that her hips are elevated
D. Insert a gloved finger into the mother's vagina to feel for cord compression
- C. Position the mother so that her hips are elevated

93. AA woman in labor whose cervix is not completely dilated is pushing

strenuously during contractions. Which method of breathing should the nurse
encourage the woman to perform to help her overcome the urge to push?

A. Cleansing breaths
B. Blowing repeatedly in short puffs
C. Holding her breath and using the Valsalva maneuver
D. Deep inspiration and expiration at the beginning and end, respectively, of
each contraction - B. Blowing repeatedly in short puffs

94. AA woman receives a subarachnoid (spinal) block for a cesarean delivery.

For which adverse effect of the block does the postpartum nurse monitor the
woman?

A. Pruritus
B. Vomiting
C. Headache
D. Hypertension - C. Headache

95. AA nurse is monitoring a woman who is receiving oxytocin (Pitocin) to

induce labor. Which action should the nurse, on suddenly noting the
presence of late decelerations on the fetal heart rate (FHR) monitor, take
first?

A. Stopping the oxytocin infusion

B. Notifying the nurse-midwife or health care provider
C. Checking the woman's blood pressure and pulse
D. Increasing the intravenous (IV) rate of the nonadditive solution - A.
Stopping the oxytocin infusion

96. Immediately after delivery, the nurse assesses the woman's uterine fundus. At
what location does the nurse expect to be able to palpate the fundus?
 A. In the pelvic cavity
B. 2 cm above the umbilicus
C. At the level of the umbilicus
D. Midway between the symphysis pubis and umbilicus - D. Midway between
the symphysis pubis and umbilicus

97. AA nurse is taking the vital signs of a woman who delivered a healthy newborn
1 hour ago. The nurse notes that the woman's radial pulse rate is 55 beats per
minute. Based on this finding, which action by the nurse is most appropriate?

A. Documenting the finding

B. Helping the woman get out of bed and walk
C. Performing active and passive range-of-motion exercises
D. Reporting the finding to the nurse-midwife or health care provider
immediately - A. Documenting the finding

98. AA nurse is monitoring the amount of lochia drainage on a perineal pad in a

woman who is 1 hour postpartum and notes a 5-inch bloodstain (see figure). How
does the nurse report the amount of lochial flow?

A. Scant
B. Light
C. Moderate
D. Heavy - C. Moderate

99. AA woman who delivered a healthy newborn 6 hours earlier complains

of discomfort at the episiotomy site. Which action by the nurse is the
most appropriate?

A. Applying an ice pack to the perineum

B. Contacting the nurse-midwife or health care provider
C. Administering an intravenous (IV) opioid analgesic
D. Assisting the woman in taking a warm sitz bath - A. Applying an ice pack
to the perineum

100. A postpartum nurse provides information to a new mother who is being

discharged from the maternity unit about signs and symptoms that should be
reported to her health care provider. Which statement by the mother indicates a
need for further information?

A. "My temperature needs to remain within a normal range."

B. "Frequent urination and burning when I urinate are expected."
C. "Feelings of pelvic fullness or pelvic pressure are a sign of a problem."
 D. "I will call my nurse-midwife if I get any redness, swelling, or tenderness in
my legs." - B. "Frequent urination and burning when I urinate are
expected."

101. A nurse, monitoring a client in the fourth stage of labor, checks the client's vital
signs every 15 minutes. The nurse notes that the client's pulse rate has
increased from 70 to 100 beats per minute. Based on this finding, which priority
action should the nurse take?

A. Checking the client's uterine fundus

B. Notifying the nurse-midwife immediately
C. Documenting the vital signs in the client's medical record
D. Continuing to check the client's vital signs every 15 minutes - A. Checking
the client's uterine fundus

102. A nurse calculates a newborn infant's Apgar score 1 minute after birth and
determines that the score is 6. The nurse should take which most appropriate
action?

A. Recheck the score in 5 minutes

B. Initiate cardiopulmonary resuscitation
C. Provide no action except to support the infant's spontaneous efforts
D. Gently stimulate the infant by rubbing his back while administering oxygen
- D. Gently stimulate the infant by rubbing his back while administering
oxygen

103. A nurse monitoring a newborn infant notes that the infant's respirations are 40
breaths per minute. Based on this finding, what is the most appropriate action for
the nurse to take?

A. Documenting the findings

B. Contacting the pediatrician
C. Placing the infant in an oxygen tent
D. Wrapping an extra blanket around the infant - A. Documenting the findings

104. A nurse in the newborn nursery, performing an assessment of a newborn,

prepares to measure the chest circumference. Where should the nurse place the
tape measure?

A. In the axillary area

B. At the level of the nipples
C. 2 inches below the nipples
D. At the level of the umbilicus - B. At the level of the nipples
105. A nurse in the pediatrician's office is checking the Babinski reflex in a 3-
month-old infant. The nurse determines that the infant's response is normal if
which finding is noted?

A. The infant turns to the side that is touched.

B. The fingers curl tightly and the toes curl forward.
C. The toes flare and the big toe is dorsiflexed.
D. There is extension of the extremities on the side to which the head is
turned, with flexion on the opposite side. - C. The toes flare and the big
toe is dorsiflexed.

106. Intramuscular phytonadione (vitamin K) 0.5 mg is prescribed for a newborn.

After the medication is prepared, in which anatomical site does the nurse
administer it?

A. Gluteal muscle
B. Deltoid muscle
C. Rectus femoris muscle
D. Vastus lateralis muscle - D. Vastus lateralis muscle

107. A newborn infant's blood glucose level is analyzed by the laboratory. The
laboratory staff calls the nurse and reports that the blood glucose level is 40
mg/dL. Based on this result, which action should the nurse take first?

A. Hold the next scheduled feeding

B. Contact the nurse-midwife or health care provider
C. Document the results in the newborn's medical record
D. Ask the laboratory to draw another blood sample in 2 hours and repeat the
test - B. Contact the nurse-midwife or health care provider

108. A nurse demonstrates the procedure for bathing a newborn to a new mother.
The next day, the nurse watches as the mother bathes the infant. The nurse
determines that the mother is performing the procedure correctly if she
performs which action?

A. Washes the diaper area first

B. Washes the infant's chest first
C. Uncovers only the body part being washed
D. Uses a cotton-tipped swab to carefully clean inside the infant's nose - C.
Uncovers only the body part being washed

109. The mother of a newborn who was circumcised before discharge from the
hospital calls the nurse at the pediatrician's office and tells the nurse that she is
concerned because she has noticed a yellow crust over the circumcision site.
Which instruction should the nurse give the mother?
 A. To bring the infant to the pediatrician's office to be checked
B. That the crust is to be expected as a normal part of healing
C. To remove the crust, using a warm, wet face cloth and a mild soap
D. That it could indicate a sign of an infection and that the infant's
temperature should be checked every 2 hours - B. That the crust is to be
expected as a normal part of healing

110. A new mother who is breastfeeding her newborn calls the nurse at the
pediatrician's office and reports that her infant is passing mustard-yellow stools.
What should the nurse tell the mother?

A. That this is normal for breastfed infants

B. To decrease the number of feedings by two per day
C. That the stools should be solid and pale yellow to light brown
D. To monitor the infant for infection and, if a fever develops, to contact the
pediatrician - A. That this is normal for breastfed infants

111. A nurse is assessing a newborn infant for jaundice. Which action should the
nurse take to assess the infant for its presence?

A. Squeeze the infant's nail beds

B. Squeeze the infant's brachial area
C. Apply pressure with a finger over the umbilical area
D. Apply pressure with a finger on the infant's forehead - D. Apply pressure
with a finger on the infant's forehead

112. A prescription is written to administer hepatitis B vaccine (Recombivax HB) to

a newborn infant. Before administering the vaccine, which action should the
nurse take?

A. Check the infant for jaundice

B. Check the infant's temperature
C. Obtain parental consent to administer the vaccine
D. Request that a hepatitis blood screen be performed on the infant - C.
Obtain parental consent to administer the vaccine

113. A nurse performing a physical assessment of a client gathers both

subjective and objective data. Which finding would the nurse document as
subjective data?

A. The client appears anxious.

B. Blood pressure is 170/80 mm Hg.
C. The client states that he has a rash.
D. The client has diminished reflexes in the legs. - C. The client states that he
has a rash.
114. A nurse is reviewing the findings of a physical examination that have been
documented in a client's record. Which piece of information does the nurse
recognize as objective data?

A. The client is allergic to strawberries.

B. The last menstrual period was 30 days ago.
C. The client takes acetaminophen (Tylenol) for headaches.
D. A 1 × 2-inch scar is present on the lower right portion of the abdomen. - D.
A 1 × 2-inch scar is present on the lower right portion of the abdomen.

115. A nurse is making an initial home visit to a client with chronic obstructive
pulmonary disease who was recently discharged from the hospital. Which type of
database does the nurse use to obtain information from the client?

A. Episodic
B. Follow-up
C. Emergency
D. Complete - D. Complete

116. A nurse is examining a 25-year-old client who was seen in the clinic 2 weeks
ago for symptoms of a cold and is now complaining of chest congestion and
cough. The nurse should proceed with the examination by collecting which?

A. Data related to follow-up care

B. A complete (total health) database
C. Data related to the respiratory system
D. Data related to the treatment for the cold - C. Data related to the
respiratory system

117. A client is brought to the emergency department after a motor vehicle accident.
The client is alert and cooperative but has sustained multiple fractures of the
legs. How should the nurse proceed with data collection?

A. Collect health history information first, then perform the physical

examination
B. Ask health history questions while performing the examination and
initiating emergency measures
C. Collect all information requested on the history form, including social
support, strengths, and coping patterns
D. Perform emergency measures and not ask any health history questions
until the client's fractures have been treated in the operating room - B. Ask
health history questions while performing the examination and initiating
emergency measures
118. A client who was given a diagnosis of hypertension 3 months ago is at the clinic
for a checkup. Which type of database does the nurse use in performing an
assessment?

A. Emergency
B. Follow-up
C. Complete (total)
D. Problem-centered - B. Follow-up

119. A Mexican-American client with epilepsy is being seen at the clinic for an initial
examination. What is the primary purpose of including cultural information in the
health assessment?

A. Confirm the medical diagnosis

B. Make accurate nursing diagnoses
C. Identify any hereditary traits related to the epilepsy
D. Determine what the client believes has caused the epilepsy - D.
Determine what the client believes has caused the epilepsy

120. A nurse performing a skin assessment uses the back of the hand to feel the
client's skin on both arms and notes that the skin is warm. What does the
nurse determine?

A. The client has a fever

B. The skin temperature is normal
C. The client needs to drink additional fluids
D. The client needs to have the blanket removed - B. The skin temperature is
normal

121. A nurse performing a skin assessment notes that the client's skin is very dry.
How should the nurse document this finding?

A. Xerosis
B. Pruritus
C. Seborrhea
D. Actinic keratoses - A. Xerosis

122. A nurse is preparing to perform a skin examination with the use of a Wood light.
Which action should the nurse perform to prepare for this diagnostic test?

A. Darken the room

B. Obtain informed consent from the client
C. Obtain a scalpel and a slide for diagnostic evaluation
D. Obtain medication to anesthetize the skin area before proceeding with the
examination - A. Darken the room
123. A nurse performing an assessment of a client with kidney failure notes that the
client has the appearance of generalized edema over the entire body. How
should the nurse document this finding?

A. Anasarca
B. Ecchymosis
C. Unilateral edema
D. Increased vascularity of the skin tissue - A. Anasarca

124. A nurse reviewing the medical record of a client with the diagnosis of heart failure
notes documentation indicating that the client has deep pitting edema, that the
indentation remains for a short time, and that the leg looks swollen. How should
the nurse document this finding?

A. 1+ edema
B. 2+ edema
C. 3+ edema
D. 4+ edema - C. 3+ edema

125. A client complains that her skin is redder than normal. The nurse assesses the
client's skin, documents hyperemia, and explains to the client that this condition
is caused by which?

A. Contraction of the underlying blood vessels

B. A reduced amount of bilirubin in the blood
C. Diminished perfusion of the surrounding tissues
D. Excess blood in the dilated superficial capillaries - D. Excess blood in the
dilated superficial capillaries

126. A clinic nurse about to meet a new client and plans to gather subjective data
regarding the client's health history. Which actions should the nurse take to help
ensure the success of the interview? Select all that apply.

A. Ensuring that the room is private

B. Seeing that distracting objects are removed from the room
C. Having the client sit across a desk or table to give the client some
personal space
D. Maintaining a distance of 2 feet or closer between the nurse and client
E. Switching on a dim light that will make the room cozier and help the client
relax - A. Ensuring that the room is private
127. B. Seeing that distracting objects are removed from the room

128. A nurse conducting an interview with a client collects subjective data.

During the interview, which action should the nurse take?
 A. Takes minimal notes to avoid impeding observation of the client's
nonverbal behaviors
B. Takes a great deal of notes to allow the client to continue at his or her own
pace as the nurse records what he or she is saying
C. Takes notes because this allows the nurse to break eye contact with the
client, which may increase the client's level of comfort
D. Takes notes to allow the nurse to shift attention away from the client,
which may make the nurse more comfortable - A. Takes minimal notes to
avoid impeding observation of the client's nonverbal behaviors

129. A nurse is preparing to screen a client's vision with the use of a Snellen chart.
Which action should the nurse take?

A. Tests the right eye, then tests the left eye, and finally tests both eyes
together
B. Assesses both eyes together, then assesses the right and left eyes
separately
C. Asks the client to stand 40 feet from the chart and read the largest line on
the chart
D. Asks the client to stand 40 feet from the chart and read the line that can
be read 200 feet away by someone with unimpaired vision - A. Tests the
right eye, then tests the left eye, and finally tests both eyes together

130. A nurse reviewing a client's record notes that the result of the client's latest
Snellen chart vision test was 20/80. How should the nurse interpret this data?

A. Is legally blind
B. Has normal vision
C. Can read at a distance of 20 feet what a client with normal vision can read
at 80 feet
D. Can read at a distance of 80 feet what a client with normal vision can read
at 20 feet - C. Can read at a distance of 20 feet what a client with normal
vision can read at 80 feet

131. A nurse is examining the peripheral vision of a client using the

confrontation test. How should the nurse carry out this procedure?

A. Asks the client to discriminate numbers on a chart composed of colored

dots
B. Darkens the room and asks the client to identify colored blocks and
shapes that appear in the visual field
C. Has both the client and nurse cover the right eye, stare at each other's
uncovered eye, and bring a small object into the visual field, then repeat
the test with the left eye
 D. Sits at eye level with the client, covers one eye, and has the client cover
the eye directly opposite the nurse's, after which each stares at the other's
uncovered eye and the nurse brings a small object into the visual field - D.
Sits at eye level with the client, covers one eye, and has the client cover
the eye directly opposite the nurse's, after which each stares at the other's
uncovered eye and the nurse brings a small object into the visual field

132. A nurse performing an eye examination uses an ophthalmoscope to best

visualize which area?

A. Iris
B. Cornea
C. Optic disc
D. Conjunctiva - C. Optic disc

133. A nurse notes that a client's physical examination record states that the client's
eyes moved normally through the six cardinal fields of gaze. How should the
nurse interpret this data?

A. Normal near vision

B. Normal central vision
C. Normal peripheral vision
D. Normal ocular movements - D. Normal ocular movements

134. A nurse conducting an eye examination notes that the client exhibits rapid,
involuntary oscillating movements of the eyeball when looking at the nurse. How
should the nurse document this finding?

A. Ptosis
B. Nystagmus
C. Scleral icterus
D. Exophthalmos - B. Nystagmus

135. A nurse assessing a client's eyes notes that the pupils get larger when the client
looks at an object in the distance and become smaller when the client looks at a
nearby object. How does the nurse document this finding?

A. Myopia
B. Hyperopia
C. Photophobia
D. Accommodation - D. Accommodation

136. An adult client tells the clinic nurse that he is susceptible to middle ear
infections. About which risk factor related to infection of the ears does the nurse
question this client?
 A. Loud music
B. Use of power tools
C. Occupational noise
D. Exposure to cigarette smoke - D. Exposure to cigarette smoke

137. A nurse is using an otoscope to inspect the ears of an adult client. Which action
does the nurse take before inserting the otoscope?

A. Pulling the pinna up and back

B. Pulling the pinna down and forward
C. Tipping the client's head down and toward the examiner
D. Tipping the client's head down and away from the examiner - A. Pulling
the pinna up and back

138. A nurse is performing a voice test. To carry out this procedure correctly, the
nurse asks the client to repeat which kind of words?

A. Spoken in a soft tone of voice by the nurse about 5 feet in front of the
client
B. Whispered by the nurse from the client's side at a distance of 1 to 2 feet
from the ear being tested
C. Spoken by the nurse from the client's side in a normal tone of voice about
10 feet from the ear being tested
D. Whispered at a distance of 20 feet by the nurse while he or she is
standing in front of the client - B. Whispered by the nurse from the client's
side at a distance of 1 to 2 feet from the ear being tested

139. A nurse is preparing to perform a Rinne test on a client who complains of

hearing loss. In which area does the nurse first place an activated tuning fork?

A. On the client's teeth

B. On the client's forehead
C. On the client's mastoid bone
D. On the midline of the client's skull - C. On the client's mastoid bone

140. A client complains that he feels as though his ear is blocked and tells the nurse
that he has a history of cerumen impaction in the external ear. What should the
nurse check for when inspecting the ears for cerumen impaction?

A. Redness and swelling of the tympanic membrane

B. An external auditory canal that is longer than normal
C. The presence of edema in the external auditory canal
D. A yellowish or brownish waxy material in the external auditory canal - D. A
yellowish or brownish waxy material in the external auditory canal
141. A nurse is palpating a client's sinus areas. Which sensation does the nurse
expect the client to indicate that he or she is feeling during palpation if the
sinuses are normal?

A. Firm pressure
B. Pain behind the eyes
C. Pain during palpation
D. Pressure producing an acute headache - A. Firm pressure

142. A nurse is preparing to test the function of cranial nerve XI. Which action does
the nurse take to test this nerve?

A. Asking the client to stick out his or her tongue and watching the client for
tremors
B. Touching the posterior pharyngeal wall with a tongue blade and noting the
gag reflex
C. Depressing the client's tongue with a tongue blade and noting pharyngeal
function as the client says "ah."
D. Placing his or her hands on the client's shoulders and asking the client to
shrug the shoulders against resistance from the nurse's hands - D. Placing
his or her hands on the client's shoulders and asking the client to shrug
the shoulders against resistance from the nurse's hands

143. A nurse is preparing to test cranial nerve I. Which item does the nurse obtain
to test this nerve?

A. Coffee
B. A tuning fork
C. A wisp of cotton
D. An ophthalmoscope - A. Coffee

144. A nurse inspecting a client's throat touches the posterior wall with a tongue
blade and elicits the gag reflex. The nurse documents normal function of which
nerve?

A. Cranial nerve V
B. Cranial nerve XII
C. Cranial nerves I and II
D. Cranial nerves IX and X - D. Cranial nerves IX and X

145. A nurse is performing a throat assessment on an assigned client. On asking

the client to stick his tongue out, the nurse notes that it protrudes in the
midline. Which of the following cranial nerves is the nurse testing?

A. Cranial nerve X
B. Cranial nerve V
 C. Cranial nerve IX
D. Cranial nerve XII - D. Cranial nerve XII

146. A nurse is preparing to listen to the breath sounds of a client. The nurse
should:

A. Ask the client to lie prone

B. Ask the client to breathe in and out through the nose
C. Hold the bell of the stethoscope lightly against the chest
D. Listen for at least one full respiration in each location on the chest - D.
Listen for at least one full respiration in each location on the chest

147. A nurse listening to a client's chest to determine the quality of vocal

resonance asks the client to repeat the word "ninety-nine" as the nurse listens
through the stethoscope. As the client says the word, the nurse is able to hear
the word clearly. The nurse documents this assessment finding as:

A. Normal egophony
B. Abnormal vesicular breath sounds
C. Abnormal bronchophony
D. Normal whispered pectoriloquy - C. Abnormal bronchophony

148. A nurse is auscultating for vesicular breath sounds in a client. Of which

quality would the nurse expect these normal breath sounds to be?

A. Harsh
B. Hollow
C. Tubular
D. Rustling - D. Rustling

149. A nurse sees documentation in the client's record indicating that the
physician has noted the presence of adventitious breath sounds. The nurse
knows that these types of sounds are:

A. Normally heard in the lungs

B. Hollow sounds heard over the trachea and larynx
C. Rustling sounds heard over the peripheral lung fields
D. Abnormal sounds that should not be heard in the lungs - D. Abnormal
sounds that should not be heard in the lungs

150. A nurse is assessing a client for the major risk factors associated with
coronary artery disease (CAD). Which modifiable risk factor does the nurse
obtain data on from the client?

A. Age
B. Ethnicity
 C. Hypertension
D. Genetic inheritance - C. Hypertension

151. A nurse is assessing the carotid artery of a client with cardiovascular

disease. The nurse performs this assessment by:

A. Palpating the carotid artery in the upper third of the neck

B. Palpating both arteries simultaneously to compare amplitude
C. Listening to the carotid artery, using the bell of the stethoscope to assess
for bruits
D. Instructing the client to take slow, deep breaths while the nurse listens to
the carotid artery - C. Listening to the carotid artery, using the bell of the
stethoscope to assess for bruits

152. A nurse is preparing to listen to the apical heart rate in the area of the mitral
valve in an adult client. The nurse should place the stethoscope at the:

A. Second left interspace

B. Second right interspace
C. Left lower sternal border
D. Fifth left interspace at the midclavicular line - D. Fifth left interspace at the
midclavicular line

153. A nurse is preparing to assess the dorsalis pedis pulse. The nurse
palpates this pulse by placing the fingertips:

A. Behind the knee

B. Lateral to the extensor tendon of the big toe
C. In the groove between the malleolus and the Achilles tendon
D. Below the inguinal ligament, halfway between the pubis and the anterior
superior iliac spines - B. Lateral to the extensor tendon of the big toe

154. A client with peripheral artery disease tells the nurse that pain develops in his left
calf when he is walking and subsides with rest. The nurse documents that the
client is most likely experiencing:

A. Venous insufficiency
B. Intermittent claudication
C. Sore muscles from overexertion
D. Muscle cramps related to musculoskeletal problems - B. Intermittent
claudication

155. A nurse conducting a peripheral vascular assessment performs the Allen test.
The nurse understands that this test is used to determine the patency of the:

A. Capillaries
 B. Pedal pulses
C. Femoral arteries
D. Radial and ulnar arteries - D. Radial and ulnar arteries

156. A nurse is performing an abdominal assessment on a client. On auscultation

of the abdomen the nurse hears a bruit over the abdominal aorta. Which
action should the nurse take as a priority on the basis of this finding?

A. Document the finding

B. Palpate the area for a mass
C. Notify the healthcare provider
D. Percuss the abdomen to check for tympany - C. Notify the healthcare
provider

157. A nurse is preparing to measure a client's calf circumference. The nurse

performs this procedure by:

A. Placing a tape measure around the widest point of the lower leg
B. Measuring 2 inches above the knee and placing the tape measure around
the client's leg at this point
C. Measuring 2 inches above the ankle and placing the tape measure around
the client's leg at this point
D. Measuring 2 inches below the patella and placing the tape measure
around the client's leg at this point - A. Placing a tape measure around the
widest point of the lower leg

158. An adult client undergoes various diagnostic tests to determine the pumping
ability of the heart. The nurse notes that the results of these tests indicate
that the client's cardiac output is 5 L/min. The nurse concludes that:

A. The client has a low cardiac output

B. The client has a high cardiac output
C. The client has a normal cardiac output
D. The client will need a blood transfusion - C. The client has a normal
cardiac output

159. A nurse palpates a client's radial pulse, noting the rate, rhythm, and force, and
concludes that the client's pulse is normal. Which of the following notations
would the nurse make in the client's record to document the force of the client's
pulse?

A. 4+
B. 3+
C. 2+
D. 1+ - C. 2+
160. At a health screening clinic, a nurse is educating a young woman about breast
self-examination (BSE). The nurse determines that the client demonstrates
understanding when she states that:

A. BSE must be performed every other month

B. BSE is performed on the day menstruation begins
C. Monthly BSE is the only way to ensure early detection of breast cancer
D. Monthly BSE includes inspection before a mirror and palpation both in the
shower and while lying down - D. Monthly BSE includes inspection before
a mirror and palpation both in the shower and while lying down

161. A community health nurse is instructing a group of female clients about breast
self-examination (BSE). The nurse instructs the clients to perform the
examination:

A. At the onset of menstruation

B. Every month during ovulation
C. Weekly, at the same time of day
D. One week after menstruation begins - D. One week after menstruation
begins

162. Performing an abdominal assessment, a nurse notes tenderness while lightly

palpating a client's right lower quadrant. The nurse determines that this finding
is most likely associated with which of the following anatomic structures?

A. Liver
B. Spleen
C. Pancreas
D. Appendix - D. Appendix

163. During a physical assessment, the client tells the nurse that he is having
difficulty swallowing medications and food. The nurse gathers additional
subjective data and documents that the client is experiencing:

A. Pyrosis
B. Anorexia
C. Eructation
D. Dysphagia - D. Dysphagia

164. A nurse is preparing to auscultate for the presence of bowel sounds in a client
who has just undergone surgery. The nurse places the stethoscope in which
abdominal quadrant first?

A. Left upper quadrant

B. Left lower quadrant
C. Right upper quadrant
 D. Right lower quadrant - D. Right lower quadrant

165. Performing an abdominal assessment, a nurse auscultates before palpating

and percussing the abdomen. The nurse performs the assessment in this
manner because:

A. It is less painful for the client

B. Palpation and percussion can increase peristalsis
C. It identifies any potential areas of abdominal tenderness
D. It gives the client more time to become comfortable with the examiner - B.
Palpation and percussion can increase peristalsis

166. A nurse performing a physical examination is preparing to auscultate the client's

bowel sounds. The client tells the nurse that he ate lunch just 45 minutes ago.
On the basis of this information, which finding does the nurse expect to note?

A. Gurgling sounds
B. Hypoactive sounds
C. Low-pitched sounds
D. An absence of sounds - A. Gurgling sounds

167. While reviewing a client's health care record, a nurse notes documentation of the
presence of borborygmus on abdominal assessment. Which of the following
findings does the nurse expect to note when auscultating the client's bowel
sounds?

A. Hypoactive bowel sounds

B. Low-pitched bowel sounds
C. Hyperactive bowel sounds
D. An absence of bowel sounds - C. Hyperactive bowel sounds

168. A nurse performing a physical examination is assessing the client for

costovertebral angle tenderness. When the nurse percusses the area, the client
complains of sharp pain. The nurse interprets this finding as most indicative of:

A. Liver enlargement
B. Ovarian infection
C. Spleen enlargement
D. Kidney inflammation - D. Kidney inflammation

169. A nurse is performing an abdominal assessment of a client with suspected

cholecystitis. Which of the following findings does the nurse expect to note if
cholecystitis is present?

A. Homan sign
 B. Murphy sign
C. Blumberg sign
D. McBurney sign - B. Murphy sign

170. A nurse performing a musculoskeletal assessment of a client with suspected

carpal tunnel syndrome plans to perform the Phalen test. The nurse should
ask the client to:

A. Dorsiflex the foot

B. Plantarflex the foot
C. Hold the hands back to back while flexing the wrists 90 degrees for 60
seconds
D. Hyperextend the fingers with the palmar surfaces of the hands touching,
holding the position for 60 seconds - C. Hold the hands back to back while
flexing the wrists 90 degrees for 60 seconds

171. A nurse reviewing a client's healthcare record notes documentation that the client
has Heberden nodes of the distal interphalangeal joints. Which disorder does the
nurse determine that the client has?

A. Scoliosis
B. Osteoarthritis
C. Rotator cuff lesions
D. Carpal tunnel syndrome - B. Osteoarthritis

172. A nurse in the emergency department is performing a musculoskeletal

assessment of a client. The presence of which of the following conditions would
cause the nurse to avoid testing range of motion (ROM) of the cervical spine?

A. Headache
B. Neck trauma
C. Sinus infection
D. Muscle spasms - B. Neck trauma

173. A nurse reviewing the healthcare record of a client notes documentation of grade
4 muscle strength. The nurse understands that this indicates:

A. Full range of motion (ROM) with gravity

B. Full ROM against gravity with some resistance
C. Full ROM with gravity eliminated (passive motion)
D. Full ROM against gravity with full resistance - B. Full ROM against gravity
with some resistance

174. A nurse performing a genital examination of a male client notes that the skin of
the penis and scrotum is wrinkled. On the basis of this finding, the nurse:
 A. Documents the normal finding
B. Checks for penile discharge, because this finding indicates infection
C. Palpates for a mass in the scrotum, because wrinkling indicates the
presence of one
D. Obtains additional subjective data from the client, focusing on the scrotal
abnormality - A. Documents the normal finding

175. A nurse is describing the procedure for testicular self-examination (TSE) to a

male client. Which statement should the nurse make to the client?

A. "A good time to examine the testicles is just before you take a shower."
B. "If you notice an enlarged testicle or a lump, you need to notify the
physician."
C. "The testicle is egg-shaped and movable. It feels firm and has a lumpy
consistency."
D. "Perform a testicular exam at least every 2 months to detect early signs of
testicular cancer." - B. "If you notice an enlarged testicle or a lump, you
need to notify the physician."

176. A nurse is assisting the physician in performing transillumination of a

client's scrotum. The nurse prepares for this procedure by:

A. Obtaining a flashlight and darkening the room

B. Instructing the client to drink three glasses of water
C. Instructing the client to take several deep breaths and bear down
D. Telling the client that the procedure is very uncomfortable but that the
discomfort will only last for a few moments - A. Obtaining a flashlight and
darkening the room

177. A female client is seen in the clinic for a gynecological examination. The nurse
begins collecting subjective data. Which of the following topics does the nurse
ask the client about first?

A. Her sexual history

B. Her menstrual history
C. Her obstetrical history
D. The presence of vaginal drainage - B. Her menstrual history

178. During a health assessment interview, the client tells the nurse that she has
some vaginal drainage. The client is concerned that it may indicate a sexually
transmitted infection (STI). Which statement should the nurse make to the
client?

A. "When was your last gynecological checkup?"

B. "Have you been engaging in unprotected sexual intercourse?"
C. "Don't worry about the discharge. Some vaginal discharge is normal."
 D. "I need some more information about the discharge. What color is it?" - D.
"I need some more information about the discharge. What color is it?"

179. A nurse is preparing to assist the physician in performing an internal

gynecological examination of a client. In which of the following positions does the
nurse place the client for this examination?

A. Prone
B. Left side-lying
C. Sims
D. Lithotomy - D. Lithotomy

180. A nurse is providing instructions to a client who is scheduled to undergo a

Papanicolaou (Pap) test in one week. Which statement does the nurse make to
the client?

A. "If you are menstruating, use pads instead of a tampon."

B. "Avoid intercourse for 24 hours before the scheduled examination."
C. "Get a douching kit from the pharmacy and douche 2 hours before the
examination."
D. "If you are having a vaginal discharge, obtain a sample of the discharge
for inspection." - B. "Avoid intercourse for 24 hours before the scheduled
examination."

181. A nurse is reviewing the healthcare record of a client who has just
undergone an examination of the internal genitalia. Which of the following
documented findings indicates an abnormality?

A. The cervix is pink.

B. The cervix is midline.
C. The cervix is about 1 inch in diameter.
D. Clear secretions with a foul odor are noted on the cervix. - D. Clear
secretions with a foul odor are noted on the cervix.

182. A nurse is preparing a female client for a rectal examination. Into which
position does the nurse assist the client?

A. Supine
B. Standing
C. Lithotomy
D. Left lateral - D. Left lateral

183. A nurse performing a neurological assessment is inspecting the client's

eyelids for ptosis. The nurse checks the client for:

A. Drooping
 B. Pupil dilation
C. Pupil constriction
D. Deviation of ocular movements - A. Drooping

184. A nurse performing a neurological assessment of an adult client asks the client
to identify various odors. In this technique, which cranial nerve is the nurse
assessing?

A. Optic
B. Abducens
C. Olfactory
D. Hypoglossal - C. Olfactory

185. A nurse performing a neurological assessment is preparing to assess the optic

nerve. The nurse performs this examination by:

A. Assessing visual acuity

B. Inspecting the eyelids for ptosis
C. Assessing pupil constriction
D. Assessing ocular movements - A. Assessing visual acuity

186. A nurse performing a cranial nerve assessment is testing the function of the
oculomotor, trochlear, and abducens nerves. Which of the following
parameters does the nurse check to determine the function of these nerves?

A. Tongue symmetry
B. Eye movements
C. Facial symmetry
D. Corneal reflex - B. Eye movements

187. During a neurological assessment, the nurse asks the client to close the jaws
tightly, after which the nurse tries to open the closed jaws. In this technique, the
nurse is assessing the motor function of the:

A. Trochlear nerve
B. Abducens nerve
C. Trigeminal nerve
D. Oculomotor nerve - C. Trigeminal nerve

188. During a neurological assessment, the nurse asks the client to puff out both
cheeks. Which cranial nerve is the nurse assessing?

A. Vagus
B. Facial
C. Abducens
D. Oculomotor - B. Facial
189. A nurse is preparing to assess the acoustic nerve during a neurological
examination. To assess this nerve, the nurse:

A. Uses a tuning fork

B. Asks the client to puff out the cheeks
C. Tests taste perception on the client's tongue
D. Checks the client's ability to clench the teeth - A. Uses a tuning fork

190. A nurse is preparing to assess the function of a client's spinal accessory nerve.
Which of the following actions does the nurse ask the client to take to aid
assessment of this nerve?

A. Smiling
B. Clenching the teeth
C. Shrugging the shoulders against the nurse's resistance
D. Identifying by taste a substance placed on the back of the tongue - C.
Shrugging the shoulders against the nurse's resistance

191. A nurse performing a neurological examination is testing the cochlear portion

of the acoustic nerve (cranial nerve VIII). Which of the following actions does
the nurse take to test this nerve?

A. Asking the client to raise his or her eyebrows and looking for symmetry
B. Asking the client to clench the teeth, then palpating the masseter muscles
just above the mandibular angle
C. Asking the client to close the eyes and then identify light and sharp touch
with a cotton ball and a pin on both sides of the face
D. Asking the client to close his or her eyes and then indicate when a ticking
watch is heard as the nurse brings the watch closer to the client's ear - D.
Asking the client to close his or her eyes and then indicate when a ticking
watch is heard as the nurse brings the watch closer to the client's ear

192. A nurse reviewing the physical assessment findings in a client's healthcare record
notes documentation that the Phalen test caused numbness and burning. Which
disorder does the nurse, on the basis of this finding, conclude that the client has?

A. Scoliosis
B. Bone deformity
C. Heberden nodules
D. Carpal tunnel syndrome - D. Carpal tunnel syndrome

193. A nurse is preparing to assess a client for the presence of the Tinel sign. Which
action does the nurse take to elicit this sign?
 A. Testing the strength of each muscle joint
B. Percussing at the location of the median nerve
C. Checking for repetitive movements in the joints
D. Asking the client to hold the hands back to back while flexing the wrist 90
degrees - B. Percussing at the location of the median nerve

194. A nurse performing an abdominal assessment is preparing to auscultate for

bowel sounds. The nurse:

A. Begins in the right lower quadrant

B. Uses the bell end of the stethoscope
C. Holds the stethoscope firmly and deeply against the skin
D. Listens for at least 1 minute before deciding that bowel sounds are absent
- A. Begins in the right lower quadrant

195. A nurse preparing to perform an abdominal assessment asks the client to void
and then assists the client into a supine position. Which primary finding does the
nurse expect to note on percussing all four quadrants of the abdominal cavity?

A. Dullness
B. Tympany
C. Borborygmus
D. Hyperresonance - B. Tympany

196. On assessing a client's skin, the nurse notes the presence of several large red-
blue and purple areas on the client's body that do not blanch when pressure is
applied. The nurse documents this finding as:

A. Psoriasis
B. Anasarca
C. Petechiae
D. Ecchymosis - D. Ecchymosis

197. A nurse preparing to examine a client's eyes plans to perform a

confrontation test. The nurse tells the client that this test measures:

A. Near vision
B. Color vision
C. Distant vision
D. Peripheral vision - D. Peripheral vision

198. A nurse conducting a physical assessment of a client plans to perform the

Romberg test. After describing the test to the client, the nurse tells the client that
it will help reveal:
 A. Loss of hearing acuity
B. A problem with balance
C. A problem with distant hearing
D. A problem discriminating high-pitched and low-pitched sounds - B. A
problem with balance

199. A nurse performing a respiratory assessment of a client plans to assess tactile

(vocal) fremitus. The nurse performs this assessment by:

A. Palpating for symmetric chest expansion

B. Auscultating the breath sounds over the trachea and larynx
C. Auscultating the breath sounds over the peripheral lung fields
D. Palpating the thorax, comparing vibrations from side to side as the client
repeats the word "ninety-nine" - D. Palpating the thorax, comparing
vibrations from side to side as the client repeats the word "ninety-nine"

200. A nurse is preparing to listen to a client's breath sounds. The nurse

should:

A. Ask the client to lie down

B. Listen to the right lung, then the left lung
C. Ask the client to take shallow rapid breaths through the mouth
D. Use the diaphragm of the stethoscope, holding it firmly against the client's
chest - D. Use the diaphragm of the stethoscope, holding it firmly against
the client's chest

201. A nurse is preparing to auscultate a client's breath sounds. To assess

vesicular breath sounds, the nurse places the stethoscope over:

A. Major bronchi
B. The xiphoid process
C. The trachea and larynx
D. The peripheral lung fields - D. The peripheral lung fields

202. A nurse reviewing a client's record notes documentation that the client has
melena. How does the nurse detect the presence of melena?

A. By checking the client's urine for blood

B. By checking the client's stool for blood
C. By checking the client's urine for a decrease in output
D. By checking the client's bowel movements for diarrhea - B. By checking
the client's stool for blood

203. A nurse suspects that a client has a distended bladder. On percussing the
client's bladder, which finding does the nurse expects to note if the bladder is
full?
 A. Dull sounds
B. Hyperresonance sounds
C. Hypoactive bowel sounds
D. An absence of bowel sounds - A. Dull sounds

204. A 35-year-old female client asks the clinic nurse when she should begin to have
yearly mammograms. What does the nurse tell the client?

A. Yearly mammograms are recommended starting at age 25.

B. Yearly mammograms are recommended starting at age 40.
C. Yearly mammograms are not necessary unless there is a family history of
breast cancer.
D. Yearly mammograms are recommended starting at the age of 20 and
continuing until menopause begins. - B. Yearly mammograms are
recommended starting at age 40.

205. A nurse teaches a client about healthy dietary measures and explains the
MyPlate food plan. The nurse determines that the client understands the
information if the client says how many of his grains should be whole grains?

A. One-quarter
B. One-third
C. One-half
D. Two-thirds - C. One-half

206. A 16-year-old girl visits the women's health clinic to obtain information about
birth control because she is sexually active and wants to avoid pregnancy. The
nurse who is interviewing the client should first:

A. Assess the client's knowledge of available birth control methods

B. Inform the client that birth control methods cannot be discussed unless the
client's boyfriend is present
C. Tell the client that for her age and lifestyle, birth control pills would be the
easiest method of contraception
D. Give the client written material about various birth control methods and
ask her to read them and to call if she has any questions - A. Assess the
client's knowledge of available birth control methods

207. A mother brings her 18-month-old child to the clinic to receive the next scheduled
vaccine. The child has previously received the following vaccines: three doses of
the hepatitis B vaccine (at birth and 1 and 6 months of age); three doses of the
diphtheria/tetanus/acellular pertussis (DTaP) vaccine (at 2, 4, and 6 months of
age); four doses ofHaemophilus influenzae type b (Hib) conjugate vaccine (at 2,
4, 6, and 12 months of age); three doses of inactivated poliovirus vaccine (IPV)
(at 2, 4, and 6 months of age); one dose of measles/mumps/rubella
 vaccine (MMR) (at 12 months of age); varicella zoster vaccine at 12 months of
age; and four doses of pneumococcal vaccine (at 2, 4, 6, and 12 months of age).
After reviewing the child's immunization record, which scheduled vaccine does
the nurse prepare to administer?

A. Hib
B. IPV
C. MMR
D. DTaP - D. DTaP

208. A nurse is supervising a student in preparing the physical environment for an

interview with a client. Which action by the student is correct?

A. Setting the room temperature at a comfortable level

B. Placing a chair for the client across from the nurse's desk
C. Providing seating for the client so that the client faces a strong light
D. Setting up seating so that the client and nurse are not at eye level - A.
Setting the room temperature at a comfortable level

209. The nurse, performing an abdominal examination, inspects the client's

abdomen. Which assessment technique does the nurse perform next?

A. Percussion
B. Auscultation
C. Light palpation
D. Deep palpation - B. Auscultation

210. The mother of a 3-year-old child tells the nurse that her child hit her doll after
the mother scolded her for picking the neighbors' flowers. Which defense
mechanism used by the child does the nurse identify in the mother's report?

A. Projection
B. Sublimation
C. Displacement
D. Identification - C. Displacement

211. A client says to the nurse, "I've been following my diet and taking my
medication. What else do you want to talk about today?" Which response would
be most helpful during the working phase of the therapeutic alliance?

A. "Sounds fine to me. Let's meet again in 6 months."

B. "I don't believe that you have been following your diet, because you
haven't lost any weight."
C. "Well, you've talked about diet in your terms, but perhaps I should test you
on specific things."
 D. "Some people have added exercise to diet and medication therapy and
gotten positive results. Do you think that this would work for you?" - D.
"Some people have added exercise to diet and medication therapy and
gotten positive results. Do you think that this would work for you?"

212. As the nurse prepares to interview a client being admitted to the mental health
unit, the client says, "I asked my family to bring me in here to talk to someone,
but now I don't know where to begin." Which response by the nurse would be
most helpful?

A. "Why not just start talking and see where it takes you?"
B. "If I were you, I'd begin with what you were doing this morning."
C. "Perhaps you can start by sharing some of your most recent concerns."
D. "Don't worry. Everyone who comes in here for the first time feels reluctant
to talk." - C. "Perhaps you can start by sharing some of your most recent
concerns."

213. During a mental health intake interview, a young adult client who lives with his
family rent free says, "I'm tired of not being able to offer my friends a beer just
because my folks don't believe in taking a drink socially." Which nursing
response would be therapeutic?

A. "Well, I guess you could move out and live on your own if you wanted to."
B. "It seems that your parents expect you to follow their rules when you live
under their roof."
C. "You tell me you live rent free, yet you expect the same privileges as an
adult who supports the household?"
D. "Well, if you directly discussed your concerns with them, I guess it's a
case of 'When in Rome, do as the Romans do.'" - B. "It seems that your
parents expect you to follow their rules when you live under their roof."

214. The nurse developing a plan of care for a client whose spouse recently died
determines the client has a problem with dysfunctional grieving. Which
priority intervention does the nurse incorporate into the plan?

A. Monitoring the client's sleep pattern

B. Assessing the client's risk for violence toward self and others health care
provider
C. Obtaining a health care provider's prescription for an antidepressant
D. Assisting the client in resolving the grief through emotional, cognitive, and
behavioral means - B. Assessing the client's risk for violence toward self
and others health care provider

215. A client in the mental health unit tells the nurse, "My husband makes all the
decisions about money, but I'm the one who's making the money now, not
 him. He needs to back off, but he's always directing every decision we make."
Which nursing response would be the most therapeutic?

A. "Have you told your husband to back off"?

B. "You're making the most money, so the decisions should be left to you."
C. "How do you feel the money decisions could best be handled in your
household?"
D. "You seem frustrated with your husband's habit of controlling financial
decisions." - C. "How do you feel the money decisions could best be
handled in your household?"

216. The nurse is developing a plan of care for a client who recently received a
diagnosis of acquired immunodeficiency syndrome and is experiencing difficulty
adjusting to the illness. Which action is an inappropriate intervention for this
client?

A. Monitoring the client for signs of self-harm

B. Helping the client verbalize concerns related to fear
C. Assisting the client with problem-solving and decision-making
D. Discouraging social networking to prevent the spread of infection - E.
Discouraging social networking to prevent the spread of infection

217. How does a client who has lost a spouse show that she is successfully
completing the tasks of mourning? Select all that apply.

A. Relating that its better "he went first"

B. Reporting that sleeping alone is so hard now
C. Purchasing a smaller car she is comfortable driving
D. Placing a picture of her husband on the bedside stand
E. Heard explaining to family that illness "took" her husband - B. Reporting
that sleeping alone is so hard now
218. C. Purchasing a smaller car she is comfortable driving
219. D. Placing a picture of her husband on the bedside stand

220. The psychiatric nurse is caring for a 15-year-old girl who has been hospitalized
for bipolar disorder. The client tells the nurse that she had her hair styled just
like her young math teacher, whom she admires. Which defense mechanism
should the nurse recognize that the client is using?

A. Projection
B. Regression
C. Identification
D. Intellectualization - C. Identification
221. The mental health home care nurse says to the client, "Do you feel ready to try
attending a group session at the clinic?" The client shakes his head. Which
nursing statement would be therapeutic?

A. "No? Why not?"

B. "You seem to be saying no. Would you tell me more about your
reluctance?"
C. "OK, but I hope you will let me know when you feel ready to attend a
group session at the clinic."
D. "Perhaps a group session would be too overwhelming for you right now.
How about just seeing me?" - B. "You seem to be saying no. Would you
tell me more about your reluctance?"

222. A single parent whose son was suspended from school for carrying a gun into
the school says to the nurse, "I know he has no dad, but I've brought him up to
know better, and anyway, where did he get the stupid gun? What should I do?
He just won't listen to me." Which nursing response would be helpful at this time?

A. "Boys who are cared for only by their moms are at highest risk for violent
behavior."
B. "There is quite a bit that you can do. Let's talk about what you're already
doing first."
C. "Do you know all of your son's friends, or is he left alone after school
because you work?"
D. "Many young people die of gunshots every day in this country, so your
son's behavior is unacceptable." - B. "There is quite a bit that you can do.
Let's talk about what you're already doing first."

223. A client says to the nurse, "My doctor says he thinks I'm ready to taper off my
pain medication, but the new painkiller he prescribed doesn't relieve my pain the
way the other pill did. I get pain when I try to do things." Which nursing response
would be most supportive to the client?

A. "Your health care providerhealth care provider feels that your body is
physically ready to make the change in medication."
B. "I think you need to listen to your health care provider health care
providerwhen it comes to taking such strong medication."
C. "Well, your health care provider is concerned that you will become
physically dependent on the first painkiller."
D. "Perhaps if I medicate you about a half-hour before you plan to start your
daily activities, the medicine will be more effective." - D. "Perhaps if I
medicate you about a half-hour before you plan to start your daily
activities, the medicine will be more effective."

224. A client who was employed as a corporate manager before being laid off says
to the nurse, "My wife thinks that I should work in a menial job to maintain
 our lifestyles until I find another job as a corporate manager, but I don't feel I
should have to humiliate myself like that." Which nursing response would be
therapeutic?

A. "Have you shared your feelings with your wife?"

B. "You seem to feel that a less prestigious job would be humiliating for you."
C. "Oh, I agree with you. Let her get another job if she needs that much
money."
D. "How soon will you be able to find work? If this is permanent, you may
need to swallow your pride." - A. "Have you shared your feelings with your
wife?"

225. A young woman who has been divorced twice says to the nurse, "I've decided
not to date men ever again! It never works out for me. Now I'm left with two
children to bring up." Which nursing response would be therapeutic?

A. "Oh, me too. I always pick the worst kind of men, so I know just how you
feel."
B. "Divorce is more difficult for children. Maybe you should focus on them for
now."
C. "You've been unfortunate, but you seem to be focusing on yourself and
what you have to do."
D. "You talk about how the divorces affected you. Tell me how your children
are dealing with the loss." - D. "You talk about how the divorces affected
you. Tell me how your children are dealing with the loss."

226. A client says to the nurse, "What does my psychiatrist mean when she says that
my illness is biologically based?" Which nursing statement would be the most
informative?

A. "Mental illness always has its roots in the family."

B. "Mental illness is a result of environmental factors."
C. "Today we know that all mental illness is genetically inherited."
D. "There are many possible physical causes of mental illness, and they
include problems in the brain." - D. "There are many possible physical
causes of mental illness, and they include problems in the brain."

227. The nurse is caring for a 39-year-old client who has experienced a mild brain
attack (stroke). The client is recently widowed, is very active physically, and has
two young sons. The client says to the nurse, "I don't know what my sons will do
if anything permanent happens to me. We have no other relatives, even on my
late wife's side." Which of the following nursing responses would be therapeutic?

A. "You seem to be feeling very troubled."

 B. "You are working to get better, but you're worrying about things that aren't
going to happen."
C. "You seem to be feeling very powerless right now, yet you're getting
better, so why worry about what won't happen?"
D. "I am troubled that you are worried over the worst possible things that
could happen rather than worrying about the efforts needed to strengthen
your family situation." - A. "You seem to be feeling very troubled."

228. A client who has been admitted to a surgical unit with a diagnosis of cancer is
scheduled for surgery in the morning. When the nurse enters the room and
begins the surgical preparation, the client states, "I'm not having surgery — you
must have the wrong person! My test results were negative. I'll be going home
tomorrow." Which defense mechanism should the nurse recognize that the client
is using?

A. Denial
B. Psychosis
C. Delusions
D. Displacement - A. Denial

229. A young adult client who is dying says to the nurse, "I keep asking my wife what I
can do for her and our daughter before I die, but she refuses to tell me." Based
on the client's statement, what is the appropriate nursing intervention?

A. Teaching the client's wife to write down her thoughts and feelings and to
read them to her husband
B. Saying to the client, "It sounds to me like your wife is truly comfortable and
doesn't want you to worry needlessly"
C. Talking with both the client and his wife about the importance of
expressing their feelings and how to do it in healthy ways
D. Talking with all family members, including the daughter, about the
importance of expressing their concerns and feelings to the dying client -
C. Talking with both the client and his wife about the importance of
expressing their feelings and how to do it in healthy ways

230. A 45-year-old client says to the nurse, "Since I left my wife and children, I can
hardly make ends meet between child support and trying to support myself. I
don't know why I bother going to work when my wife and kids take just about
everything I make." Which nursing statement would be therapeutic?

A. "I wonder why you left your wife and children."

B. "What would you expect your wife and children to do? They didn't leave
you."
C. "You seem to be very angry about carrying out your responsibility to your
children."
 D. "Do you feel that child support is designed to help children, not punish
spouses who leave?" - D. "Do you feel that child support is designed to
help children, not punish spouses who leave?"

231. A survivor of a nightclub fire that killed more than 100 people says to the nurse,
"It should have been me. How come I got out and they didn't?" Which
response by the nurse is appropriate?

A. "I don't know what to say. It was a terrible fire. I'm so sorry this happened."
B. "It seems that you're blaming yourself for something that was beyond your
control."
C. "It seems to me that you're making this all about you when many people
died in that fire."
D. "You should be thankful that you're a survivor. The victims and their
families lost, not you." - B. "It seems that you're blaming yourself for
something that was beyond your control."

232. In planning the care of a client dying of cancer, the nurse seeks to have the
client verbalize acceptance of his impending death. Which statement indicates
to the nurse that this goal has been met?

A. "I'd like to have my family here when I die."

B. "I'll be ready to die once my daughter gets married."
C. "I want to go to my family reunion; then I'll be ready to die."
D. "I just want to live to see my grandchildren graduate from college." - A. "I'd
like to have my family here when I die."

233. A client says to the nurse at the mental health clinic, "My husband and sister-in-
law both have terminal illnesses, and my family thinks that because I'm a nurse I
should be able to handle everything." Which nursing response would be
therapeutic?

A. "Are you saying you are overly involved and will need to emotionally
distance yourself to be therapeutic for your family?"
B. "Shame on them for expecting so much from you. Perhaps we need to
schedule a family meeting so I can help you set them straight."
C. "I'm sorry to hear that your loved ones are so ill. As a nurse, you should be
able to assist them by using your professional expertise. Perhaps that's
what your family expects from you."
D. "You've seen your loved ones dealing with some troubling events recently.
Sounds as if you feel that your family expects more from you than from
others in the family because you're a nurse." - D. "You've seen your loved
ones dealing with some troubling events recently. Sounds as if you feel
that your family expects more from you than from others in the family
because you're a nurse."
234. A 79-year-old client, recently widowed, says to the nurse, "My wife kept up our
condominium single-handedly, and now my kids expect me to cook and clean for
myself. I'm not lazy, but I don't know how to cook and I've burnt myself twice just
frying up what was supposed to be bacon and eggs. I'm so frustrated and I've
already lost 10 lb this month." Which initial nursing statement should the nurse
make to the client?

A. "I'm calling the doctor immediately to obtain a homemaker for you!"

B. "Seems as if you feel lost without your wife and maybe a bit ignored by
your children."
C. "First things first. What are you doing eating bacon and eggs? That's not a
good meal for you."
D. "Meals-on-Wheels can help you minimize the frustration you are having
cooking. Are you a member of the local senior center?" - B. "Seems as if
you feel lost without your wife and maybe a bit ignored by your children."

235. A health care provider (HCP) tells a client that she has cancer, that her illness
is terminal, and that she has a 6-month prognosis. After the health care
providerHCP leaves the client's room, which therapeutic statement should the
nurse make to the client?

A. "I am so sorry about this. You are my favorite client, and I will take good
care of you."
B. "What did your HCP tell you about your condition? Can you tell me what
you're thinking about?"
C. "Do you have any questions about what is happening with you? I can
assure you that I will do everything I can to help minimize your pain."
D. "Do you want me to get the phone so you can talk to your loved ones, or
do you have questions for me about what's happening with you?" - B.
"What did your HCP tell you about your condition? Can you tell me what
you're thinking about?"

236. The wife of a client who is dying says to the nurse, "I am able to take off the 6
months from work our doctor feels that my husband will live, but what if he lives
beyond that time?" Which therapeutic response should the nurse make?

A. "Only you and your husband can determine how you should best allocate
your work leave."
B. "Your husband has managed to be active up to now, so he could live
longer than predicted, but his actual lifespan remains unclear."
C. "Are there other options for you in taking work leave? Perhaps you could
simply reduce your work hours at first so that you can extend your
compassionate leave."
D. "Why not write down the pros and cons of taking work leave all at once
and any other options and then decide with your husband and family
which would be most helpful?" - C. "Are there other options for you in
 taking work leave? Perhaps you could simply reduce your work hours at
first so that you can extend your compassionate leave."

237. The wife of a dying man is ignoring his rapid physiological decline and
imminent death. She continues with her usual activities, exhibits inability to
remember what others have just told her, and misses important appointments.
Which therapeutic statement should the nurse make to the wife?

A. "It isn't unusual for family to suffer from anticipatory grief when a loved one
is dying."
B. "I cannot emphasize how much your husband needs you to be there for
him right now. He is in the stage of denial."
C. "You will need to concentrate on getting to these appointments on time
and write down what everyone says so you will remember."
D. "Can you talk about what's happening to you right now? Your behavior is
not appropriate at this stage of your husband's illness. You seem to be
having sympathy pains for him, like men during their wives' pregnancies."
- A. "It isn't unusual for family to suffer from anticipatory grief when a loved
one is dying."

238. An older adult client who is dying says to the nurse, "My son is 40 years old, but
he works in a very poorly paying job and is always borrowing money from me. I
don't know how he's going to manage without me." Which response by the nurse
would be therapeutic?

A. "Could you share your feelings with your son just as you have with me?"
B. "Sounds as if your son will never grow up and learn to take care of
himself."
C. "Goodness. At 22, I supported myself and never asked my mother for
anything."
D. "I wonder why you're so worried about your adult son when you need to
concentrate on you?" - A. "Could you share your feelings with your son
just as you have with me?"

239. The widow of a man who was killed a week ago in a hit-and-run accident while
walking the family dog says, "I should have just let the dog run in the backyard
or gone with my husband. Our own parish priest hit my husband and finally
surrendered to the police. He brought a lawyer with him because he's worried
about himself, not my husband. I hate him so much, my stomach hurts." Which
nursing statement would be therapeutic?

A. "Of course you're angry. Who wouldn't be? Yet nothing is ever clear cut, is
it?"
B. "You not only lost your husband but also learned it was at the hands of
someone you looked up to."
 C. "You're having stomach pain? You should get checked for an ulcer or
other gastric problem."
D. "I wouldn't blame you if you never entered a church again. This is a
terrible thing for the head of a church to do." - B. "You not only lost your
husband but also learned it was at the hands of someone you looked up
to."

240. A single mother whose only son died 2 months ago says to the nurse, "I've been
bothered at work with thoughts of my son. Suddenly I'll think of something awful I
said to him years ago or some punishment I gave him because he'd been bad."
Which plan should the nurse include in caregiving?

A. Scheduling the client for an appointment with the psychiatrist, because

this is a pathological manifestation.
B. Calling the health care provider to report that the client is a high risk for
suicide and increasing the frequency of visits with the client.
C. Seeking emergency certification for the psychiatric inpatient unit at the
community hospital because of high lethality concerns and visiting the
client daily.
D. Explaining that bereaved persons often describe intrusive thoughts of
negative experiences with the deceased and then increasing the
frequency of nurse-client visits. - D. Explaining that bereaved persons
often describe intrusive thoughts of negative experiences with the
deceased and then increasing the frequency of nurse-client visits.

241. A client who is a health care provider says to the nurse, after receiving a
diagnosis of terminal lung cancer, "All my life I took care of my clients, and now
my family is taking care of me." Which statement is a therapeutic nursing
response?

A. "Your family is caring for you now."

B. "Well, you'd expect them to care for you, wouldn't you?"
C. "It is an honor for all of us to care for you. We want to help you."
D. "You can look back on so many wonderful people you saved and cared
for." - A. "Your family is caring for you now."

242. The parents of a 20-year-old who was killed while driving drunk say to the nurse,
"We're so devastated, but we are also angry that she would drink and drive
when we told her over and over not to." Which statement by the nurse would be
therapeutic?

A. "Young people don't always obey their parents."

B. "Everyone feels guilt or anger when they lose a loved one."
C. "Does anyone in the family have a drinking or drug problem?"
 D. "Your sadness over losing your daughter is mixed with anger at her driving
while intoxicated." - D. "Your sadness over losing your daughter is mixed
with anger at her driving while intoxicated."

243. A nursing student is assigned to work in the emergency department to assist

victims after a tornado. The student says to the nurse in charge, "I don't know
how to help these parents. Their son was just decapitated by a flying piece of
glass, and they won't leave him. They did mention that they are Catholic." Which
intervention does the nurse suggest for inclusion in a plan of immediate care for
the family?

A. Telling the student not to disturb the family until the end of shift
B. Calling their family priest immediately to come help them to let their son go
C. Asking the emergency department health care provider to join the student
in requesting that the family let the nursing staff care for their son
D. Joining the family and, after they have been able to be with their son for
some time, helping them relinquish their son's body to the nurses - D.
Joining the family and, after they have been able to be with their son for
some time, helping them relinquish their son's body to the nurses

244. The nurse is caring for a bereaved man with acquired immunodeficiency
syndrome who lost his twin brother in a rock-climbing accident a month ago.
Which statement by the client should cause the nurse to be concerned?

A. "Lately I've been feeling that life isn't that great."

B. "You'd have thought that I would be the one to die first."
C. "I should have made him stay home. He was always clumsy."
D. "I miss him so much. We were close and talked almost daily." - A. "Lately
I've been feeling that life isn't that great."

245. A client whose husband died 2 months ago says to the nurse, "After church, I
visit my husband's grave and talk to him. It comforts me, but my daughter
thinks I'm morbid and crazy and is upset with me because I don't want to meet
her for coffee after church like I used to." Which statement by the nurse would
be therapeutic?

A. "You need to stop your visits immediately, or your daughter will have you
examined for a mental disorder."
B. "Perhaps you could reduce your visits to his grave to once a month and
meet your daughter for coffee like you used to."
C. "I think your visits are perfectly normal. After all, you were married for a
long time. You'll stop when the winter weather comes."
D. "Sounds as if you have had difficulty letting your husband go from your
life. What would happen if you visited his grave less frequently?" - D.
"Sounds as if you have had difficulty letting your husband go from your
life. What would happen if you visited his grave less frequently?"
246. The nurse is talking to a client whose spouse died 10 months ago. Which
statement by the client indicates successful mourning?

A. "I'm planning a trip to England next fall to tour the mansions and their
gardens."
B. "I must confess that I have taken to drinking more than I should at night,
but a drink or two helps me to sleep alone in that big house."
C. "My son has taken over managing my money because I got into a little
mischief with my charge cards. I'm restricted to one debit card now."
D. "Last night they had to treat me in the emergency department because I
swallowed a few too many pills. Lately I've felt as if I can't go on alone." -
A. "I'm planning a trip to England next fall to tour the mansions and their
gardens."

247. A 74-year-old widower of 3 months says to the nurse, "When my wife died, I lost
my love and my best friend. Everyone I cared about is dead. We both were only
children, and we had no kids. I'm more than ready to go when the time comes."
Which nursing response should the nurse make?

A. "Are you thinking of ending your life because your time has come?"
B. "Did you know that many people live happier lives without children?"
C. "It must seem very lonely to you. I can't believe that you never had any
children."
D. "When my dad died, my mother said some of the things you're saying
now, and she had three kids." - A. "Are you thinking of ending your life
because your time has come?"

248. The nurse coordinates the use of hospice care to visit a dying client who will be
going home with his family. Which is a function of hospice services that the
nurse should tell the family?

A. Helping the client focus completely on his physical health

B. Providing bereavement support to the family after the client's death
C. Helping the family stop the client's efforts to go out at night with his friends
D. Working with the client to sustain hope by talking of recent research
breakthroughs regarding his illness - B. Providing bereavement support to
the family after the client's death

249. A dying client with agoraphobia says to the nurse, "I've been unable to leave
this house without tremendous effort for so long, and now it doesn't matter."
Which statement by the nurse would be therapeutic?

A. "It doesn't matter? Can you share your feelings with me?"
B. "Your gardens are beautiful now. Would you like to stroll in them after our
work?"
 C. "Did you go through systematic desensitization with your doctor? I
understand that it works well."
D. "I know what you mean. I spent more than $2,000 on a dental implant and
still wound up with false teeth." - A. "It doesn't matter? Can you share your
feelings with me?"

250. A dying client says to the nurse, "How do I tell my parents that I am dying of
AIDS ?" Which statement by the nurse would be therapeutic?

A. "Well, isn't it better that they learn from you than for them to learn on their
own?"
B. "Sounds as if you're thinking that it's time for you to tell your parents about
your disease."
C. "I've worked with this illness for many years now, and there just doesn't
seem to be an easy way to do this."
D. "Are you saying that your parents don't know about your illness?" - B.
"Sounds as if you're thinking that it's time for you to tell your parents about
your disease."

251. The wife of a victim of a gas explosion says, "It's not bad enough that I've been
left alone to care for two children — now the company is denying our claim for
compensation and we have to join a class action suit to get my husband's
pension." Which statement by the nurse would be therapeutic?

A. "Get a lawyer! That's what you all need to do."

B. "Do you believe that a class action suit is the correct thing and that you
are in the right?"
C. "You're saying that being left a widow with children is difficult enough, but
now you've got to fight for your benefits."
D. "Walk away. It's too much to even think about at your age, and how can
you get caught up in all this with children and work, too?" - C. "You're
saying that being left a widow with children is difficult enough, but now
you've got to fight for your benefits."

252. A young widow of 18 months says to the nurse, "I'm going to need a babysitter,
because I'm going on a blind date at my brother and sister-in-law's house. They
fixed me up, but I think it may be too soon." Which statement by the nurse would
be therapeutic?

A. "Hello? You go girl! You can see it's only natural, can't you?"
B. "By the end of a year, most people are able to renew their interest in other
people and activities."
C. "Nonsense. Your children need a new father, as your family knows. Your
husband would want you to go on with life."
 D. "If it were me, I would be dating other men by now. After 6 months of
mourning, most of society feels that it's okay." - B. "By the end of a year,
most people are able to renew their interest in other people and activities."

253. A client who is an attorney says to the clinic nurse, "I'm worried about my wife.
She's been so distant and disorganized since our son died of leukemia 4
months ago. She never suggests that we go out or take our other children
anywhere. Is this normal, or do I need to get her to a doctor?" Which statement
by the nurse would be therapeutic?

A. "Absolutely. It sounds as if she may be experiencing a severe

depression."
B. "To be safe, it would not hurt to have her see your family doctor, or maybe
you have a member of the clergy she can talk to."
C. "The reluctance to resume activities and overprotect your other children is
a normal part of bereavement and will subside in 2 months."
D. "It's normal, but by the end of a year you can expect that your wife is
improving and able to redirect her energy. Have you expressed your
concerns to her?" - D. "It's normal, but by the end of a year you can expect
that your wife is improving and able to redirect her energy. Have you
expressed your concerns to her?"

254. The young nurse has just completed postmortem care of a 16-year-old client
who died of cancer. The nurse says to the nurse manager, "I never get sick, and
this client kept telling me that he couldn't remember not being ill. I feel terrible
and so bad for him and about what he went through." Which statement by the
nurse manager would be therapeutic?

A. "Next time, take someone else in with you for postmortem care, OK?"
B. "Your feelings are normal and will go away after a good night's sleep."
C. "Let's go for coffee and talk about this some more, shall we? We're both
due for our coffee breaks."
D. "I should never have assigned you someone so close to your own age. I'll
be more careful in the future." - C. "Let's go for coffee and talk about this
some more, shall we? We're both due for our coffee breaks."

255. The 45-year-old husband of a client with breast cancer who just died says to the
nurse, "If our doctor had operated sooner, my wife would be alive now." Which
statement by the nurse would be therapeutic?

A. Say nothing. Simply nod and say "Mm-hmm" noncommittally.

B. "Sounds as if you're feeling angry and pretty helpless right now."
C. "Let's focus not on what was not done but instead on what was done for
your wife."
 D. "Your doctor did all he could for your wife. You know, health care
providers can only apply their best clinical judgment." - B. "Sounds as if
you're feeling angry and pretty helpless right now."

256. During a one-to-one nurse-client session, the client plays with her pack of
cigarettes and says, "I just get a couple of DVDs and watch movies so I won't
have to look at my husband or talk to him." Which coping mechanism does the
nurse recognize in the client's behaviors?

A. Self-blame
B. Avoidance
C. Reframing
D. Wishful thinking - B. Avoidance

257. A 16-year-old client says, "My dad thinks I'm evil, but we get into fights because
I let things build up. He never has any time for me because he's always glued to
the TV. He doesn't even look at me when he talks." Which statement by the
nurse encourages the client to use assertive behavior with his father?

A. "So you're saying that you let your feelings build up and then you just
explode?"
B. "Have you tried standing in front of the television when your dad is
watching it?"
C. "What makes you feel that you have the right to fly off the handle just
because you feel ignored?"
D. "Have you tried saying that directly to your dad? For example, you could
say, 'I notice that you watch television when I'm telling you things that are
important to me.'" - D. "Have you tried saying that directly to your dad? For
example, you could say, 'I notice that you watch television when I'm telling
you things that are important to me.'"

258. A client who was formerly a workaholic has lost his job and is being supported
financially by his wife. The client says to the nurse, "I know that my wife is
disappointed in me, but I can't seem to get a job doing what I've done for 25
years. Why should I take a low-level job when she's able to support us
financially?" Which response by the nurse would be therapeutic?

A. "Can you tell me a little more about this?"

B. "I would dig ditches if it contributed to my family's well-being."
C. "Sounds as if you're lucky to have your wife's job to fall back on."
D. "I'm surprised that such a hardworking man is not able to find a job." - A.
"Can you tell me a little more about this?"

259. The psychiatrist notes that a client being admitted to the inpatient mental health
unit uses avoidance and denial to cope with stress. Which positive stress
response will the nurse plan to focus on when working with the client?
 A. Reframing
B. Locus of control
260. C.Problem-solving
261. D. Use of social supports - C.Problem-solving

262. The husband of a terminally ill client says to the nurse, "My company went
bankrupt, my son is a drug addict, my daughter is an alcoholic, and now this! My
doctor wants me to try some stress reduction because my blood pressure is up.
Whose wouldn't be? I've tried music and relaxation, but they don't work." Which
statement by the nurse would be therapeutic?

A. "Let's talk more about what has been helpful to you in the past."
B. "Before we talk about stress management, let's discuss your children."
C. "You have a lot of problems. How long does your wife have to live, and
what is her relationship with your children?"
D. "Can you afford to pay for therapy sessions? I see that your benefits are
pretty much maxed out, and I'd hate to ask you to take on any additional
burden." - A. "Let's talk more about what has been helpful to you in the
past."

263. A young adult client says to the nurse, "All my friends are married and have
children. I can't seem to meet anyone, and I know I'll never be happy until I meet
someone I can care about enough to marry." Which statement by the nurse
would assist the client in reframing the situation?

A. "Sounds as if you're exaggerating your situation and looking only at the

half-full glass."
B. "It seems that you measure your life and what you need to do against the
behaviors of others."
C. "Aren't you a little young to be thinking in such negative terms? You do still
have plenty of time before your biological clock winds down."
D. "You can't seem to meet someone that you care about? You can still find
enjoyment in friendships, work, books, and other things as well." - D. "You
can't seem to meet someone that you care about? You can still find
enjoyment in friendships, work, books, and other things as well."

264. The client says to a nurse, "Do you know that after 24 years of marriage I still
serve my husband breakfast in bed? After all I do for him, he still doesn't treat me
well. He should treat me better." Which nursing response is appropriate?

A. "You know, you could work and make money serving food to people."
B. "I agree. If you can do all that for your husband, he should treat you
better."
C. "It seems that you feel that your husband could treat you well just as you
treat him."
 D. "Ask your husband to do the things you'd like. If he doesn't, tell him you're
leaving him." - C. "It seems that you feel that your husband could treat you
well just as you treat him."

265. A client says to the nurse, "My doctor wants me to start keeping a journal every
day about what's happening in my job." Which response by the nurse is
appropriate?

A. "You can erase your stresses by identifying things that set off negative
physical experiences."
B. "Well, it has always helped me to write down daily happenings and relate
them to my stress level."
C. "Yes, that is an excellent suggestion. You need to keep a meticulous diary
of your day with all of the details."
D. "Journal-keeping that identifies what seems to cause a strain in a person's
life is a good way of improving one's health." - D. "Journal-keeping that
identifies what seems to cause a strain in a person's life is a good way of
improving one's health."

266. A 62-year-old woman says, "Since my husband retired, 4 months ago, he's
started playing golf 24/7, so after rearing our children alone while my
workaholic husband ran his business I'm suddenly a golf widow." Which
response by the nurse is appropriate?

A. "Do other people call you a golf widow?"

B. "Have you shared your feelings with your husband?"
C. "'When you can't beat 'em, join 'em' — that's what I always say. Why not
play golf with him?"
D. "Some women wish they had your problem. My mother keeps complaining
that Dad is always messing around in the house, driving her nuts." - B.
"Have you shared your feelings with your husband?"

267. A client's son and daughter were killed during a fellow student's murderous
rampage at their high school 9 months ago. The client says to the nurse, "My
wife and I just feel empty and exhausted. I can't believe that I had a vasectomy
after our son and daughter were born because we wanted to give them both
whatever they needed. We have college funds for both of them that they'll
never use now." The nurse should make which appropriate statement to the
client?

A. "My parents would be devastated if they lost me and my sister, too. How
can I be of service to you?"
B. "Your feelings are appropriate for the extent of your loss and how your
children's deaths happened."
C. "Your loss touches me so. How truly devastated you both must be. Can
you share what things you have been doing to grieve?"
 D. "Your loss is incalculable. Perhaps you could consider some ways in
which to commemorate their lives for you and in your community." - C.
"Your loss touches me so. How truly devastated you both must be. Can
you share what things you have been doing to grieve?"

268. The slightly overweight mother of a morbidly obese 11-year-old girl says, "My
family health care provider is wild over my daughter's weight gain. He says she's
not eating correctly and is too sedentary, and now she's at risk for diabetes. He
says the sugar in her blood was up this month. It's all my fault because I eat the
wrong things, too, and I never get off the couch." Which statement by the nurse
would be therapeutic in easing the client's self-blame?

A. "Well, it seems very bleak to you, but your daughter is responsible for her
eating and exercising, too."
B. "What about her father? Isn't it partly his fault, too? I want to meet with
you, him, and your daughter tomorrow."
C. "It's all this fast food and TV-watching these days. If our kids aren't
watching television, they're playing with their computers."
D. "Your daughter has a serious problem, but there are many successful
programs that you can join with her to lose weight and improve your
overall lifestyle." - D. "Your daughter has a serious problem, but there are
many successful programs that you can join with her to lose weight and
improve your overall lifestyle."

269. A client says to the nurse, "My doctor tells me that I need to start progressive
muscle relaxation(PMR) to ease my stress, but I just can't get the hang of it."
Which response by the nurse would be most helpful?

A. "PMR requires training sessions. Let's check into classes that you can
attend to learn the technique."
B. "I want you to practice it as often as you can. Play soft, soothing music in
the background when you practice your exercises."
C. "For it to be effective and produce deep relaxation, the technique requires
your complete receptivity to its benefit and your need for it."
D. "I could never master the technique myself, so I understand your
frustration. Would you like me to explain its difficulty for you to the doctor?"
- A. "PMR requires training sessions. Let's check into classes that you can
attend to learn the technique."

270. The nurse is teaching assertiveness training to a client with anger- management
issues. Which instruction would the nurse give for helping the client assertively
confront someone?

A. Emphasize how much you like the person but insist that the other person
make the changes you need.
 B. Tell the person that the behavior has become intolerable for you and that
the behavior must be changed immediately.
C. Demonstrate that you understand how the other person feels but state that
you still expect the other person to make the changes you need.
D. Ask for private time to talk and point out the facts without being
accusatory, then determine areas of mutual misunderstanding and request
the changes you need. - D. Ask for private time to talk and point out the
facts without being accusatory, then determine areas of mutual
misunderstanding and request the changes you need.

271. A client who recently lost his hand in a workplace accident says to the nurse,
"I don't know how I'm going to support my family with a plastic hand. I might
as well be dead." Which nursing response would be therapeutic?

A. "You're saying that you feel useless without your hand?"

B. "Perhaps you need to focus on being happy that you survived."
C. "Don't worry about all of that at this point. You're going to be fine."
D. "You'll never need to worry about work again, because your employer will
cover all of your expenses and make a settlement that will support you for
life." - A. "You're saying that you feel useless without your hand?"

272. A client whose adolescent son committed suicide by hanging himself in the
family's garage says to the nurse, "The coroner just informed us that our son
had AIDS." Which response to the client by the nurse is appropriate?

A. "You didn't know that he had AIDS? How did he see the family health care
provider without your knowing?"
B. "Your poor son. How troubled he must have been. It's a shame he couldn't
talk to you and get some help."
C. "Your son had an autopsy because he committed suicide, but the coroner
didn't have to tell you that he was ill."
D. "Your son was keeping a very troubling diagnosis to himself. I am so sorry.
No matter how close and loving children are to their parents, some
children just aren't able to confide in their parents." - D. "Your son was
keeping a very troubling diagnosis to himself. I am so sorry. No matter
how close and loving children are to their parents, some children just
aren't able to confide in their parents."

273. A recently widowed client says, "I lived my whole life for my husband and
children. Now he's dead and my daughter and son have each married and
moved across the country. They hardly ever call or visit. It's just that there's really
nothing much for me to do." Which response by the nurse to the client is
appropriate?

A. "Your children seem very distant. They hardly ever call?"

B. "Are you thinking of hurting yourself just because you're alone?"
 C. "You're feeling pretty useless right now, but I wonder if you've taken
enough time to grieve?"
D. "You seem to be identifying some issues in your life that are troubling, and
you sound very down right now." - D. "You seem to be identifying some
issues in your life that are troubling, and you sound very down right now."

274. A 61-year-old client whose two sons and daughter-in-law died in a nightclub
fire says to the nurse, "We were going to retire early, but now we are the only
ones who can care for our two grandchildren." Which response by the nurse
would be therapeutic?

A. "I am sorry you've had so many losses."

B. "I lost my nephew in that nightclub fire, so I understand your sorrow."
C. "Your grandchildren sound as if they will give you a run for your money."
D. "Don't you just want to scream at someone when such bad things
happen? Do you have to work to support your grandchildren?" - A. "I am
sorry you've had so many losses."

275. The family of a client who is being discharged after trying to kill himself with one
of his father's guns asks for a family meeting with the nurse to discuss their son's
situation. Which statement by the nurse would be the most therapeutic start to
the meeting?

A. "I must begin by saying that I am uncomfortable meeting without your son
here to talk for himself."
B. "Let's start by introducing ourselves and talking about what is most
troubling to each of you about having your son home."
C. "Why don't we all introduce ourselves and say what our relationship is to
your son? I'll begin, because I'm the nurse who'll be seeing him after he
comes home."
D. "I am going to begin by talking in general terms about your son's return
home and some of the things that might happen. I can suggest measures
that might be helpful, and then you can ask questions." - D. "I am going to
begin by talking in general terms about your son's return home and some
of the things that might happen. I can suggest measures that might be
helpful, and then you can ask questions."

276. A client with depression says to a nurse, "Why is my family meeting with you?
Are you telling them about me?" Which response by the nurse would be
therapeutic?

A. "Have you talked with your family? What have they said to you about the
meetings?"
B. "I am committed to keeping everything you say to me confidential, so it is
troubling when you accuse me of talking to your family."
 C. "You sound concerned that I would tell your family something about you
even though you know that what we talk about is confidential."
D. "Your family is learning about depression and how best to help you so that
they can be supportive of you. We do not talk about you or anything
confidential about you." - D. "Your family is learning about depression and
how best to help you so that they can be supportive of you. We do not talk
about you or anything confidential about you."

277. A client who has been referred for group therapy asks the nurse about the
therapy. The nurse tells the client that this type of therapy is focused on which
purpose?

A. Social skills training

B. Social functioning in groups
C. Cognitive behavioral therapy
D. The development of interpersonal skills, resolution of family problems, and
effective use of community support - D. The development of interpersonal
skills, resolution of family problems, and effective use of community
support

278. The parents of an adopted child schedule an appointment at a psychiatric clinic,

and when they arrive the nurse conducts an initial assessment. One of the
parents says to the nurse, "We need to speak to a psychiatrist about our adopted
daughter. Could you please get one for us?" Which intervention by the nurse
would be therapeutic?

A. "I'd like to accommodate you both, but he is busy right now and you will
have to talk to me."
B. "Do you feel that I am incompetent to talk with you? Everyone who comes
here sees me first."
C. "That is not the procedure here. If you can't work with the system, you're
free to go elsewhere."
D. "The doctors here feel that clients are best served when I conduct the
initial assessment, after which the psychiatrist will see you with complete
information." - D. "The doctors here feel that clients are best served when
I conduct the initial assessment, after which the psychiatrist will see you
with complete information."

279. A 45-year-old fireman says to the nurse, "I've worked at some fires recently that
were just devastating, but last week was the worst. I carried this little girl from a
fire — she was badly burned and lived just a few minutes after I brought her out,
and she said to me, 'Tell my mom and Rudy I love them both very much.' Her
mom told me that Rudy is their dog, and he just mopes around the house since
the little girl died. I keep thinking about her and just don't know if I can go on."
Which response by the nurse would be therapeutic?
 A. "Maybe you could help the mother find a home for Rudy, and then your
troubling thoughts would go away."
B. "Would you listen to yourself? You've seen firemen stress out before.
What is your responsibility in all this?"
C. "You've helped victims of some horrific fires lately, and yet you question
your calling. Do you feel the need to resign?"
D. "You're questioning your job because you're upset about the little girl you
tried to save. Work stress can be treated and help you cope better. It is so
important for you to seek treatment." - D. "You're questioning your job
because you're upset about the little girl you tried to save. Work stress can
be treated and help you cope better. It is so important for you to seek
treatment."

280. A 68-year-old client whose husband died 2 months ago says to the nurse, "I'm
having trouble sleeping lately, even though I don't nap in the daytime. I've been
using warm milk without any results." Which statement by the nurse would be
therapeutic?

A. "So you've started having sleeping problems but no other problems?"

B. "Perhaps you should join the grieving spouses group that meets on
Monday nights."
C. "Since you've lost your husband, have you experienced any other
problems besides trouble sleeping?"
D. "One of the things that I've found has helped others is a small snack with
your warm milk before sleep and a moderate increase in walking during
the day. Is that something you could try?" - D. "One of the things that I've
found has helped others is a small snack with your warm milk before sleep
and a moderate increase in walking during the day. Is that something you
could try?"

281. A 25-year-old client says to the nurse, "I got my degree in criminal justice. I
graduated first in my class from the police academy and had just started as a
patrolman when my partner and I responded to a domestic violence call in the
most rural part of our patrol area. Someone started shooting at us, and I'm
terrified. Maybe I'm not right for this job." Which statement by the nurse would be
therapeutic?

A. "You're saying that because you felt afraid in a violent situation, you may
not be right for the job?"
B. "Did you really think that you wouldn't be frightened? You're fortunate if
this is the first time you've ever been afraid."
C. "You seem to be surprised that you were frightened by the violence. Have
you talked with your co-workers about their experiences?"
D. "My earlier work as a nurse involved trips through our local crack houses.
Wait until you've had some experience working narcotics and then tell me
 how you feel." - A. "You're saying that because you felt afraid in a violent
situation, you may not be right for the job?"

282. The home care nurse makes a new-baby visit to a young husband and wife.
The visit takes two-and-a-half hours because the parents are so detailed in
giving information and asking questions of the nurse. Which intervention by the
nurse would be therapeutic?

A. Ordering a follow-up visit to the family pediatrician and mental health

clinical specialist
B. Informing all home care nurses to schedule their visits to the couple as
their last visit of the day
C. Having the home care office secretary call the nurse's cell phone 20
minutes after starting the visit to expedite the nurse's departure
D. Blocking out more time for the next visit and scheduling a follow-up visit as
soon as possible to assess how they are coping and gauge their level of
anxiety - D. Blocking out more time for the next visit and scheduling a
follow-up visit as soon as possible to assess how they are coping and
gauge their level of anxiety

283. A 35-year-old recently divorced parent of twins comes to the intake office of the
psychiatric clinic for the first time with a possible diagnosis of generalized
anxiety disorder. The client says to the nurse, "My mother always called me a
worrywart like my nana, so I guess I come by my problems naturally. I keep
worrying about things I can't change, like my divorce, and blaming myself when I
know I'm not the only one responsible for the divorce." Which nursing statement
would be therapeutic?

A. "Yet you seem to be dwelling on the thought that the divorce is all your
fault."
B. "Can you tell me more about the worrying and blaming you are
experiencing?"
C. "I wonder whether you think you're responsible for making everything turn
out right."
D. "So you're a natural worrywart, divorced with twins. I guess you can be
forgiven for a little worrying, but tell me about the blaming you've been
doing." - B. "Can you tell me more about the worrying and blaming you are
experiencing?"

284. A female victim of incest says to the nurse, "I've had tons of therapy but still
can't let my fiancé get too close. He knows I've been sexually abused by my
dad and older brother, but I'm wondering whether I'll ever be able to lead a
normal sexual life." Which statement by the nurse would be therapeutic?

A. "Can you share with me some of the strategies you've been using?"
B. "Do you want a normal sexual life? If you do, you will have one, I'm sure."
 C. "It almost seems that you're saying that you will never be able to love your
fiancé."
D. "You seem to be saying that you and your fiancé haven't been close, yet
you found each another." - A. "Can you share with me some of the
strategies you've been using?"

285. A client who witnessed her husband being shot and killed in an incident of road
rage says to the nurse, "It's been 3 months now, and I still can't drive my car
without acting crazy. My sister says I grip the wheel like I'm glued to it. I can't
merge with traffic until it's almost completely clear, and I'm parking a mile from in
the mall when there's plenty of parking close to the building." Which statement by
the nurse would be therapeutic?

A. "I still grip the wheel when I merge with traffic, and I just wonder whether
your sister needs to see me do it."
B. "If I were you, I'd have trouble driving the car again. Driving a car and
being the victim of road rage are two very different things, and you need
therapy and time to heal."
C. "Smart of you to take no chances. You should see the dents and dings on
my car from mall parking. Does your sister depend on you for many
things? It seems like she's pushing you too hard."
D. "You're seeking help appropriately, and there are many things you can do
to get comfortable behind the wheel again. You've returned to driving, but
remember, you're still grieving. It's normal to still feel this way." - D.
"You're seeking help appropriately, and there are many things you can do
to get comfortable behind the wheel again. You've returned to driving, but
remember, you're still grieving. It's normal to still feel this way."

286. A 35-year-old client says to the nurse, "I got divorced less than a year after
getting married. I left the Navy SEALs shortly after I joined. Now I teach in the air
marshal program to avoid being recalled for war, but I'd really like to quit. I start
something, am great at it, then get bored and move on. I date, but I'm still living
at home. I never seem to be on my own like other guys my age." Which
response by the nurse is most appropriate?

A. "You made the Navy SEALs but can't live on your own like an adult and
can't stick with anything."
B. "Can you tell me more about your marriage and relationships? If you leave
home, what do you fear will happen?"
C. "You have many years to find a new relationship, but moving out of your
parents' home is a first step to growing up."
D. "When will your mother let you go? Seems to me that jobs have come
easy to you but that you can't grow up and separate from your parents." -
B. "Can you tell me more about your marriage and relationships? If you
leave home, what do you fear will happen?"
287. A client says to the nurse, "I have to do everything. My family can't plan or
organize anything. My wife just wants to go out and socialize. My grown son and
his wife live with us. They never do anything around the house but 'their' stuff,
because they say they pay rent. We really need their rent money since I lost my
job. My wife could work but she says 'it's too late to start over' for her. Well, that's
what I'm doing—more work at far less money." Which response by the nurse
would be therapeutic?

A. "Do the terms 'divorce' and 'leave the nest' mean anything to you or your
family?"
B. "Would your family come in to see me so I can hear their version of the
problems you cite?"
C. "You seem to be going through quite a lot recently. I'd like to hear more
from you about your concerns. Would your family come in and talk with
us?"
D. "You tell me that you do everything. You don't say what happens when
you stop doing everything. Does your wife understand that you are not
able to work as you once did and that you need her help?" - C. "You seem
to be going through quite a lot recently. I'd like to hear more from you
about your concerns. Would your family come in and talk with us?"

288. On the initial visit to the mental health clinic, a client says to the nurse, "When I
married my husband, more than 30 years ago, he was a big, handsome,
competent professional who never wanted me to work and was so loving. Well,
two kids later he's a slob who gambles and loses one job after another. Now I'm
the breadwinner and he's content to be a shiftless town joke." Which statement
by the nurse would be therapeutic?

A. "You sound disgusted with your husband. Is this an accurate assessment?

Why not divorce him?"
B. "Can you tell me how long you have felt like this and how much longer you
plan to continue this way?"
C. "You seem to have changed your feelings about your husband completely.
This didn't happen overnight, so why are you here now?"
D. "Many things have happened to you and your husband. Sounds as if
you've both been struggling for some time. Would you like to have him
come in with you to talk with me about all of this?" - D. "Many things have
happened to you and your husband. Sounds as if you've both been
struggling for some time. Would you like to have him come in with you to
talk with me about all of this?"

289. A client says to the nurse, "I was cheating on my lover because I need the thrill
of seeing someone new, and now my lover has left me to go live with this other
woman. I know that this other woman wants more than friendship from my lover,
and I can't make my lover see that I love her and that my affairs are
 meaningless. I don't want to lose her, but I can't stop cheating, because I need
the thrill it brings." Which statement by the nurse would be therapeutic?

A. "So she's left you for cheating on her. If you can't be monogamous, I
guess you'll have to be content with one-night stands."
B. "I'm confused. What is it that you've come to me for? It sounds like your
lover refuses to share her lover with others, no matter how trivial the
dalliances."
C. "Perhaps your task is not to make your lover see that your dalliances are
meaningless but to look at your own behavior and determine what you
would like or not like to be different."
D. "It sounds like you want to have your cake and eat it, too. If you can't have
both things, which would you prefer — the thrills of one-night stands or the
steady support of a loving relationship?" - C. "Perhaps your task is not to
make your lover see that your dalliances are meaningless but to look at
your own behavior and determine what you would like or not like to be
different."

290. A 52-year-old client is admitted to the hospital for surgery to treat lung cancer.
The client says to the nurse, "I was an alcoholic for 15 years, and now that I'm
25 years sober, I'm being punished." Which statement by the nurse would be
therapeutic?

A. "You started drinking at 12 years of age — is that why you feel that the
cancer is retribution?"
B. "Because you seem to be blaming yourself unnecessarily, perhaps we can
talk about your illness and what you can expect after surgery."
C. "Sounds like you feel that you're being punished for your drinking, yet
you've been sober, so perhaps you're being rewarded by having a cancer
that's curable."
D. "You feel that you're being punished even though you've been sober for
25 years. Your doctor must have told you that the cancer is unrelated to
alcohol." - B. "Because you seem to be blaming yourself unnecessarily,
perhaps we can talk about your illness and what you can expect after
surgery."

291. A 32-year-old married woman who recently gave birth to her first child by
cesarean section says, "My husband and I worry about our baby all the time. We
did everything right, yet he had so many problems at birth." Which statement by
the nurse would be therapeutic?

A. "I'd like to ask you a series of parenting questions to determine your

fitness."
B. "What's been happening since you all came home? As I understand it, the
baby is thriving."
 C. "Can you tell me more about the worrying? What's been happening since
you brought your baby home?"
D. "Lots of women do everything right but wind up having cesarean sections.
Why worry when it won't change anything?" - C. "Can you tell me more
about the worrying? What's been happening since you brought your baby
home?"

292. A client in group therapy says to the two nurses conducting the group, "You two
are great at psychoanalyzing us, but what about you two? Do you have trouble
being assertive with your bosses or the doctors like we do?" Which statement by
one of the nurses would be most therapeutic?

A. "Maybe some others in this group want to talk about the assignment that
we all agreed would be completed today."
B. "Why do I feel attacked by someone whom I'm trying to help? Could it be
that you don't want to work in this group anymore?"
C. "You're interested in talking with us about our assertiveness, but this
group is for all of you here to help you to deal with problems more
effectively."
D. "Your deflection from your own problems here in this group is
inappropriate. Let us remind you that you signed up for this group and
agreed to participate in it." - C. "You're interested in talking with us about
our assertiveness, but this group is for all of you here to help you to deal
with problems more effectively."

293. A 56-year-old client says to the nurse, "I'm a guidance counselor at the middle
school, and the kids like to come to see me for help, but I just found out from my
wife that my 22-year-old daughter is a lesbian, and now I'm the one who needs
advice. How am I supposed to accept that? She was the boy we didn't have, and
I made a tomboy of her by taking her to baseball games with me. Is that why
she's gay?" Which statement by the nurse would be therapeutic?

A. "Are you prejudiced against lesbian and gay people?"

B. "You're good at talking with middle schoolers, but how about young
adults?"
C. "How did your wife happen to tell you about this? Did your daughter ask
her to tell you?"
D. "It sounds like you and your daughter were very close but she kept her
sexual orientation from you." - D. "It sounds like you and your daughter
were very close but she kept her sexual orientation from you."

294. A client who delivered a baby 4 weeks ago says, "I'm feeling as if I'm hanging on
by a thread to keep my wits about me." Which statement by the nurse would be
therapeutic?
 A. "Can your husband help you with the baby and your chores? Is he on
paternity leave?
B. "You have a beautiful new baby, and caring for her will help you feel
better. Your hormones will be back in balance soon."
C. "Can you share with me more specifically how you feel that you're hanging
on by a thread? Are you having thoughts of hurting yourself?"
D. "You seem to be experiencing postpartum depression. I suggest that you
have someone take your baby for a while until your hormones level off." -
C. "Can you share with me more specifically how you feel that you're
hanging on by a thread? Are you having thoughts of hurting yourself?"

295. A client with an alcohol problem who has been sober for 8 months asks the
nurse, "Do you think I should add individual therapy to my treatment plan?"
Which response by the nurse would be therapeutic?

A. "What do you think? What is the individual therapy all about?"

B. "Are you feeling that you're vulnerable to a slip? If not, why complicate
treatment further?"
C. "Okay, what's going on with you? You had to be coerced into treatment,
but now you seem to want the full monty."
D. "The best time to add individual therapy seems to be after 2 to 5 years of
sobriety. Individuals vary, though, and it may be that you are asking
because you feel ready to work on your issues." - D. "The best time to add
individual therapy seems to be after 2 to 5 years of sobriety. Individuals
vary, though, and it may be that you are asking because you feel ready to
work on your issues."

296. The wife of an alcoholic client says to the nurse, "I can't afford to bail my
husband out of this mess. Our business is filing for bankruptcy, and the Internal
Revenue Service has posted a notice of auction on our home." Which statement
by the nurse would be therapeutic?

A. "You're having a very difficult time, and the problem stems entirely from
your husband's drinking."
B. "It's a shame. So many troubling things have been happening to you both
because of the disease of alcoholism."
C. "The lack of money has stopped you from saving your husband? It sounds
like you need to help yourself right now. What do you think?"
D. "You're codependent with your husband. Don't you see this? Are you
willing to attend some group meetings to learn about ways to deal more
effectively with your problem?" - C. "The lack of money has stopped you
from saving your husband? It sounds like you need to help yourself right
now. What do you think?"
297. A client with an anxiety disorder who has been prescribed an antibiotic for otitis
media asks the nurse, "Why'd the doctor tell me not to discontinue the
medication until the pills are gone?" Which response by the nurse is appropriate?

A. "Doctors always tell clients to take all of their medicine."

B. "Completing the medication ensures that the infection will be resolved."
C. "Medication is always prescribed for 1 month. Do you have a month's
supply?"
D. "It's because insurance companies pay for the medications and want to
make sure that the client is healed." - B. "Completing the medication
ensures that the infection will be resolved."

298. The client is the wife of a former workaholic who now has not worked in years,
refusing to get a job or help with chores around the house. The man watches
television and snacks all day. The client tells the nurse that her husband now
weighs more than 300 lb and expects her to support him. The client states, "I
keep saying everything will be fine. It will be if he keeps up these bad health
habits, because they'll kill him, and then I would be free and wouldn't have to
deal with his obnoxious behavior." Which negative stress response does the
nurse recognize in the client's behavior?

A. Blaming
B. Daydreaming
C. Problem- solving
D. Wishful thinking - D. Wishful thinking

299. The parent of a 25-year-old man who has just been found to have a left frontal
brain tumor says to the nurse, "At the local hospital, our doctor thought that his
headaches were nothing and prescribed an analgesic. If I hadn't insisted on a
CT scan, no one would have found the tumor." Which statement by the nurse
would be therapeutic?

A. "What's being planned for your son now?"

B. "You and your son are having a very trying time. What's happened since
your son's diagnosis?"
C. "These days only the squeaky wheel gets the grease in medicine. Your
squeaking was excellent advocacy."
D. "Sounds like you have to be your own health care provider these days —
good for you! — but I'm sure your health care provider was following
medical protocol." - B. "You and your son are having a very trying time.
What's happened since your son's diagnosis?"

300. A client is going to receive instruction in biofeedback technique to lower his

stress level. The client asks the nurse to describe this technique. What should the
nurse tell the client?
 A. It is a technique that trains the mind to elicit a relaxation response
B. It is the purposeful use of one's imagination to achieve relaxation and
control
C. It involves learning to contract and relax muscles in a systematic way and
may be combined with breathing exercises
D. It is a therapeutic modality that enables an individual to monitor skin
temperature, muscle activity, heart rate, blood pressure, and other bodily
functions, then learn to control these physiologic responses to stressful or
challenging events - D. It is a therapeutic modality that enables an
individual to monitor skin temperature, muscle activity, heart rate, blood
pressure, and other bodily functions, then learn to control these
physiologic responses to stressful or challenging events

301. A university professor meeting with the mental health nurse for his weekly
therapy session says, "I have a very intelligent student who keeps disrupting my
classroom by bragging, and all I want to do is say, 'OK, you're great and you
know it all! Now shut up!' But I just don't want to be rude." Which statement by
the nurse is therapeutic?

A. "Sounds like you feel pretty helpless, yet you are the professor here."
B. "Just say, 'Gee where did you earn your doctorate?' and move on with
your lecture."
C. "Just smile and say nothing. Go on with your lecture and then talk with the
student after class."
D. "You're having a pretty strong reaction to this student, aren't you? Why not
ask the student to leave the room and use the time to write down his or
her thoughts so you can give the others your complete attention?" - A.
"Sounds like you feel pretty helpless, yet you are the professor here."

302. The nurse is reading the medical record of a client who has a diagnosis of
moderate anxiety and notes that the health care provider has documented that
the client exhibits eustress. Based on this information, which finding would the
nurse expect to encounter while assessing the client?

A. The client complains of fatigue.

B. The client complains of feeling drained.
C. The client complains of feeling anxious.
D. The client engages in purposeful movement. - D. The client engages in
purposeful movement.

303. A client says to the nurse, "I've started a journal because my health care
provider suggested it, and I'm writing about the things that bother me each day.
Sometimes I dictate my feelings and what happened during the day into a
recorder and write them up before I go to bed — and, do you know, they seem
silly to me then. Is this helping me?" Which response by the nurse would be
appropriate?
 A. "I'm not certain that using a tape recorder will help you with the journal-
keeping."
B. "Well, I wonder about the dictation, because the writing is what helps
reduce stress."
C. "Well, it will take some time, but let's see how you're doing over a month.
In the meantime, keep writing."
D. "It seems that people who write in their journals and can share traumatic
events improve their self-awareness." - D. "It seems that people who write
in their journals and can share traumatic events improve their self-
awareness."

304. A client who was recently admitted to the mental health unit has a history of
paranoia. When the meal tray is delivered, the client refuses to eat and tells the
nurse that someone is poisoning the food. Which statement by the nurse is
appropriate?

A. "Your food is not poisoned."

B. "Why do you think the food is poisoned?"
C. "There is no poison in the food. Here, I'll taste the food for you."
D. "It must be frightening to you. Has something made you feel that your food
is poisoned?" - D. "It must be frightening to you. Has something made you
feel that your food is poisoned?"

305. The nurse reviews the nursing care plan of a client being seen in the
mental health clinic and notes that the client is experiencing dysfunctional
grieving after losing his spouse. Which is the appropriate outcome for the
treatment plan for this client?

A. The client plans to attend a community grief group.

B. The client reports that he is trying to use coping strategies.
C. The client verbalizes an absolute need to spend time with friends.
D. The client verbalizes the relationship between significant loss and
depression. - A. The client plans to attend a community grief group.

306. The nurse is talking to a client with depression when the client says, "I don't
know why my son turned out like he did. I never thought that he would rob a
bank! I don't know what I did wrong. I know that he didn't grow up with a father,
but I gave him everything. I wish I could start over and do things differently."
Which response by the nurse would be therapeutic?

A. "You seem to be feeling regret."

B. "Don't blame yourself. Some people just turn out bad no matter what."
C. "All we can do is give our children love and do our very best. The rest is
up to them."
 D. "Do I hear you saying that you feel that your son's behavior was caused
by his upbringing?" - A. "You seem to be feeling regret."

307. The nurse is evaluating the coping skills of a client with a diagnosis of
depression. Which statement indicates to the nurse the need to help the client
learn and appropriately use these skills?

A. "I need to take my medications."

B. "I know that I can't do everything."
C. "I won't ever be depressed again."
D. "I have learned ways to deal with stress." - C. "I won't ever be depressed
again."

308. A victim of sexual assault is being seen in the crisis center. The client states
that she still feels "as though the assault just happened," even though it has
been a few months since she was attacked. Which supportive statement
should the nurse make to the client?

A. "Things like this take time to get over."

B. "Be realistic. Remember, the assault didn't just happen."
C. "Why keep thinking about this? It'll only make matters worse."
D. "Tell me more about why you feel like the assault just occurred." - D. "Tell
me more about why you feel like the assault just occurred."

309. A client who is experiencing suicidal thoughts says to the nurse, "Life is just
not worth it anymore." What is the appropriate initial response?

A. "You have a lot to live for."

B. "Tell me what you mean by that."
C. "A good night's sleep will help you feel better."
D. "You should feel grateful for everything you have." - B. "Tell me what you
mean by that."

310. A client comes to the mental health clinic after losing all of his personal
belongings in a hurricane. The client tells the nurse that the loss of his
possessions is his fault because he didn't prepare for the storm. The nurse
determines that the client is coping ineffectively and develops goals with the
client. Which goal is the least realistic?

A. The client will identify effective coping skills.

B. The client will develop and use adaptive coping patterns.
C. The client will express and share his feelings about this crisis.
D. The client will stop blaming himself for the loss of his belongings. - D. The
client will stop blaming himself for the loss of his belongings.
311. A client who was admitted to the mental health unit 1 month ago with
agoraphobia is cooperative, shares with peers, and makes appropriate
suggestions during group discussions. Which is most consistent with the client's
behavior?

A. Manipulation
B. Improvement
C. Attention-seeking
D. A desire to be accepted - B. Improvement

312. A 12-year-old client who has been reported for drawing sexually explicit scenes
in her textbooks during class says to the psychiatric nurse, "I just felt like it."
Which response by the nurse would be therapeutic and aid assessment of
abuse-related symptoms?

A. "Well, a picture paints a thousand words."

B. "You just felt like destroying your textbooks?"
C. "Your parents and teachers are very concerned about your drawings."
D. "I am concerned about you. Are you being or have you ever been
abused?" - D. "I am concerned about you. Are you being or have you ever
been abused?"

313. During a nursing interview, a client says, "My daughter was murdered in her
apartment, and her estranged husband called to tell me. I can't stop myself
from wondering whether he killed her, but the police have ruled him out as a
suspect." Which response by the nurse would be therapeutic?

A. "Sounds like it."

B. "It feels terrible to lose a daughter."
C. "I agree. What do you want to bet he did it?"
D. "Have you shared your concerns with the police?" - D. "Have you shared
your concerns with the police?"

314. A schizophrenic client says, "I'm away for the day ... but don't think we should
play or do we have feet of clay?" Which alteration in the client's speech does
the nurse document?

A. Neologism
B. Word salad
C. Clang association
D. Associative looseness - C. Clang association

315. A client with schizophrenia and his parents are meeting with the nurse. One of
the young man's parents says to the nurse, "We were stunned when we learned
that our son had schizophrenia. He was no different than from his older brother
when they were growing up. Now he's had another relapse, and we can't
 understand why he stopped his medication." Which response by the nurse is
appropriate?

A. Telling the parents, "Medication noncompliance is the most frequent

reason that people with this diagnosis relapse."
B. Telling the parents, "Well, it's his decision to take his medicine, but it's
yours to have him live with you if he stops the medication."
C. Asking the client, "How can we help you to take your medicine or to tell us
when you're having problems so that your medication can be adjusted?"
D. Saying to the parents, "Your concerns are appropriate, but I wonder
whether your son was having trouble telling someone that he had
concerns about his medication." - C. Asking the client, "How can we help
you to take your medicine or to tell us when you're having problems so
that your medication can be adjusted?"

316. An acutely ill schizophrenic client says to the nurse, "He keeps saying that he
likes you, and I keep telling him you're married, but he won't listen, and I think
he's going to get fresh with you." Once the nurse has determined that the client is
hallucinating, which response to the client would be most appropriate statement?

A. "Try not to listen to the voices right now so that I can talk with you."
B. "I think that you can help him stop his behavior if you concentrate."
C. "Tell him I said to mind his p's and q's or I'll call the police on him."
D. "I think that you're trying to share your own feelings toward me, but you're
shy." - A. "Try not to listen to the voices right now so that I can talk with
you."

317. A client says to the nurse, "It's over for me — the whole thing is over." Which
response by the nurse would be therapeutic?

A. "What do you mean, 'The whole thing is over'?"

B. "Over? Well, that sounds pretty drastic to me. Let's discuss this in the
strictest confidence."
C. "Can you tell me more about why it's over for you? I'll keep your thoughts
strictly confidential."
D. "Let's talk more about your feeling that the whole thing is over for you.
This is important, and I may need to share your feelings with other staff
members." - D. "Let's talk more about your feeling that the whole thing is
over for you. This is important, and I may need to share your feelings with
other staff members."

318. The nurse performing a lethality assessment asks the client whether he is
thinking of suicide. Which statement by the client would be of most concern to
the nurse?

A. "No, I wasn't, but I am now, thanks to you."

 B. "I hadn't thought of that, but I can see that you are."
C. "Of course not, but there are days when I think that I should be."
D. "What is suicide going to do for me except get me excommunicated from
the church?" - A. "No, I wasn't, but I am now, thanks to you."

319. A client who has expressed suicidal ideation in the past says to the nurse, while
shuffling several documents in an effort to organize them, "Well, I'm feeling so
much better now since I got organized. My lawyer wrote my will and durable
power of attorney." Which response by the nurse is most appropriate?

A. "Good grief! You don't look organized to me."

B. "Okay, what are you up to today? Your behavior is not appropriate."
C. "You talk about getting organized. Are you thinking of killing yourself?"
D. "If you keep behaving like this, you know that I'll have to tell the health
care provider, and we'll have to seclude you." - C. "You talk about getting
organized. Are you thinking of killing yourself?"

320. An adolescent client says, "I'm just a burden to my folks. They wish I'd never
been born. My dad told me he had to marry Mom because she got
pregnant." Which response by the nurse would be therapeutic?

A. "You're feeling that your folks didn't want you, but they chose to marry and
have you."
B. "You feel that you were a burden and not wanted? Let's talk with your
parents to see whether you're right."
C. "Let's speak with your parents about what you've just told me. Let's ask
whether you were truly unwanted."
D. "Sounds like your father was very inappropriate, but I'm certain that he
didn't mean that you were a burden to him." - A. "You're feeling that your
folks didn't want you, but they chose to marry and have you."

321. A client says to the nurse, "I've ruined my life. I left college with only a few credits
to go. I keep telling myself that I'm going to make it as a writer, but I'll be a loser
and a nothing for the rest of my life." Which response by the nurse is
therapeutic?

A. "What are you saying? Sounds like you need to pull yourself together and
go back to school."
B. "Having faith in yourself is one thing, but looking at your alternatives
realistically is another."
C. "You seem to be saying that your choices are final and that you've lost any
other opportunities."
D. "Sounds like you feel that things should come easy for you, unlike the rest
of us, who work for what we get." - C. "You seem to be saying that your
choices are final and that you've lost any other opportunities."
322. A client who has twice attempted suicide says, "If people would just leave me
alone and let me do what I want with my life, I could get on with what I want to
do." Which response should the nurse give to the client?

A. "Of course you can't be left alone to get on with what you want to do."
B. "Okay, go ahead and do whatever you want to do. Human beings have
free will."
C. "You've tried to end your life twice, yet you feel that everyone should let
you do what you want to do?"
D. "Sounds like you're angry with people for caring enough about you to try to
keep you from hurting yourself." - C. "You've tried to end your life twice,
yet you feel that everyone should let you do what you want to do?"

323. A homeless client with an antisocial disorder is brought to the emergency

department by the police after disturbing customers in a department store. The
client says to the nurse, "I need to be hospitalized. It's getting cold out, and I
need a warm bed. If you don't get me into a hospital, I'll jump off a bridge." Which
nursing intervention would be therapeutic?

A. Sending the client to the psychiatric hospital intake center immediately for
evaluation
B. Asking the police to pick the client up and arrest him for vagrancy, as they
should have done immediately
C. Discharging the client with a follow-up appointment for the next day and
guaranteeing him a hospital bed if he shows up
D. Sending the client to a shelter that will provide temporary housing if he
signs a contract agreeing not to attempt suicide - D. Sending the client to
a shelter that will provide temporary housing if he signs a contract
agreeing not to attempt suicide

324. A client is admitted to the medical-surgical unit of a hospital, and suicide

precautions are taken until the client can be admitted to the psychiatric unit.
Which nursing intervention should the nurse implement?

A. Placing the client in a private room and locking the client's closets and
bathroom
B. Placing the client in a private room and removing all knives and glass from
the client's meal tray
C. Allowing the client to go out on pass as long as the client is accompanied
by a responsible adult
D. Placing the client in a semiprivate room, providing plastic utensils for
eating, and keeping an arm's distance from the client at all times - D.
Placing the client in a semiprivate room, providing plastic utensils for
eating, and keeping an arm's distance from the client at all times
325. A client is admitted to the psychiatric inpatient unit and suicide precautions are
instituted. Which intervention should the nurse implement?

A. Restricting visitors
B. Placing the client in a private room and locking the bathroom door
C. Removing perfume, shampoo, and other toiletries from the client's room
D. Placing flowers brought to the client in a small glass vase and putting
them in the client's room - C. Removing perfume, shampoo, and other
toiletries from the client's room

326. A client who is undergoing psychiatric counseling calls a nurse on a hotline,

crying, and states, "My priest assaulted me when I was an altar boy, and my dad
just found out. He's got a gun, and he's driving over to the church rectory. I don't
know what to do." Which response by the nurse is most appropriate initially?

A. "How did your dad learn of your abuse by clergy?"

B. "Call the police immediately and then call the priest to warn him that your
dad has a gun."
C. "Call the priest immediately and tell him to lock the doors until the police
arrive. I'll call the police."
D. "You will want to come in to see our psychiatrist with your father, but, for
now, call the police and tell them what happened." - C. "Call the priest
immediately and tell him to lock the doors until the police arrive. I'll call the
police."

327. The nurse determines that a client whose son died in a car accident is at risk
for self-harm. Which intervention is most appropriate initially?

A. Making a "no suicide" contract with the client

B. Telling the client that anger should be suppressed
C. Providing a peaceful place for the client to meditate
D. Helping the client control expression of his feelings - A. Making a "no
suicide" contract with the client

328. A client says to the nurse, "I'm worried about my husband. He's talking about
ending it all since his law practice dropped off and his son by his late first wife
died of a drug overdose — but he's too intelligent to hurt himself, isn't he?"
Which response by the nurse is appropriate?

A. "Yes, he's too intelligent to end it all."

B. "I'm not sure. I don't know him that well."
C. "Most people who talk about ending it all are just looking for attention."
D. "Your husband is displaying behaviors that indicate a risk for self-harm." -
D. "Your husband is displaying behaviors that indicate a risk for self-
harm."
329. A client says to the nurse, "I came in to see you because I've been off my
medication for 4 years but I feel as though I may be getting depressed again. I've
been despondent again and thinking I should have ended it. That's why I'm here
to get help." Which response by the nurse would be therapeutic?

A. "Well, you really have had a good long drug-free time, but it sounds as if
the health care provider needs to reorder your medication at once."
B. "If you've been able to be drug free all this time, you probably don't need
to restart the medicine. You probably just need some therapy to help you
manage stress."
C. "Well, it's been more than 4 years, so you've done really well. Sounds like
you're right about getting depressed again, though. Can you tell me what's
been happening with you lately?"
D. "Well, it's similar to when a client is battered — things have to boil over
before the police can act — so you need to be suicidal to get admitted to a
hospital or hurt yourself before the health care provider can restart the
medication." - C. "Well, it's been more than 4 years, so you've done really
well. Sounds like you're right about getting depressed again, though. Can
you tell me what's been happening with you lately?"

330. A client who delivered a baby 4 months ago says, "I keep thinking that this boy is
some sort of demon. All he does is cry. It's as if I can't feed him enough or satisfy
him in any way. My daughter never gave me this kind of trouble. I really can't
stand it." Which statement by the nurse is most important?

A. "Have you been having any thoughts of hurting your baby?"

B. "Do you think that something physically wrong is causing your baby to
cry?"
C. "Do you think that your baby cries so frequently because he's not getting
enough nourishment from breastfeeding?"
D. "You say that he doesn't seem to be satisfied. Do you feel that this is
significantly different from when your daughter was a baby?" - A. "Have
you been having any thoughts of hurting your baby?"

331. An alcoholic client who has been admitted to the mental health unit states to the
nurse, "The judge made me come in here. My blood alcohol level was only
0.20% when the cop pulled me over in my car." Which statement by the nurse is
most appropriate?

A. "Did you ask the judge to clarify his decision to make you come here?"
B. "This limit means that you had consumed enough alcohol to put you close
to the legal intoxication level. You were lucky because you just missed
that level."
 C. "Well, the legal limit is much less than that, so you avoided a drunken
driving charge by coming here. Seems to me that the judge treated you
pretty leniently by allowing you to take refuge here. Don't you agree?"
D. "This level means that you consumed several drinks of alcohol and would
be experiencing depressed motor function of the brain. You would have
been staggering and clumsy and your judgment would have been
impaired, but you seem to feel that the judge was unreasonable for
sending you here." - D. "This level means that you consumed several
drinks of alcohol and would be experiencing depressed motor function of
the brain. You would have been staggering and clumsy and your judgment
would have been impaired, but you seem to feel that the judge was
unreasonable for sending you here."

332. An adolescent client has graduated high school and is preparing to leave home
to attend college. The adolescent is distressed about this life change. The nurse
plans to implement crisis interventions, knowing that this situation is
characteristic of which type of crisis?

A. A situational crisis
B. An individual crisis
C. A maturational crisis
D. An adventitious crisis - C. A maturational crisis

333. A heroin addict who overdoses on the drug is brought into the emergency
department. The client is having seizures, and the nurse notes that his pupils are
dilated. Which intervention does the nurse anticipate that the emergency
department health care provider will prescribe?

A. Gastric lavage
B. Intravenous fluid
C. Naloxone (Narcan)
D. Ammonium chloride - C. Naloxone (Narcan)

334. A client in a retirement center rings the night alarm and says to the nurse, "Look
at this old man! He keeps breaking into my apartment! You've got to get him to
stay out of here so I can sleep." Which statement by the nurse would be most
therapeutic?

A. "Why not just throw him out yourself and lock up once and for all?"
B. "Now, you know that you're always seeing things and people at night who
aren't there."
C. "This must be very troubling to you, but I can't see the old man. Perhaps I
could stay with you for an hour or so while you try to rest."
D. "I'm sure you're very frightened right now. Do you recall my telling you that
this is called sundowner syndrome? Go to sleep and he'll leave your
 apartment." - C. "This must be very troubling to you, but I can't see the old
man. Perhaps I could stay with you for an hour or so while you try to rest."

335. A schizophrenic client is seen seemingly talking to someone who isn't there.
Which nursing statement would be most therapeutic initially?

A. "Today is my birthday. Would you like to go on an outing with my family?"

B. "You need to wash up and get ready to go to supper in the cafeteria with
the other clients now."
C. "I've noticed your eyes darting back and forth, and I wondered whether
you might be hearing voices."
D. "You were telling me yesterday that your mother died last June of cancer.
Can you tell me more about that?" - C. "I've noticed your eyes darting
back and forth, and I wondered whether you might be hearing voices."

336. The nurse brings a meal tray to a psychotic client in his hospital room. The client
refuses the meal and says, "I'm not eating any more poisoned food while I'm
vacationing here. I'm starting on a fast to stay healthy and alive." Which nursing
intervention would be most appropriate initially?

A. Taking the tray away and canceling all meals until further notice
B. Having the client eat with other clients in the community dining room
C. Eating some of the food from the client's tray to prove that it isn't poisoned
D. Telling the client that the psychiatrist will be called for a prescription for a
tube feeding - B. Having the client eat with other clients in the community
dining room

337. The nurse caring for a schizophrenic client is assessing the client's ability to
control distorted thought processes. Which finding indicates a positive
outcome?

A. The client is able to identify when hallucinations or delusions are real.

B. The client can describe in detail the frequency and context of the
hallucinatory and delusional behavior.
C. The client can describe the hallucinations and delusions in detail and is
able to interact with others and share in their delusional systems.
D. The client can identify the recurrence of hallucinations, can refrain from
responding to them, and reports a significant decrease in the incidence of
hallucinations. - D. The client can identify the recurrence of hallucinations,
can refrain from responding to them, and reports a significant decrease in
the incidence of hallucinations.

338. A schizophrenic client says, "I feel like I'm rotting away inside and all of my
organs are rusting." Which type of delusion does the nurse identify in the client's
statement?
 A. Somatic
B. Jealousy
C. Persecution
D. Idea of reference - A. Somatic

339. A schizophrenic client attending a support group held by a clinic nurse says to
the nurse and the group, "I've been laid off from my job at the factory, and so
have 300 other people, so I'll have to get a new job. For now, there's
unemployment." Which statement by the nurse would be most therapeutic at this
time?

A. "It seems that the stock market is responsible for mass unemployment in
our factory-based city."
B. "I'm sorry to hear that you've lost your job. Why not make an appointment
to come in and talk with me this week?"
C. "How do people feel about this loss of employment? Does anyone in the
group who experienced this have any advice?"
D. "Have other people in the group been feeling the job crunch this week?
When changes like this occur, it's best to increase the number of your
appointments with me for a short time." - D. "Have other people in the
group been feeling the job crunch this week? When changes like this
occur, it's best to increase the number of your appointments with me for a
short time."

340. A schizophrenic client arrives for a scheduled appointment with the mental health
nurse. The nurse notes that the client's hygiene is poor and that the client is
having difficulty concentrating on what the nurse is saying and responding
appropriately. Which nursing intervention would be most appropriate?

A. Saying nothing and contacting the psychiatrist to sign a commitment order

B. Saying, "I notice that you don't seem to be caring for yourself. Are you
taking your medication?"
341. G. Giving the client his antipsychotic medication and asking him to return in the
morning for a follow-up visit
342. D. Asking, "Will you voluntarily admit yourself for a couple of days so that you
can straighten out your medicine and thinking?" - B. Saying, "I notice that you
don't seem to be caring for yourself. Are you taking your medication?"

343. A postpartum client says to the nurse, "Sometimes I hear voices telling me to kill
my baby to save her all the heartache I've been through." Which statement by
the nurse would be most therapeutic?

A. "The voices will disappear in a few weeks as your hormones stabilize."

B. "This must be very distressing to you. Can you tell me more about the
voices?"
 C. "It is so good that you shared your feelings and thoughts with me. I'm
going to help you get immediate attention for your voices."
D. "You will want to tell the health care provider about them when you visit
him next week. He is very interested in these voices and will want to help
you with them." - C. "It is so good that you shared your feelings and
thoughts with me. I'm going to help you get immediate attention for your
voices."

344. A schizophrenic client exhibits confused and unintelligible speech. Which

nursing statement would be most therapeutic?

A. "Got it. The 'blinks' are 'taking over' the 'bumpers.'"

B. "I can't understand what you're saying. You have to talk more clearly!"
C. "This morning you are participating in the tree-decorating ceremony for the
unit."
D. "I can't understand you. Are you asking me to stay with you while you eat
supper?" - C. "This morning you are participating in the tree-decorating
ceremony for the unit."

345. A schizophrenic client says to the nurse, "I keep getting these thoughts and
hearing voices. They worry and consume me so that I can't always stop
myself like my health care provider told me to." Which intervention would the
nurse suggest as a distraction technique?

A. "Pretend that you're on the phone and talk to the voices."

B. "Have you tried to count back from 100 or listen to music?"
C. "The next time this happens, try telling the voices to go away."
D. "Tell the voices that you will only listen to them just before you watch
television at 8:30 in the evening." - B. "Have you tried to count back from
100 or listen to music?"

346. The nurse plans outcomes for a client who is being treated for psychosis. Which
step would be included during the stable or discharge phase of treatment?

A. Evaluation of neurological status

B. Use of directive communications with the client
C. Administration of acute psychotropic medications
D. Keeping the client active with hobbies, exercise, and work - D. Keeping
the client active with hobbies, exercise, and work

347. A schizophrenic client is admitted to the inpatient psychiatric unit. The client is
exhibiting clang associations, word salad, and loose associations. Which
problem does the nurse recognize that the client is experiencing?

A. Defensive coping
B. Inability to cope effectively
 C. Sensory perception alterations
D. Inability to communicate effectively - D. Inability to communicate
effectively

348. A 24-year-old schizophrenic client says, "I was in college and suddenly I
was hearing voices telling me I was no good and that I should jump off the bridge
by our college. My parents came and got me when I called them. We thought that
I had inadvertently taken drugs at a party or something. My psychiatrist says that
if I can improve, I can return to college next semester." Which guideline does the
nurse plan to incorporate into teaching of the client and family about self-care on
the client's return to college?

A. Compliance with the treatment regimen, immediate reporting of any

relapse signs, avoidance of alcohol and drugs, and living a balanced
lifestyle
B. Telling all friends about the illness so that they support the client's
avoidance of alcohol and drugs and help the client maintain a balanced
lifestyle
C. Limiting college attendance to commuter status to maintain a supportive
family group and avoiding drugs, alcohol, and the strain of socialization
D. Compliance with treatment, immediate reporting of any relapse signs,
avoidance of alcohol and drugs, and socialization with one supportive
friend - A. Compliance with the treatment regimen, immediate reporting of
any relapse signs, avoidance of alcohol and drugs, and living a balanced
lifestyle

349. A schizophrenic client in the psychiatric inpatient unit is yelling, "The CIA is trying
to kill me. I know they're plotting to kill me so they can overthrow the
government." Based on the client's statement, which clinical manifestation should
the nurse document in the client record?

A. Demonstrates paranoia
B. Exhibits ideas of reference
C. Evidence of persecutory delusions
350. D Evidence of ideas of somatic delusions - C. Evidence of persecutory
delusions

351. A manic client who tends to be manipulative says angrily, "You had better let me
out of here, or I'm going to call my lawyer. My boss has good friends with the
owners of this tin-pot place you call a 'mind holism respite.'" Which statement by
the nurse would be most therapeutic?

A. "When you can speak to me without yelling and being aggressive, I'll be
happy to speak with you."
B. "Just get your anger out with me, because we're not going to allow you be
discharged until you calm down."
 C. "Do threats and name-calling usually work for you? Do people tend to
listen to you and do as you order them to?"
D. "I know that you feel that you're doing your very best right now, but you
are yelling. Take some time out and some deep breaths, and I'll speak to
you in half an hour." - D. "I know that you feel that you're doing your very
best right now, but you are yelling. Take some time out and some deep
breaths, and I'll speak to you in half an hour."

352. A client in a mental health unit gets into a fight with another client over the use of
the public telephone on the unit. The client is accused of making two telephone
calls and staying on the telephone for 1 hour. Which intervention by the nurse
would be most therapeutic?

A. Taking telephone privileges away from both clients for the day and giving
them time-outs in their rooms
B. Saying to the clients, "Okay, this is the last straw. Neither of you may use
the telephone until tomorrow, and then only with a nurse timing you."
C. Saying to the clients, "Go to your rooms, both of you. I don't want to hear
anything more about the telephone on this unit for at least 2 hours."
D. Saying to the clients, "You may each use the phone for 10 minutes. I will
time the calls for both of you. Do you both agree to abide by my decision?"
- D. Saying to the clients, "You may each use the phone for 10 minutes. I
will time the calls for both of you. Do you both agree to abide by my
decision?"

353. The nursing instructor enters a classroom to begin class and finds two students
yelling and physically assaulting each other. Which intervention by the
instructor would be most appropriate?

A. Walking out of the classroom and asking the secretary to call security,
then telling all of the students to leave and go to the nursing laboratory
B. Getting the class to leave with her and sending everyone to the nursing
laboratory, then calling security to the classroom and reentering to
observe what is happening with the two students.
C. Telling the class, "Take a break. I'll come and get you to restart class as
soon as I can," then closing the classroom door, refusing to let anyone
else in, and asking a passing instructor to get security
D. Telling the class to go to the nursing laboratory at once, then asking a
student to tell the nursing secretary to have security come to the
classroom, and asking the students who are fighting to stop fighting and
take their seats - D. Telling the class to go to the nursing laboratory at
once, then asking a student to tell the nursing secretary to have security
come to the classroom, and asking the students who are fighting to stop
fighting and take their seats
354. A student calls the campus crisis hotline and tells the nurse, "I went out to a
sorority party last week and drank too much. Someone raped me, but when I
told my folks about it, they acted like it was my fault. I feel so dirty and used."
Which statement by the nurse would be most therapeutic?

A. "Would you come in to talk with me in the strictest confidence?"

B. "I believe that you can feel a lot better about yourself. Won't you come in
to see me tomorrow?"
C. "Parents always feel that their daughters could never be raped. I could talk
to them for you, if you'll let me."
D. "You've had an awful experience, but it's not your fault that it happened.
Can you come in and talk to me about it in more detail?" - D. "You've had
an awful experience, but it's not your fault that it happened. Can you come
in and talk to me about it in more detail?"

355. A psychiatric nurse is playing a card game with a client in the day room. The
client states to the nurse, "The voice in my head is telling me that you're
cheating." Which response by the nurse is therapeutic?

A. "Is the voice telling you to do anything?"

B. "I don't believe that you are hearing voices."
C. "It isn't possible for people to hear voices in their head."
D. "I do not hear any voices. Has the voice said anything else?" - D. "I do not
hear any voices. Has the voice said anything else?"

356. A client says to the nurse, "I'm really phobic about flying, so my husband and I
always drove or took the train everywhere. Now he's been offered a big job in
Europe, and if I don't get over this and fly with him, he says we're done. I'll be left
to bring up our three children by myself." Which statement by the nurse would be
therapeutic?

A. "No problem. You can be hypnotized to sleep through your trip."

B. "I'm interested that it took his threat of leaving you to motivate you to seek
help."
C. "You seem more anxious and afraid of raising three children alone than of
flying."
D. "I can teach you strategies to help master your panic. An anti-anxiety
medicine would also help you." - D. "I can teach you strategies to help
master your panic. An anti-anxiety medicine would also help you."

357. The nurse is trying to deescalate aggressive behavior exhibited by a client with
schizophrenia. Which nursing action would be contraindicated in this situation?

A. Being assertive with the client

B. Negotiating options with the client
 C. Maintaining a nonaggressive posture
D. Standing close to the client and telling the client that the behavior is
unacceptable - D. Standing close to the client and telling the client that the
behavior is unacceptable

358. A client is scheduled to undergo electroconvulsive therapy (ECT). Which client

concern is of the highest priority?

A. Fear
B. Anxiety
C. Distorted body image
D. Risk for impaired breathing - D. Risk for impaired breathing

359. The mother of a child who is taking methylphenidate hydrochloride (Ritalin)

tells the school nurse that she is administering an over-the-counter (OTC)
cough syrup to her son. Which response by the nurse would be
appropriate?

A. "His cough could be a side effect of the Ritalin."

B. "Your son should never take any medicine, even if it's OTC."
C. "You may administer a small amount of OTC cough syrup without a
problem, but not for more than 3 days."
D. "I think that you should stop giving this medicine to your son until I can
check its content with the pharmacy." - D. "I think that you should stop
giving this medicine to your son until I can check its content with the
pharmacy."

360. A nurse notices a paranoid stare during a conversation with a client. The client
then begins to fidget and gets up to pace around the room. Which action by the
nurse would be beneficial?

A. Allowing the client to pace

B. Escorting the client to a quiet room
C. Changing the conversation to a less threatening subject
D. Sharing the observation with the client and helping the client recognize
and acknowledge his or her feelings - D. Sharing the observation with the
client and helping the client recognize and acknowledge his or her feelings

361. The nurse working in a mental health unit reads a client's medical record and
notes documentation that the client has been experiencing flashbacks. The
nurse interprets this as a classic sign of which disorder?

A. Depression
B. Schizophrenia
C. Post-traumatic stress disorder
D. Obsessive-compulsive disorder - C. Post-traumatic stress disorder
362. A client arrives in the emergency department in a crisis state. The client
demonstrates signs of profound anxiety and is unable to focus on anything but
the object of the crisis and the impact on herself. The nurse plans to focus the
initial assessment on which client factor?

A. Sources of support
B. The object of the crisis
C. The client's coping mechanisms
D. The physical condition of the client - D. The physical condition of the client

363. The nurse has been closely observing a client who has been displaying
aggressive behaviors and notes that the client's aggressiveness is escalating.
Which nursing intervention would be least helpful to this client at this time?

A. Initiating confinement measures

B. Acknowledging the client's behavior
C. Assisting the client to an area that is quiet
D. Maintaining a safe distance with the client - A. Initiating confinement
measures

364. The nurse is assigned to care for a client experiencing a crisis. What is the
appropriate initial nursing intervention for this client?

A. Providing authority and action

B. Displaying an attitude of detachment and efficiency
C. Providing hope and reassurance that the crisis is temporary
D. Demonstrating confidence in the client's ability to deal with the crisis - A.
Providing authority and action

365. The home care nurse makes a visit to a client with a diagnosis of depression.
The nurse finds the client unconscious on the floor, with an empty bottle of a
prescribed tricyclic antidepressant lying near the client. What action must the
nurse take immediately?

A. Inducing vomiting
B. Calling an ambulance
C. Administering syrup of ipecac
D. Counting the pills remaining in the bottle - B. Calling an ambulance

366. Which client is at the highest risk for suicide?

A. A 24-year-old man who is angry with his family

B. A 71-year-old man with mild depression and social withdrawal
C. A 75-year-old woman with severe depression and crippling arthritis
 D. A 30-year-old newly divorced woman who has custody of her children - C.
A 75-year-old woman with severe depression and crippling arthritis

367. A client brought to the emergency department by the police after being
mugged is extremely agitated, trembling and hyperventilating. What is the
appropriate initial nursing action?

A. Staying with the client

B. Teaching the client how to relax
C. Asking the client questions about the mugging
D. Allowing the client to be alone in a room at the end of the emergency
department corridor, where it is quiet - A. Staying with the client

368. A woman is brought to the emergency department after an assault. She

presents with complaints of dizziness, dyspnea, visual disturbance, and motor
tension with hyperactivity. Which level of anxiety does the nurse recognize in the
client's presentation?

A. Mild
B. Panic
C. Severe
D. Moderate - C. Severe

369. The nurse is monitoring a client who is in seclusion. The nurse determines that it
is safe for the client to come out of seclusion when the client makes which
statement?

A. "I need to go to the bathroom."

B. "I'm no longer a threat to myself or others."
C. "I want to be alone for a while in my own room."
D. "I can't breathe in here. The walls are closing in on me." - B. "I'm no longer
a threat to myself or others."

370. The nurse is preparing a discharge plan for a client who has attempted
suicide. The nurse understands that the plan of care should have which focus?

A. Follow-up appointments
B. Providing the hospital phone number
C. Contracts and immediate available crisis resources
D. Encouraging the family to always be with the client - C. Contracts and
immediate available crisis resources

371. The nurse observes that a client is pacing back and forth. The nurse asks the
client how she is feeling, and the client responds by telling the nurse that she
feels "out of control!" Which intervention is most appropriate initially to maintain a
safe environment?
 A. Restraining the client
B. Placing the client in seclusion
C. Continuing to monitor the client
D. Moving the client to a quiet room and talking about her feelings - D.
Moving the client to a quiet room and talking about her feelings

372. The nurse employed in an emergency department is assisting in caring for an

adult client who is a victim of family violence. Which priority instruction does the
nurse include in the discharge plan?

A. Calling the police

B. Self-defense classes
C. The locations of shelters
D. The importance of leaving the violent situation - C. The locations of
shelters

373. The nurse is caring for a client who has been identified as a victim of physical
abuse. Which action is the priority as the nurse plans care for the client?

A. Notifying the caseworker of the situation

B. Adhering to mandatory abuse reporting laws
C. Removing the client from any immediate danger
D. Obtaining treatment for the abusing family member - C. Removing the
client from any immediate danger

374. The nurse in the emergency department is helping care for a young female
victim of sexual assault. The client's physical assessment is complete, and
physical evidence has been collected. The nurse notes that the client is
withdrawn, confused, and, at times, physically immobile. The nurse interprets
these behaviors as which type of reaction?

A. Signs of depression
B. Normal reactions to a devastating event
C. Indicative of the need for hospital admission
D. Evidence that the client is at high risk for suicide - B. Normal reactions to a
devastating event

375. The nurse preparing to admit a client with obsessive-compulsive disorder

(OCD) to the mental health unit observes the client for certain characteristic
behaviors. Which characteristic behavior should the nurse observe?

A. Hostility
B. Inflexibility
C. Adaptability
D. Extreme fear - B. Inflexibility
376. A client has just been admitted to the mental health unit with a diagnosis of
obsessive-compulsive disorder. The nurse observes the client for compulsive
behavior involving which repetative element?

A. Fears
B. Actions
C. Thoughts
D. Delusions - B. Actions

377. A client with obsessive-compulsive disorder who continually cleans her room
with paper towels becomes enraged with her roommate for throwing the
package of paper towels into the waste basket, begins to yell, and slaps the
roommate. Which action would the nurse take first?

A. Restraining the client

B. Filling out an incident report
C. Removing both clients to safe locations
D. Calling the hospital's risk-management department - C. Removing both
clients to safe locations

378. The nurse is preparing a care plan for a client with obsessive-compulsive
disorder (OCD). Which should be the nurse's primary focus?

A. Group therapy
B. Recreational therapy
C. Goals and objectives
D. The client's medical diagnosis - C. Goals and objectives

379. A moderately depressed client who was admitted to the mental health unit 2
days ago suddenly begins smiling and reports that the crisis is over. The client
says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue
to modify the treatment plan by:

A. Suggesting a reduction of medication

B. Allowing increased in-room activities
C. Increasing the level of suicide precautions
D. Allowing the client off-unit privileges as necessary - C. Increasing the level
of suicide precautions

380. The nurse employed in a mental health unit is reviewing the work
schedule. At what time does the nurse expect that additional client safety
precautions will be provided?

A. Day shift
B. Weekdays
 C. Weekends
D. 7 to 10 a.m. - C. Weekends

381. An adolescent is returning home after an acute psychiatric hospitalization for a

suicide attempt. Which strategy will be least effective in preparing the client for
discharge?

A. Encouraging the sharing of feelings

B. Suggesting that the client's mother quit her job
C. Identifying the family's strengths and weaknesses
D. Offering and providing the family options and resources - B. Suggesting
that the client's mother quit her job

382. A client is admitted to the psychiatric unit after a serious suicide attempt
involving a drug overdose. What is the priority nursing intervention?

A. Remain with the client at all times

B. Request that a family member remain with the client at all times
C. Remove the client's clothing and dress the client in a hospital gown
D. Place the client in a seclusion room from which all potentially dangerous
articles have been removed - A. Remain with the client at all times

383. The nurse working with a victim of rape in a clinic setting is developing a plan
of care for the client. Which short-term initial goal is most appropriate?

A. The client will care for her own physical wounds.

B. The client will verbalize her feelings about the event.
C. The client will identify an appropriate treatment plan.
D. The client will resolve feelings of fear and anxiety related to the rape
trauma. - B. The client will verbalize her feelings about the event.

384. A furious and aggressive client is put in restraints and told that the restraints will
be removed once the she regains control. At which time is removal of the
restraints by the nurse appropriate?

A. When medication that has been administered has taken effect

B. When the client apologizes and tells the nurse that it will never happen
again
C. When the nurse explores with the client the reasons for the angry and
aggressive behavior
D. When no acts of aggression are observed in the hour following the release
of two extremity restraints - D. When no acts of aggression are observed
in the hour following the release of two extremity restraints

385. The nurse is preparing a plan of care for an older client with a diagnosis of
depression. In preparing the plan, which should the nurse recall?
 A. Older clients do not commit suicide
B. Depression in an older person is never treatable
C. Depression in an older person will not cause physical manifestations
D. Indications of dementia may be present in an older client with depression -
D. Indications of dementia may be present in an older client with
depression

386. A resident of a long-term care facility who has Alzheimer's disease

becomes agitated when a group of children comes to sing and dance at the
facility and tries to take one of the children to her room. Which piece of
information should the nurse use when approaching the client about this
behavior?

A. This resident is a dangerous individual.

B. Individuals with Alzheimer's disease are likely to be child molesters.
C. This resident probably had an unfortunate experience while singing and
dancing in his own youth.
D. Individuals with Alzheimer's disease have difficulty tolerating excessive
stimulation and changes in routine. - D. Individuals with Alzheimer's
disease have difficulty tolerating excessive stimulation and changes in
routine.

387. The nurse is working with an older client who has been hospitalized and the
client's family to formulate a plan for discharge. In guiding the discussion with the
client and family, which living arrangement should the nurse understand most
older persons prefer?

A. Alone
B. With their children
C. In long-term care facilities
D. Independently but close to their children - D. Independently but close to
their children

388. The nurse is collecting data from a client in crisis and assessing the potential
for self-harm. Which finding indicates that the client is at high risk for suicide?

A. The client is impulsive.

B. The client is disorganized.
C. The client has a history of suicide attempts.
D. The client has an immediate plan for a suicide attempt. - D. The client has
an immediate plan for a suicide attempt.

389. The nurse is providing information to a group of nursing staff members about
caring for suicidal clients. What should the nurse tell the group?
 A. Discussing suicide with a client is not harmful
B. Those clients who talk about suicide never actually try it
C. Depressed clients are the only people who commit suicide
D. When a person makes suicide threats, the only thing the person wants is
attention - A. Discussing suicide with a client is not harmful

390. A 2-year-old child is a suspected victim of child abuse and the nurse is
interviewing the child's parent. Which statement by the parent indicates the
possibility of child abuse?

A. "My child can't be expected to learn everything at once."

B. "I can expect my child to talk using some words at this age."
C. "I expect my child to try doing some things without my help."
D. "When I tell my child to do something, I don't expect to have to repeat
myself." - D. "When I tell my child to do something, I don't expect to have
to repeat myself."

391. The mental health nurse is conducting the initial assessment of an obese client.
The client confides that she was sexually molested at age 7 and began putting
on weight thereafter. The nurse determines that the client's symptoms are
compatible with a somatization disorder and recalls that obesity for this client
most likely represents which?

A. Satisfaction with self

B. A form of functional coping
C. Protection from the risk of intimacy
D. Long-term lack of compliance with weight programs - C. Protection from
the risk of intimacy

392. A client with a history of multiple somatic complaints involving several organ
systems has no evidence of organic pathologic conditions. It is important for the
nurse planning care for this client to understand that the client is afflicted with
which disorder?

A. Paranoia
B. Depression
C. Schizophrenia
D. Somatization disorder - D. Somatization disorder

393. The nurse sees a nursing assistant talking in an unusually loud voice to a client
with delirium. Which action should the nurse take?

A. Informing the client that everything is all right

B. Speaking to the nursing assistant immediately, while in the client's room,
to solve the problem
 C. Explaining to the nursing assistant that yelling in the client's room is
tolerated only if the client is talking loudly
D. Determining that the client is safe, calmly asking the nursing assistant to
join you outside the room, and informing the nursing assistant of the
observation - D. Determining that the client is safe, calmly asking the
nursing assistant to join you outside the room, and informing the nursing
assistant of the observation

394. The nurse is preparing to provide nursing unit information to a client who does
not speak English who is being admitted to the mental health unit. Which action
is best for the nurse to take to ensure that the client understands the
information?

A. Asking a family member to translate for the client

B. Obtaining a hospital interpreter to communicate with the client
C. Asking a hospitalized client who speaks the same language as the client
to translate
D. Providing the client with a pamphlet that explains the nursing unit
information in the client's language - B. Obtaining a hospital interpreter to
communicate with the client

395. A client says to the nurse, "I'm going to die, and I wish my family would stop
hoping for a cure! I get so angry when they carry on like this! I'm the one
who's dying." Which response by the nurse would be most therapeutic?

A. "Have you shared your feelings with your family?"

B. "Well, it sounds like you're being pretty pessimistic."
C. "I think we should talk more about your anger with your family."
D. "You're feeling angry that your family continues to hope for you to be
cured." - D. "You're feeling angry that your family continues to hope for
you to be cured."

396. The nurse is caring for an older adult client who says, "I don't want to talk with
you — you're only a nurse. I'll wait for my health care provider." Which
response by the nurse would be therapeutic?

A. "I'll leave you now and call your health care provider."
B. "So you're saying that you want to talk to your health care provider?"
C. "I'm angry with the way you've dismissed me. I am your nurse!"
D. "I'm assigned to work with you. Your health care provider placed you in my
hands." - B. "So you're saying that you want to talk to your health care
provider?"

397. A client and her newborn have undergone human immunodeficiency virus (HIV)
testing, and the results for both clients are positive. The news is
 devastating, and the mother is crying. What is the appropriate nursing action at
this time?

A. Describe the stages of and treatments for HIV

B. Listen quietly while the mother talks and cries
C. Discuss with the mother how she might have gotten HIV
D. Call an HIV counselor and make an appointment for the woman - B. Listen
quietly while the mother talks and cries

398. The nurse employed in a home care agency is assigned a recently

widowed client. When the nurse arrives at the client's home, the ordinarily
immaculate house is in chaos and the client is disheveled, with the odor of
alcohol on his breath. Which statement by the nurse would be therapeutic?

A. "I can see that this isn't a good time to visit."

B. "You seem to be having a very difficult time."
C. "Do you think your wife would want you to behave like this?"
D. "What are you doing? How much are you drinking, and how long has this
been going on?" - B. "You seem to be having a very difficult time."

399. A client says to the nurse, "I don't do anything right. I'm such a loser." What
is the appropriate response?

A. "Everything will get better."

B. "You don't do anything right?"
C. "You do things right all the time."
D. "You are not a loser; you are sick. - B. "You don't do anything right?"

400. A client who is experiencing suicidal thoughts says to the nurse, "It just doesn't
seem worth it anymore. Why shouldn't I just end it all?" Which statement should
the nurse use to gather additional data from the client?

A. "Did you sleep at all last night?"

B. "Tell me what you mean by that."
C. "I know you've had a stressful night."
D. "I'm sure that your family is worried about you." - B. "Tell me what you
mean by that."

401. The nurse working in the emergency department is performing an initial

assessment on a client, and notes many physical injuries. The nurse suspects
family-related violence. Which finding is specific to this type of violence?

A. The client lives in an assisted living facility.

B. The client is financially dependent on him or herself.
C. The client relies on neighbors and friends for transportation to and from
appointments.
 D. The client lives with one of their children and requires extensive
assistance with activities of daily living. - D. The client lives with one of
their children and requires extensive assistance with activities of daily
living.

402. A client in halo traction says to the nurse, "I can't get used to this
contraption. I can't see properly on the side, and I keep misjudging where
everything is." Which response by the nurse is therapeutic?

A. "No one ever gets used to that thing! It's horrible."

B. "If I were you, I'd have had the surgery rather than suffer like this."
C. "Halo traction involves many difficult adjustments. Practice scanning with
your eyes after standing up, before you move."
D. "Why do you feel like this when you could have died of a broken neck?
This is the way it will be for several months. You need to accept it, don't
you think?" - C. "Halo traction involves many difficult adjustments. Practice
scanning with your eyes after standing up, before you move."

403. A client with major depression says to the nurse, "I should have died. I've
always been a failure." Which response by the nurse is therapeutic?

A. "I see a lot of positive things in you."

B. "You still have a great deal to live for."
C. "Feeling like a failure is part of your illness."
D. "You've been feeling like a failure for some time now?" - D. "You've been
feeling like a failure for some time now?"

404. An alcoholic client says to the nurse, "I'm taking milk thistle, so I can drink all I
want and never get cirrhosis." Which statement by the nurse would be
therapeutic?

A. "Milk thistle aside, you still need to stop using alcohol. You have a severe
drinking problem."
B. "If milk thistle is so effective, I wonder why the liquor industry isn't lobbying
to put it in alcohol?"
C. "Milk thistle is used in Europe this way, but research findings are limited,
so I'd stop drinking if I had a problem like you do."
D. "Milk thistle is an herbal extract. It does seem to prevent liver damage and
stimulate liver cell regeneration, but it can't prevent damage to other
organs, like your brain." - D. "Milk thistle is an herbal extract. It does seem
to prevent liver damage and stimulate liver cell regeneration, but it can't
prevent damage to other organs, like your brain."

405. Which statement made by a client with anorexia nervosa would indicate to the
nurse that treatment has been effective?
 A. "I no longer have to lose weight."
B. "I won't starve myself anymore."
C. "I'll eat until I don't feel hungry."
D. "I went out to lunch today with my cousin." - D. "I went out to lunch today
with my cousin."

406. The nurse is admitting a client with a diagnosis of anorexia nervosa to the
mental health unit. Which characteristic is a hallmark of this disorder?

A. Social contacts are important.

B. The client is not concerned about food and meal planning.
C. Personal relationships tend to become more superficial and distant.
D. The client with anorexia will usually keep his or her weight near normal
weight. - C. Personal relationships tend to become more superficial and
distant.

407. A client with the diagnosis of schizophrenia is unable to speak, although

nothing is wrong with the organs of communication. The nurse plans care
knowing that this condition is referring to which?

A. Mutism
B. Verbigeration
C. Pressured speech
D. Poverty of speech - A. Mutism

408. A client tells the nurse, "I am a queen. I'm mean, and I gleam." The nurse
recognizes this as an example of which speech pattern?

A. Echolalia
B. Tangential speech
C. Clang associations
D. Loosened associations - C. Clang associations

409. A client is severely injured, sustaining a full-thickness circumferential burn to the

left leg, after passing out as a result of drinking alcohol and falling into a fire while
on a camping trip. In report, the nurse is told that the client has just signed
consent for amputation of the limb and that the procedure is scheduled for
tomorrow. While caring for the client, the nurse notes that the client is upset and
withdrawn. What is the most appropriate nursing action at this time?

A. Reflecting back to the client that he appears upset

B. Letting the client have some time alone to grieve the impending loss of the
limb
C. Reminding the client that the injury was a result of alcohol abuse and
referring him for counseling
 D. Informing the health care provider of the client's depression and
requesting medication to assist the client in coping with the diagnosis - A.
Reflecting back to the client that he appears upset

410. A male client reports difficulty concentrating, outbursts of anger, and a feeling of
being keyed up all the time and states that peer relations are poor. He then tells
the nurse that the symptoms started after his best friend was killed in the
terrorist attack at the World Trade Center. The nurse suspects that the client is
experiencing which disorder?

A. Social phobia
B. Panic disorder
C. Post-traumatic stress disorder
D. Obsessive-compulsive disorder - C. Post-traumatic stress disorder

411. A client in skeletal traction says to the nurse, "I can't get any help with my care! I
call and call, but the nurses never answer my light. Last night one of them told
me she had other patients besides me! I'm very sick, but the nurses don't care!"
Which response by the nurse would be therapeutic?

A. "You poor thing! I'm so sorry this happened to you. That nurse should be
reported!"
B. "I think you're being very impatient. The nurses work very hard and come
as quickly as they can."
C. "It's hard to be in bed and have to ask for help. You call for a nurse who
never seems to come?"
D. "I can hear your anger. That nurse had no right to speak to you that way. I
will report her to the director. It won't happen again." - C. "It's hard to be in
bed and have to ask for help. You call for a nurse who never seems to
come?"

412. The nurse is caring for a hospitalized client with an alcohol abuse disorder. In
reviewing the client's discharge outcomes, the most positive outcome is that the
client states that he or she will perform which action?

A. Learn to play tennis

B. Take a painting class
C. Start an exercise program
D. Continue to attend Alcoholics Anonymous meetings - D. Continue to
attend Alcoholics Anonymous meetings

413. A 30-year-old client says to the nurse, "I want to die. I think about it a lot, but I
don't know how in the world to do it." Based on the client's statement, what
does the nurse determine?

A. There is no suicide risk

 B. There is a minimal suicide risk
C. Suicide has been attempted unsuccessfully
D. The risk for suicide exists and continued assessment is needed - D. The
risk for suicide exists and continued assessment is needed

414. Family members awaiting the outcome of a suicide attempt are tearful. Which
response by the nurse would be most therapeutic to the family at this time?

A. "I can see that you are worried."

B. "You have nothing to worry about."
C. "You can see your loved one soon."
D. "Everything possible is being done." - A. "I can see that you are worried."

415. Which step should be included in the care of a 13-year-old hospitalized child
who has been abused?

A. Encouraging the child to avoid the abuser

B. Providing a caring environment that fosters the development of trust
C. Teaching the child to make intelligent choices when confronted with an
abusive situation
D. Having the child identify the abuser if that person should visit while the
child is hospitalized - B. Providing a caring environment that fosters the
development of trust

416. The nurse collects data from an older client and monitors him for signs of
abuse. Which psychosocial factor does the nurse recognize as placing the client
at risk for abuse?

A. The client lives alone.

B. The client is independent.
C. The client shows signs and symptoms of depression.
D. The client is completely dependent on family members for food and
medicine. - D. The client is completely dependent on family members for
food and medicine.

417. A client with leukemia is being considered for a bone marrow transplant. The
healthcare team is discussing the risks and benefits of this treatment and other
possible treatments with the goal of inflicting the least possible harm on the
client. Which principle of healthcare ethics is the team practicing?

A. Justice
B. Fidelity
C. Autonomy
D. Nonmaleficence - D. Nonmaleficence
418. Which action by the nurse represents the ethical principle of beneficence?

A. The nurse upholds a client's decision to refuse chemotherapy for lung

cancer.
B. The nurse follows a plan of care designed to relieve pain in a client with
cancer.
C. The nurse administers an immunization to a child even though it may
cause discomfort.
D. The nurse provides equal amounts of care to all assigned clients on the
basis of illness acuity. - C. The nurse administers an immunization to a
child even though it may cause discomfort.

419. The nursing instructor asks a student to name an example of false

imprisonment. Which situation reflects a violation of this client right?

A. Performing a procedure without consent

B. Telling the client that he or she may not leave the hospital
C. Threatening to give a client a medication against his or her will
D. Observing the provision of care to the client without the client's permission
- B. Telling the client that he or she may not leave the hospital

420. The nurse and an unlicensed assistive personnel (UAP)enter a client's room
to provide care and find the client lying on the floor. Which action should the
nurse take first?

A. Ask the nursing assistant to complete an incident report

B. Check the client's level of consciousness and vital signs
C. Ask the nursing assistant to assist in getting the client back to bed
D. Contact the unit secretary on the intercom and ask that the client's health
care provider be called - B. Check the client's level of consciousness and
vital signs

421. Which action exemplifies the use of evidence-based practice in the

delivery of client care?

A. Donning sterile gloves to change an abdominal wound dressing

B. Encouraging a client to take an herbal substance to treat his insomnia
C. Advising a client to agree to the treatment recommended by her health
care provider
D. Taking a rectal temperature from a client for whom bleeding precautions
have been instituted - A. Donning sterile gloves to change an abdominal
wound dressing

422. The registered nurse has accepted a new position as case manager in a
hospital. Which responsibilities are part of the nurse's new role? Select all that
apply.
 A. Evaluating and updating the plan of care as needed
B. Prescribing treatments specific to the client's needs
C. Assessing the client's needs for home supplies and equipment
D. Coordinating consultations and referrals to facilitate discharge
E. Establishing a safe and cost-effective plan of care with the client - A.
Evaluating and updating the plan of care as needed
423. C. Assessing the client's needs for home supplies and equipment
424. D. Coordinating consultations and referrals to facilitate discharge
425. E. Establishing a safe and cost-effective plan of care with the client

426. The nurse manager of a quality improvement program asks a nurse in the
neurological unit to conduct a retrospective audit. Which action should the
auditing nurse plan to perform in this type of audit?

A. Checking the documentation written by a new nursing graduate on her

assigned clients at the end of the shift
B. Checking the crash cart to ensure that all needed supplies are readily
available should an emergency arise
C. Reviewing neurological assessment checklists for all clients on the unit to
ensure that these assessments are being conducted as prescribed
D. Obtaining the assigned medical record from the hospital's medical record
room to review documentation made during a client's hospital stay - D.
Obtaining the assigned medical record from the hospital's medical record
room to review documentation made during a client's hospital stay

427. The nurse preparing a client for a bronchoscopy notes that the client is
wearing a gold necklace. What should the nurse do to safeguard the client's
necklace?

A. Ask the client whether the necklace is gold

B. Ask the client for permission to lock the necklace in the hospital safe
C. Ask the client to remove the necklace and place it in the top drawer of the
bedside table
D. Ask the client to sign a release to free the hospital of responsibility if the
necklace is damaged or lost during the procedure - B. Ask the client for
permission to lock the necklace in the hospital safe

428. The nurse providing preoperative care to a client who is scheduled for a left
mastectomy and axillary lymph node dissection notes that the client is wearing
a wedding band on her left ring finger. Which action should the nurse take?

A. Tape the wedding band in place

B. Explain to the client why the wedding band must be removed
 C. Ask the client whether she would like to remove the wedding band or wear
it to surgery
D. Ask the client to sign a release to free the hospital of responsibility if the
wedding band is lost during surgery - B. Explain to the client why the
wedding band must be removed

429. The nurse preparing a client to go to the radiology department for a chest x-ray
notes that the client is wearing a religious medal on a chain around the neck.
The client, a Catholic, expresses a concern about removing the medal.
What is the most appropriate action for the nurse to take?

A. Asking the client to remove the medal until the x-ray has been completed
B. Assisting the client in pinning the medal and chain to the waistband of the
client's pajama bottoms
C. Asking the client to place the medal in the top drawer of the bedside stand
just before leaving for the radiology department
D. Telling the client that the medal and chain will be kept at the nurses'
station for safekeeping while the client is undergoing the x-ray - B.
Assisting the client in pinning the medal and chain to the waistband of the
client's pajama bottoms

430. A health care provider writes a medication prescription in a client's record. While
transcribing the prescription, the nurse notes that the prescribed dose is three
times higher than the recommended dose. The nurse calls the health care
provider, who states that this is the dose that the client takes at home and that it
is acceptable for this client's condition. What is the appropriate action for the
nurse to take?

A. Contacting the nursing supervisor

B. Continuing to transcribe the prescription
C. Asking the nurse assigned to care for the client to administer the
medication
D. Verifying the prescribed dose with the client before administering the
medication - A. Contacting the nursing supervisor

431. The nurse monitoring a client with a chest tube notes that there is no tidaling of
fluid in the water seal chamber. After further assessment, the nurse suspects
that the client's lung has reexpanded and notifies the health care provider. The
health care provider verifies with the use of a chest x-ray that the lung has
reexpanded, then calls the nurse to asks that the chest tube be removed.
Which action should the nurse take first?

A. Call the nursing supervisor

B. Explain the procedure to the client, then remove the chest tube
C. Inform the health care provider that removal of a chest tube is not a
nursing procedure
 D. Obtain petrolatum-impregnated gauze and ask another nurse to assist in
removing the chest tube - C. Inform the health care provider that removal
of a chest tube is not a nursing procedure

432. The nurse calls a health care provider to report that a client with congestive
heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The health
care provider, who is in a hurry because of a situation in the emergency
department, gives the nurse a telephone prescription for furosemide (Lasix) but
does not specify the route of administration. What is the appropriate action on
the part of the nurse?

A. Calling the health care provider who gave the telephone prescription to
clarify the prescription
B. Calling the nursing supervisor for assistance in determining the route of
administration
C. Administering the medication intravenously, because this route is
generally used for clients with CHF
D. Administering the medication orally and clarifying the prescription once the
health care provider has finished caring for the client in the emergency
department - A. Calling the health care provider who gave the telephone
prescription to clarify the prescription

433. A nurse is assisting a health care provider in assessing a hospitalized client.

During the assessment, the health care provider is paged to report to the
recovery room. The health care provider leaves the client's bedside after giving
the nurse a verbal prescription to change the solution and rate of the intravenous
(IV) fluid being administered. What is the appropriate nursing action in this
situation?

A. Calling the nursing supervisor to obtain permission to accept the verbal

prescription
B. Changing the solution and rate of the IV fluid per the physician's verbal
prescription
C. Asking the health care provider to write the prescription in the client's
record before leaving the nursing unit
D. Telling the health care provider that the prescription will not be
implemented until it is documented in the client's record - C. Asking the
health care provider to write the prescription in the client's record before
leaving the nursing unit

434. A client scheduled for surgery tells the nurse that he signed an informed
consent for the surgical procedure but was never told about the risks of the
surgery. The nurse serves as the client's advocate by taking which action?

A. Reassuring the client that the risks are minimal

B. Calling the surgeon and asking that the risks be explained to the client
 C. Noting in the client's record that the client was not told about the risks of
the surgery
D. Writing a note on the front of the client's record so that the surgeon will
see it when the client arrives in the operating room - B. Calling the
surgeon and asking that the risks be explained to the client

435. The nurse is planning to administer an oral antibiotic to a client with a

communicable disease. The client refuses the medication and tells the nurse that
the medication causes abdominal cramping. The nurse responds, "The
medication is needed to prevent the spread of infection, and if you don't take it
orally I will have to give it to you in an intramuscular injection." Which statement
accurately describes the nurse's response to the client?

A. The nurse could be charged with battery.

B. The nurse could be charged with assault.
C. The nurse is justified in administering the medication by way of the
intramuscular route, because the client has a communicable disease.
D. The nurse will be justified in administering the medication by the
intramuscular route once a prescription has been obtained from the
physician - B. The nurse could be charged with assault.

436. The nurse discovers that another nurse has administered an enema to a client
even though the client told the nurse that he did not want one. Which action is the
most appropriate for the nurse to take?

A. Contact the client's health care provider

B. Report the incident to the nursing supervisor
C. Tell the client that the nurse did the right thing in giving the enema
D. Confront the nurse who gave the enema and tell the nurse that she is
going to be charged with battery - B. Report the incident to the nursing
supervisor

437. The nurse calls a health care provider to question a prescription written for a
higher-than-normal dosage of morphine sulfate. The health care provider
changes the prescription to a dosage within the normal range, and the nurse
documents the new telephone prescription in accordance with the agency's
guidelines in the client's record. Which other statement does the nurse document
in the nursing notes?

A. The health care provider was called to clarify the prescription for morphine
sulfate.
B. The health care provider made an error in the written prescription for
morphine sulfate.
C. The health care provider was called to correct an error in the dosage of
morphine sulfate.
 D. An incorrect dosage of morphine sulfate was prescribed and the health
care provider was notified. - A. The health care provider was called to
clarify the prescription for morphine sulfate.

438. The charge nurse on the 11 pm-to-7 am shift is gathering the nursing staff
together to listen to the 3-to-11 pm intershift report. The charge nurse notes that
a staff member has an odor of alcohol on her breath, slurred speech, and an
unsteady gait and suspects alcohol intoxication. Which is the most
appropriateaction for the charge nurse to take?

A. Send the staff member home

B. Ask the staff member how much alcohol she has consumed
C. Tell the staff member that she is not allowed to administer medications
D. Ask the staff member to rest in the nurses' lounge until the effects of the
alcohol wear off - A. Send the staff member home

439. A client asks the nurse about the procedure for becoming an organ donor. What
should the nurse tell the client?

A. That anatomical gifts should be made in writing and signed by the client
B. To speak with the chaplain about the psychosocial aspects of becoming a
donor
C. That this decision must be made by the next of kin at the time of the
client's death
D. To let the health care provider know about the request so that it may be
documented in the client's record - A. That anatomical gifts should be
made in writing and signed by the client

440. The nurse enters a client's room to administer a medication that has been
prescribed by the health care provider. The client asks the nurse about the
medication. Which response by the nurse is appropriate?

A. "It's to help get rid of the swelling in your feet."

B. "You need to discuss this medication with your physician."
C. "I know that it's for fluid buildup, and I think you've taken it before."
D. "It's called furosemide (Lasix), and it will promote urination and rid your
body of the excess fluid. It can cause an alteration in electrolyte levels, so
we'll need to increase the potassium in your diet." - D. "It's called
furosemide (Lasix), and it will promote urination and rid your body of the
excess fluid. It can cause an alteration in electrolyte levels, so we'll need
to increase the potassium in your diet."

441. A nursing student is assigned to care for a client who requires a total bed bath.
When the student explains to the client that she is going to gather supplies to
administer the bath, the client states, "I don't want a bath. I've been up all
 night, and I'm clean enough." The student reports the client's refusal to the nurse
in charge. Which action by the nurse in charge is appropriate?

A. Telling the nursing student to allow the client to rest

B. Telling the nursing student to give the client the bath anyway
C. Telling the client that the health care provider will be informed of the
refusal of care
D. Telling the nursing student to persuade the client to have a bath so that
the evening shift staff will not have to do it - A. Telling the nursing student
to allow the client to rest

442. A client with cancer is transported to the radiology department for a bone scan to
determine whether the cancer has metastasized to bone. While the client is in
the radiology department, the client's wife arrives for a visit and asks what test is
being performed on the client. What should the nurse tell the wife?

A. A bone scan is being performed.

B. She will have to discuss the prescribed test with the client.
C. The radiology department is not clear as to which test has been
prescribed.
D. She can read the client's medical record to determine what the health care
provider prescribed. - B. She will have to discuss the prescribed test with
the client.

443. A married couple is attending a hospital program about in vitro fertilization.

During the program, a crew from a local television station arrives to film the
proceedings because the station is publicizing a series on hospital services. The
nurse conducting the program should:

A. Allow the television crew to videotape the program

B. Explain to the television crew that videotaping is not allowed
C. Ask the television crew to interview the individuals attending the program
individually
D. Allow the television crew to videotape the program as long as they do not
publicize that the program is about in vitro fertilization - B. Explain to the
television crew that videotaping is not allowed

444. A nurse is taking a morning break with the unit secretary in the nurses' lounge.
The unit secretary says to the nurse, "I read in Mr. Gage's medical record that he
has gonorrhea." How should the nurse respond to the secretary?

A. "Oh, really? I didn't see that!"

B. "We can't discuss a client's medical condition."
C. "Yes, that's why we've imposed contact precautions."
D. "Yes, he does, but be sure not to discuss this with anyone else." - B. "We
can't discuss a client's medical condition."
445. A nurse on the night shift is making client rounds. When the nurse checks a
client who is 97 years old and has successfully been treated for heart failure, he
notes that the client is not breathing. If the client does not have a do-not-
resuscitate (DNR) order, the nurse should:

A. Call the client's health care provider

B. Contact the nursing supervisor for directions
C. Administer cardiopulmonary resuscitation (CPR)
D. Administer oxygen to the client and call the health care provider - C.
Administer cardiopulmonary resuscitation (CPR)

446. A health care provider informs a nurse that the husband of an unconscious
client with terminal cancer will not grant permission for a do-not- resuscitate
(DNR) order. The health care provider tells the nurse to perform a "slow code"
and let the client "rest in peace" if she stops breathing. How should the nurse
respond?

A. Telling the health care provider that "slow codes" are not acceptable
B. Telling the health care provider that the client would probably want to die
in peace
C. Telling the health care provider that all of the nurses on the unit agree with
this plan
D. Telling the health care provider that if the client stops breathing, the health
care provider will be called before any other actions are taken - A. Telling
the health care provider that "slow codes" are not acceptable

447. A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig's disease) is
admitted to the hospital because his condition is deteriorating. The client tells
the nurse that he wants a do-not-resuscitate (DNR) order. The nurse should tell
the client that:

A. Consent must be obtained from the family

B. The health care provider makes the final decision about a DNR request
C. The DNR request should be discussed with the physician, who will write
the order
D. Oral consent is sufficient and that his request will be honored by all
healthcare providers - C. The DNR request should be discussed with the
physician, who will write the order

448. A man who is visiting his wife in a long-term care facility for people with
Alzheimer's disease collapses and is transported to a hospital. The client remains
unconscious, and testing reveals that he has cancer that has metastasized to
bone, brain, and liver. The nursing staff at the wife's care facility report to the
hospital health care provider that the client has no other family members and that
 his wife is mentally incompetent. What information regarding do-not-resuscitate
(DNR) orders does the nurse remember?

A. That a DNR order may be written by a client's health care provider

B. That everything possible must be done if the client stops breathing
C. That medications only may be given to the client if the client stops
breathing
D. That life support measures will have to be implemented if the client stops
breathing - A. That a DNR order may be written by a client's health care
provider

449. A client admitted to the hospital has a do-not-resuscitate (DNR) order in his
medical record. The nurse understands that:

A. The DNR order may not be changed once it is in effect

B. The DNR order requires frequent review as specified by state or agency
policy
C. The only people who may change the DNR order are members of the
client's immediate family
D. The DNR order, as written on admission, must remain in effect for the
duration of the client's hospitalization - B. The DNR order requires
frequent review as specified by state or agency policy

450. A registered nurse (RN) is planning client assignments for the day. Which of the
following clients should the RN assign to the nursing assistant?

A. A client who requires periodic suctioning

B. A client who needs a colostomy irrigation
C. A client who needs frequent ambulation with a walker
D. A client who has undergone an arteriogram and requires close monitoring
- C. A client who needs frequent ambulation with a walker

451. A registered nurse (RN) who has a licensed practical nurse (LPN) and a nursing
assistant on the nursing team is planning client assignments for the day. Which
of the following clients should the RN assign to the LPN?

A. A client on bedrest who needs assistance with feeding

B. A client who must be turned and repositioned every 2 hours
C. A client receiving oxygen who requires frequent pulse oximetry monitoring
and respiratory treatments
D. A client with retinal detachment who is wearing eye patches and requires
assistance with hygiene measures - C. A client receiving oxygen who
requires frequent pulse oximetry monitoring and respiratory treatments

452. A registered nurse (RN) in charge of a long-term care facility who is working
with a nursing assistant on the night shift prepares to take her break. To
 ensure client safety during her break, which of the following actions should the
nurse take? Select all that apply.

A. Conducting client rounds before taking the break

B. Taking the break in the staff lounge located on the nursing unit
C. Asking the nursing assistant to administer a medication placed at the
client's bedside if the client awakens
D. Asking the nursing assistant to monitor a client's tube feeding and to
contact the nurse when the feeding bag is empty
E. Asking the nursing assistant to contact the health care provider during the
nurse's break if a client's pain medication is not effective
F. Informing the nursing assistant that she is leaving the nursing unit to get a
cup of coffee from a vending machine in the lobby - A. Conducting client
rounds before taking the break
453. B. Taking the break in the staff lounge located on the nursing unit

454. A nurse is providing a change-of-shift report on his assigned clients, using an

audiotape. Which of the following pieces of information should the nurse include
in the report about each assigned client? Select all that apply.

A. Family history
B. Client needs and priorities of care
C. Current diagnosis and any secondary diagnoses
D. Results of laboratory studies conducted that day
E. Client response to treatments implemented that day
F. The steps used to perform the procedure for changing the client's sterile
dressing at the gastrostomy tube site - B. Client needs and priorities of
care
455. C. Current diagnosis and any secondary diagnoses
456. D. Results of laboratory studies conducted that day
457. E. Client response to treatments implemented that day

458. A nurse working the 7 am-to-3 pm shift is reviewing the records of her
assigned clients. Which client should the nurse assess first?

A. A client scheduled for hemodialysis at 10 am

B. A client scheduled for a nuclear scanning procedure at 10 am
C. A client scheduled for contrast computed tomography (CT) at noon
D. A client scheduled for hydrotherapy for treatment of a burn injury at 10:30
am - A. A client scheduled for hemodialysis at 10 am

459. A nurse has delegated several nursing tasks to staff members. The
nurse's primary responsibility after delegation of the tasks is:

A. Documenting completion of each task

B. Assigning any tasks that were not completed to the next nursing shift
 C. Allowing each staff member to make judgments when performing the
tasks
D. Following up with each staff member regarding the performance of the
task and the outcomes related to implementation of the task. - D.
Following up with each staff member regarding the performance of the
task and the outcomes related to implementation of the task.

460. The nurse reviewing a client's record sees that the following medications are
prescribed. Which medication should the nurse plan to administer first?
461. Client Medications
1. Atorvastatin (Lipitor) 10 mg orally
2. Zolpidem (Ambien) 5 mg orally daily
3. Ferrous sulfate (Feosol) 1 tablet orally
4. Levothyroxine (Synthroid) 137 mg orally

A. 1
B. 2
C. 3
D. 4 - D. 4

462. A nurse manager has announced a change to computerized

documentation of nursing care. A licensed practical nurse (LPN) on the team,
resistant to the change, is not taking an active part in facilitating implementation
of the new procedure. Which of the following strategies would be the best
approach to dealing with the conflict?

A. Ignoring the resistance

B. Telling the LPN that his noncompliance will be documented in his
personnel record
C. Confronting the LPN and encouraging him to express his feelings
regarding the change
D. Telling the LPN that a registered nurse will perform all of the computer
documentation if he will document all intake and output and vital signs - C.
Confronting the LPN and encouraging him to express his feelings
regarding the change

463. A registered nurse (RN) is planning client assignments for the day. Which
clients should the nurse assign to a nursing assistant (unlicensed assistive
personnel)? Select all that apply.

A. A client with a permanent tracheostomy

B. A client requiring a gastrostomy tube dressing change
C. A client who requires transport to the radiology department in a wheelchair
D. A client with a Foley catheter for whom a 24-hour urine collection is in
progress
 E. A client who underwent surgery an hour earlier and has a nasogastric tube
and a Foley catheter - C. A client who requires transport to the radiology
department in a wheelchair
464. D. A client with a Foley catheter for whom a 24-hour urine collection is in
progress

465. A registered nurse (RN) is planning assignments for five clients on the
nursing unit. The team includes a licensed practical nurse (LPN) and a nursing
assistant. Which clients should the nurse assign to the LPN? Select all that
apply.

A. A client who is confused and requires assistance with a shower

B. A client requiring a bed bath and frequent ambulation with a cane
C. A client who must be accompanied to physical therapy twice during the
shift
D. A client with a colostomy who requires reinforcement regarding the
procedure for irrigation
466. E A client with diabetes mellitus who requires the administration of regular
insulin in accordance with a sliding dosage scale every 4 hours - D. A client with
a colostomy who requires reinforcement regarding the procedure for irrigation
467. E A client with diabetes mellitus who requires the administration of regular
insulin in accordance with a sliding dosage scale every 4 hours

468. A registered nurse (RN) has received the assignment for the day shift.
Once the RN has made initial rounds and checked all of the assigned clients,
which client will she plan to care for first?

A. A client who is scheduled for surgery at 1 pm

B. A client scheduled for physical therapy at 11 am
C. A client in skeletal traction who has just received pain medication
D. A client who is able to perform activities of daily living independently - A. A
client who is scheduled for surgery at 1 pm

469. A nurse working the 7 am-to-3 pm shift is assigned to care for four clients.
List the clients in order of priority for the nurse. - The correct order is:

470. A client with pneumonia who is receiving oxygen

471. A client with diabetes mellitus who requires the administration of NPH
insulin before breakfast
472. A client with a wound requiring dressing changes at 10 am and 2 pm
473. A client preparing for discharge after surgery

474. A case manager is reviewing the records of the clients in the nursing unit.
Which note(s) in a client's record indicate an unexpected outcome and the need
for follow-up? Select all that apply.
 A. A client is performing his own colostomy irrigations.
B. A client with a central venous catheter has a temperature of 100.6° F.
C. A client with a new diagnosis of diabetes mellitus is self-administering
insulin.
D. A client who has just undergone surgery has a urine output of more than
30 mL/hr.
E. A client who has just undergone surgery is getting relief from the
prescribed pain medication. - B. A client with a central venous catheter
has a temperature of 100.6° F.

475. A nurse on the day shift is assigned to care for four clients. List the clients
in order of priority for nurse. - The correct order is:

476. A client with asthma who had shortness of breath during the night
477. A client scheduled to have a chest x-ray at 9 am
478. A client scheduled for an echocardiogram at 10 am
479. A client with pneumonia who is scheduled for discharge home

480. A case manager is serving on a community task force on violence in

schools. The members of the task force are planning to develop interventions to
help prevent violence. According to the nursing process, the first activity that the
nurse would suggest to the task force is:

A. Teaching schoolchildren about the dangers of school violence

B. Looking at what other communities are doing about school violence
C. Distributing fliers that identify the causes of school violence to families in
the community
D. Conducting a community survey to assess community perceptions
regarding school violence - D. Conducting a community survey to assess
community perceptions regarding school violence

481. A nurse planning care for her assigned clients understands that the
purpose of the hospital's standards of care is to:

A. Identify methods of treatment

B. Provide direction for the practice of nursing
C. Provide direction for care on the basis of the client's diagnosis
D. Identify new care methods on the basis of current medical research - B.
Provide direction for the practice of nursing

482. A registered nurse (RN) is supervising a nursing assistant ambulating a

client with right-sided weakness. The RN would conclude that the nursing
assistant is performing the procedure incorrectly after observing that the nursing
assistant:

A. Stands behind the client

 B. Stands on the right side of the client
C. Positions the free hand on the client's shoulder
D. Grasps the security belt in the midspine area of the small of the client's
back - A. Stands behind the client

483. A registered nurse (RN) is watching as a new licensed practical nurse

(LPN) administer an intramuscular (IM) injection in a client's deltoid muscle. The
RN determines that the LPN is performing the procedure correctly if the LPN:

A. Administers the injection in the thigh

B. Places the client in the Sims position
C. Positions the client in a prone toe-in position
D. Administers the injection 2 inches below the acromion process - D.
Administers the injection 2 inches below the acromion process

484. A graduate nurse hired to work in a medical unit of a hospital is attending

an orientation session. The nurse educator, discussing care maps, asks the
graduate nurse whether she understands how a care map is used. Which
response indicates understanding?

A. "The care map is developed by a nurse and identifies nursing diagnoses."

B. "The care map is a plan that is used only by the nurse to provide client
care."
C. "The care map outlines the day-to-day expected outcomes of care and the
outcomes anticipated at discharge."
D. "The care map is a standard plan, rather than an individualized one, that is
developed strictly by a nurse and used for a client with a particular
diagnosis." - C. "The care map outlines the day-to-day expected outcomes
of care and the outcomes anticipated at discharge."

485. The nurse is preparing client assignments for the day. Which client should
the nurse assign to a nursing assistant?

A. A client scheduled for a liver biopsy

B. An unconscious client who requires oral care
C. A client who has just undergone cardiac catheterization
D. A client who is getting up to ambulate for the first time after surgery - B. An
unconscious client who requires oral care

486. A nurse manager tells the nursing staff that they will need to comply with
the mandatory overtime policy that the hospital has implemented. Later that day,
the nurse manager overhears a nurse complaining about the policy and telling
other nurses that she will not work the overtime if she has made other plans after
her regular shift. What is the best approach for the nurse manager to use in
dealing with the conflict?
 A. Ignoring the complaints
B. Avoiding assigning the nurse mandatory overtime
C. Confronting the nurse regarding her behavior regarding the overtime
policy
D. Providing a positive reward system for the nurse so that the nurse will
agree to work the mandatory overtime - C. Confronting the nurse
regarding her behavior regarding the overtime policy

487. A nurse manager is planning client assignments for the day. Which of the
following clients should the nurse assign to the nursing assistant (unlicensed
assistive personnel)?

A. A client scheduled for a cardiac stress test

B. A client who had a mastectomy 2 days ago
C. A client scheduled for a laparoscopic cholecystectomy
D. A client with renal calculi whose urine must be strained - D. A client with
renal calculi whose urine must be strained

488. A registered nurse (RN) must determine how best to assign co-workers
(another RN and one licensed practical nurse [LPN]) to provide care to a group of
clients. Which of the following is the best assignment?

A. The RN is assigned to care for a woman with newly diagnosed leukemia

who has a newborn at home.
B. The LPN is assigned to provide discharge teaching about dressing
changes and medications to a 35-year-old man.
C. The LPN is assigned to care for a client with newly diagnosed diabetes
mellitus who will need to be taught how to self-administer insulin.
D. The RN is assigned to care for a 75-year-old woman, hospitalized for
dehydration, who is being discharged home today with no medications. -
A. The RN is assigned to care for a woman with newly diagnosed
leukemia who has a newborn at home.

489. A client who had a stroke has left-side weakness and is having difficulty
holding utensils while eating. To which of these services does the nurse suggest
a referral?

A. Home care
B. Social services
C. Physical therapy
D. Occupational therapy - D. Occupational therapy

490. A case manager is reviewing notations made in clients' records. Which

note indicates an unexpected outcome and the need for immediate follow-up?

A. A client who has sustained a stroke dresses herself.

 B. A client exhibits signs of increased intracranial pressure after a
craniotomy.
C. Normal neurological findings are noted in a client with a cerebral
aneurysm.
D. A client with a spinal cord injury transfers himself from a bed to a
wheelchair. - B. A client exhibits signs of increased intracranial pressure
after a craniotomy.

491. A client with diabetes mellitus who takes a daily dose of NPH insulin has a
hard time drawing the insulin into a syringe because he has difficulty seeing the
markings on the syringe. To which of the following services does the nurse
suggest a referral?

A. Home care
B. Social services
C. Physical therapy
D. Occupational therapy - A. Home care

492. A nurse is planning client assignments for the day. Which of the following
assignments is the least appropriate for the nursing assistant?

A. Assisting a client with dysphagia in eating

B. Providing hygiene to a client with dementia
C. Ambulating a client with Parkinson's disease
D. Assisting a client with an above-the-knee amputation in showering - A.
Assisting a client with dysphagia in eating

493. A nurse is assigned to care for four clients. Which client should the nurse
assess first?

A. A client scheduled for a colonoscopy

B. A client preparing for discharge after surgery
C. A client requiring a tube feeding through a gastrostomy tube
D. A client with a tracheostomy who is receiving humidified oxygen by way of
a tracheostomy mask - D. A client with a tracheostomy who is receiving
humidified oxygen by way of a tracheostomy mask

494. A nurse is planning the client assignments for the shift. Which client
should the nurse assign to the nursing assistant?

A. A client who needs a blood transfusion

B. A client with diarrhea on whom contact precautions have been imposed
C. A client with angina who needs to be ambulated for the first time since
admission
 D. A client with a draining abdominal wound that requires frequent dressing
changes - B. A client with diarrhea on whom contact precautions have
been imposed

495. A nurse is assisting a new nursing graduate with organizational skills in

delivering client care. The nurse determines that the new nursing graduate needs
assistance with time management if he:

A. Allows time for unexpected tasks

B. Prioritizes client needs and daily tasks
C. Gathers supplies before beginning a task
D. Documents task completion and client information at the end of the day -
D. Documents task completion and client information at the end of the day

496. A new nurse employed at a community hospital is reading the

organization's mission statement. The new nurse understands that this
statement:

A. Describes the benefits available to employees

B. Outlines what the organization plans to accomplish
C. Identifies the policies and procedures of the organization
D. Defines the rules of the organization that the employees must follow - B.
Outlines what the organization plans to accomplish

497. A nurse, newly employed by a home health agency, is told that the
organization's decision-making process is centralized. The nurse determines that
this means that the authority to make decisions is vested in:

A. Every employee
B. A few individuals, such as the board of directors
C. All nursing employees, pharmacists, and hospital physicians
D. Many individuals, with decisions filtering down to the individual employee -
B. A few individuals, such as the board of directors

498. A nurse employed in a community hospital as a nurse manager

understands that in this position, the term authority most appropriately refers to:

A. Being responsible for what staff members do

B. Accepting the responsibility for the actions of others
C. Carrying the legal responsibility for others' performance of tasks
D. The official power to see that an organizational decision is enforced - D.
The official power to see that an organizational decision is enforced

499. A nursing instructor asks a nursing student to describe accountability.

Which statement(s) by the student indicate(s) an accurate description of
accountability? Select all that apply.
 A."Accountability can be delegated."
B."You are responsible for your own actions."
C."It carries legal implications for task performance."
D."You must answer for the care that you ask others to complete."
E."It refers to the process of answering or being responsible for what
occurs." - B. "You are responsible for your own actions."
500. C. "It carries legal implications for task performance."
501. D. "You must answer for the care that you ask others to complete."
502. E. "It refers to the process of answering or being responsible for what
occurs."

503. A registered nurse is in charge of the emergency department (ED) during

the night shift. A client arrives at the ED for treatment after a sexual assault. The
nurse has never cared for anyone who has been raped. To determine the
necessary actions in regard to this client's injury, the nurse should:

A. Ask a licensed practical nurse

B. Call the nurse in charge of the day shift
C. Ask the police officers who brought the client to the ED
D. Check the unit policy for the protocol for the care of clients who have been
sexually assaulted - D. Check the unit policy for the protocol for the care of
clients who have been sexually assaulted

504. A nurse educator describes the standards of care formulated by the

American Nurses Association to a group of new nursing graduates hired by the
hospital. Which of the following options are accurate descriptions of these
standards of care? Select all that apply.

A. Are specific guidelines

B. Define professional practice
C. Have some similarity to policies and procedures
D. Are statements that relate only to the agency in which the nurse is
employed
E. Are authoritative statements that describe a common or acceptable level
of client care or performance - B. Define professional practice
505. C. Have some similarity to policies and procedures
506. E. Are authoritative statements that describe a common or acceptable
level of client care or performance

507. In which situation is the nurse upholding the ethical principle of fidelity?

A. Allowing a client to decide when to receive daily hygiene care

B. Inserting a 19-gauge intravenous catheter into a client requiring a blood
transfusion
 C. Providing complete information regarding treatment options to a client with
newly diagnosed cancer
D. Contacting the health care provider about the client's request to
incorporate complementary therapies for pain into the treatment plan - D.
Contacting the health care provider about the client's request to
incorporate complementary therapies for pain into the treatment plan

508. Which of the following situations is an example of the use of evidence-

based practice in the delivery of client care?

A. Encouraging a client who has had a stroke to consume thin liquids and
foods
B. Blowing on a fingerstick site to dry it after cleaning the site with an alcohol
swab
C. Immediately picking up a dislodged radiation implant with gloved hands
and placing it in a lead container
D. Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing
into a plastic-lined waste receptacle before pouring the solution into a
sterile basin - D. Pouring 1 to 2 mL of sterile solution that will be used for
wound cleansing into a plastic-lined waste receptacle before pouring the
solution into a sterile basin

509. A nurse is preparing for the admission of a client with pulmonary

tuberculosis. Which of the following actions reflects the use of evidence-based
practice in the care of the client?

A. Keeping the door to the client's room closed

B. Using a surgical mask when entering the client's room
C. Placing the client in a semiprivate room with a cohort client
D. Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask
to be worn at all times - A. Keeping the door to the client's room closed

510. A nurse manager asks a nurse to work overtime because of a short-

staffing problem. The nurse has made plans to do her Christmas shopping after
work and does not want to work overtime. What is the most assertive response
by the nurse to her nurse manager?

A. "I'm not working overtime today."

B. "You know how I hate to work overtime."
C. "I will if you need me, but I am not happy about this."
D. "I have plans after work and will not be able to work overtime." - D. "I have
plans after work and will not be able to work overtime."

511. A nurse manager arrives at work and is immediately faced with several
activities that require his attention. Which activity will the nurse manager attend
to first?
 A. Stocking the medication closet
B. Client assignments for the day
C. A phone message from a client's wife
D. A phone message from employee health services - B. Client assignments
for the day

512. A nurse who has been employed in a hospital for 8 weeks is consistently
taking extended lunch breaks. The nurse's behavior has caused problems with
client care during lunch hours. What is the appropriate way for the nurse
manager to deal with this situation?

A. Ignoring the situation

B. Asking other staff members to cover for the nurse
C. Documenting the problem in the nurse's personnel file
D. Confronting the nurse to discuss the behavior and initiate problem-solving
measures - D. Confronting the nurse to discuss the behavior and initiate
problem-solving measures

513. A health care provider repeatedly asks a nurse to write his verbal
prescriptions in his clients' charts after he makes his rounds. The nurse is
uncomfortable with writing the prescriptions and explains this to the physician,
but the health care provider tells the nurse that she will be reported if she does
not write the prescriptions. How should the nurse manage this conflict?

A. Fulfilling the physician's request

B. Discussing the situation with the nurse manager
C. Reporting the health care provider to the chief of medicine at the hospital
D. Stating to the physician, "I don't really care whether you report me. I am
not writing your prescriptions." - B. Discussing the situation with the nurse
manager

514. A nurse manager notes that an employee is constantly calling in sick.

Which action should the nurse manager take initially to handle this problem?

A. Reporting the employee to administration

B. Documenting the employee's behavior in the personnel file
C. Telling the employee that she will be fired if she calls in sick again
D. Reminding the employee of the employment standards of the agency - D.
Reminding the employee of the employment standards of the agency

515. A nursing staff member approaches a nurse manager and announces that
another nurse is not using alcohol swabs to clean the intravenous port when
administering intravenous push medications. What is the appropriate way for the
nurse manager to handle this situation?
 A. Telling the nurse that it is inappropriate to report other nurses
B. Providing an in-service educational session on aseptic technique for
everyone on the nursing unit
C. Informing the nurse who reported the occurrence that intravenous ports do
not need to be cleaned with alcohol before medication administration
D. Reviewing the skills checklist of the nurse who is not using aseptic
technique to determine whether the nurse has ever performed this skill
and had her technique validated - D. Reviewing the skills checklist of the
nurse who is not using aseptic technique to determine whether the nurse
has ever performed this skill and had her technique validated

516. A nurse on the day shift receives her client assignments for the day. List
the clients in order of their priority for assessment. - The correct order is:

517. A client with heart failure whose condition has been stable since the
administration of furosemide (Lasix)
518. A client with gastroenteritis and diarrhea
519. A client with suspected gallbladder disease who is scheduled for an
ultrasound of the abdomen
520. A client with a herniated disc who is scheduled to be discharged today

521. A nurse is preparing the client assignments for the day. One of the
registered nurses on the team has just learned that she is pregnant. Which client
does the nurse refrain from assigning to the pregnant team member?

A. A client with a solid sealed cervical radiation implant

B. A client with diarrhea for whom enteric precautions are in effect
C. A client with metastatic cancer who is receiving a continuous infusion of
intravenous morphine sulfate
D. A client for whom contact precautions have been implemented and who
requires frequent wound irrigations - A. A client with a solid sealed cervical
radiation implant

522. A client has signed the informed consent for mastectomy of the left breast.
On the morning of the surgical procedure, the client asks the nurse several
questions about the procedure that make it obvious that she has does not have
an adequate comprehension of the procedure. What is the most appropriate
response by the nurse?

A. Telling the client that it is her surgeon's responsibility to explain the

procedure
B. Contacting the surgeon and requesting that she visit the client to answer
her questions
C. Informing the client that she has the right to cancel the surgical procedure
if she wishes
 D. Telling the client that she needed to ask these questions before signing
the informed consent for surgery - B. Contacting the surgeon and
requesting that she visit the client to answer her questions

523. A nurse sees another nurse changing an intravenous (IV) solution

because the wrong solution is infusing into the client. The nurse who changed
the IV solution does not report the error. What should the nurse who observed
the error do first?

A. Call the client's health care provider

B. Document the error in the client's chart
C. Report the nurse who changed the IV solution
D. Ask the nurse whether she intends to report the error - D. Ask the nurse
whether she intends to report the error

524. A nurse leader in a medical-surgical unit overhears the nursing staff

openly discussing a client and stating that the client is "uncooperative and a real
pain to care for." The nurse leader would most appropriately manage this issue
by:

A. Discouraging the judgmental comments

B. Ignoring the comments made about the client
C. Reporting the nurses' comments to administration
D. Leaving articles about judgmental opinions in the nurses' report room - A.
Discouraging the judgmental comments

525. A client receives cefazolin sodium (Ancef) by way of the intravenous route.
During the infusion, the client begins exhibiting signs of an allergic reaction. The
client states that his skin is itchy, and the nurse notes that the skin is warm and
flushed, with a red rash on the arms, chest, and back. The nurse immediately
discontinues the medication, further assesses the client, contacts the physician,
and begins to document the reaction in an incident report. The nurse most
accurately documents which of the following?

A. The client had an allergy to cefazolin sodium.

B. The health care provider was notified because a rash developed while the
client was receiving cefazolin sodium.
C. The client is apparently allergic to cefazolin sodium, as indicated by warm,
flushed skin and a rash on the arms, chest, and back.
D. During an infusion of cefazolin sodium, the client complained that his skin
was itchy. The client's skin was warm and flushed, with a red rash on the
arms, chest, and back. The health care provider was notified. - D. During
an infusion of cefazolin sodium, the client complained that his skin was
itchy. The client's skin was warm and flushed, with a red rash on the arms,
chest, and back. The health care provider was notified.
526. A nurse who works in a medical care unit is told that she must float to the
intensive care unit because of a short-staffing problem on that unit. The nurse
reports to the unit and is assigned to three clients. The nurse is angry with the
assignment because she believes that the assignment is more difficult than the
assignment delegated to other nurses on the unit and because the intensive care
unit nurses are each assigned only one client. The nurse should most
appropriately:

A. Refuse to do the assignment

B. Tell the nurse manager to call the nursing supervisor
C. Ask the nurse manager of the intensive care unit to discuss the
assignment
D. Return to the medical care unit and discuss the assignment with the nurse
manager on that unit - C. Ask the nurse manager of the intensive care unit
to discuss the assignment

527. A client with a left arm fracture complains of severe diffuse pain that is
unrelieved by pain medication. On further assessment, the nurse notes that the
client experiences increased pain during passive motion, compared with active
motion, of the left arm. On the basis of these assessment findings, which action
should the nurse take first?

A. Contacting the health care provider

B. Reassessing the client in 30 minutes
C. Checking to see whether it is time for more pain medication
D. Encouraging the client to continue active range of motion exercises of the
left arm - A. Contacting the health care provider

528. A client with terminal cancer is receiving a continuous intravenous infusion

of morphine sulfate. On assessment of the client, what does the nurse check
first?

A. Pulse
B. Urine output
C. Temperature
D. Respiratory status - D. Respiratory status

529. A nurse is preparing to administer medications to a client by way of a

nasogastric (NG) tube. Before administering the medication, the nurse must first:

A. Check the client's apical pulse

B. Check the placement of the tube
C. Check when the last feeding was given
530. D Check when the last medications were given - B. Check the placement
of the tube
531. A health care provider asks the nurse who is caring for a client with a new
colostomy to ask the hospital's stoma nurse to visit the client and assist the client
with care of the colostomy. The nurse initiates the consultation, understanding
that the stoma nurse will be able to influence the client because of his:

A. Expert power
B. Reward power
C. Referent power
D. Coercive power - A. Expert power

532. An emergency department nurse is performing an assessment of a client

who has sustained circumferential burns of both legs. What should the nurse
assess first?

A. Heart rate
B. Radial pulse rate
C. Peripheral pulses
D. Blood pressure (BP) - C. Peripheral pulses

533. A nurse employed at a hospital is asked by a nurse manager to review the

organizational chart. The nurse reviews the chart so that he will:

A. Understand the organization's reason for existence

B. Be familiar with the organization's line of authority
C. Be familiar with the beliefs and values of the organization
D. Be aware of the geographical area that the organization serves - B. Be
familiar with the organization's line of authority

534. A nurse manager discusses staff empowerment with the nursing team.
The nurse manager explains that staff empowerment:

A. Allows the staff to make every decision regarding employee scheduling

B. Fosters the growth of others so that they are less dependent on the leader
C. Means that the staff has the power to reprimand and punish any individual
who is not meeting the standards of care delivery
D. Indicates that the nurse leader will make decisions regarding the nursing
unit and expects that the staff will comply with the changes - B. Fosters
the growth of others so that they are less dependent on the leader

535. The nurse notes that a health care provider has documented the following
prescription in a client's record: Furosemide (Lasix) 40 mg stat once. What action
should the nurse take?

A. Contacting the health care provider

B. Administering the medication
C. Drawing up the medication in a syringe
 D. Planning to have the nurse on the next shift administer the medication - A.
Contacting the health care provider

536. A 17-year-old client arrives at the clinic and asks to be examined because
she believes that she has contracted a sexually transmitted infection. In regard to
informed consent, the nurse tells the client that:

A. She will need to sign an informed consent form

B. Her mother or father will need to be contacted for permission to treat her
C. Anyone over the age of 18 years may sign a consent form for her
treatment
D. A consent form is not needed if the problem is a sexually transmitted
infection - A. She will need to sign an informed consent form

537. An 18-year-old client is brought to the emergency department (ED) by

emergency medical services after sustaining life-threatening injuries in an
automobile accident. The client is unconscious and requires an emergency
splenectomy. A nurse in the ED assists in quickly preparing the client for surgery
and tries to contact the client's parents but is unsuccessful. In regard to informed
consent for the surgery:

A. The nurse understands that consent is not needed

B. The nurse will contact the hospital clergy to provide informed consent
C. The nurse will sign informed consent on behalf of the client and ask
another nurse to witness the signature
D. The nurse will prepare the client to undergo mechanical ventilation until
the client's parents can be contacted - A. The nurse understands that
consent is not needed

538. A nurse is supervising a new nursing graduate in various procedures.

Which of the following actions by the new nursing graduate constitutes a
negligent act?

A. Giving a verbal report to the nurse on the oncoming shift

B. Checking neurological signs in a client with a head injury
C. Using clean gloves to change a gastrostomy tube dressing
D. Contacting a health care provider about a change in a client's blood
pressure - C. Using clean gloves to change a gastrostomy tube dressing

539. A nurse is reviewing the notes written by a nurse on a previous shift.

Which note in the client's record reflects the correct use of guidelines for
documentation?

A. The client seems anxious

B. The client's intake was 360 mL
C. The client's wound is healing well
 D. The client is voiding large amounts - B. The client's intake was 360 mL

540. A nurse is reading the nurse practice act for the state in which she is
employed. The nurse uses the information in this act to:

A. Identify healthcare policies in her state

B. Know how to perform certain procedures
C. Be aware of the role of the professional nurse
D. Be aware of hospital and long-term care facilities policies - C. Be aware of
the role of the professional nurse

541. A client whose right leg is in skeletal traction complains of pain in the leg.
Which action should the nurse take first?

A. Realigning the client

B. Asking the client to wiggle her toes
C. Removing some of the traction weights
D. Medicating the client with the prescribed analgesic - A. Realigning the
client

542. A nurse is performing suctioning through an adult client's tracheostomy

tube. The nurse notes that the client's oxygen saturation is 89% and terminates
the procedure. Which action would the nurse take next?

A. Calling the health care provider

B. Calling the respiratory therapist
C. Rechecking the pulse oximetry reading
D. Oxygenating the client with 100% oxygen - D. Oxygenating the client with
100% oxygen

543. A nurse is assisting a client with a closed chest tube drainage system in
bathing. As the nurse is turning the client onto his side, the chest tube is
disconnected. What should the nurse do first?

A. Call the health care provider

B. Clamp the chest tube with a Kelly clamp
C. Instruct the client to inhale and hold his breath
D. Submerge the end of the chest tube in a bottle of sterile water - D.
Submerge the end of the chest tube in a bottle of sterile water

544. Which event would require a nurse to complete and file an incident report?

A. A client has a seizure.

B. The nurse determines that a client would benefit from the use of a walker
to ambulate.
 C. The nurse, preparing an intravenous infusion, notes that the battery of an
intravenous infusion pump is not working.
D. When a visitor suddenly becomes weak and dizzy, the nurse checks the
visitor's blood pressure and takes the visitor to the emergency department
for treatment. - D. When a visitor suddenly becomes weak and dizzy, the
nurse checks the visitor's blood pressure and takes the visitor to the
emergency department for treatment.

545. A nurse, charting the administration of medications to an assigned client at

9 pm, notes that atenolol (Tenormin) was prescribed to be administered at 9 am
instead of 9 pm. The nurse checks the client's vital signs, completes an incident
report, and calls the physician to report the error. The physician tells the nurse
that an incident report is not needed but instructs her to monitor the client during
the night for hypotension. What action should the nurse take?

A. Notifying the nursing supervisor

B. Tearing up and discarding the incident report
C. Telling the physician that the error warrants the completion of an incident
report
D. Telling the nursing supervisor that the physician did not want an incident
report completed and filed - C. Telling the physician that the error warrants
the completion of an incident report

546. Contact precautions are initiated for a client with methicillin-resistant

Staphylococcus aureus (MRSA) infection. The nurse, providing instructions to a
nursing assistant about caring for the client, tells the assistant:

A. To transfer the client to a semiprivate room

B. That gloves only are needed to care for the client
C. To wear gloves and a gown when changing the client's bed linen.
D. To wear a gown when caring for the client and remove the gown
immediately after leaving the client's room - C. To wear gloves and a gown
when changing the client's bed linen.

547. A nurse hears someone calling, "Help! My bed is on fire!" On entering the
room, the nurse finds a client trying to beat out the flames with a pillow. Place in
order of priority the actions that the nurse should take: - The correct order is:

548. Removing the client from the room

549. Pulling the nearest fire alarm
550. Closing the door to the room
551. Running to get the nearest fire extinguisher

552. The mother of a 3-year-old calls a neighbor who is a nurse and reports
that her child just drank some window cleaner that had been stored in a cabinet.
The nurse should instruct the mother to immediately:
 A. Call a poison control center
B. Administer an excessive amount of fluids to induce vomiting
C. Call an ambulance to bring the child to the emergency department
D. Leave a message at the physician answering service about the incident -
A. Call a poison control center

553. A hurricane is forecast to make landfall in 48 hours, and the staff of the
emergency department of an area hospital is advised to prepare for causalities.
Which action should the nurse manager who receives the telephone call
regarding this warning take first?

A. Activating the agency disaster plan

B. Supplying the triage rooms with additional equipment
C. Increasing the number of nursing staff for the day on which the hurricane
is expected
D. Calling the hospital maintenance department to secure the building
against the storm - A. Activating the agency disaster plan

554. A home health nurse has instructed a client about safety measures during
the use of an oxygen concentrator in the home. Which statement by the client
indicates to the nurse that the client has understood the directions? Select all that
apply.

A. "I need to follow the oxygen prescription exactly."

B. "I can use my electric razor while I'm using oxygen."
C. "I have to keep the oxygen concentrator out of direct sunlight."
D. "I need to keep the oxygen concentrator as close to the wall as possible or
put it in a corner."
E. "I have to tell everyone that they can't smoke or have an open flame within
10 feet of the oxygen concentrator." - A. "I need to follow the oxygen
prescription exactly."
555. C. "I have to keep the oxygen concentrator out of direct sunlight."
556. E. "I have to tell everyone that they can't smoke or have an open flame
within 10 feet of the oxygen concentrator."

557. A nurse is providing instructions to a nursing assistant who will be caring

for a client in hand restraints. The nurse instructs the nursing assistant to release
the restraints to permit muscle exercise:

A. Every 2 hours
B. Every 3 hours
C. Every 4 hours
D. Every 30 minutes - A. Every 2 hours
558. A community health nurse working in a school setting is concerned
because parents are not participating in health activities designed to promote
child safety. In this situation, the most appropriate initial action is:

A. Implementing a child safety program

B. Planning a focused child safety program
C. Performing an analysis of health problems related to child safety
D. Determining the appropriateness of the planned health activity - D.
Determining the appropriateness of the planned health activity

559. The nurse administers a dose of ramipril (Altace) 2.5 mg to a client at 9

am. While documenting administration of the medication, the nurse discovers
that 1.25 mg, not 2.5 mg, was the prescribed dose. The nurse assesses the
client, completes an incident report, and notifies the physician and nursing
supervisor of the error. What statement does the nurse add to the client's record?

A. An incident report was completed and filed.

B. Ramipril (Altace) 2.5 mg was administered at 9 am.
C. Twice the amount of the prescribed ramipril was administered at 9 am.
D. Client's blood pressure was 128/82 mm Hg after the administration of the
incorrect dose of ramipril. - B. Ramipril (Altace) 2.5 mg was administered
at 9 am.

560. A home health nurse has been called to the home of an older
postoperative cardiovascular client by the client's son. The son tells the nurse,
"We're using a hospital bed here at home, but my mother has fallen out of bed
three times." Which observation by the nurse reflects an increased risk of this
client's falling out of bed?

A. The client's bed is in a low position.

B. The client is oriented to person, place, and time.
C. The caregiver uses the overbed table for feedings.
D. The caregiver leaves both siderails down while the client is in bed. - D.
The caregiver leaves both siderails down while the client is in bed.

561. A community health nurse is providing information to local residents about

the transmission of anthrax. Through which body systems does the nurse tell the
residents that anthrax can be contracted? Select all that apply.

A. Skin
B. Lung
C. Immune
D. Urinary
E. Lymphatic
F. Gastrointestinal - A. Skin Correct
562. B. Lungs Correct
563. F. Gastrointestinal Correct

564. A nurse is preparing a chemotherapy infusion to be administered to a

client with a diagnosis of Hodgkin's disease. Which precaution should the nurse
take while working with this intravenous (IV) infusion?

A. Wearing gloves and a mask

B. Wearing gloves and a gown
C. Wearing gloves, a mask, and eye protection
D. Wearing gloves, a mask, and a head covering - C. Wearing gloves, a
mask, and eye protection

565. A nurse is preparing a continuous intravenous (IV) infusion at the

medication cart. As the nurse goes to attach the IV tubing port to the solution
bag, the tubing drops, hitting the top of the medication cart. Which action should
the nurse take to maintain asepsis?

A. Obtaining new IV tubing

B. Obtaining a new IV solution bag
C. Scrubbing the tubing port with an alcohol swab
D. Wiping the tubing port with povidone-iodine solution (Betadine) - A.
Obtaining new IV tubing

566. A home health nurse is visiting a client with tuberculosis (TB). Which
action by the client tells the nurse that the client understands the necessary
respiratory precautions to be taken at home?

A. Staying secluded in the bedroom

B. Wearing an oxygen mask at all times
C. Keeping the house closed up to minimize the spread of disease
D. Disposing of contaminated tissues in a container with a leak-proof bag - D.
Disposing of contaminated tissues in a container with a leak-proof bag

567. A home health nurse teaches a client about home modifications to reduce
the risk of falls. Which statements by the client indicate a need for further
teaching? Select all that apply.

A. "I need to use night lights."

B. "I need to remove my wall-to-wall carpeting."
C. "I need to get handrails put up in the bathroom."
D. "I need to use the staircase handrails when I go up the stairs."
E. "I should walk barefoot as much as possible so that I'll know about any
wet spots on the floor." - B. "I need to remove my wall-to-wall carpeting."
F. "I should walk barefoot as much as possible so that I'll know about any
wet spots on the floor."
568. A nurse caring for a client who is under airborne precautions notes that
the client is scheduled for a nuclear scan. Which action on the part of the nurse is
appropriate?

A. Planning to have the nuclear scan performed at the bedside

B. Asking the technicians in the nuclear scan department to wear masks
C. Placing a surgical mask on the client for transport and for contact with
other individuals
D. Calling the nuclear medicine department and telling the technician that the
test will have to be delayed until airborne precautions have been
discontinued - C. Placing a surgical mask on the client for transport and
for contact with other individuals

569. A nurse employed in a physician's office hears a client in the waiting room
call out, "Help! Fire!" The nurse rushes to the waiting room and finds that the
wastebasket is on fire. The nurse immediately:

A. Confines the fire

B. Extinguishes the fire
C. Activates the fire alarm
D. Removes the clients from the waiting room - D. Removes the clients from
the waiting room

570. A nurse enters the laundry room to empty a bag of dirty linen and
discovers a fire in a laundry basket. What action should the nurse take first?

A. Confining the fire

B. Extinguishing the fire
C. Activating the fire alarm
D. Running for the fire extinguisher - C. Activating the fire alarm

571. The safety department is providing a yearly educational session on fire

safety and the use of fire extinguishers. A nurse is asked to demonstrate the use
of a fire extinguisher after the session. The nurse demonstrates appropriate use
of the fire extinguisher by first:

A. Aiming at the base of the fire

B. Pulling the pin on the fire extinguisher
C. Squeezing the handle of the extinguisher
D. Sweeping from the top to the bottom of the fire with the extinguisher - B.
Pulling the pin on the fire extinguisher

572. A nurse provides instruction to a new nursing assistant regarding the

application of a restraint to a client. The nurse watches as the nursing assistant
applies the restraint. What observation tells the nurse that the nursing assistant is
using correct procedure?
 A. The assistant applies a tie knot in the restraint strap.
B. The assistant attaches the restraint straps securely to the siderails.
C. The assistant applies the restraint so that the strap does not tighten when
force is applied against it.
D. The assistant secures the restraint in such a way that it is impossible to
slip a finger between the restraint and the client's skin. - C. The assistant
applies the restraint so that the strap does not tighten when force is
applied against it.

573. A registered nurse is instructing a group of nursing assistants in the

principles of body mechanics. Which of these observations tell the nurse that a
student is using the principles appropriately? Select all that apply.

A. The assistant leans forward when turning a client in bed.

B. The assistant positions a box that is to be lifted between his knees.
C. The assistant turns his back to change position while moving a client.
D. The assistant keeps the object to be moved as close to his body as
possible.
E. The assistant helps a client requiring total care into a chair without
additional assistance. - B. The assistant positions a box that is to be lifted
between his knees
574. D. The assistant keeps the object to be moved as close to his body as
possible

575. A home care nurse visits a client who lives in a small apartment to perform
an admission assessment. During the home safety assessment, the client asks
the nurse whether it is safe to use a space heater. What is the appropriate
response by the nurse?

A. "A space heater should never be used in an apartment."

B. "A space heater can be used as long as it is kept at a low setting at all
times."
C. "A space heater can be used as long as it is kept in the bedroom at night
in case a fire occurs."
D. "A space heater can be used as long as it's placed at least 3 feet from
anything that may ignite." - D. "A space heater can be used as long as it's
placed at least 3 feet from anything that may ignite."

576. A nurse is preparing to initiate a continuous tube feeding, using a tube-

feeding pump. On bringing the pump to the bedside and preparing to plug the
pump in, the nurse discovers that there is no available plug in the wall socket.
What should the nurse do?

A. Plug in the pump cord into an available plug above the sink
B. Ask the physician to change the prescription to intermittent feedings
 C. Determine the need for the appliances now plugged into the needed wall
socket
D. Use a regular extension cord to allow the use of more than one electrical
appliance - C. Determine the need for the appliances now plugged into the
needed wall socket

577. A nurse, preparing a sterile field on which to perform a dressing change,

places the sterile drape on the overbed table. Which of these actions on the part
of the nurse indicate correct understanding of the principles of aseptic technique?
Select all that apply.

A.Holding the pair of sterile forceps below waist level area

B.Positioning the sterile field so that it remains in full view
C.Reaching across the sterile field to pick up a sterile gauze
D.Leaving the room to obtain a bottle of sterile normal saline solution
E.Picking up a pair of sterile scissors from the sterile field with a sterile
gloved hand
F. Pouring sterile wound cleansing solution into a sterile cup before donning
sterile gloves - B. Positioning the sterile field so that it remains in full view
578. E. Picking up a pair of sterile scissors from the sterile field with a sterile
gloved hand
579. F. Pouring sterile wound cleansing solution into a sterile cup before
donning sterile gloves

580. A licensed practical nurse (LPN) tells the registered nurse (RN) that she
administered acetaminophen (Tylenol) to a client by way of the rectal route rather
than the prescribed oral route because the client was extremely nauseated. The
RN most appropriately:

A. Asks the LPN to complete and file an incident report

B. Asks the LPN to check the client in 30 minutes to see whether the nausea
has subsided
C. Tells the LPN that she made a sound judgment in administering the
medication by way of the rectal route
D. Instructs the LPN to write "pr" (per rectum) on the medication record next
to the time at which the medication was administered - A. Asks the LPN to
complete and file an incident report

581. A nurse receives a telephone call from the admissions office and is told
that a client scheduled for an internal radiation implant will be admitted to the
nursing unit. Which of the following precautions does the nurse include in the
client's plan of care?

A. Wearing gloves when emptying the client's bedpan

B. Allowing the client to ambulate in the hall only once a day
C. Placing the client in a semiprivate room at the end of a hallway
 D. Placing used linen in double bags and sending a bag to the laundry room
every evening - A. Wearing gloves when emptying the client's bedpan

582. A nursing instructor is observing a nursing student who is practicing the

use of standard precautions in the nursing laboratory. Which of the following
observations by the instructor indicates a need for further teaching?

A. The nursing student changes gloves between tasks and procedures.

B. The nursing student washes hands before making contact with the client.
C. The nursing student wears a gown to change the bed of an incontinent
client.
D. The nursing student washes her hands before glove removal after
emptying a Foley bag. - D. The nursing student washes her hands before
glove removal after emptying a Foley bag.

583. A physician writes a prescription for the application of a heating pad to a

client's back. Which of the following actions should the nurse take when
implementing this prescription? Select all that apply.

A. Placing the heating pad under the client

B. Adjusting the heating pad to the high setting
C. Frequently assessing the client's skin for signs of burns
D. Assessing the client's medical history and risk factors for burns
E. Assessing the heating pad periodically for proper electrical function - C.
Frequently assessing the client's skin for signs of burns
584. D. Assessing the client's medical history and risk factors for burns
585. E. Assessing the heating pad periodically for proper electrical function

586. A home care nurse is instructing a client in the use of ice packs to treat an
eye injury. The nurse instructs the client to:

A. Place the ice pack directly on the eye

B. Avoid the use of commercially prepared ice bags
C. Keep the ice pack on the eye continuously for 24 hours
D. Wrap a plastic bag filled with ice in a pillowcase and place it on the eye -
D. Wrap a plastic bag filled with ice in a pillowcase and place it on the eye

587. A fever develops in a client who has been hospitalized for 2 months and is
receiving parenteral nutrition by way of a central venous line, and central venous
line-related sepsis is diagnosed. The nurse interprets this finding as meaning that
this infection is:

A. An iatrogenic infection
B. A result of bacterial colonization
C. A community-acquired infection
D. A healthcare-associated infection - D. A healthcare-associated infection
588. A nurse educator is providing inservice sessions to the nursing staff
regarding employee safety and the prevention of occupationally acquired HIV
infection. Which of the following precautions does the nurse instruct the nursing
staff to take as a means of preventing accidental needlesticks? Select all that
apply.

A. The use of latex gloves

B. The use of shielded needles
C. The use of recessed needles
D. The use of needleless devices
E. Disposal of needles in special puncture-resistant containers - B. The use
of shielded needles
589. C. The use of recessed needles
590. D. The use of needleless devices
591. E. Disposal of needles in special puncture-resistant containers

592. A nurse is preparing to clean up a blood spill on the client's bedside table
that occurred when a blood tube containing a specimen from the client broke.
What steps should the nurse take to clean up the blood spill? Select all that
apply.

A. Using tongs to collect any broken glass

B. Wearing gloves for the cleanup procedure
C. Placing the pieces of broken glass in a plastic bag
D. Blotting up the spill with a face cloth or cloth towel
E. Disinfecting the area of the blood spill with a dilute bleach solution - A.
Using tongs to collect any broken glass
593. B. Wearing gloves for the cleanup procedure
594. E. Disinfecting the area of the blood spill with a dilute bleach solution

595. The unit supervisor of an emergency department (ED) is called at home

and told by an emergency department nurse who is on duty that an airplane
crash has occurred and numerous casualties will be arriving at the ED. What
should the initial response by the unit supervisor be?

A. "Has the disaster plan been activated?"

B. "Call as many nursing staff as you can to come in to work."
C. "Make sure all of the rooms are well stocked with supplies."
D. "Be sure that the nursing staff finds as many stretchers as they can." - A.
"Has the disaster plan been activated?"

596. A community health nurse is providing an educational session on

childhood poisoning at a local school. The nurse tells the group that when an
accidental poisoning occurs the first action is to:
 A. Induce vomiting
B. Call an ambulance
C. Call the poison control center
D. Bring the child to the emergency department (ED) - C. Call the poison
control center

597. A client undergoing chemotherapy is found to have an extremely low white

blood cell count, and neutropenic precautions, including a low-bacteria diet, are
immediately instituted. Which of these food items will the client be allowed to
consume? Select all that apply.

A. Fresh apple
B. Raw celery
C. Italian bread
D. Tossed salad
E. Baked chicken
F. Well-cooked cheeseburger - C. Italian bread
598. E. Baked chicken
599. F. Well-cooked cheeseburger

600. Which actions should the nurse take in the event of an accidental
poisoning? Select all that apply.

A. Saving vomitus for laboratory analysis

B. Placing the client in the supine position
C. Determining the type and amount of substance ingested
D. Removing any visible materials from the nose and mouth
E. Inducing vomiting if a household cleaner has been ingested
F. Assessing the client's airway patency, breathing, and circulation - A.
Saving vomitus for laboratory analysis
601. C. Determining the type and amount of substance ingested
602. D. Removing any visible materials from the nose and mouth
603. F. Assessing the client's airway patency, breathing, and circulation

604. A nurse is assigned to care for a client with an infection caused by

methicillin-resistant Staphylococcus aureus (MRSA). The client has an
abdominal wound that requires irrigation and has a tracheostomy attached to a
mechanical ventilator that requires frequent suctioning. While gathering the
needed supplies before entering the client's room, which necessary protective
items does the nurse obtain? Select all that apply.

A. Mask
B. Gown
C. Gloves
D. Face shield
E. Shoe protectors - B. Gown
605. C. Gloves
606. D. Face shield

607. A nurse is assisting with disaster relief after a tornado. The nurse's goal
with the overall community is to prevent as much injury and death resulting from
the uncontrollable event as possible. Finding safe housing for survivors,
providing support to families, organizing counseling sessions, and securing
physical care when needed are all examples of which level of prevention?

A. Initial
B. Primary
C. Tertiary
D. Secondary - C. Tertiary

608. A nurse in a postanesthesia care unit (PACU) receives a client from the
operating room. For what finding should the PACU nurse assess the client first?

A. Airway patency
B. Active bowel sounds
C. Adequate urine output
D. Orientation to surroundings - A. Airway patency

609. A staff nurse caring for a client with a head injury notes that the client is
restless and pulling at the intravenous (IV) line. The client's physician does not
want to prescribe sedation, and the family has requested that the client not be
restrained. Which action by the nurse is appropriate?

A. Asking a family member to sit with the client

B. Asking a nursing assistant to monitor the client
C. Staying with the client and consulting with the nurse manager about the
situation
D. Telling the family that the application of wrist restraints is critical in
preventing injury to the client - C. Staying with the client and consulting
with the nurse manager about the situation

610. A nurse manager of an emergency department (ED) arrives at work and is

told that four registered nurses scheduled to work will not be reporting to work
because they are ill. Every trauma room is busy, and emergency medical
services (EMS) has just called to report that several victims involved in a 10-car
wreck on the interstate will be brought to the ED. The nurse manager initially
manages this situation by:

A. Telling EMS to take the victims to another hospital

B. Closing the emergency department temporarily to incoming clients
C. Calling the nursing supervisor to discuss activation of the disaster plan
 D. Demanding that the nurses from the night shift stay until all of the victims
have been treated - C. Calling the nursing supervisor to discuss activation
of the disaster plan

611. A nurse responds to an external disaster that occurred in a large city when
a building collapsed. Numerous victims require treatment. Which victim should
the nurse attend to first?

A. A victim who has died of multiple serious injuries

B. A hysterical victim who has sustained a head injury
C. An alert victim who has numerous bruises on the arms and legs
D. A victim with a partial amputation of a leg who is bleeding profusely - D. A
victim with a partial amputation of a leg who is bleeding profusely

612. A nurse giving a client a bed bath drops the towel on the floor. The nurse
should:

A. Use a bath blanket as a towel

B. Borrow a towel from the client's roommate
C. Wash her hands, pick up the towel, and shake the towel out
D. Wash her hands and go to the linen room to obtain another towel - D.
Wash her hands and go to the linen room to obtain another towel

613. A nurse is attending an inservice program on disaster preparedness.

Which of the following events is described as an example of a natural disaster?

A. Drought
B. Bus accident
C. Terrorist attack
D. Toxic waste spill - A. Drought

614. A nurse manager tells the nursing staff that the agency's disaster
preparedness plan will be distributed to all employees for review. The nurse
manager states that the plan is an important component of disaster readiness
because it primarily:

A. Identifies the location of healthcare supplies

B. Identifies the types of disasters that may occur
C. Aids determination of how victims will be triaged
D. Describes a formal plan of action for the coordination of a response - D.
Describes a formal plan of action for the coordination of a response

615. A nurse is reading an article about the role of the American Red Cross
(ARC) in a disaster. Which of the following responsibilities does the article
ascribe to the ARC?
 A. Declaring a disaster
B. Providing disaster relief
C. Activating disaster medical assistant teams
D. Developing a federal disaster response plan - B. Providing disaster relief

616. A nurse leading an educational session about terrorism for members of

the community is discussing anthrax. Which of the following pieces of information
should the nurse provide to the group attending the session? Select all that
apply.

A. Anthrax is never fatal.

B. No vaccine to prevent anthrax is available.
C. Anthrax can be transmitted from person to person.
D. A blood test is available for the detection of anthrax.
E. One way that anthrax can be contracted is through the skin. - D. A blood
test is available for the detection of anthrax.
F. One way that anthrax can be contracted is through the skin.

617. Acccording to the Federal Emergency Management Agency (FEMA)

description of the phases of disaster management, in which phase are the
available resources for the care of infants, older clients, the disabled, and people
with chronic health problems addressed?

A. Response
B. Recovery
C. Mitigation
D. Preparedness - C. Mitigation

618. An older client is extremely anxious after admission, having never been
hospitalized before. To help provide a safe environment and minimize the stress
of hospitalization on the client, what does the nurse plan to do? Select all that
apply.

A. Keep visitors to a minimum

B. Acknowledge the client's feelings
C. Provide information about hospital routines
D. Put the client in a room far from the nurses' station
E. Keep the door open and the room lights on at all times
F. Allow the client to have as many choices regarding his care as possible -
B. Acknowledge the client's feelings
619. C. Provide information about hospital routines
620. F. Allow the client to have as many choices regarding his care as possible

621. A nurse is preparing a disaster preparedness checklist, identifying

emergency plans and supplies that will be needed in the event of a disaster, for a
 community group. Which instructions should be included on the list? Select all
that apply.

A. Have a first aid kit available.

B. Have a firearm or other weapon available.
C. Plan a meeting place for family members.
D. Obtain a 1-day supply of water (1 gallon per person).
E. Have an adequate supply of prescription medications.
F. Have a battery-operated radio and a flashlight and batteries available. - A.
Have a first aid kit available.
622. C. Plan a meeting place for family members.
623. E. Have an adequate supply of prescription medications.
624. F. Have a battery-operated radio and a flashlight and batteries available.

625. A triage nurse in an emergency department (ED) is attending to the

victims of a train crash. All victims are alert. Which of these clients does the
nurse assign to the emergent category? Select all that apply.

A. A victim with respiratory distress

B. A victim with a fractured humerus
C. A victim with partial amputation of the foot
D. A victim with a forehead laceration that is not bleeding
E. A victim with multiple nonbleeding bruises of the arms and legs - A. A
victim with respiratory distress
626. C. A victim with partial amputation of the foot

627. A nurse is questioning a client about hazards in the home environment.

Which of the following items in the home is an indication that the client requires
instruction about safety? Select all that apply.

A. Untacked rugs on the stairs

B. Small rugs in the living room
C. Carpet on stairs secured with tacks
D. Clothes hamper at the end of the hallway
E. Cereal boxes, canned foods, and infrequently used cooking utensils
stored on top of the refrigerator - A. Untacked rugs on the stairs
628. B. Small rugs in the living room
629. E. Cereal boxes, canned foods, and infrequently used cooking utensils
stored on top of the refrigerator

630. A home health nurse is performing an assessment of a client's skin. The

nurse, noting multiple threadlike lines, both straight and wavy, beneath the skin,
recognizes the presence of scabies. Which of the following precautions should
the nurse institute before completing the assessment of the client?

A. Putting on a pair of gloves

 B. Donning a mask and gloves
C. Putting on a gown and gloves
D. Avoiding sitting on the client's furniture - C. Putting on a gown and gloves

631. An industrial nurse at a large factory provides information to the

employees in the mailroom and shipping department about the signs of skin
(cutaneous) anthrax. For which early sign of cutaneous anthrax does the nurse
tell the employees to check their skin?

A. An open ulcer
B. An itchy bump
C. A weeping blister
D. A black skin area of skin - B. An itchy bump

632. A nurse educator is providing an inservice program to emergency

department nurses about the signs of inhalation anthrax. The nurse educator tells
the nurses that one early indication of inhalation anthrax is:

A. Hemorrhage
B. Signs of shock
C. Flulike symptoms
D. Respiratory distress - C. Flulike symptoms

633. A post office employee with suspected skin anthrax asks the emergency
department nurse whether the infection is curable. What is the appropriate
response by the nurse?

A. "You really need to ask your doctor about that."

B. "That's hard to say. We won't know for a week or two."
C. "Antibiotic therapy is usually prescribed and will cure the infection."
D. "It is not curable, but fortunately, unlike inhalation anthrax, it is not deadly."
- C. "Antibiotic therapy is usually prescribed and will cure the infection."

634. The nursing staff in an emergency department is reviewing and updating

the disaster preparedness plan. The staff members, discussing ways to help
prevent the transmission of smallpox, know that this infection is transmitted by
which route?

A. Enteric
B. Inhalation
C. Gastrointestinal
D. Through open wounds - B. Inhalation

635. A nurse in a long-term care facility recognizes the need to place wrist
restraints on a client, but the client does not want the restraints applied. The
appropriate nursing action would be to:
 A. Contact the physician
B. Apply the restraints anyway
C. Medicate the client with a sedative, then apply the restraints
D. Compromise with the client and use only one wrist restraint instead of two
- A. Contact the physician

636. After discussing the use of restraints with a client and family, a physician
has written a prescription for wrist restraints to be applied to a client. The nurse
instructs the nursing assistant to apply the restraints. Which of the following
observations by the nurse indicates that the nursing assistant is using the
restraints safely and correctly? Select all that apply.

A. The restraints are applied tightly.

B. The restraints are being released every 2 hours.
C. A safety knot has been used to secure the restraints
D. The restraints have been tied to the siderails of the bed.
E. The call light has been placed within reach of the client. - B. The restraints
are being released every 2 hours.
637. C. A safety knot has been used to secure the restraints
638. E. The call light has been placed within reach of the client.

639. A nurse caring for a 9-month-old who has undergone repair of a cleft
palate applies elbow restraints to the child. The mother visits her child and asks
the nurse to remove the restraints. According to the guidelines for the use of
restraints, what should the nurse do in response to the mother's request?

A. Remove both restraints

B. Remove a restraint from one extremity
C. Tell the mother that the restraints may not be removed
D. Loosen the restraints after telling the mother that they may not be
removed - B. Remove a restraint from one extremity

640. A community health nurse is asked to assist in developing a community

disaster plan. The nurse determines that this responsibility is a component of
which disaster management phase identified by the Federal Emergency
Management Agency (FEMA)?

A. Response
B. Recovery
C. Mitigation
D. Preparedness - D. Preparedness

641. A nurse is admitting a postoperative client from the postanesthesia care

unit to the surgical nursing unit. Which of the following measures should the
nurse take for the safety of the client?
 A. Asking the client to slide from the stretcher to the bed
B. Quickly moving the client from the stretcher to the bed
C. Putting the siderails up after moving the client from the stretcher
D. Uncovering the client before making the transfer from the stretcher to the
bed - C. Putting the siderails up after moving the client from the stretcher

642. A nurse prepares to teach a client with chronic vertigo about safety
measures to help prevent exacerbation of symptoms and injury. Which
instructions should the nurse provide to the client? Select all that apply.

A. "Change positions slowly." Correct

B. "Remove clutter from your home." Correct
C. "Use public transportation as much as possible."
D. "Drive your car only if you're not feeling dizzy."
E. "Turn your head slowly when someone speaks to you." - A. "Change
positions slowly."
643. B. "Remove clutter from your home."

644. An emergency department (ED) nurse is triaging victims of an explosion at

a nearby manufacturing plant. To which victims should the nurse assign the
emergent (priority 1) designation? Select all that apply.

A. A victim with a limb amputation Correct

B. A victim who is alert but complaining of loss of vision Correct
C. A victim who is bleeding profusely from a head laceration Correct
D. A victim who is dazed and staggering around the other victims
E. A victim who has sustained minor bruising of an arm and the lower legs -
A. A victim with a limb amputation
645. B. A victim who is alert but complaining of loss of vision
646. C. A victim who is bleeding profusely from a head laceration

647. A client with an infection is receiving antibiotics by way of intramuscular

(IM) injection. The client is also receiving subcutaneous (SC) injections of
heparin. Which precaution does the nurse understand is most appropriate to help
ensure the safety of this client?

A. Doubling the dose of anticoagulant

B. Applying a pressure bandage to the site after each IM injection
C. Applying prolonged pressure to the sites of the IM and SC sites
D. Decreasing the sizes of the needles used for the IM and SC injections - C.
Applying prolonged pressure to the sites of the IM and SC sites

648. A nurse, assessing a client's readiness for discharge, is performing a

home safety assessment to determine whether there are any environmental
 hazards in the home. Which of the following statements, if made by the client,
would prompt the nurse to investigate further? Select all that apply.

A. "I live in a single-story house."

B. "I don't have any nightlights in the house."
C. "I've removed the scatter rugs from the house."
D. "I keep my personal items within reach when I sit in my easy chair."
E. "I haven't changed the batteries in the smoke detectors in my home for
quite a few years now." - B. "I don't have any nightlights in the house."
F. "I haven't changed the batteries in the smoke detectors in my home for
quite a few years now."

649. A nurse caring for a client with leukemia who is undergoing chemotherapy
reviews the latest laboratory results and notes that the neutrophil count is below
500 cells/mm3. Which of the following interventions does the nurse implement on
the basis of this finding? Select all that apply.

A. Providing a soft toothbrush for oral care

B. Monitoring the client's oral temperature
C. Maintaining sterile occlusion of intravenous (IV) catheters
D. Requiring the client to use an electric shaver rather than a razor
E. Performing meticulous skin decontamination before venipuncture
F. Avoiding overinflation of the blood pressure cuff and rotating the cuff
among several sites when measuring the blood pressure - B. Monitoring
the client's oral temperature
650. C. Maintaining sterile occlusion of intravenous (IV) catheters
651. E. Performing meticulous skin decontamination before venipuncture

652. A client with a new diagnosis of tuberculosis (TB) is being admitted to the
hospital. During the collection of data from the client, which of the following
considerations is especially important?

A. The religious affiliation or church of preference

B. The names of close friends and family member
C. What medications have been prescribed and what the client knows about
their side effects
D. The name of the person from whom the client contracted TB, so that the
person may be reported for follow-up care - B. The names of close friends
and family members

653. A client with osteoporosis is at risk for falls. Which statement by the client
indicates the need for instruction regarding measures to prevent falls?

A. "I took the bathmat out of my tub."

B. "I use a shower chair when I bathe."
C. "I've placed nightlights in my hallway."
 D. "The railings on my stairs are sturdy and secure." - A. "I took the bathmat
out of my tub."

654. An adolescent client asks the nurse questions about the transmission of
the Epstein-Barr virus (infectious mononucleosis). By which route should the
nurse tell the client that the disease is transmitted?

A. Fecal-oral
B. Airborne particles
C. Respiratory droplets
D. Close intimate contact - D. Close intimate contact

655. A teenage client returns to the gynecological (GYN) clinic for a follow-up
visit after diagnosis and initial treatment of a sexually transmitted infection (STI).
Which statement by the client indicates the need for further teaching?

A. "I finished all the antibiotic, just like you said."

B. "I know you won't tell my parents that I'm sick."
C. "I always make sure my boyfriend uses a condom."
D. "My boyfriend doesn't have to come in for treatment." - D. "My boyfriend
doesn't have to come in for treatment."

656. A nurse has provided instructions to a mother regarding the use of safety
seats in car travel for her newborn infant. Which statement by the mother
indicates understanding of the instructions?

A. "I'll put the baby's car seat in the front seat, facing forward and reclined a
little."
B. "I'll put the baby's car seat in the front seat, facing backward and reclined
a little."
C. "I'll put the baby's car seat in the middle back seat, facing forward and
reclined a little."
D. "I'll put the baby's car seat in the middle back seat, facing backward and
reclined a little." - D. "I'll put the baby's car seat in the middle back seat,
facing backward and reclined a little."

657. During a laboratory training session, the nurse is watching as a nursing

assistant repositions a client. Which observation tells the nurse that further
training is necessary?

A. The nursing assistant positions himself close to the client.

B. The nursing assistant keeps his neck, back, pelvis, and feet aligned.
C. The nursing assistant encourages the client to assist as much as possible.
D. The nursing assistant keeps his knees straight and his feet close together.
- D. The nursing assistant keeps his knees straight and his feet close
together.
658. A nurse preparing to perform a sterile dressing change notes that the
covering of a package of sterile 4 × 4 gauze pads has a small tear. Which action
should the nurse take?

A. Discarding the package

B. Using the gauze pads, because the tear was small
C. Examining the gauze pads and using them as long as they appear
untouched
D. Discarding the gauze pad closest to the outside of the package and using
the others - A. Discarding the package

659. A nurse preparing a sterile field is placing sterile items on the field. The
nurse understands that the border of the sterile drape is considered
contaminated. How many inch(es) is the contaminated border? Type your
answer in the box provided.
660. inch(es) - 1

661. A nurse who is preparing to leave the room of a client who is under
airborne precautions needs to remove the following protective items: gloves,
gown, mask, and goggles. Place in order of priority the items that need to be
removed. - The correct order is:

662. Gloves
663. Goggles
664. Gown
665. Mask

666. A nurse employed on a medical care unit is administering medications.

She tells a client that she is going to administer his furosemide (Lasix) through
his intravenous (IV) line. The client tells the nurse that he takes this medication
orally at home every day and is concerned that it is being administered by way of
a different route. The nurse should take which most appropriate action?

A. Verifying the physician's prescription

B. Sitting and talking to the client to alleviate his concern
C. Explaining to the client that the oral route will not permit the medication to
exert an adequate effect
D. Letting the client know that most medications are administered by way of
the IV route when a client is hospitalized - A. Verifying the physician's
prescription

667. At the beginning of the 7 am-3 pm shift, the nurse checks her assigned
clients and notes that a client with diabetes mellitus has an intravenous (IV) bag
of 5% dextrose in water hanging and infusing instead of the prescribed 0.9%
normal saline. The nurse verifies the prescription and changes the IV solution to
 the correct one. The nurse assesses the client noting that the blood glucose level
at 7:15 am was 149 mg/dL, notifies the physician, and completes an incident
report. Which information about the event is appropriate for inclusion on the
incident report? Select all that apply.
668. INCIDENT REPORT
669. Events that Occurred

A. The physician was contacted.

B. The blood glucose level at 7:15 am was 149 mg/dL.
C. An IV solution of 5% dextrose in water was infusing at 7 am.
D. A solution of 5% dextrose in water was infusing instead of the prescribed
0.9% normal saline solution.
E. A 5% dextrose in water solution is not usually prescribed for clients with
diabetes, and the solution was changed immediately on its discovery. - A.
The physician was contacted.
670. B. The blood glucose level at 7:15 am was 149 mg/dL.
671. C. An IV solution of 5% dextrose in water was infusing at 7 am.

672. A nurse performs an evaluation to determine whether a client's home is

electrically safe. Which finding indicates the need for further investigation and
intervention?

A. Wiring for the television runs under the carpet.

B. Electrical cords are free of frayed and damaged wires.
C. Electrical kitchen appliances are located away from the sink.
D. A safety-type extension cord is secured to the floor with electrical tape. -
A. Wiring for the television runs under the carpet.

673. Which of the following safety guidelines should the nurse include in the
plan of care for a client with an internal radiation implant? Select all that apply.

A.Wear a lead shield when in the client's room. Correct

B.Limit visits from family to 60 minutes per day.
C.Wear a dosimeter film badge when in the client's room.
D.Allow children to visit the client as long as they are at least 12 years old.
E.Keep all bed linens and dressings in the client's room until the implant is
removed. - A. Wear a lead shield when in the client's room.
674. C. Wear a dosimeter film badge when in the client's room.
675. E. Keep all bed linens and dressings in the client's room until the implant
is removed

676. A sedated client is being transported to the radiology department on a

stretcher. Which type of restraint should the nurse suggest applying to help
ensure the client's safety?

A. Belt
 B. Wrist
C. Elbow
D. Mitten - A. Belt

677. A hospitalized client, experiencing confusion, is at risk of falling because

she continually tries to climb out of bed. Which of these safety devices that the
nurse might suggest is the least restrictive?

A. Belt
B. Wrist
C. Elbow
D. Ambularm - D. Ambularm

678. Which of the following points should the nurse include when documenting
information about a client who is wearing wrist restraints? Select all that apply.

A. The client's temperature

B. The client's 24-hour urine output
C. Skin integrity of the restrained body part
D. The procedure used in applying the restraint
E. The date and time of application of the restraint
F. Circulatory and neurovascular status of the restrained extremities - C. Skin
integrity of the restrained body part
679. D. The procedure used in applying the restraint
680. E. The date and time of application of the restraint
681. F. Circulatory and neurovascular status of the restrained extremities

682. Which of the following actions are in keeping with the principles of
standard precautions? Select all that apply.

A. Handwashing between client contacts

B. Cleaning of blood spills with soap and warm water
C. Discarding needles in puncture-resistant containers
D. Handwashing before removal of a pair of soiled gloves
E. Wearing a face shield as a part of the protective garb during a wound
irrigation
F. Wearing a gown and gloves when changing the linens on the bed of a
client with a draining lesion of the leg - A. Handwashing between client
contacts
683. C. Discarding needles in puncture-resistant containers
684. E. Wearing a face shield as a part of the protective garb during a wound
irrigation
685. F. Wearing a gown and gloves when changing the linens on the bed of a
client with a draining lesion of the leg
686. A nurse is reading the history and physical examination findings of an
older client who has just been admitted to the hospital. Which findings
documented in the history indicate an increased risk for accidents? Select all that
apply.

A. The client's range of motion is limited.

B. Transmission of hot impulses is delayed.
C. The client's peripheral vision is decreased.
D. The client complaints of frequent nocturia.
E. High-frequency hearing tones are perceptible.
F. Voluntary and autonomic reflexes are slowed. - A. The client's range of
motion is limited.
687. B. Transmission of hot impulses is delayed.
688. C. The client's peripheral vision is decreased
689. D. The client complaints of frequent nocturia.
690. F. Voluntary and autonomic reflexes are slowed.

691. The nurse plans to wear this protective mask (see figure) when caring for
clients with certain disorders. What are these disorders? Select all that apply.

A. Scabies
B. Hepatitis A
C. Tuberculosis
D. Pharyngeal diphtheria
E. Streptococcal pharyngitis
F. Meningococcal pneumonia - D. Pharyngeal diphtheria
692. E. Streptococcal pharyngitis
693. F. Meningococcal pneumonia

694. Wrist restraints have been prescribed for a client who is constantly pulling
at his gastrostomy tube. Which of the following findings does the nurse,
developing a care plan, recognize as unexpected outcomes related to the use of
restraints? Select all that apply.

A. The client is agitated.

B. The skin under the restraint is red.
C. The client's left hand is pale and cold.
D. The client verbalizes the reason for the restraints.
E. The client is unable to reach the gastrostomy tube with his hands.
F. The client slips his hand from its restraint and pulls at his gastrostomy
tube. - A. The client is agitated.
695. B. The skin under the restraint is red.
696. C. The client's left hand is pale and cold.
697. F. The client slips his hand from its restraint and pulls at his gastrostomy
tube.
698. A nurse is discussing accident prevention with the family of an older client
who is being discharged from the hospital after hip surgery. Which items in the
home increase the client's risk for injury? Select all that apply.

A. A nightlight in the bathroom

B. Elevated toilet seat with armrests
C. Cooking equipment such as a stove
D. Smoke and carbon monoxide detectors
E. Common household objects such as doormats
F. A water heater thermostat adjusted to a low setting - C. Cooking
equipment such as a stove
699. E. Common household objects such as doormats

700. In which of the following situations would the nurse use this type of
restraint (see figure)? Select all that apply.

A.To secure the shoulders and the waist

B.To immobilize a client's arm and shoulders
C.To prevent the client from getting out of bed
D.To prevent dislodgment of an intravenous line
E.To prevent the client from turning from side to side
701. F.To prevent the use of the hands while allowing free arm movement - D.
To prevent dislodgment of an intravenous line
702. F.To prevent the use of the hands while allowing free arm movement

703. A home care nurse is visiting an older client who has been recovering
from a mild brain attack (stroke) affecting her left side. The client lives alone but
receives regular assistance from her daughter and son, who both live within 10
miles. Which of the following actions should the nurse take to assess the client's
safety risk? Select all that apply.

A. Assessing the client's visual acuity

B. Observing the client's gait and posture
C. Evaluating the client's muscle strength
D. Looking for any hazards in the home environment
E. Asking a family member to move in with the client until her recovery is
complete
F. Requesting that the client transfer to an assisted living environment for at
least 1 month - A. Assessing the client's visual acuity
704. B. Observing the client's gait and posture
705. C. Evaluating the client's muscle strength
706. D. Looking for any hazards in the home environment

707. Which of the following statements reflect the principles of sterile

technique? Select all that apply.
 A. The edge of a sterile field and a border 1 inch inward is unsterile.
B. If a package is not labeled as sterile, it should be considered unsterile.
C. Sterile objects that come in contact with unsterile objects are to be
considered contaminated.
D. Any part of a sterile field that hangs below the top of the table is sterile as
long as it is not touched.
E. When a sterile field becomes wet, it remains sterile as long as the items
on the field are not touched.
F. Items in a sterile package must be used immediately once the package
has been opened; otherwise they are considered contaminated. - A. The
edge of a sterile field and a border 1 inch inward is unsterile.
708. B. If a package is not labeled as sterile, it should be considered unsterile.
709. C. Sterile objects that come in contact with unsterile objects are to be
considered contaminated
710. F. Items in a sterile package must be used immediately once the package
has been opened; otherwise they are considered contaminated.

711. Which of the following actions are means of maintaining medical asepsis
to reduce and prevent the spread of microorganisms? Select all that apply.

A. Practicing hand hygiene

B. Reapplying a sterile dressing
C. Sterilizing contaminated items
D. Applying a sterile gown and gloves
E. Routinely cleaning the hospital environment
F. Wearing clean gloves to prevent direct contact with blood or body fluids -
A. Practicing hand hygiene
712. E. Routinely cleaning the hospital environment
713. F. Wearing clean gloves to prevent direct contact with blood or body fluids

714. Which of these interventions does a nurse manager, reviewing infection

control interventions with the nursing staff, tell the staff will reduce reservoirs of
infection? Select all that apply.

A. Keeping bedside table surfaces clean and dry

B. Placing tissues and soiled dressings in paper bags
C. Changing dressings that become wet or soiled Correct
D. Placing capped needles and syringes in puncture-resistant containers
E. Using soap and water to remove drainage, dried secretions, or excess
perspiration from a client's skin
F. Emptying urinary drainage systems (Foley catheter drainage) on each
shift unless prescribed otherwise by a physician - A. Keeping bedside
table surfaces clean and dry
715. C. Changing dressings that become wet or soiled
716. E. Using soap and water to remove drainage, dried secretions, or excess
perspiration from a client's skin
717. F. Emptying urinary drainage systems (Foley catheter drainage) on each
shift unless prescribed otherwise by a physician

718. Place in order of priority the actions that the nurse should take to perform
hand-washing procedure. - The correct order is:

719. Wet the hands and wrists, keeping the hands lower than the elbows.
720. Obtain 3 to 5 mL of soap from the dispenser.
721. Wash all surfaces for 15 to 30 seconds.
722. Rinse the hands and wrists.
723. Dry the hands.
724. Turn off the water faucet.

725. A nurse is performing sterile wound irrigation for an assigned client. A

nursing assistant enters the client's room and tells the nurse that a physician has
telephoned and has asked to speak to the nurse. What is the appropriate action
by the nurse?

A. Asking the nursing assistant to take a message

B. Covering the client and answering the telephone call
C. Finishing the wound irrigation while the physician waits on the telephone
D. Asking the nursing assistant to obtain a telephone number from the
physician so that the nurse may return the call after the wound irrigation is
complete - D. Asking the nursing assistant to obtain a telephone number
from the physician so that the nurse may return the call after the wound
irrigation is complete

726. A registered nurse (RN) is watching as a new licensed practical nurse

(LPN) suctions a client with a diagnosis of acquired immunodeficiency syndrome
(AIDS). Which of the following protective devices worn by the LPN would cause
the RN to determine that the LPN was performing the procedure safely?

A. Gloves and mask

B. Gloves and gown
C. Gloves, gown, and face shield.
D. Gown and protective eyewear - C. Gloves, gown, and face shield.

727. The nurse is instructing a client with hypertension about foods that are low
in sodium. Which menu selections by the client indicate to the nurse that the
client understands what has been taught? Select all that apply.

A. Spaghetti with fresh tomatoes

B. Boiled lobster with baked potato
C. Grilled chicken with turnip greens
D. Instant hot cereal with bacon
E. Tomato soup with a ham sandwich - A. Spaghetti with fresh tomatoes
728. C. Grilled chicken with turnip greens

729. A nurse has provided dietary instructions to a client with a new diagnosis
of gout. Which menu suggestions by the client indicate to the nurse that the client
needs additional instruction? Select all that apply.

A. Carrots
B. Tapioca
C. Scallops
D. Broccoli
E. Chicken liver - C. Scallops
F. Chicken liver

730. A clear liquid diet has been prescribed for client who has just undergone
surgery. Which foods should the nurse offer to the client? Select all that apply.

A. Custard
B. Apple juice
C. Orange juice
D. Chicken broth
E. Orange gelatin
F. Vanilla ice cream - B. Apple juice
731. D. Chicken broth
732. E. Orange gelatin

733. Triamterene has been prescribed for a client with a history of

hypertension. Which fruits should the nurse tell the client are acceptable to eat
while taking this medication? Select all that apply.

A. Prunes
B. Apples
C. Peaches
D. Avocados
E. Nectarines
F. Cranberries - B. Apples
734. C. Peaches
735. F. Cranberries

736. Diverticulitis has been diagnosed in a client who has been experiencing
episodes of gastrointestinal cramping. The nurse should tell the client to maintain
which type of diet, during the asymptomatic period?

A. Low in fat
B. High in fiber
C. Low in residue
D. High in carbohydrates - B. High in fiber
737. A nurse is teaching a client with heart disease about a low-fat diet. Which
foods should the nurse tell the client are acceptable to eat? Select all that apply.

A. Avocados
B. Baked tuna
C. Green olives
D. Baked potato
E. Fresh cherries
F. Cream cheese - B. Baked tuna
738. D. Baked potato
739. E. Fresh cherries

740. A client with atrial fibrillation has been placed on warfarin sodium. As part
of the instructions for the medication, which foods does the nurse tell the client
are acceptable to eat? Select all that apply.

A. Lettuce
B. Cherries
C. Broccoli
D. Cabbage
E. Potatoes - B. Cherries
F. Potatoes
G. Spaghetti

741. A regular diet has been prescribed for a client with a leg fracture who has
been placed in skeletal traction. Which foods that will promote wound healing
does the nurse encourage the client to select from the hospital menu?

A. Spare ribs, rice, gelatin, tea

B. Pasta, garlic bread, ginger ale
C. Chicken breast, broccoli, strawberries, milk
D. Peanut butter and jelly sandwich, chocolate cake, tea - C. Chicken breast,
broccoli, strawberries, milk

742. A client who experienced a stroke (brain attack) is experiencing residual

dysphagia. Which foods should the nurse remove from the client's meal tray?

A. Peas
B. Scrambled eggs
C. Cheese casserole
D. Mashed potatoes - A. Peas

743. A client recovering from acute kidney injury (AKI) is being discharged
home. The nurse determines that the client understands the therapeutic dietary
 regimen when the client states that he will plan to eat foods that are low in which
substance?

A. Fats
B. Vitamins
C. Potassium
D. Carbohydrates - C. Potassium

744. A client is resuming eating after undergoing partial gastrectomy. What

measures should the nurse tell the client to take to minimize the risk of
complications? Select all that apply.

A. Lying down after eating

B. Eating high-protein foods
C. Drinking liquids with meals
D. Eating six small meals per day
E. Eating concentrated sweets during the day - A. Lying down after eating
745. B. Eating high-protein foods
746. D. Eating six small meals per day

747. A client with renal calculi is instructed to follow an alkaline ash diet. Which
menu choice by the client indicates to the nurse that the client understands the
prescribed regimen?

A. Chicken, potatoes, and cranberries

B. Spinach salad, milk, and a banana
C. Peanut butter sandwich, milk, and prunes
D. Linguini with shrimp, tossed salad, and a plum - B. Spinach salad, milk,
and a banana

748. A client who has sustained multiple fractures of the left leg is in skeletal
traction. The nurse has obtained an overhead trapeze to improve the client's bed
mobility. To which high-risk area must the nurse pay particular attention during
assessment for indications of pressure and skin breakdown?

A. Left heel
B. Scapulae
C. Right heel
D. Back of the head - C. Right heel

749. Which food should the nurse offer to a client who has been prescribed a
full liquid diet?

A. Toast
B. Plain bagel
C. Cooked custard
 D. Scrambled eggs - C. Cooked custard

750. A client with heart failure and hypertension who has been admitted to the
hospital is unable to make own selections from the menu. Which meal does the
nurse select for the client's supper on the day of admission?

A. Smoked ham, fresh carrots, boiled potato

B. Hot dog in a bun, sauerkraut, baked beans
751. C Turkey, baked potato, salad with oil and vinegar
752. D. Shrimp, baked potato, salad with blue cheese dressing - C Turkey,
baked potato, salad with oil and vinegar

753. The nurse teaches a client who has begun taking phenelzine, a
monoamine oxidase inhibitor (MAOI), about the medication. Which foods are
allowed in the diet of the client taking phenelzine? Select all that apply.

A. Peas
B. Broccoli
C. Potatoes
D. Red wine
E. Avocados
F. Cereal with raisins - A. Peas
754. B. Broccoli
755. C. Potatoes

756. A client with a genitourinary tract infection has been prescribed

metronidazole and fluid therapy. The nurse concludes that the client understands
the dietary regimen to be followed while taking the medication when the client
states to eliminate which from the diet?

A. Alcohol
B. Diet cola
C. Bran flakes
D. Chicken livers - A. Alcohol

757. Calcitriol is prescribed for a client with hypocalcemia. Which foods does
the nurse, knowing that they may interfere with calcium absorption, instruct the
client to limit in the diet? Select all that apply.

A. Bran
B. Milk
C. Clams
D. Spinach
E. Orange juice - A. Bran
758. D. Spinach
759. The nurse provides instructions to a client who is beginning therapy with
oral theophylline. The nurse recognizes that the client understands the
instructions when the client states to limit consumption of which items?

A. Coffee, cola, and chocolate

B. Oysters, lobster, and shrimp
C. Apples, oranges, and pineapple
D. Cottage cheese, cream cheese, and dairy creamers - A. Coffee, cola, and
chocolate

760. A client with a urinary tract infection has been started on nitrofurantoin, a
urinary antiseptic medication, and is taught about the foods that will maintain the
urinary pH in the acid range. Which food does the nurse tell the client to eliminate
from the diet while taking this medication?

A. Prunes
B. Oranges
C. Rhubarb
D. Cranberries - C. Rhubarb

761. For which vitamin deficiency should the nurse monitor the client who is on
a vegan diet?

A. Vitamin A
B. Vitamin B12
C. Vitamin C
D. Vitamin E - B. Vitamin B12

762. A client with cirrhosis has an increased ammonia level. Which diet does
the nurse anticipate will be of benefit to the client?

A. One low in protein

B. One high in fluids
C. One high in carbohydrates
D. One with a moderate amount of fat - A. One low in protein

763. A nurse provides dietary instructions to a client with cholecystitis. Which

menu selection by the client indicates to the nurse that the client understands the
instructions?

A. Roast turkey with a baked potato

B. Fruit plate with fresh whipped cream
C. Fried chicken with macaroni and cheese
D. Barbecued spare ribs with buttered noodles - A. Roast turkey with a baked
potato
764. A client is found to have ulcerative colitis, and the nurse provides
instructions to the client about the diet that should be followed while the disease
is in remission. Which menu selection by the client indicates to the nurse that the
client best understands the instructions?

A. Milk
B. Cabbage
C. Boiled potatoes
D. Coffee with cream - C. Boiled potatoes

765. A nurse has taught a client with a new colostomy about measures to
control stool odor in the ostomy drainage bag. Which foods listed on the client's
shopping list indicate to the nurse that the client has understood the information?
Select all that apply.

A. Eggs
B. Yogurt
C. Parsley
D. Broccoli
E. Cucumbers
F. Cranberry juice - B. Yogurt
766. C. Parsley
767. F. Cranberry juice

768. A nurse is teaching a client with an ileostomy about foods that could result
in the production of liquid stools. Which food that just arrived on the client's meal
tray should the nurse discourage the client from eating?

A. Bran
B. Pasta
C. Boiled rice
D. Low-fat cheese - A. Bran

769. A client with liver cancer who is undergoing chemotherapy tells the nurse
that some foods on the meal tray taste bitter. Which food does the nurse suggest
that the client eliminate from the diet, knowing that it is most likely to taste bitter
to the client?

A. Beef
B. Custard
C. Potatoes
D. Cantaloupe - A. Beef

770. A client with diabetes mellitus who has been taught about dietary
management of the disease wishes to have 8 oz of nonfat yogurt with breakfast.
 The nurse determines that the client understands diet management when the
client states that which action will be taken after eating the nonfat yogurt?

A. Not eating ice cream for 2 days

B. Omitting 8 oz of skim milk from that meal
C. Omitting salad dressing and butter at lunchtime
D. Eating only half of an allowed meat product at supper - B. Omitting 8 oz of
skim milk from that meal

771. A nurse is caring for a client with cirrhosis. As part of the teaching
regarding dietary means of minimizing the effects of the disorder, the nurse
educates the client about foods that are high in thiamine. The nurse determines
that the client has the best understanding of the material if the client states to
increase the intake of which foods? Select all that apply.

A. Milk
B. Peanuts
C. Chicken
D. Broccoli
E. Asparagus
F. Whole-grain cereals - B. Peanuts
772. E. Asparagus
773. F. Whole-grain cereals

774. A nurse is monitoring the nutritional status of a client receiving enteral

nutrition. Which parameter does the nurse use to determine the effectivenessof
the tube feedings?

A. Daily weight
B. Serum protein level
C. Calorie count sheets
D. Daily intake and output records - A. Daily weight

775. A nurse is instructing a client in the first trimester of pregnancy about

nutrition. Which statement by the client indicates the need for further instruction?

A. "I need to eat foods high in calcium."

B. "How I eat can affect my baby's growth."
C. "I need to take vitamins throughout my pregnancy."
D. "My risk for malnourishment is much higher while I'm pregnant." - D. "My
risk for malnourishment is much higher while I'm pregnant."

776. A client who has recently been started on enteral feedings complains of
abdominal cramping and diarrhea. The nurse reviews the nutritional content on
the label of the can of feeding solution. Which ingredient is the nurse looking for
that may be causing this problem?
 A. Maltose
B. Lactose
C. Sucrose
D. Fructose - B. Lactose

777. A nurse provides dietary instructions to a client with iron-deficiency

anemia. Which foods does the nurse recommend to the client? Select all that
apply.

A. Lentils
B. Raisins
C. Pineapple
D. Egg whites
E. Kidney beans
F. Refined white bread - A. Lentils
778. B. Raisins
779. E. Kidney beans

780. A client has a serum sodium level of 151 mEq/L (151 mmol/L), and the
nurse provides instruction regarding foods to avoid. Which menu choice by the
client indicates to the nurse that the client needs further instruction?

A. Fish
B. Spinach
C. Rhubarb
D. American cheese - D. American cheese

781. A nurse instructs a client at risk for hypokalemia about the foods high in
potassium that should be included in the daily diet. Which menu selection, cited
by the client as a good source of potassium, indicates to the nurse that the client
needs further instruction?

A. Pork
B. Beef
C. Eggs
D. Raisins - C. Eggs

782. A nurse is providing dietary instructions to a client with tuberculosis. Which

foods would the nurse specifically instruct the client to include more of in the daily
diet?

A. Rice and fish

B. Eggs and bacon
C. Cereals and broccoli
D. Meats and citrus fruits - D. Meats and citrus fruits
783. A nurse is providing dietary instructions to a client with uric acid renal
calculi. The nurse should provide the client with which instruction?

A. To increase the intake of legumes

B. That seafood should be included in the diet
C. That organ meats should be included in the diet
D. To have at least one serving each day of a citrus fruit - A. To increase the
intake of legumes

784. The nurse instructs a unlicensed assistive personnel (UAP) that a client
who is recovering from a myocardial infarction requires a complete bed bath. The
nurse would intervene if the nurse observed the UAP doing which?

A. Washing the client's feet

B. Washing the client's chest
C. Giving the client a back rub
D. Asking the client to wash his arms - D. Asking the client to wash his arms

785. A nurse asks an unlicensed assistive personnel (UAP) to provide

afternoon care to a client. The nurse expects that the UAP will take which action?

A. Give the client a complete bed bath

B. Ask the client whether he would like to wash his face
C. Give the client a back massage and prepare the client for sleep
D. Assist the client in washing his hands and face and performing mouth
care, offering a bedpan or urinal, and straightening the bed linens - D.
Assist the client in washing his hands and face and performing mouth
care, offering a bedpan or urinal, and straightening the bed linens

786. A client requires a partial bed bath. The nurse, giving instructions to an
unlicensed assistive personnel (UAP) about the bath, tells the UAP to take which
action?

A. Just wash the client's hands and face

B. Provide mouth care and perineal care only
C. Let the client decide what she wants washed
D. Bathe the client's body parts that, if left unbathed, would give rise to
discomfort or odor - D. Bathe the client's body parts that, if left unbathed,
would give rise to discomfort or odor

787. An unlicensed assistive personnel (UAP) is providing morning care to a

client with a fractured leg who is in skeletal traction. The nurse determines that
the UAP needs instruction regarding the guidelines for client bathing if the UAP is
implementing which action?
 A. Giving the client a complete bed bath
B. Pulling the room curtains around the bathing area
C. Turning up the thermostat in the client's room for the bath
D. Keeping the side rails (per agency policy)up while away from the client - A.
Giving the client a complete bed bath

788. A nurse notes documentation in a client's medical record indicating that

the client is experiencing oliguria. On the basis of this notation, the nurse
determines which about the client when planning care?

A. Is unable to produce urine

B. Is voiding large amounts of urine
C. Has difficulty with leakage of urine
D. Has a diminished capacity to form urine - D. Has a diminished capacity to
form urine

789. A nurse is providing information to a mother of a 1-year-old who has

asked about bladder-training her child. The nurse should provide which
information to the mother?

A. That she may start bladder training at any time

B. That her child is too young and that she should not yet be worrying about
it
C. That a child cannot begin to control urination until approximately the age
of 24 months
D. That bowel training should be started immediately and then begin bladder
training in about 1 month - C. That a child cannot begin to control urination
until approximately the age of 24 months

790. A client has been found to have a bladder infection. When planning care,
which area of dysfunction would cause the nurse to monitor the client most
closely for signs of a kidney infection?

A. Urethra
B. Nephron
C. Glomerulus
D. Ureterovesical junction - D. Ureterovesical junction

791. A nurse is caring for a client whose urine output was 25 mL for 2
consecutive hours. When planning care, which client-related factors does the
nurse recognize as increasing blood flow to the kidneys?

A. Physiological stress
B. Release of dopamine
C. Release of norepinephrine
D. Sympathetic nervous system stimulation - B. Release of dopamine
792. A nurse is caring for an older adult client. When planning care, which
occurrence does the nurse recognize as part of the normal aging process?

A. Tubular reabsorption increases.

B. Urine-concentrating ability increases.
C. Glomerular filtration rate (GFR) is diminished.
D. Medications are metabolized in larger amounts. - C. Glomerular filtration
rate (GFR) is diminished.

793. An adult client rings the call bell and asks the nurse for assistance in
getting to the bathroom to void. The nurse assists the clientestimating that the
client has approximately how many mL inthe bladder if the client is feeling a
sensation of fullness?

A. 100 mL
B. 250 mL
C. 400 mL
D. 800 mL - C. 400 mL

794. A client taking a potassium-retaining diuretic has a serum potassium level

of 5.8 mEq/L (5.8 mmol/L). The nurse understands that the kidneys will respond
to this via which physiological action?

A. Increased sodium retention

B. Increased sodium excretion
C. Increased glucose retention
D. Increased magnesium excretion - B. Increased sodium excretion

795. A nurse has administered a dose of furosemide to a client with diminished

urine output. The nurse expects the urine output to increase once the medication
has had time to exert an effect on which structure in the kidney?

A. Distal tubule
B. Loop of Henle
C. Collecting duct
D. Proximal tubule - B. Loop of Henle

796. A client complains of feeling fatigued because of the need to get up

several times during the night to urinate. The nurse documents that the client is
experiencing which problem?

A. Anuria
B. Oliguria
C. Polyuria
D. Nocturia - D. Nocturia
797. A client tells the nurse that during the past 2 weeks her urine output has
been greater than usual. The nurse, gathering subjective data from the client,
should most appropriately ask the client about which?

A. Has she been regularly exercising

B. Has she been experiencing headaches
C. Has she been having heavy menstrual cycles
D. Has she been drinking an excessive amount of coffee - D. Has she been
drinking an excessive amount of coffee

798. A nurse is caring for a client who has a fever and is diaphoretic. The nurse
monitors the client's urinary output and laboratory values, anticipating which
about the client?

A. Urine output will be decreased

B. Urine production will be increased
C. Serum osmolality will be decreased
D. Urine specific gravity will decreased - A. Urine output will be decreased

799. A nurse is instructing a client about the foods that will acidify the urine and
inhibit the growth of microorganisms. Which foods does the nurse tell the client
are most likely to acidify the urine? Select all that apply.

A. Plums
B. Prunes
C. Apples
D. Broccoli
E. Cabbage
F. Cranberries - A. Plums
800. B. Prunes
801. F. Cranberries

802. A nurse is caring for a client who has just returned from a cardiac
catheterization through the right side of the groin. The client tells the nurse that
he feels the urge to urinate. The nurse assists the client in using a urinal, but the
client is unable to void. Which action should the nurse take to stimulate the
client's micturition reflex?

A. Helping the client stand

B. Elevating the head of the bed 90 degrees
C. Turning on the water in the sink in the client's room and allowing it to run
D. Obtaining assistance to ambulate the client to the bathroom in the client's
room - C. Turning on the water in the sink in the client's room and allowing
it to run
803. A nurse provides information to a client about the importance of
consuming fluids every day. If the client has no renal or cardiac disease or any
other disorder requiring fluid alterations, how many milliliters of fluid should the
nurse recommend that the client consume each day?

A. 500 to 1000 mL
B. 1000 to 1500 mL
C. 1500 to 2000 mL
D. 2000 to 2500 mL - D. 2000 to 2500 mL

804. A nurse provides instructions to a female client regarding the procedure

for collecting a midstream urine specimen. What should the nurse tell the client?

A. That she should douche before collecting the specimen

B. That she should cleanse the perineum from front to back
C. That she should collect the urine in the cup as soon as the urine flow
begins
D. That she should collect the specimen at bedtime and bring it to the
laboratory the next morning - B. That she should cleanse the perineum
from front to back

805. A nurse is monitoring a client's fluid balance. Which 24-hour intake and
output totals indicates to the nurse that the client has the proper fluid balance?

A. Intake 1600 mL, output 800 mL

B. Intake 1500 mL, output 1400 mL
C. Intake 2400 mL, output 2900 mL
D. Intake 3000 mL, output 2400 mL - B. Intake 1500 mL, output 1400 mL

806. A health care provider states that a client's insensible fluid loss is
approximately 600 mL/day. The nurse interprets this statement to reflect fluid
loss occurring through which routes?

A. Wound drain and skin

B. Skin and mechanical ventilator
C. Nasogastric tube and wound drain
D. Foley catheter and nasogastric tube - B. Skin and mechanical ventilator

807. A nurse has taught a client how to ambulate with the use of a cane. The
nurse determines that the client needs additional instruction if which is observed?

A. The client holds the cane close to the body

B. The client holds the cane on the unaffected side
C. The client moves the cane and the unaffected side together
D. The client uses the cane to support the affected side and to maintain
balance - C. The client moves the cane and the unaffected side together
808. A nurse provides instructions to a client about preventing injury while
using crutches. The nurse tells the client to avoid resting the underside of the
arm on the crutch pad, mainly because it could result in which problem?

A. Skin breakdown
B. Injury to the nerves
C. An abnormal stance
D. A fall and further injury - B. Injury to the nerves

809. A nurse has taught a client how to stand on crutches. The nurse
determines that the client understands the instructions if the client places the
crutches in which position?

A. 2 inches to the front and side of the toes

B. 8 inches to the front and side of the toes
C. 15 inches to the front and side of the toes
D. 22 inches to the front and side of the toes - B. 8 inches to the front and
side of the toes

810. A nurse is providing instructions to a client regarding the use of crutches.

Which information should the nurse include in the teaching plan? Select all that
apply.

A. It is not safe to use someone else's crutches.

B. Rubber crutch tips will not slip, even when wet.
C. The client should use both crutches when navigating stairs.
D. Lean into the crutches as needed to support the body's weight.
E. Crutch tips are made of a material that will not wear down. - A. It is not
safe to use someone else's crutches.
811. C. The client should use both crutches when navigating stairs.

812. A client with right-sided weakness must learn how to use a cane. The
nurse tells the client to position the cane by holding it in which way?

A. Left hand, 6 inches lateral to the left foot

B. Right hand, 6 inches lateral to the right foot
C. Left hand, placing the cane in front of the left foot
D. Right hand, placing the cane in front of the right foot - A. Left hand, 6
inches lateral to the left foot

813. A nurse is evaluating the client's use of a cane for left-sided weakness.
The nurse determines that the client needs further teaching if the client is
observed doing what?

A. Holds the cane on the right side

 B. Moves the cane when the right leg is moved
C. Leans on the cane when the right leg moves forward
D. Keeps the cane 6 inches out to the side of the right foot - B. Moves the
cane when the right leg is moved

814. A nurse is repositioning a client who has returned to the nursing unit after
internal fixation of a fractured right hip. The nurse should use which for
repositioning?

A. Pillow to keep the right leg abducted while turning the client
B. Rolled bath blanket to prevent abduction while turning the client
C. Trochanter roll to keep the right leg adducted while turning the client
D. Rolled bath blanket to prevent external rotation while turning the client - A.
Pillow to keep the right leg abducted while turning the client

815. A nurse has a prescription to get the client out of bed and into a chair on
the first postoperative day after total knee replacement. Which action should the
nurse take to protect the knee?

A. Assisting the client into the chair, using a walker to minimize weight
bearing on the affected leg
B. Securely covering the surgical dressing with an elastic wrap and applying
ice to the knee while the client is sitting
C. Lifting the client to the bedside chair, leaving the continuous passive
motion (CPM) machine in place.
D. Applying a knee immobilizer before getting the client up, then elevating the
affected leg while the client is sitting - D. Applying a knee immobilizer
before getting the client up, then elevating the affected leg while the client
is sitting

816. The nurse is supervising an unlicensed assistive personnel (UAP)in caring

for a client who has just undergone lumbar spinal fusion after herniation of a
lumbar disc. Which action by the UAP while repositioning the client would cause
the nurse to intervene?

A. Keeping the head of the bed flat

B. Placing pillows beneath the full length of the legs
C. Using a log-rolling technique for repositioning
D. Having the client assist by using the overhead trapeze - D. Having the
client assist by using the overhead trapeze

817. A nurse has taught the client with a herniated lumbar disk about proper
body mechanics and other information about low back care. The nurse
determines that the client needs further instruction if the client makes which
statement?
 A. "I should bend at the knees to pick things up."
B. "I need to increase the fiber and fluids in my diet."
C. "I can strengthen my back muscles by swimming or walking."
D. "I should get out of bed by sitting up straight and swinging my legs over
the side of the bed." - D. "I should get out of bed by sitting up straight and
swinging my legs over the side of the bed."

818. A client has been placed in Buck's extension traction. The nurse can
provide counter traction to reduce shear and friction by implementing which
measure?

A. Flexing the feet against a footboard

B. Slightly elevating the foot of the bed
C. Keeping the head of the bed elevated 45 degrees
D. Placing the bed in reverse Trendelenburg position - B. Slightly elevating
the foot of the bed

819. A nurse is inserting an indwelling urinary catheter into the urethra of a

male client. As the nurse inflates the balloon, the client complains of discomfort.
The nurse should take which action?

A. Asking the client to take slow, deep breaths

B. Removing the catheter and contacting the health care provider (HCP)
C. Aspirating the fluid, advancing the catheter farther, and reinflating the
balloon
D. Aspirating the fluid, withdrawing the catheter slightly, and reinflating the
balloon - C. Aspirating the fluid, advancing the catheter farther, and
reinflating the balloon

820. A nurse is inserting an indwelling urinary catheter into a female client. As

the catheter is inserted into the urethra, urine begins to flow into the tubing. At
this point, the nurse should take which action?

A. Immediately inflate the balloon

B. Insert the catheter 2.5 to 5 cm and inflate the balloon
C. Wait until the urine flow stops and inflate the balloon
D. Insert the catheter until resistance is met and inflate the balloon - B. Insert
the catheter 2.5 to 5 cm and inflate the balloon

821. A nurse is providing information to the mother of an 18-month-old about

bowel training. The nurse should provide the mother with which information?

A. The child should be able to control defecation at the age of 18 months

B. The child will let you know when she is ready to begin bowel training
C. Girls usually achieve the neuromuscular development necessary for
controlling defecation much sooner than boys do
 D. The neuromuscular development needed to control defecation does not
take develop until 2 to 3 years of age - D. The neuromuscular
development needed to control defecation does not take develop until 2 to
3 years of age

822. A nurse is developing a plan of care for an older client who is being
admitted to a long-term care facility. Which intervention should the nurse include
in the plan of care to help maintain an appropriate bowel elimination pattern?

A. Limiting vegetable intake to one serving per day

B. Limiting whole grains to three servings per week
C. Providing cooked fruits such as prunes or apricots
D. Including spicy foods in the diet to increase peristalsis - C. Providing
cooked fruits such as prunes or apricots

823. A nurse is developing a bowel-training program for a client after a stroke.

Which interventions are appropriate for inclusion in the plan? Select all that
apply.

A. Providing privacy and time for defecation

B. Assisting the client into a sitting position
C. Limiting the amount of fiber in the client's diet
D. Providing a cool drink before defecation time
E. Initiating defecation measures every day at the same time
F. Administering a cathartic suppository a half-hour before defecation time -
A. Providing privacy and time for defecation
824. B. Assisting the client into a sitting position
825. E. Initiating defecation measures every day at the same time
826. F. Administering a cathartic suppository a half-hour before defecation time

827. A cleansing enema is prescribed for an adult client. The nurse

understands that which is the maximal volume of fluid that can be administered?

A. 250 mL
B. 500 mL
C. 750 mL
D. 1000 mL - D. 1000 mL

828. A nurse administers a tap water enema to an adult client who is

constipated. The client defecates a scant amount of brown fecal matter, which
the nurse interprets as a poor result. The nurse should take which action?

A. Document the results

B. Administer a second tap water enema
C. Add soap suds to the enema bag and repeat the enema
 D. Administer a Fleet enema, then a tap water irrigation - A. Document the
results

829. A nurse administers an oil retention enema to a client. Afterward, the

nurse should provide which instruction to the client?

A. Immediately expel the enema

B. Retain the enema for several hours
C. Expect to defecate within 30 minutes
D. Expect to experience cramping induced by the solution - B. Retain the
enema for several hours

830. A nurse is administering a high cleansing enema. At what level above the
client's hips should the nurse place the enema bag?

A. 4 inches
B. 8 inches
C. 10 inches
D. 18 inches - D. 18 inches

831. The health care provider (HCP) prescribes "enemas until clear" for a
client. The nurse has administered three enemas to the client, but the client is
still passing brown stool and fluid. Which action should the nurse take?

A. Notify the HCP

B. Continue administering enemas until the fluid returns clear
C. Administer a glycerin suppository and then administer one more enema
D. Allow the client to rest for 1 hour and then continue with another enema -
A. Notify the HCP

832. A nurse is preparing to administer a soap suds enema to an adult client.

After explaining the procedure and positioning the client, the nurse begins the
procedure. The nurse inserts the rectal tube into the client's rectum a maximal
distance of of how many inches?

A. 1½ inches
B. 3 inches
C. 4 inches
D. 6 inches - C. 4 inches

833. A nurse is administering an enema to a client. While the enema solution is

being instilled, the client complains of abdominal cramping. Which action should
the nurse take?

A. Clamp the enema bag tubing

B. Remove the enema tube and allow the client to rest
 C. Stop the instillation and allow the client to expel the solution
D. Raise the enema bag to quickly finish instillation of the solution - A. Clamp
the enema bag tubing

834. A nurse is preparing to perform a digital removal of feces on a client with

an impaction. The nurse checks the client's heart rate before performing the
procedure and counts 88 beats per minute. The nurse begins to loosen the fecal
mass and then stops the procedure to allow the client to rest. During this time the
nurse checks the client's heart rate again and counts 82 beats per minute. The
nurse should take which action?

A. Contact the health care provider

B. Discontinue the digital removal procedure
C. Continue the digital removal procedure
D. Wait 1 hour and then continue the digital removal procedure - C. Continue
the digital removal procedure

835. A nurse is developing a plan of care for a client who reports difficulty
sleeping. Which initial intervention does the nurse include in the plan of care?

A. Offering the client a sleeping pill at night

B. Providing the client with a snack at bedtime
C. Asking the client what is done to prepare for sleep
D. Leaving the television in the client's room on at a very low volume - C.
Asking the client what is done to prepare for sleep

836. A home care nurse makes a visit to a new mother who delivered a 7-lb girl
72 hours ago. The mother tells the nurse that her newborn seems to sleep
almost all day. The nurse most appropriately responds by making which
statement to the mother?

A. "Most newborns sleep about 16 hours a day"

B. "We should probably have the baby checked out by the doctor."
C. "If you see any other neurological alterations, call the pediatrician."
D. "It's important to wake the baby every hour to provide stimulation. - A.
"Most newborns sleep about 16 hours a day"

837. An older adult client tells the nurse that she is tired during the day
because she awakens frequently during the night. Which information should the
nurse provide to the client?

A. She should avoid napping during the day

B. The only thing that will help is a sleeping pill
C. This is a normal occurrence as a person gets older
D. She needs to stay up later at night to prevent these awakenings - C. This
is a normal occurrence as a person gets older
838. A nurse is preparing a list of measures that will help promote sleep. Which
measures that would be included on the list? Select all that apply.

A. Exercise just before bedtime.

B. Drink a glass of wine at bedtime.
C. Drink a cup of black tea before bedtime.
D. Adjust the room temperature to a comfortable level.
E. Eliminate lights, noise, and other environmental distractions.
F. Get up at the same time each day and avoid naps during the day. - D.
Adjust the room temperature to a comfortable level.
839. E. Eliminate lights, noise, and other environmental distractions.
840. F. Get up at the same time each day and avoid naps during the day.

841. A client asks a nurse about complementary and alternative measures to

promote sleep. What should the nurse suggest?

A. Herbal therapy
B. Acupuncture
C. Muscle relaxation techniques
D. Traditional Chinese medicine - C. Muscle relaxation techniques

842. A nurse notes that a client has a diagnosis of acute back pain. The nurse
plans care based on which characteristic of acute pain?

A. It has a prolonged presence

B. It is a result of injury
C. It lasts longer than 6 months
D. It is usually the result of a chronic disorder - B. It is a result of injury

843. The nurse is assigned to care for four clients. Which client does the nurse
expect is likely to experience chronic pain?

A. A client with osteoarthritis

B. A client with angina pectoris
C. A client who has undergone appendectomy
D. A client with a leg fracture who is in skeletal traction - A. A client with
osteoarthritis

844. A nurse develops a plan of care for a postoperative client who is receiving
intravenous morphine sulfate every 4 hours as needed for pain. Whichpriority
intervention does the nurse include in the plan?

A. Encouraging oral fluid intake

B. Maintaining the client in a supine position
C. Encouraging coughing and deep breathing
 D. Administering the morphine sulfate around the clock - C. Encouraging
coughing and deep breathing

845. A client is receiving intravenous meperidine hydrochloride as prescribed.

For which side/adverse effects does the nurse assess the client while the clientis
receiving this medication? Select all that apply.

A. Polyuria
B. Diarrhea
C. Tachycardia
D. Hypotension
E. Mental clouding - C. Tachycardia
846. D. Hypotension
847. E. Mental clouding

848. Codeine sulfate is prescribed for a client with severe back pain. Which
parameters does the nurse monitor while the client is taking this medication?
Select all that apply.

1. Volume of urine output

2. Strength of peripheral pulses
3. Ability to move the extremities
4. Frequency of bowel movements
5. Color, motion, and sensation of extremities - 1. Volume of urine output
5. Frequency of bowel movements

849. A client requests the use of an alternative or complementary therapy to

help control pain and asks about the use of guided imagery. The nurse responds
by telling the client that in this technique, the clientwill experience which?

A. Become totally unaware of pain

B. Ignore the pain by focusing on the alternate activity
C. Alter pain perception though the influence of positive suggestion
D. Become less aware of pain by creating and then concentrating on a
mental image - D. Become less aware of pain by creating and then
concentrating on a mental image

850. A client has been told to apply cold packs to a knee injury, and the client
asks the nurse how this will help the injury. The nurse hould provide the clent
with which information about a cold pack?

A. Reduces muscle tension

B. Dilates the blood vessels
C. Promotes muscle relaxation
D. Reduces blood flow to the extremity - D. Reduces blood flow to the
extremity
851. A client arrives at the emergency department after sustaining an ankle
injury, and the health care provider (HCP) prescribes the application of a cold
compress to the ankle. The nurse, preparing to apply the compress, assesses
the ankle and notes that it is extremely edematous. The nurse should take which
action?

A. Apply the cold compress to the ankle

B. Consult with the HCP before applying the cold compress
C. Apply the cold compress for 20 minutes, and then apply a hot compress
for 20 minutes
D. Elevate the ankle and place cold compresses under and on top of the
ankle - B. Consult with the HCP before applying the cold compress

852. A nurse provides instructions to a client about the use of an electric

heating pad. The nurse determines that the client needs further instruction if the
client makes which statement?

A. "I shouldn't lie on the pad."

B. "I'll avoid using the high setting."
C. "I can pin the pad around the affected area."
D. "I'll need to keep an eye on my skin for redness." - C. "I can pin the pad
around the affected area."

853. Which client does the nurse recognize as being at the greatest risk for
injury resulting from the use of heat or cold application?

A. An older client
B. A client with renal calculi
C. A client with osteoporosis
D. A client with rheumatoid arthritis - A. An older client

854. A client about to undergo surgery is instructed in postoperative pain relief

measures is asked whether he would like to use a patient-controlled analgesia
(PCA) pump. The client asks the nurse to describe the pump. Which information
should the nurse provide to the client?

A. The PCA pump eliminates the need for an intravenous (IV) line
B. The client will be able to deliver his own dose of medication every 4 hours
C. The client's spouse will be able to administer medication for the client
D. The client administers his own medication by pressing a control button - D.
The client administers his own medication by pressing a control button

855. Which clients does the nurse recognize as candidates for patient-
controlled analgesia (PCA)? Select all that apply.
 A. A client who has undergone colectomy
B. A client with acute pancreatitis
C. A client who has undergone gastrectomy
D. A client with renal insufficiency
E. A client with Alzheimer's disease - A. A client who has undergone
colectomy
856. B. A client with acute pancreatitis
857. C. A client who has undergone gastrectomy

858. A nurse notes that the site of a client's peripheral intravenous (IV) catheter
is reddened, warm, painful, and slightly edematous near the insertion point of the
catheter. On the basis of this assessment, the nurse should take which action
first?

A. Remove the IV catheter

B. Slow the rate of infusion
C. Notify the health care provider
D. Check for loose catheter connections - A. Remove the IV catheter

859. A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned
client. One hour later the client complains of chest tightness, is dyspneic and
apprehensive, and has an irregular pulse. The IV bag has 100 mL remaining.
Which action should the nurse take first?

A. Remove the IV
B. Sit the client up in bed
C. Shut off the IV infusion
D. Slow the rate of infusion - C. Shut off the IV infusion

860. A nurse discontinues an infusion of a unit of packed red blood cells

(RBCs) because the client is experiencing a transfusion reaction. After
discontinuing the transfusion, which action should the nurse take next?

A. Remove the IV catheter

B. Contact the health care provider
C. Change the solution to 5% dextrose in water
D. Obtain a culture of the tip of the catheter device removed from the client -
B. Contact the health care provider

861. The nurse determines that the client is exhibiting signs of a hemolytic
transfusion reaction while receiving a blood transfusion. The nurse should
perform these actions in which priority order? Arrange the actions in the order
that they should be performed. All options must be used. - The correct order is:

862. Documenting the findings

863. Obtaining vital signs/oxygen saturation
864. Hanging an IV bag of normal saline solution (NS) at a keep-vein-open
(KVO) rate
865. Notifying the health care provider
866. Stopping the infusion of blood

867. A client with heart failure is being given furosemide and digoxin. The client
calls the nurse and complains of anorexia and nausea. Which action should the
nurse take first?

A. Administer an antiemetic
B. Administer the daily dose of digoxin
C. Discontinue the morning dose of furosemide
D. Check the result of laboratory testing for potassium on the sample drawn 3
hours ago - D. Check the result of laboratory testing for potassium on the
sample drawn 3 hours ago

868. The health care provider (HCP)prescribes the administration of

totalparenteral nutrition (TPN), to be started at a rate of 50 mL/hr by way of
infusion pump through an established subclavian central line. After the first 2
hours of the TPN infusion, the client suddenly complains of difficulty breathing
and chest pain. The nurse should take which immediate action?

A. Obtain blood for culture

B. Clamp the TPN infusion line
C. Obtain an electrocardiogram (ECG)
D. Obtain a sample for blood glucose testing - B. Clamp the TPN infusion line

869. The health care provider prescribes 2000 mL of 5% dextrose and normal
saline 0.45% for infusion over 24 hours. The drop factor is 15 gtt/mL. At how
many drops per minute does the nurse set the flow rate? (Round to the nearest
whole number). - 1.21

870. A nurse is assessing a peripheral intravenous (IV) site and notes

blanching, coolness, and edema at the insertion site. What should the nurse
dofirst?

A. Remove the IV
B. Apply a warm compress
C. Check for blood return
D. Measure the area of infiltration - A. Remove the IV

871. A home care nurse has been assigned a client who has been discharged
home with a prescription for total parenteral nutrition (TPN). Which parameters
does the nurse plan to check at each visit as a means of identifying
complications of the TPN therapy? Select all that apply.
 A. Weight
B. Glucose test
C. Temperature
D. Peripheral pulses
E. Hemoglobin and hematocrit - A. Weight
872. B. Glucose test
873. C. Temperature

874. A nurse is caring for a group of adult clients on an acute care nursing unit.
Which clients does the nurse recognize as the most likely candidates for total
parenteral nutrition (TPN)? Select all that apply.

A. A client with pancreatitis

B. A client with severe sepsis
C. A client with renal calculi
D. A client who has undergone repair of a hiatal hernia
E. A client with a severe exacerbation of ulcerative colitis - A. A client with
pancreatitis
875. B. A client with severe sepsis
876. E. A client with a severe exacerbation of ulcerative colitis

877. A client with a peripheral intravenous (IV) line in place has a new
prescription for infusion of total parenteral nutrition (TPN), a solution containing
25% glucose. Which action should be taken by the nurse?

A. Hanging the IV solution as prescribed

B. Questioning the health care provider about the prescription
C. Diluting the solution with sterile water to half-strength
D. Hanging the IV solution but setting the infusion at just half the prescribed
rate - B. Questioning the health care provider about the prescription

878. The first bag of total parenteral nutrition (TPN) solution has arrived on the
clinical unit for a client beginning this nutritional therapy. The solution is to be
infused by way of a central line. Which essential piece of equipment should the
nurse obtain before hanging the solution?

A. Pulse oximeter
B. Blood glucose meter
C. Electronic infusion device
D. Noninvasive blood pressure monitor - C. Electronic infusion device

879. A nurse is monitoring a client who is receiving total parenteral nutrition

(TPN). Which t signs and symptoms causes the nurse to suspect that the client is
experiencing hyperglycemia as a complication?

A. Pallor, weak pulse, and anuria

 B. Nausea, vomiting, and oliguria
C. Nausea, thirst, and increased urine output
D. Sweating, chills, and decreased urine output - C. Nausea, thirst, and
increased urine output

880. At 1600 the nurse checks a client's total parenteral nutrition (TPN) infusion
bag and notes that the solution is running at a rate of 100 mL/hr. The bag was
hung the previous day at 1800. The nurse plans to change the infusion bag and
tubing this evening at what time?

A. 1700
B. 1800
C. 2000
D. 2100 - B. 1800

881. A nurse is changing the central line dressing of a client receiving total
parenteral nutrition (TPN). The nurse notes moisture under the dressing covering
the catheter insertion site. What should the nurse assess next?

A. Temperature
B. Time of the last dressing change
C. Expiration date on the infusion bag
D. Tightness of the tubing connections - D. Tightness of the tubing
connections

882. A client receiving total parenteral nutrition (TPN) requires fat emulsion
(lipids), which will be piggybacked to the TPN solution. On obtaining a bottle of
fat emulsion, the nurse notes that fat globules are floating at the top of the
solution. Which action should the nurse take?

A. Shake the bottle vigorously

B. Request a new bottle from the pharmacy
C. Rotate the bottle gently back and forth to mix the globules
D. Run the bottle under warm water until the globules disappear - B. Request
a new bottle from the pharmacy

883. A nurse is preparing a client for the insertion of a central intravenous line
into the subclavian vein by the health care provider. The nurse gathers the
equipment, places it at the bedside, and prepares to assist the health care
provider with the procedure. As further preparation for the procedure, the nurse
places the client in which position?

A. Flat on the left side

B. In the prone position
C. In the supine position
D. In a slight Trendelenburg position - D. In a slight Trendelenburg position
884. A client is receiving total parenteral nutrition (TPN) with fat emulsion
(lipids) piggybacked to the TPN solution. For which signs of an adverse reaction
to the fat emulsion should the nurse monitor the client? Select all that apply.

A. Chills
B. Pallor
C. Headache
D. Chest and back pain
E. Nausea and vomiting
F. Subnormal temperature - A. Chills
885. C. Headache
886. D. Chest and back pain
887. E. Nausea and vomiting

888. The nurse is preparing to change the solution bag and intravenous tubing
of a client receiving total parenteral nutrition (TPN) through a left subclavian
central venous line. Which essential action does the nurse ask the client to
perform just before switching the tubing?

A. Turn the head to the left

B. Turn the head to the right
C. Exhale slowly and evenly
D. Take a deep breath and hold it - D. Take a deep breath and hold it

889. A nurse suspects that a client receiving total parenteral nutrition (TPN)
through a central line has an air embolism. The nurse immediately places the
client in which position?

A. Left side with the head lower than the feet

B. Left side with the head higher than the feet
C. Right side with the head lower than the feet
D. Right side with the head higher than the feet - A. Left side with the head
lower than the feet

890. A nurse is making initial rounds on a group of assigned clients. Which

client should the nurse see first?

A. A client receiving total parenteral nutrition (TPN) at a rate of 50 mL/hr for

the last 24 hours
B. A client receiving TPN at a rate of 50 mL/hr whose temp was 99° F on the
previous shift
C. A client receiving TPN at a rate of 100 mL/hr who has complained of
needing frequent trips to the bathroom to void
D. A client whose TPN solution was decreased to a rate of 25 mL/hr who is
now complaining of weakness, headache, and sweating - D. A client
 whose TPN solution was decreased to a rate of 25 mL/hr who is now
complaining of weakness, headache, and sweating

891. A nurse answers a call bell and finds that the total parenteral nutrition
(TPN) solution bag of an assigned client is empty. The new prescription was
written for a new bag at the beginning of the shift, but it has not yet arrived from
the pharmacy. Which action should the nurse take first?

A. Call the health care provider

B. Call the pharmacy for further instructions
C. Hang a solution of 10% dextrose in water
D. Hang a solution of 5% dextrose in 0.9% sodium chloride - C. Hang a
solution of 10% dextrose in water

892. A young female client with schizophrenia says to the nurse, "Since I
started on olanzapine last year, I'm doing well in school and all, but I've gained
so much weight, and it's really bothering me. What can I do about this?" Which
response by the nurse would be therapeutic?

A. "Well, I think you're overreacting. Today people think they should be

skinny-minnies, even though it's not healthy."
B. "Weight gain can be a side effect of the medication, so you need to watch
your diet and exercise. How much weight have you gained?"
C. "That medication isn't any more likely to cause weight gain than the others
you're taking. Perhaps we could go over your diet and exercise habits."
D. "I want you to stop taking this medication immediately, and I'm calling the
doctor, because this is a very serious side effect and you may need
dialysis." - B. "Weight gain can be a side effect of the medication, so you
need to watch your diet and exercise. How much weight have you
gained?"

893. A client with schizophrenia has been taking an antipsychotic medication

for 2 months. For which adverse effect should the nurse monitor the client
closely?

A. Akathisia
B. Pelvic thrusts
C. Athetoid limbs
D. Protruding tongue - A. Akathisia

894. A client with schizophrenia who has been taking an antipsychotic

medication calls the clinic nurse and says, "I need to cancel my appointment with
the psychiatrist again, because I still have this awful sore throat. It's so bad that
my mouth has a sore." How does the nurse respond to the client?

A. "I wouldn't be upset. It happens when you aren't drinking enough water."
 B. "I think you need to come in for blood work today, because this may be an
adverse effect of your medicine."
C. "Do you remember when you started this medication? Your psychiatrist
told you how important it is to keep your appointments with him."
D. "You probably have a simple flu, but it might help if you gargle with some
antiseptic mouthwash every 2 hours or so and drink plenty of water." - B.
"I think you need to come in for blood work today, because this may be an
adverse effect of your medicine."

895. A client rings the call bell and complains of pain at the site of an IV
infusion. The nurse assesses the site and determines that phlebitis has
developed. Which actions should the nurse take? Select all that apply.

A. Removing the IV catheter at that site

B. Applying warm, moist compresses to the IV site
C. Notifying the health care provider about the finding
D. Encouraging the client to scrub the site while in the shower
E. Starting a new IV line in a proximal portion of the same vein - A. Removing
the IV catheter at that site
896. B. Applying warm, moist compresses to the IV site
897. C. Notifying the health care provider about the finding

898. A nurse notes that the site of a client's peripheral IV catheter is reddened,
warm, painful, and slightly edematous in the area of the insertion site. After
taking appropriate steps to care for the client, the nurse documents in the
medical record that the client has experienced which problem?

A. Phlebitis of the vein

B. Infiltration of the IV line
C. Hypersensitivity to the IV solution
D. An allergic reaction to the IV catheter material - A. Phlebitis of the vein

899. A nurse has a written prescription to remove an intravenous (IV) line.

Which item should the nurse obtain from the unit supply area for use in applying
pressure to the site after removing the IV catheter?

A. Alcohol swab
B. Adhesive bandage
C. Sterile 2 × 2 gauze
D. Povidone-iodine (Betadine) swab - C. Sterile 2 × 2 gauze

900. A client has just undergone insertion of a central venous catheter by the
health care provider at the bedside. Which result would the nurse be sure to
check before initiating infusion of the IV solution that the health care provider has
prescribed?
 A. Serum osmolality
B. Serum electrolytes
C. Portable chest x-ray
D. Intake and output record - C. Portable chest x-ray

901. A nurse has obtained a unit of blood from the blood bank and properly
checked the blood bag with another nurse. Which parameter should the nurse
assess just before hanging the transfusion?

A. Skin color
B. Vital signs
C. Latest platelet count
D. Urine output over the last 24 hours - B. Vital signs

902. A nurse has just received a prescription to transfuse a unit of packed red
blood cells for an assigned client. For how long does the nurse plan to stay with
the client after the unit of blood is hung?

A. 5 minutes
B. 15 minutes
C. 45 minutes
D. 60 minutes - B. 15 minutes

903. A client has a prescription for a unit of packed red blood cells (RBCs).
Which IV solution should the nurse obtain to hang with the blood product at the
client's bedside?

A. 0.9% sodium chloride

B. Lactated Ringer's solution (LR)
C. 5% dextrose in 0.9% sodium chloride
D. 5% dextrose in water in 0.45% sodium chloride - A. 0.9% sodium chloride

904. The health care provider prescribes 1000 mL of normal saline 0.45% for
infusion over 8 hours. The drop factor is 10 gtt/mL. At how many drops per
minute does the nurse set the flow rate? (Round to the nearest whole number). -
1.21

905. A nurse discontinues an infusion of a unit of blood after the client

experiences a transfusion reaction. Once the incident has been documented
appropriately, where does the nurse send the blood transfusion bag?

A. Blood bank
B. Risk management
C. Microbiology laboratory
D. Infection-control department - A. Blood bank
906. Packed red blood cells have been prescribed for a client with low
hemoglobin and hematocrit values. The nurse takes the client's temperature
orally before hanging the blood transfusion and notes that it is 100.0° F (37.7 C).
What should the nurse do next?

A. Call the health care provider

B. Begin the transfusion as prescribed
C. Administer an antihistamine and begin the transfusion
D. Administer 2 tablets of acetaminophen and begin the transfusion - A. Call
the health care provider

907. A nurse has just hung a transfusion of packed red blood cells and stayed
with the client for the appropriate amount of time. Before leaving the room, the
nurse tells the client that it is most important to immediately report which specific
signs if it occurs? Select all that apply.

A. Rash
B. Chills
C. Fatigue
D. Backache
908. E.Tiredness - A. Rash
909. B. Chills
910. D. Backache

911. At 1300, the nurse is documenting the receipt of a unit of packed blood
cells at the hospital blood bank. The nurse calculates that the transfusion must
be started by which time?

A. 1315
B. 1330
C. 1345
D. 1400 - B. 1330

912. A client who needs to receive a blood transfusion has experienced a

pruritic rash during previous transfusions. The client asks the nurse whether it is
safe to receive the transfusion. Which medication does the nurse anticipate will
most likely be prescribed before the transfusion?

A. Ibuprofen
B. Acetaminophen
C. Diphenhydramine
D. Acetylsalicylic acid - C. Diphenhydramine

913. The health care provider prescribes 1000 mL of 5% dextrose in water to

be infused over 8 hours. The drop factor is 15 gtt/mL. At how many drops per
 minute does the nurse set the flow rate? (Round to the nearest whole number). -
1.31

914. The health care provider prescribes an intramuscular dose of 200,000

units of penicillin G benzathine for an adult client. The label on the 10-mL ampule
sent from the pharmacy reads,
915. "Penicillin G benzathine,300,000 units/mL." How many milliliters of
medication does the nurse prepares to ensure administration of the correct
dose? (Round to the nearest tenth.) - 0.7

916. The health care provider's prescription for an adult client reads,
"Potassium chloride 15 mEq by mouth." The label on the medication bottle reads,
"20 mEq potassium chloride/15 mL." How many milliliters of KCl does the nurse
prepare to ensure administration of the correct dose of medication? (Round to
the nearest whole number.) - 1.11

917. The health care provider prescribes 1000 mL of 5% dextrose in water, to

be infused over 24 hours. The drop factor is 60 gtt/mL. At how many drops per
minute does the nurse set the flow rate? (Round to the nearest whole number). -
1.42

918. The health care provider's prescription reads, "Clindamycin phosphate 0.3
g in 50 mL NS, to be administered IV over 30 minutes." The medication label
reads, "Clindamycin phosphate 150 mg/mL." How many milliliters of medication
does the nurse prepare to ensure that the correct dose is administered? - 1.2

919. The health care provider's prescription reads, "Phenytoin 0.1 g by mouth
twice daily." The medication label indicates that the bottle contains 100-mg
capsules. How many capsules does the nurse prepare for administration of one
dose? - 1.1

920. A nurse is preparing a plan of care for a client who will be receiving
meperidine hydrochloride. Which side/adverse effects does the nurse make a
note of needing to be alert to in the plan of care? Select all that apply.

A. Hypotension
B. Constipation
C. Bradycardia
D. Urine retention
E. Respiratory depression - A. Hypotension
921. B. Constipation
922. D. Urine retention
923. E. Respiratory depression
924. A nurse is preparing a plan of care for a client with a diagnosis of cancer
who is receiving morphine sulfate for pain. Which action does the nurse identify
as a priority in the plan of care for this client?

A. Monitoring urine output

B. Encouraging increased fluids
C. Monitoring the client's temperature
D. Monitoring the client's respiratory rate - D. Monitoring the client's
respiratory rate

925. A client who has been taking lisinopril complains to the nurse of a
persistent dry cough. What should the nurse tell the client?

A. This is a side effect of therapy

B. He probably has an upper respiratory infection
C. He needs to have his blood counts checked
D. A chest x-ray is required because the cough is a sign of heart failure - A.
This is a side effect of therapy

926. A client has been given a prescription to begin using nitroglycerin

transdermal patches for the management of angina pectoris. What should the
nurse tell the client about the medication?

A. Place the patch in the area of a skin fold to promote adherence

B. Apply the patch at the same time each day and leave it in place for 12 to
16 hours as directed
C. If the patch becomes dislodged, do not reapply and wait until the next day
to apply a new patch.
D. Alternate daily dose times between the morning and the evening to
prevent the development of tolerance to the medication - B. Apply the
patch at the same time each day and leave it in place for 12 to 16 hours
as directed

927. A client with newly diagnosed angina pectoris has taken 2 sublingual
nitroglycerin tablets for chest pain. The chest pain is relieved, but the client
complains of a headache. What should the nurse tell the client?

A. This is an indication that the medication should not be used again

B. Headache indicates medication tolerance, and the dosage must be
increased
C. This may be an allergic reaction to the nitroglycerin, and the health care
provider must be notified
D. This is an expected side effect of the nitroglycerin, and the client can
relieve it by taking acetaminophen - D. This is an expected side effect of
the nitroglycerin, and the client can relieve it by taking acetaminophen
928. A client has been taking metoprolol. Which finding indicates to the nurse
that the medication is effective?

A. The client's ankles are swollen.

B. The client's weight has increased.
C. The client's blood pressure has decreased.
D. The client has wheezes in the lower lobes of the lungs. - C. The client's
blood pressure has decreased.

929. A nurse has taught a client taking a methylxanthine bronchodilator about

beverages that must be avoided. Which beverage choices by the client indicate
to the nurse that the client needs further education? Select all that apply.

A. Cocoa
B. Coffee
C. Lemonade
D. Orange juice
E. Chocolate milk - A. Cocoa
930. B. Coffee
931. E. Chocolate milk

932. A client taking hydrochlorothiazide reports to the clinic for follow-up blood
tests. For which side/adverse effect of the medication does the nurse monitor the
client's laboratory results?

A. Hypokalemia
B. Hypocalcemia
C. Hypernatremia
D. Hypermagnesemia - A. Hypokalemia

933. A nurse has taught a client who is taking lithium carbonate about the
medication. The nurse determines that the client needs additional teaching if the
client makes which comment to the nurse?

A. The medication should be taken with meals

B. The lithium blood levels must be monitored very closely
C. It is important to decrease fluid intake while taking the medication to avoid
nausea
D. The health care provider must be called if excessive diarrhea, vomiting, or
diaphoresis occurs - C. It is important to decrease fluid intake while taking
the medication to avoid nausea

934. A nurse is developing a plan of care for a client, hospitalized with heart
failure, who has a history of Parkinson disease and is taking benztropine
mesylate daily. Which intervention does the nurse identify as a priority in the
plan?
 A. Monitoring intake and output Correct
B. Monitoring the client's pupillary response
C. Placing the client in a right side-lying position
D. Checking the client's hemoglobin level daily - A. Monitoring intake and
output

935. A nurse is providing instructions to a client regarding quinapril

hydrochloride. The nurse should teach the client to implement which measure?

A. To take the medication with meals

B. To rise slowly from a lying to a sitting position
C. To discontinue the medication if nausea occurs
D. That a therapeutic effect will be felt immediately - B. To rise slowly from a
lying to a sitting position

936. Methylergonovine intramuscularly is prescribed for a postpartum client.

Before administering the medication, the nurse explains to the client that the
medication will promote which effect?

A. Reduce lochial drainage

B. Prevent postpartum bleeding
C. Maintain a normal blood pressure
D. Decrease the strength of uterine contractions - B. Prevent postpartum
bleeding

937. Carbamazepine is prescribed for a client with trigeminal neuralgia. Which

side/adverse effects does the nurse instruct the client to report to the health care
provider? Select all that apply.

A. Fever
B. Nausea
C. Headache
D. Sore throat
E. Mouth sores - A. Fever
938. D. Sore throat
939. E. Mouth sores

940. Disulfiram is prescribed for a client. Which questions does the nurse make
a priority of asking the client before administering this medication? Select all that
apply.

A. "When did you have your last full meal?"

B. "Do you have a history of diabetes insipidus?"
C. "When was your last drink of alcohol?"
D. "Do you have a history of thyroid problems?"
 E. "Do you have a history of cancer in your family?" - C. "When was your last
drink of alcohol?"
941. D. "Do you have a history of thyroid problems?"

942. A nurse is assessing a client who is being hospitalized with a diagnosis of

pneumonia. The client's husband tells the nurse that the client is taking donepezil
hydrochloride. The nurse should ask the husband about the client's history of
which disorder?

A. Dementia
B. Seizure disorder
C. Diabetes mellitus
D. Posttraumatic stress disorder - A. Dementia

943. Fluoxetine hydrochloride is prescribed for a client, and the nurse provides
instruction regarding the use of the medication. The nurse tells the client that it is
best to take the medication at what time?

A. At lunchtime
B. In the morning
C. With the evening meal
D. Midafternoon, with an antacid - B. In the morning

944. A nurse is teaching a client how to mix regular and NPH insulin in the
same syringe. The nurse should provide the client with which information about
the insulin?

A. Keep insulin refrigerated at all times

B. Draw the regular insulin into the syringe first
C. Shake the NPH insulin bottle before mixing the two types
D. Remove all of the air from the bottle before mixing the two types - B. Draw
the regular insulin into the syringe first

945. A nurse provides instructions to a client who will be taking furosemide.

Which statement by the client indicates to the nurse that the client needs
additional instruction?

A. "I need to sit or stand up slowly."

B. "I need to maintain my fluid intake."
C. "This medication will make me urinate."
D. "I should expect to have ringing in my ears." - D. "I should expect to have
ringing in my ears."

946. A client is receiving heparin sodium by way of continuous IV infusion. For

which adverse effects of the therapy does the nurse assess the client?Select all
that apply.
 A. Tinnitus
B. Tarry stools
C. Slowed pulse
D. Bleeding from the gums
E. Increased blood pressure - B. Tarry stools
947. D. Bleeding from the gums

948. A client has a prescription for short-term therapy with enoxaparin . The
nurse explains to the client that this medication is being prescribed for which
purpose?

A. Prevent pain
B. Relieve back spasms
C. Increase the client's energy level
D. Reduce the risk of deep vein thrombosis - D. Reduce the risk of deep vein
thrombosis

949. Metoprolol has been prescribed for a client with hypertension. For which
common side effects of the medication does the nurse monitor the client?Select
all that apply.

A. Fatigue
B. Dry eyes
C. Weakness
D. Impotence
E. Nightmares - A. Fatigue
950. C. Weakness
951. D. Impotence

952. A client with HIV infection has been started on therapy with zidovudine.
The nurse tells the client to report to the laboratory in 3 months for testing to
detect adverse effects of the therapy. Which laboratory test is most important to
monitor for this client?

A. Creatinine
B. Serum potassium
C. Blood urea nitrogen (BUN)
D. Complete blood count (CBC) - D. Complete blood count (CBC)

953. A nurse is reading the medical record of a client receiving haloperidol. The
nurse notes that the health care provider has documented that the client is
experiencing signs of akathisia. On the basis of the health care provider's note,
which clinical manifestation would the nurse expect to find during assessment of
the client?
 A. Motor restlessness
B. Puffing of the cheeks
C. Puckering of the mouth
D. Protrusion of the tongue - A. Motor restlessness

954. Phenelzine sulfate is being administered to a client with depression. The

client suddenly complains of a severe frontally radiating occipital headache, neck
stiffness and soreness, and vomiting. On further assessment, the client exhibits
signs of hypertensive crisis. Which medication should the nurse prepare to
administer, anticipating that it will be prescribed as the antidote to treat
phenelzine-induced hypertensive crisis?

A. Phentolamine
B. Acetylcysteine
C. Protamine sulfate
D. Calcium gluconate - A. Phentolamine

955. Risperidone is prescribed for a client with a diagnosis of schizophrenia.

Which laboratory study does the nurse expect to see among the health care
provider's prescriptions?

A. Platelet count
B. Creatinine level
C. Sedimentation rate
D. Red blood cell count - B. Creatinine level

956. Betaxolol eye drops have been prescribed for the treatment of a client's
glaucoma. The nurse tells the client to return to the clinic for follow-up for which
purpose?

A. To have weight checked

B. To give a sample for urinalysis
C. To have the blood glucose level checked
D. For measurement of blood pressure and apical pulse - D. For
measurement of blood pressure and apical pulse

957. Intravenous tobramycin sulfate is prescribed for a client with a respiratory

tract infection. For which of the following symptoms, indicative of an adverse
effect, does the nurse monitor the client?

A. Nausea
B. Vertigo
C. Vomiting
D. Hypotension - B. Vertigo
958. A client who is taking bupropion in an attempt to stop smoking tells a
nurse that he has been doubling the daily dose to make it easier to resist
smoking. The nurse warns the client that doubling the daily dosage is dangerous.
Of which adverse effect of the medication does the nurse warn the client?

A. Insomnia
B. Seizures
C. Weight gain
D. Orthostatic hypotension - B. Seizures

959. A nurse is caring for a client with histoplasmosis who is receiving

intravenous amphotericin B . What should the nurse do while the medication is
being administered?

A. Monitor the client's urine output

B. Monitor the client for hypothermia
C. Check the client's neurological status
D. Check the client's blood glucose level - A. Monitor the client's urine output

960. A client with rheumatoid arthritis is taking high doses of acetylsalicylic

acid. While assessing the client for aspirin toxicity, which question should the
nurse ask the client?

A. "Are you constipated?"

B. "Are you having any diarrhea?"
C. "Do you have any double vision?"
D. "Do you have any ringing in the ears?" - D. "Do you have any ringing in
the ears?"

961. A nurse is reviewing the laboratory results of a client receiving intravenous

chemotherapy. Which laboratory finding prompts the nurse to initiate neutropenic
precautions?

A. A clotting time of 10 minutes

B. An ammonia level of 20 mcg N/dL (14.6 μmol N/L)
C. A platelet count of 100 × 103/μL (100× 109/L).
D. A white blood cell (WBC) count of 2.0 × 103/μL (2.0 × 109/L). - D. A white
blood cell (WBC) count of 2.0 × 103/μL (2.0 × 109/L).

962. Cyclophosphamide has been prescribed for a client with a diagnosis of

breast cancer, and the nurse is providing instructions to the client. The nurse
should provide which information to the client?

A. To avoid salt while taking this medication

B. That it is best to take the medication with food
C. To increase fluid intake to 2000 mL to 3000 mL/day
 D. To drink at least 2 glasses of orange juice every day - C. To increase fluid
intake to 2000 mL to 3000 mL/day

963. A client is receiving intravenous bleomycin sulfate. During administration

of the chemotherapy, nursing assessment is the priority?

A. Heart rate
B. Lung sounds
C. Peripheral pulses
D. Level of consciousness - B. Lung sounds

964. The serum theophylline level of a client who is taking the medication
(Theo-24) is 16 mcg/mL. On the basis of this result, the nurse should take which
action initially?

A. Document the normal value on the chart

B. Call the health care provider immediately
C. Call the rapid response team to help with the emergency
D. Call the pharmacy to alert the pharmacist regarding the client's
theophylline level - A. Document the normal value on the chart

965. A client with tuberculosis is being started on isoniazid and the nurse
stresses the importance of returning to the clinic for follow-up blood testing.
Which blood test will be performed?

A. Liver enzymes
B. Serum creatinine
C. Blood urea nitrogen
D. Red blood cell count - A. Liver enzymes

966. Baclofen is prescribed for a client with a spinal cord injury who is
experiencing muscle spasms. While providing instructions to the client, which
side effect does the nurse tell the client is possible?

A. Photosensitivity
B. Nasal congestion
C. Increased appetite
D. Increased salivation - B. Nasal congestion

967. A nurse is caring for a client with myasthenia gravis who is exhibiting signs
of cholinergic crisis. Which medication does the nurse ensure is available to treat
this crisis?

A. Acetylcysteine
B. Atropine sulfate
C. Protamine sulfate
968. D Pyridostigmine bromide - B. Atropine sulfate

969. A nurse is providing instruction to a client who is taking codeine sulfate for
severe back pain. Which instruction should the nurse provide to the client?

A. Decrease fluid intake

B. Maintain a high-fiber diet
C. Avoid all exercise to help prevent lightheadedness
D. Avoid the use of stool softeners to help prevent diarrhea - B. Maintain a
high-fiber diet

970. A nurse is preparing a plan of care for a pregnant client who will be given
oxytocin to induce labor. Which occurrence does the nurse include in the plan of
care as a reason for immediate discontinuation of the oxytocin infusion?

A. Uterine atony
B. Severe drowsiness
C. Uterine hyperstimulation
D. Early decelerations of the fetal heart rate - C. Uterine hyperstimulation

971. A home health nurse provides instructions to a client who is taking

allopurinol for the treatment of gout. Which instruction should the nurse provide
to the client?

A. Place an ice pack on the lips if they swell

B. Drink at least 8 glasses of fluid every day
C. Take the medication on an empty stomach 2 hours before meals
D. Use an over-the-counter (OTC) antihistamine lotion if a rash develops - B.
Drink at least 8 glasses of fluid every day

972. A client taking metronidazole for the treatment of trichomoniasis vaginalis

calls the clinic nurse to express concern because her urine has turned dark in
color. The nurse should provide which information to the client?

A. To increase her fluid intake

B. To discontinue the medication
C. That darkening of the urine is a harmless side effect
D. To report to the clinic to see the health care provider - C. That darkening
of the urine is a harmless side effect

973. Erythromycin is prescribed for a client with a respiratory tract infection.

The nurse provides instructions to the client regarding the administration of the
oral medication and tells the client that it is best to take the medication in which
way?

A. With juice
 B. With a meal
C. On an empty stomach
D. At bedtime, with a snack - C. On an empty stomach

974. A nurse is monitoring a client who is receiving a continuous intravenous

infusion of morphine sulfate. Which finding should cause the nurse to contact the
health care provider?

A. Temperature of 97.6° F
B. Urine output of 30 mL/hr
C. Blood pressure of 100/60 mm Hg
D. Respiratory rate of 10 breaths/min - D. Respiratory rate of 10 breaths/min

975. A nurse is providing dietary instructions to a client taking spironolactone.

Which foods does the nurse instruct the client are acceptable to consume?Select
all that apply.

A. Rice
B. Cereal
C. Carrots
D. Bananas
976. E.Citrus fruits - A. Rice
977. B. Cereal
978. C. Carrots

979. A nurse is caring for a client with a diagnosis of chronic kidney disease
who is receiving dialysis. Epoetin alfa, to be administered subcutaneously, has
been prescribed, and the nurse is drawing the medication from a single-use vial.
What should the nurse do to prepare the medication?

A. Shake the vial before drawing up the medication

B. Draw up the medication and discard the unused portion
C. Obtain the medication from the medication freezer and allow it to thaw
D. Mix the medication with 0.1 mL of heparin before administration to prevent
clotting - B. Draw up the medication and discard the unused portion

980. Zidovudine (is prescribed for an adult client with HIV infection. The nurse
should provide which instruction to the client about the medication?

A. That the medication must be taken with milk

B. That aspirin can be taken to treat headache
C. To discontinue the medication if nausea occurs
D. To space the doses evenly around the clock - D. To space the doses
evenly around the clock
981. A nurse is to administer a dose of digoxin to a client with atrial fibrillation
and notes that the client has a potassium level of 4.6 mEq/L (4.6 mmol/L). The
nurse determines which about the administration of the dose?

A. Should be withheld that day

B. Should be administered as prescribed
C. Should be preceded with a dose of potassium
D. Should be withheld and the health care provider notified - B. Should be
administered as prescribed

982. A client with heart failure being discharged home will be taking
furosemide. Which statement by the client indicates to the nurse that the
teaching has been effective?

A. "I'll weigh myself every day."

B. "I'll take my pulse every day."
C. "I'll measure my urine output."
D. "I'll check my ankles every day for swelling." - A. "I'll weigh myself every
day."

983. A client who has undergone adrenalectomy is prescribed prednisone.

Which finding indicates that the client is experiencing an adverse effect of the
medication?

A. Dry mouth
B. Tarry stools
C. Hypotension
D. Hypoglycemia - B. Tarry stools

984. A pregnant client is receiving magnesium sulfate for the management of

preeclampsia. Which assessment finding indicates to the nurse that the client is
experiencing magnesium toxicity?

A. Proteinuria of +3
B. Sudden drop in fetal heart rate
C. Presence of deep tendon reflexes
D. Serum magnesium level of 2.5 mEq/L (1.25 mmol/L) - B. Sudden drop in
fetal heart rate

985. A client with a thoracic spinal cord injury is receiving dantrolene sodium.
Which statement by the client indicates to the nurse that the client is
experiencing an adverse effect of the medication?

A. "I'm feeling really drowsy."

B. "My legs are very relaxed."
C. "I can't seem to get enough to eat."
 D. "I urinate about the same amount as I always did." - A. "I'm feeling really
drowsy."

986. The emergency department staff prepares for the arrival of a child who
has ingested a bottle of acetaminophen. Which medication does the nurse
ensure is available?

A. Pancreatin
B. Phytonadione
C. Acetylcysteine
D. Protamine sulfate - C. Acetylcysteine

987. A nurse is caring for a client who has been taking acetazolamide for
glaucoma. Which, if documented in the assessment data, indicates to the nurse
that the client may be experiencing an adverse effect of the medication?

A. Tinnitus
B. Jaundice
C. No change in peripheral vision
D. Pupillary constriction in response to light - B. Jaundice

988. A nurse instructs a client with hypothyroidism about the dosage, method of
administration, and side effects of levothyroxine sodium. Which statement by the
client indicates an understanding of the nurse's instructions?

A. "I should take the medication in the evening."

B. "I can expect diarrhea, insomnia, and excessive sweating."
C. "If I feel nervous or have tremors, I should only take half the dose."
D. "I need to report any episodes of palpitations, chest pain, or dyspnea." - D.
"I need to report any episodes of palpitations, chest pain, or dyspnea."

989. Warfarin sodium has been prescribed, and the nurse teaches the client
about the medication. Which statement by the client indicates that further
teaching is necessary?

A. "I won't play football anymore."

B. "I won't take any over-the-counter medications except aspirin."
C. "I'll use an electric shaver until the doctor stops the Coumadin
prescription."
D. "I'll buy one of those medication alert tags that tells people I'm taking an
anticoagulant." - B. "I won't take any over-the-counter medications except
aspirin."

990. A client is taking a folic acid supplement. Which laboratory parameter

does the nurse use to evaluate the effectiveness of this therapy? Select all that
apply.
 A. Magnesium
B. Hemoglobin
C. Blood glucose
D. Hematocrit
E. Alkaline phosphatase - B. Hemoglobin
991. D. Hematocrit

992. A client who has undergone abdominal surgery calls the nurse and reports
that she just felt "something give way" in the abdominal incision. The nurse
checks the incision and notes the presence of wound dehiscence. The nurse
should take which immediate action?

A. Document the findings

B. Contact the health care provider
C. Place the client in a supine position with the legs flat
D. Cover the abdominal wound with a sterile dressing moistened with sterile
saline solution - D. Cover the abdominal wound with a sterile dressing
moistened with sterile saline solution

993. A client who just returned from the recovery room after a tonsillectomy and
adenoidectomy is restless and the pulse rate is increased. As the nurse
continues the assessment, the client begins to vomit a copious amount of bright-
red blood. The nurse should take which immediate action?

A. Notify the surgeon

B. Continue the assessment
C. Check the client's blood pressure
D. Obtain a flashlight, gauze, and a curved hemostat - A. Notify the surgeon

994. A client who has just undergone surgery suddenly experiences chest pain,
dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary
embolism and immediately sets about to take which action?

A. Preparing the client for a perfusion scan

B. Attaching the client to a cardiac monitor
C. Administering oxygen by way of nasal cannula
D. Ensuring that the intravenous (IV) line is patent - C. Administering oxygen
by way of nasal cannula

995. A nurse is assessing a client who has a closed chest tube drainage
system. The nurse notes constant bubbling in the water seal chamber. What
actions should the nurse take? (Select all that apply).

A. Clamp the chest tube

B. Chang the drainage system
 C. Assess the system for an external air leak
D. Reduce the degree of suction being applied
E. Document assessment findings, actions taken, and client response - C.
Assess the system for an external air leak

996. A nurse is helping a client with a closed chest tube drainage system get
out of bed and into a chair. During the transfer, the chest tube is caught on the
leg of the chair and dislodged from the insertion site. What is the immediate
nursing action?

A. Reinsert the chest tube

B. Contact the health care provider
C. Transfer the client back to bed
D. Cover the insertion site with a sterile occlusive dressing - D. Cover the
insertion site with a sterile occlusive dressing

997. A nurse performing nasopharyngeal suctioning and suddenly notes the

presence of bloody secretions. Which action should the nurse take first?

A. Continue suctioning to remove the blood

B. Check the degree of suction being applied
C. Encourage the client to cough out the bloody secretions
D. Remove the suction catheter from the client's nose and begin vigorous
suctioning through the mouth - B. Check the degree of suction being
applied

998. A nurse is suctioning a client through a tracheostomy tube. During the

procedure, the client begins to cough, and the nurse hears a wheeze. The nurse
tries to remove the suction catheter from the client's trachea but is unable to do
so. Which action should the nurse take first?

A. Call a code
B. Contact the health care provider
C. Administer a bronchodilator
D. Disconnect the suction source from the catheter - D. Disconnect the
suction source from the catheter

999. A nurse assesses the closed chest tube drainage system of a client who
underwent lobectomy 24 hours ago. The nurse notes that there has been no
chest tube drainage for the past hour.
1000. Which action should the nurse take first?

A. Contact the health care provider

B. Check for kinks in the drainage system
C. Check the client's blood pressure and heart rate
 D. Connect a new drainage system to the client's chest tube - B. Check for
kinks in the drainage system

1001. A nurse is assessing a postoperative client on an hourly basis. The nurse

notes that the client's urine output for the past hour was 25 mL. On the basis of
this finding, the nurse should take which action first?

A. Call the health care provider

B. Increase the rate of the IV infusion
C. Check the client's overall intake and output record
D. Administer a 250-mL bolus of normal saline solution (0.9% - C. Check the
client's overall intake and output record

1002. A nurse is getting a client out of bed for the first time since surgery. The
nurse raises the head of the bed, and the client complains of dizziness. Which
action should the nurse take first?

A. Check the client's blood pressure

B. Check the oxygen saturation level
C. Have the client take some deep breaths
D. Lower the head of the bed slowly until the dizziness is relieved - D. Lower
the head of the bed slowly until the dizziness is relieved

1003. A nurse is preparing for intershift report when an unlicensed assistive

personnel (UAP) pulls an emergency call light in a client's room. Upon answering
the light, the nurse finds a client who returned from surgery earlier in the day
experiencing tachycardia and tachypnea. The client's blood pressure is 88/60
mm Hg. Which action should the nurse take first?

A. Call the health care provider

B. Check the hourly urine output
C. Check the IV site for infiltration
D. Place the client in a modified Trendelenburg position - D. Place the client
in a modified Trendelenburg position

1004. A nurse is assessing the chest tube drainage system of a postoperative

client who has undergone a right upper lobectomy. The closed drainage system
contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in
the water seal chamber. One hour after the initial assessment, the nurse notes
that the bubbling in the water seal chamber is now constant, and the client
appears dyspneic. On the basis of these findings, what should the nurse
assessfirst?

A. The client's vital signs

B. The amount of drainage
C. The client's lung sounds
 D. The chest tube connections - D. The chest tube connections

1005. A client recovering from surgery has a large abdominal wound. Which
food, high in vitamin C, should the nurse encourage the client to eat as a means
of promoting wound healing?

A. Steak
B. Veal
C. Cheese
D. Oranges - D. Oranges

1006. A nurse is caring for a client who has just regained bowel sounds after
undergoing surgery. The health care provider has prescribed a clear liquid diet
for the client. Which item does the nurse ensure is available in the client's room
before allowing the client to drink?

A. Straw
B. Napkin
C. Suction equipment
D. Oxygen saturation monitor - C. Suction equipment

1007. A client in the postanesthesia care unit has an as-needed prescription for
ondansetron. Which occurrence would prompt the nurse to administer this
medication to the client?

A. Paralytic ileus
B. Incisional pain
C. Urine retention
D. Nausea and vomiting - D. Nausea and vomiting

1008. A nurse administers scopolamine as prescribed to a client. For which side

effect of this medication does the nurse monitor the client?

A. Pupil constriction
B. Increased urine output
C. Complaints of dry mouth
D. Complaints of feeling sweaty - C. Complaints of dry mouth

1009. A nurse is preparing a client for transfer to the operating room. Which
action should the take in the care of this client at this time?

A. Ensuring that the client has voided

B. Administering all daily medications
C. Practicing postoperative breathing exercises
D. Verifying that the client has not eaten for the last 24 hours - A. Ensuring
that the client has voided
1010. A nurse receives a telephone call from a nurse on the post-anesthesia
care unit, who reports that a client is being transferred to the surgical unit. What
should the nurse plan to do first on arrival of the client?

A. Assess the patency of the airway

B. Check tubes and drains for patency
C. Check the dressing for bleeding
D. Assess the vital signs to compare them with preoperative measurements -
A. Assess the patency of the airway

1011. A client without a history of respiratory disease has a pulse oximeter in

place after surgery. The nurse monitors the pulse oximeter readings to ensure
that oxygen saturation remains above which value?

A. 85%
B. 89%
C. 95%
D. 100% - C. 95%

1012. A client who underwent preadmission testing 1 week before surgery had
blood drawn for several serum laboratory studies. Which abnormal laboratory
results should the nurse report to the surgeon's office? Select all that apply.

A. Hematocrit 30% (0.30)

B. Sodium 141 mEq/L (141 mmol/L)
C. Hemoglobin 8.9 g/dL (89 g/L)
D. Platelets 210× 103/μL (210 × 109/L)
E. Serum creatinine 0.8 mg/dL (70 μmol/L) - A. Hematocrit 30% (0.30)

1013. A client has been scheduled for magnetic resonance imaging (MRI). For
which condition, a contraindication to MRI, does the nurse check the client's
medical history?

A. Pancreatitis
B. Pacemaker insertion
C. Type 1 diabetes mellitus
D. Chronic airway limitation - B. Pacemaker insertion

1014. A client has just undergone lumbar puncture. Into which position does the
nurse assist the client after the procedure?

A. Flat
B. Semi-Fowler
C. Side-lying, with the head of the bed elevated
D. Sitting up in a recliner with the feet elevated - A. Flat
1015. A client has just returned to the nursing unit after computerized
tomography (CT) with contrast medium. Which action should the nurse plan to
take as part of routine after-care for this client?

A. Administering a laxative
B. Encouraging fluid intake
C. Maintaining the client on strict bed rest
D. Holding all medications for at least 2 hours - B. Encouraging fluid intake

1016. A client reports for a scheduled electroencephalogram (EEG). Which

statement by the client indicates a need for additional preparation for the test?

A. "I didn't shampoo my hair."

B. "I ate breakfast this morning."
C. "I didn't take my anticonvulsant today."
D. "It was hard not to drink coffee this morning, but I knew that I couldn't, so I
didn't." - A. "I didn't shampoo my hair."

1017. Blood is drawn from a male client with suspected uric acid calculi for a
serum uric acid determination. Which value does the nurse recognize as a
normal uric acid level?

A. 1.7 mg/dL (101.2 μmol/L)

B. 4.4 mg/dL (262 μmol/L)
C. 8.9 mg/dL (529.9 μmol/L)
D. 12.8 mg/dL (762.1 μmol/L - B. 4.4 mg/dL (262 μmol/L)

1018. A nurse is providing post-procedure instructions to a client returning home

after arthroscopy of the shoulder. The nurse should provide the client with which
information?

A. To resume full activity the next day

B. Not to eat or drink anything until the next morning
C. To keep the shoulder completely immobilized for the rest of the day
D. To report to the health care provider the development of fever or redness
and heat at the site - D. To report to the health care provider the
development of fever or redness and heat at the site

1019. A client is tested for HIV with the use of an enzyme-linked immunosorbent
assay (ELISA), and the test result is positive. The nurse should provide which
information to the client about the test?

A. HIV infection has been confirmed

B. The client probably has an opportunistic infection
C. The test will need to be confirmed with the use of a Western blot
 D. A positive test is a normal result and does not mean that the client is
infected with HIV - C. The test will need to be confirmed with the use of a
Western blot

1020. A CD4+ lymphocyte count is performed on a client who is infected with

HIV. The results of the test indicate a CD4+ count of 450 cells per cubic
millimeter of blood. The nurse interprets this test result as indicating which?

A. Improvement in the client

B. The need for antiretroviral therapy
C. The need to discontinue antiretroviral therapy
D. An effective response to the treatment for HIV - B. The need for
antiretroviral therapy

1021. A client has just undergone a renal biopsy. Which intervention should the
nurse include in the post-procedure plan of care?

A. Restricting fluid intake for the first 24 hours

B. Periodically testing the urine for occult blood
C. Avoiding the administration of opioid analgesics
D. Having the client ambulate in the room and hall for short distances - B.
Periodically testing the urine for occult blood

1022. A nurse has a prescription to collect a 24-hour urine specimen from a

client. Which measure should the nurse take during this procedure?

A. Keeping the specimen at room temperature

B. Saving the first urine specimen collected at the start time
C. Discarding the last voided specimen at the end of the collection time
D. Asking the client to void, discarding the specimen, and noting the start
time - D. Asking the client to void, discarding the specimen, and noting the
start time

1023. A nurse is preparing a client for intravenous pyelography (IVP). Which

action by the nurse is most important?

A. Administering a sedative
B. Encouraging fluid intake
C. Administering an oral preparation of radiopaque dye
D. Questioning the client about allergies to iodine or shellfish - D.
Questioning the client about allergies to iodine or shellfish

1024. A client who has undergone renal biopsy complains of pain, radiating to
the front of the abdomen, at the biopsy site. For which finding should the nurse
assess the client?
 A. Bleeding
B. Renal colic
C. Infection at the site
D. Increased temperature - A. Bleeding

1025. A client has undergone renal angiography by way of the right femoral
artery. The nurse determines that the client is experiencing a complication of the
procedure on noting which finding?

A. Urine output of 40 mL/hr

B. Blood pressure of 118/76 mm Hg
C. Respiratory rate of 18 breaths/min
D. Pallor and coolness of the right leg - D. Pallor and coolness of the right leg

1026. A nurse reviews a client's urinalysis report. Which finding does the nurse
recognize as abnormal?

A. pH of 6.0
B. An absence of protein
C. The presence of ketones
D. Specific gravity of 1.018 - C. The presence of ketones

1027. A nurse provides information to a client who is scheduled for cardiac

catheterization to rule out coronary occlusion. The nurse should provide which
information to the client?

A. The procedure is performed in the operating room

B. It is necessary to lie quietly on a hard x-ray table for about 4 hours
C. The room is bright and well lit, and it is best to keep the eyes closed
D. The client may have feelings of warmth or flushing during the procedure -
D. The client may have feelings of warmth or flushing during the
procedure

1028. A client who has sustained a myocardial infarction is scheduled to have an

echocardiogram. Which measure should the nurse take before the procedure?

A. Imposing nothing-by-mouth (NPO) status for 4 hours

B. Asking the client to sign an informed consent form
C. Asking the client about a history of allergy to iodine or shellfish
D. Telling the client that the procedure is painless and takes 30 to 60 minutes
to complete - D. Telling the client that the procedure is painless and takes
30 to 60 minutes to complete

1029. A nurse in a health care provider's office has just made an appointment for
a client to undergo an exercise stress test. The nurse, in providing pre-procedure
teaching, should provide which information to the client?
 A. Wear sweatpants and a heavy sweatshirt
B. Eat a small meal just before the procedure
C. Wear comfortable rubber-soled shoes such as sneakers
D. Avoid consuming caffeine for 30 minutes before the procedure - C. Wear
comfortable rubber-soled shoes such as sneakers

1030. A nurse has a prescription to apply a Holter monitor to a client for

continuous cardiac monitoring for a 24-hour period. What steps should the nurse
take to initiate this prescription? Select all that apply.

A.Giving the client a device holder to wear around the waist

B.Giving the client a diary in which to record activity and symptoms
C.Telling the client to rest as much as possible during the next 24 hours
D.Instructing the client to enclose the monitor in plastic wrap before taking a
bath
E. Telling the client that occasional slight shocks from the monitor will be felt
but that they are harmless - A. Giving the client a device holder to wear
around the waist
1031. B. Giving the client a diary in which to record activity and symptoms

1032. A client has undergone pericardiocentesis to treat cardiac tamponade. For

which signs should the nurse assess the client to determine whether the
tamponade is recurring?

A. Decreasing pulse
B. Rising blood pressure
C. Distant muffled heart sounds
D. Falling central venous pressure (CVP) - C. Distant muffled heart sounds

1033. A nurse is watching as an unlicensed assistive personnel (UAP) measure

the blood pressure (BP) of a hypertensive client. Which actions on the part of the
UAP would interfere with accurate measurement and prompt the nurse to
intervene? Select all that apply.

A. Measuring the BP after the client has sat quietly for 5 minutes
B. Having the client sit with the arm bared and supported at heart level
C. Used a cuff with a rubber bladder that encircles at least 60% of the limb
D. Measuring the BP after the client reports that he just drank a cup of coffee
E. Allowing the client to talk as the blood pressure is being measured - C.
Used a cuff with a rubber bladder that encircles at least 60% of the limb
1034. D. Measuring the BP after the client reports that he just drank a cup of
coffee
1035. A nurse is watching as a nursing student suctions a client through a
tracheostomy tube. Which actions on the part of the student would prompt the
nurse to intervene and demonstrate correct procedure? Select all that apply.

A. Setting the suction pressure to 60 mm Hg

B. Applying suction throughout the procedure
C. Assessing breath sounds before suctioning
D. Placing the client in a supine position before the procedure
E. Hyperoxygenating the client with 100% oxygen before suctioning - A.
Setting the suction pressure to 60 mm Hg
1036. B. Applying suction throughout the procedure
1037. D. Placing the client in a supine position before the procedure

1038. Oxygen by way of nasal cannula has been prescribed for a client with
emphysema. The nurse checks the health care provider's prescriptions to ensure
that the prescribed flow is not greater than which liter (L) per minute (min)?

A. 1 L/min
B. 3 L/min
C. 4 L/min
D. 6 L/min - B. 3 L/min

1039. A client who experienced the sudden onset of respiratory distress has
been intubated with an endotracheal tube. After the tube is placed in the trachea,
the nurse should take which immediate action?

A. Tape the tube in place

B. Send the client for a chest x-ray
C. Note how far the tube has been inserted
D. Auscultate both lungs for the presence of breath sounds - D. Auscultate
both lungs for the presence of breath sounds

1040. A client has a chest drainage system in place. The fluid in the water seal
chamber rises and falls during inspiration and expiration. The nurse interprets
this finding as an indication of which?

A. The tube is patent

B. There is probably a kink in the tubing
C. Suction should be added to the system
D. The client is retaining airway secretions - A. The tube is patent

1041. A nurse is performing nasotracheal suctioning on a client. Which

observations should be cause for concern to the nurse? Select all that apply.

A. The client becomes cyanotic.

B. Secretions are becoming bloody.
 C. The client gags during the procedure.
D. Clear to opaque secretions are removed.
E. The heart rate varies from 80 to 82 beats/min. - A. The client becomes
cyanotic.
1042. B. Secretions are becoming bloody.

1043. A nurse is monitoring the respiratory status of a client who has just
undergone surgery and is wearing a pulse oximeter. Which coexisting problem is
cause for the nurse to suspect that the oxygen saturation readings are not
entirely accurate?

A. Infection
B. Hypertension
C. Low blood pressure
D. Loss of cough reflex - C. Low blood pressure

1044. A nurse is reading the radiology report of a client with a chest tube
attached to a closed drainage system who has undergone a chest x-ray. The
report states that the client's affected lung is fully reexpanded. The nurse
anticipates that the assessment of the chest tube system will reveal which
finding?

A. No fluctuation in the water seal chamber

B. Continuous bubbling in the water seal chamber
C. Increased drainage in the collection chamber
D. Continuous gentle suction in the suction control chamber - A. No
fluctuation in the water seal chamber

1045. A client has just undergone insertion of a chest tube that is attached to a
closed chest drainage system. Which action should the nurse plan to take in the
care of this client?

A. Assessing the client's chest for crepitus once every 24 hours

B. Taping the connections between the chest tube and the drainage system
C. Adding 20 mL of sterile water to the suction control chamber every shift
D. Recording the volume of secretions in the drainage collection chamber
every 24 hours - B. Taping the connections between the chest tube and
the drainage system

1046. A client who has just undergone bronchoscopy was returned to the
nursing unit 1 hour ago. With which assessment finding is the nurse
mostconcerned?

A. Oxygen saturation of 97%

B. Equal breath sounds in both lungs
C. Absence of cough and gag reflexes
 D. Respiratory rate of 20 breaths/min - C. Absence of cough and gag reflexes

1047. A nurse is caring for a client who has undergone pulmonary angiography
with catheter insertion through the right femoral vein. The nurse assesses for
allergic reaction to the contrast medium by monitoring for the presence of which?

A. Bradycardia
1048. CorrectB. Respiratory distress
1049. C. Hematoma in the right groin
1050. D. Discomfort in the right groin - B. Respiratory distress

1051. A nurse is conducting an assessment of a client who underwent

thoracentesis of the right side of the chest 3 hours ago. Which findings does the
nurse report to the health care provider? Select all that apply.

A. Unequal chest expansion

B. Pulse rate of 82 beats/min
C. Respiratory rate of 22 breaths/min
D. Diminished breath sounds in the right lung
E. Complaints of discomfort at the needle insertion site - A. Unequal chest
expansion

1052. A nurse is monitoring a client who has undergone pleural biopsy. Which
finding causes the nurse to suspect that the client is experiencing a
complication?

A. Warm, dry skin

B. Mild pain at the biopsy site
C. Complaints of shortness of breath
D. Capillary refill time of less than 3 seconds - C. Complaints of shortness of
breath

1053. A client has just returned to the nursing unit after bronchoscopy. To which
intervention should the nurse give priority?

A. Ambulating the client

B. Administering pain medication
C. Encouraging copious fluid intake
D. Checking for the return of the gag reflex - D. Checking for the return of the
gag reflex

1054. A client is receiving intermittent bolus feedings by way of a nasogastric

tube. In which position should the nurse place the client once the feeding is
complete?

A. Supine
 B. Head of bed flat
C. Left lateral position
D. Head of bed elevated 30 to 45 degrees - D. Head of bed elevated 30 to 45
degrees

1055. A nurse has a prescription to discontinue a client's nasogastric tube. The

nurse auscultates the client's bowel sounds, positions the client properly, and
flushes the tube with 15 mL of air to clear secretions. The nurse then instructs
the client to take a deep breath and do what?

A. Exhale during tube removal

B. Bear down during tube removal
C. Hold the breath during tube removal
D. Breathe normally during tube removal - C. Hold the breath during tube
removal

1056. A nurse checks the residual volume from a client's nasogastric tube
feeding before administering an intermittent tube feeding and finds 35 mL of
gastric contents. What should the nurse do before administering the prescribed
100 mL of formula to the client?

A. Pour the residual volume into the nasogastric tube through a syringe with
the plunger removed
B. Discard the residual volume properly and record it as output on the client's
fluid balance record
C. Dilute the residual volume with water and inject it into the nasogastric
tube, applying pressure on the plunger
D. Mix the residual volume with the formula and pour it into the nasogastric
tube, using a syringe without a plunger - A. Pour the residual volume into
the nasogastric tube through a syringe with the plunger removed

1057. A nurse has a prescription to insert a nasogastric tube into the stomach of
an assigned client. Which action should the nurse take to insert the tube safely
and easily?

A. Placing the tube in warm water

B. Hyperextending the head while inserting the tube
C. Removing the tube if any resistance to insertion is met
D. Asking the client to swallow as the tube is being advanced - D. Asking the
client to swallow as the tube is being advanced

1058. A client who has undergone an esophagogastroduodenoscopy (EGD)

returns from the endoscopy department. After checking the client's gag reflex,
which action should the nurse take?

A. Taking the client's vital signs

 B. Giving the client a drink of water
C. Monitoring the client for a sore throat
D. Being alert to complaints of heartburn - A. Taking the client's vital signs

1059. A client has just been scheduled for endoscopic retrograde

cholangiopancreatography (ERCP). What should the nurse tell the client about
the procedure? Select all that apply.

A. That informed consent is required Correct

B. That the test takes about 4 hours to complete
C. That no premedication for sedation will be necessary
D. That food and fluids will be withheld before the procedure Correct
1060. Correct
1061. E. That multiple position changes may be necessary to pass the tube - A.
That informed consent is required
1062. D. That food and fluids will be withheld before the procedure
1063. E. That multiple position changes may be necessary to pass the tube

1064. A client is scheduled for a barium swallow (esophagography) in 2 days.

The nurse, providing preprocedure instructions, should tell the client to
implement which measure?

A. Eat a regular supper and breakfast

B. Remove all metal and jewelry before the test
C. Expect diarrhea for a few days after the procedure
D. Take all oral medications as scheduled with milk on the day of the test - B.
Remove all metal and jewelry before the test

1065. A nurse is preparing a client for colonoscopy. Into which position does the
nurse assist the client for the procedure?

A. Left Sims' position

B. Lithotomy position
1066. C.Knee-chest position
1067. D. Right Sims' position - A. Left Sims' position

1068. Polyethylene glycol-electrolyte solution is prescribed for a hospitalized

client scheduled for colonoscopy. The client begins to experience diarrhea after
drinking the solution. Which action by the nurse is appropriate?

A. Administering a cleansing enema.

B. Calling the health care provider
C. Documenting the diarrhea in the medical record
D. Giving intravenous replacement fluids in large amounts - C. Documenting
the diarrhea in the medical record
1069. A health care provider is about to perform paracentesis on a client with
abdominal ascites. Into which position would the nurse assist the client?

A. Supine
B. Upright
C. Left side-lying
D. Right side-lying - B. Upright

1070. A nurse is reviewing the results of serum laboratory studies of a client with
suspected hepatitis. Which increased parameter is interpreted by the nurse as
the most specific indicator of this disease?

A. Hemoglobin
B. Serum bilirubin
C. Blood urea nitrogen (BUN)
D. Erythrocyte sedimentation rate (ESR) - B. Serum bilirubin

1071. A nurse is preparing to examine a client's skin using a Wood light. What
should the nurse do to facilitate this procedure?

A. Darken the examining room

B. Administer a local anesthetic
C. Obtain a signed informed consent
D. Shave the skin and scrub it with povidone-iodine (Betadine) - A. Darken
the examining room

1072. A nurse is assessing the status of a client with diabetes mellitus. The
nurse concludes that the client is exhibiting adequate diabetic control if the serum
level of glycosylated hemoglobin A1C (HbA1C) is less than which value?

A. 7%
B. 9%
C. 10%
D. 15% - A. 7%

1073. A client with diabetes mellitus is scheduled to have blood drawn in the
morning for a fasting blood glucose determination. What does the nurse tell the
client that it is acceptable to consume on the morning of the test?

A. Water Correct
1074. B.Tea without any sugar
1075. C. Coffee without any milk
1076. D. Clear liquids such as apple juice - A. Water
1077. A client is scheduled to undergo computerized tomography (CT) with
contrast for evaluation of an abdominal mass. The nurse should provide the
client with which information about the test?

A. The test may be painful

B. The test takes 2 to 3 hours
C. Food and fluids are not allowed for 4 hours after the test
D. Dye is injected and may cause a warm flushing sensation - D. Dye is
injected and may cause a warm flushing sensation

1078. A pelvic ultrasound is prescribed to evaluate a client's ovarian mass. What

should the nurse giving preprocedure instructions tell the client that it important to
do before the procedure?

A. Eat only a light breakfast

B. Wear comfortable clothing and shoes
C. Drink 6 to 8 glasses of water without voiding
D. Stop eating or drinking at midnight before the test - C. Drink 6 to 8 glasses
of water without voiding

1079. A client has been given a diagnosis of multiple myeloma. Which result
does the nurse reviewing the client's laboratory findings recognize as being
specifically related to this diagnosis?

A. Increased calcium level

B. Decreased blood urea nitrogen (BUN)
C. Increased white blood cell (WBC) count
D. Decreased number of plasma cells in the bone marrow - A. Increased
calcium level

1080. A woman has been scheduled for a routine mammogram. The nurse
should provide the client with which information about the test?

A. That mammography takes about 1 hour

B. Not to eat or drink on the morning of the test
C. That there is no discomfort associated with the procedure
D. That deodorants, powders, or creams used in the axillary or breast area
must be washed off before the test - D. That deodorants, powders, or
creams used in the axillary or breast area must be washed off before the
test

1081. A client has made an appointment to for her annual Papanicolaou test
(a.k.a. Pap smear). The nurse who schedules the appointment should provide
which information to the client?

A. Vaginal douching is required an hour before the test

 B. Spicy foods should not be eaten on the day of the test
C. The test has absolutely no discomfort associated with it
D. The test cannot be performed while the client is menstruating - D. The test
cannot be performed while the client is menstruating

1082. A client who has just undergone a skin biopsy is listening to discharge
instructions from the nurse. The nurse determines that the client needs further
teachingif the client indicates that he plans to do what as part of aftercare?

A. Use the antibiotic ointment as prescribed

B. Return in 7 days to have the sutures removed
C. Apply cool compresses to the site twice a day for 20 minutes
D. Call the health care provider if excessive drainage from the wound occurs
- C. Apply cool compresses to the site twice a day for 20 minutes

1083. A serum phenytoin determination is prescribed for a client with a seizure

disorder who is taking phenytoin. Which result indicates that the prescribed dose
of phenytoin is therapeutic?

A. 3 mcg/mL
B. 8 mcg/mL
C. 16 mcg/mL
D. 28 mcg/mL - C. 16 mcg/mL

1084. A client is receiving a continuous IV infusion of heparin for the treatment of

deep vein thrombosis. The client's activated partial thromboplastin time (aPTT)
level is 88 seconds (88 seconds). The client's baseline before the initiation of
therapy was 30 seconds (30 seconds). Which action does the nurse anticipate is
needed?

A. Shutting off the heparin infusion

B. Increasing the rate of the heparin infusion
C. Decreasing the rate of the heparin infusion
D. Leaving the rate of the heparin infusion as is - C. Decreasing the rate of
the heparin infusion

1085. A client with cardiovascular disease is scheduled to receive a daily dose of

furosemide. Which potassium level would cause the nurse, reviewing the client's
electrolyte values, to contact the health care provider before administering the
dose?

A. 3.0 mEq/L (3.0 mmol/L)

B. 3.8 mEq/L (3.8 mmol/L)
C. 4.2 mEq/L (4.2 mmol/L)
D. 5.2 mEq/L (5.2 mmol/L) - A. 3.0 mEq/L (3.0 mmol/L)
1086. A young adult asks the nurse about the normal cholesterol level. The
nurse tells the client that the total cholesterol level should be maintained at less
than which value?

A. 140 mg/dL (<3.64 mmol/L)

B. 200 mg/dL (<5.2 mmol/L)
C. 250 mg/dL (<6.5 mmol/L)
D. 300 mg/dL (<7.8 mmol/L) - B. 200 mg/dL (<5.2 mmol/L)

1087. A nurse is reviewing the results of renal function testing in a client with
renal calculi. Which finding indicates to the nurse that the client's blood urea
nitrogen (BUN) level is within the normal range?

A. 2 mg/dL (0.7 mmol/L)

B. 18 mg/dL (6.3 mmol/L)
C. 25 mg/dL (8.75 mmol/L)
D. 35 mg/dL (12.25 mmol/L) - B. 18 mg/dL (6.3 mmol/L)

1088. An adult female client has undergone a routine health screening in the
clinic. Which of the following values indicates to the nurse who receives the
report of the client's laboratory work that the client's hematocrit is normal?

A. 10% ( 0.10)
B. 22% ( 0.22)
C. 30% ( 0.30)
D. 43% ( 0.43) - D. 43% ( 0.43)

1089. A client admitted to the hospital with a diagnosis of acute pancreatitis has
blood drawn for several serum laboratory tests. Which serum amylase value,
noted by the nurse reviewing the results, would be expected in this client at this
time?

A. 48 units/L (0.816 μkat/L)

B. 97 units/L (1.649 μkat/L)
C. 150 units/L (2.55 μkat/L)
D. 395 units/L (6.715 μkat/L) - D. 395 units/L (6.715 μkat/L)

1090. A nurse is reviewing laboratory results for a client who is at risk for
nephrotoxicity because of medications being taken. Which serum creatinine
result does the nurse document as normal?

A. 0.2 mg/dL (17.6 μmol/L)

B. 1.0 mg/dL (88.3 μmol/L)
C. 2.8 mg/dL (247.3 μmol/L)
D. 3.9 mg/dL (344.5 μmol/L) - B. 1.0 mg/dL (88.3 μmol/L)
1091. A client with type 1 diabetes mellitus has a blood glucose level of 620
mg/dL (34.4 mmol/L). After the nurse calls the health care provider to report the
finding and monitors the client closely for which condition?

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis - A. Metabolic acidosis

1092. A nurse reviews the blood gas results of a client in respiratory distress.
The pH is 7.32 and the PaCO2 is 50 mm Hg (6.65 kPa). Which acid-base
imbalance does the nurse recognize in these findings?

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis - C. Respiratory acidosis

1093. Blood for arterial blood gas determinations is drawn on a client with
pneumonia, and testing reveals a pH of 7.45, PaCO2 of 30 mm Hg (3.99 kPa).,
and HCO3 of 19 mEq/L (19 mmol/L). The nurse interprets these results as
indicative of which disorder?

A. Compensated metabolic acidosis

B. Compensated respiratory alkalosis
C. Uncompensated metabolic alkalosis
D. Uncompensated respiratory acidosis - B. Compensated respiratory
alkalosis

1094. A nurse is caring for a client who is vomiting. For which acid-base
imbalance does the nurse assess the client?

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosi - B. Metabolic alkalosis

1095. A nurse is caring for a client with diarrhea. For which acid-base disorder
does the nurse assess the client?

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis - A. Metabolic acidosis
1096. A client tells the nurse that he has been experiencing frequent heartburn
and has been "living on antacids." For which acid-base disturbance does the
nurse recognize a risk?

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis - B. Metabolic alkalosis

1097. A client has the following arterial blood gas (ABG) results: pH 7.51,
PaCO231 mm Hg (4.12 kPa), PaO2 94 mm Hg (12.45 kPa), HCO3 24 mEq/L (24
mmol/L). Which acid-base disturbance does the nurse recognize in these
results?

1098. A .Metabolic acidosis

1099. B. Metabolic alkalosis
1100. C. Respiratory acidosis
1101. D. Respiratory alkalosis - D. Respiratory alkalosis

1102. A client with histoplasmosis has the following arterial blood gas (ABG)
results: pH 7.30, PaCO2 58 mm Hg (7.72 kPa), PaO2 75 mm Hg (9.93 kPa),
HCO3 26 mEq/L (26 mmol/L). Which acid-base disturbance does the nurse
recognize in these results?

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis - C. Respiratory acidosis

1103. A client is brought to the emergency department by a neighbor. The client

is lethargic and has a fruity odor on the breath. The client's arterial blood gas
(ABG) results are pH 7.25, PaCO234 mm Hg (4.52 kPa), PaO2 86 mm Hg (11.3
kPa), HCO3 14 mEq/L (14 mmol/L). Which acid-base disturbance does the nurse
recognize in these results?

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis - A. Metabolic acidosis

1104. A client who is anxious about an impending surgery is at risk for

respiratory alkalosis. For which signs and symptoms of respiratory alkalosis does
the nurse assess this client?

A. Disorientation and dyspnea

B. Drowsiness, headache, and tachypnea
 C. Tachypnea, dizziness, and paresthesias
D. Dysrhythmias and decreased respiratory rate and depth - C. Tachypnea,
dizziness, and paresthesias

1105. A client with a history of lung disease is at risk for respiratory acidosis. For
which signs and symptoms does the nurse assess this client?

A. Disorientation and dyspnea

B. Drowsiness, headache, and tachypnea
C. Tachypnea, dizziness, and paresthesias
D. Dysrhythmias and decreased respiratory rate and depth - A. Disorientation
and dyspnea

1106. A client who has received sodium bicarbonate in large amounts is at risk
for metabolic alkalosis. For which signs and symptoms does the nurse assess
this client?

A. Disorientation and dyspnea

B. Drowsiness, headache, and tachypnea
C. Tachypnea, dizziness, and paresthesias
D. Dysrhythmias and decreased respiratory rate and depth - D. Dysrhythmias
and decreased respiratory rate and depth

1107. A client who is mouth breathing is receiving oxygen by face mask. The
unlicensed assistive personnel (UAP) asks the nurse why a water bottle is
attached to the oxygen tubing near the wall oxygen outlet. The nurse responds
that the primary purpose of the water is to promote which goal?

A. Prevent the client from getting a nosebleed

B. Give the client added fluid by way of the respiratory tree
C. Humidify the oxygen that is bypassing the client's nose
D. Prevent fluid loss from the lungs during mouth breathing - C. Humidify the
oxygen that is bypassing the client's nose

1108. A client's baseline vital signs are temperature 98° F oral, pulse 74
beats/min, respiratory rate 18 breaths/min, and blood pressure 124/76 mm Hg.
The client suddenly spikes a fever of 103° F. Which respiratory rate would the
nurse anticipate as part of the body's response to the change in client status?

A. 12 breaths/min
B. 16 breaths/min
C. 18 breaths/min
D. 22 breaths/min - D. 22 breaths/min

1109. A client with chronic obstructive pulmonary disease (COPD) who is

beginning oxygen therapy asks the nurse why the flow rate cannot be increased
 to more than 2 L/min. The nurse responds that this would be harmful because it
could cause which effect?

A. Be drying to nasal passages

B. Decrease the client's oxygen-based respiratory drive
C. Increase the risk of pneumonia as a result of drier air passages
D. Decrease the client's carbon dioxide-based respiratory drive - B. Decrease
the client's oxygen-based respiratory drive

1110. A nurse is reading the chest x-ray report of a client who has just been
intubated. The report states that the tip of the endotracheal tube lies 1 cm above
the carina. The nurse interprets that the tube is positioned above which
anatomical area?

A. The first tracheal cartilaginous ring

B. The point where the larynx connects to the trachea
C. The bifurcation of the right and left main stem bronchi
D. The area connecting the oropharynx to the laryngopharynx - C. The
bifurcation of the right and left main stem bronchi

1111. A nurse is caring for a client who has lost a significant amount of blood as
a result of complications during a surgical procedure. Which parameter does the
nurse recognize as the earliest indication of new decreases in fluid volume?

A. Pulse rate
B. Blood pressure
C. Pulmonary artery systolic pressure
D. Pulmonary artery end-diastolic pressure - A. Pulse rate

1112. A nurse is admitting a client with a diagnosis of hypothermia to the

hospital. Which signs does the nurse anticipate that this client will exhibit?

A. Increased heart rate and increased blood pressure

B. Increased heart rate and decreased blood pressure
C. Decreased heart rate and increased blood pressure
D. Decreased heart rate and decreased blood pressure - D. Decreased heart
rate and decreased blood pressure

1113. A nurse is teaching a nursing student how to measure a carotid pulse. The
nurse should tell the student to measure the pulse on only one side of the client's
neck primarily for which reason?

A. It is unnecessary to use both hands

B. Feeling dual pulsations may lead to an incorrect measurement
C. Palpating both carotid pulses simultaneously could occlude the trachea
 D. Palpating both carotid pulses simultaneously could cause the heart rate
and blood pressure to drop - D. Palpating both carotid pulses
simultaneously could cause the heart rate and blood pressure to drop

1114. A nurse is assigned to care for four clients on the medical-surgical unit.
Which client should the nurse see first on the shift assessment?

A. A client admitted with pneumonia with a fever of 100° F and some

diaphoresis
B. A client with congestive heart failure with clear lung sounds on the
previous shift
C. A client with new-onset of shortness of breath (SOB) and a history of
pulmonary edema
D. A client undergoing long-term corticosteroid therapy with mild bruising on
the anterior surfaces of the arms - C. A client with new-onset of shortness
of breath (SOB) and a history of pulmonary edema

1115. A client with gastroenteritis who has been vomiting and has diarrhea is
admitted to the hospital with a diagnosis of dehydration. For which clinical
manifestations that correlate with this fluid imbalance would the nurse assess the
client? Select all that apply.

A. Decreased pulse
B. Decreased urine output
C. Increased blood pressure
D. Increased respiratory rate
E. Decreased respiratory depth - B. Decreased urine output

1116. A nurse is reviewing the medical records of the clients to whom she is
assigned on the 7 am-7 pm shift. Which client will the nurse monitor most closely
for excessive fluid volume?

A. A 48-year-old client receiving diuretics to treat hypertension

B. A 35-year old client who is vomiting undigested food after eating
C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100
mL/hr
D. A 65-year-old client with a nasogastric tube attached to low suction
following partial gastrectomy - C. An 85-year-old client receiving
intravenous (IV) therapy at a rate of 100 mL/hr

1117. A nurse is caring for a client who is being treated for congestive heart
failure and has been assigned a nursing diagnosis of excessive fluid volume.
Which assessment finding causes the nurse to determine that the client's
condition has improved?

A. Dyspnea
 B. 1+ edema in the legs
C. Moist crackles in the lower lobes of the lungs
D. Weight loss of 4 lb in 24 hours - D. Weight loss of 4 lb in 24 hours

1118. A nurse notes that a client has ST-segment depression on the

electrocardiogram (ECG) monitor. With which serum potassium reading does the
nurse associate this finding?

A. 3.1 mEq/L (3.1 mmol/L)

B. 4.2 mEq/L (4.2 mmol/L)
C. 4.5 mEq/L (4.5 mmol/L)
D. 5.4 mEq/L (5.4 mmol/L) - A. 3.1 mEq/L (3.1 mmol/L)

1119. A healthcare provider writes a prescription for the administration of

intravenous (IV) potassium chloride to a client with hypokalemia. What does the
nurse plan to do when preparing and administering this medication?

A. Insert a Foley catheter in the client

B. Prepare the client for insertion of a central IV line
C. Administer the medication with the use of a macrodrip IV tubing set
D. Ensure that the medication is diluted in an appropriate amount of normal
saline solution - D. Ensure that the medication is diluted in an appropriate
amount of normal saline solution

1120. A nurse notes that a client's serum potassium level is 5.8 mEq/L(5.8
mmol/L). The nurse interprets this as an expected finding in the client with:

A. Diarrhea
B. Wound drainage
C. Addison disease
D. Heart failure being treated with loop diuretics - C. Addison disease

1121. A nurse is caring for a client experiencing hyponatremia who was admitted
to the medical-surgical unit with fluid-volume overload. For which clinical
manifestations of this electrolyte imbalance does the nurse monitor this client?
Select all that apply.

A. Slow pulse
B. Decreased urine output
C. Skeletal muscle weakness
D. Hyperactive bowel sounds
E. Hyperactive deep tendon reflexes - C. Skeletal muscle weakness
1122. D. Hyperactive bowel sounds
1123. A nurse is monitoring a client with hyperparathyroidism for signs of
hypercalcemia. For which clinical manifestations, associated with this electrolyte
imbalance, does the nurse assess the client? Select all that apply.

A. Paresthesias
B. Muscle weakness
C. Increased urine output
D. Chvostek sign
E. Hyperactive deep tendon reflexes - B. Muscle weakness
1124. C. Increased urine output

1125. A nurse is caring for a client with Crohn disease whose magnesium level
is 1.0 mEq/L (0.5 mmol/L). Which assessment findings does the nurse expect to
note? Select all that apply.

A. Hypotension
B. Abdominal distention
C. Trousseau sign
1126. D . Skeletal muscle weakness
1127. E. Decreased deep tendon reflexes - B. Abdominal distention
1128. C. Trousseau sign

1129. A nurse enters a client's room and finds the client unconscious. The nurse
quickly performs an assessment and determines that the client is not breathing.
Which action does the nurse take first?

A. Beginning chest compressions

B. Checking the client's pulse oximetry reading
C. Placing an oxygen mask on the client
D. Counting the client's carotid pulse for 15 seconds - A. Beginning chest
compressions

1130. A nurse arrives at the scene of a code and begins to assist with
cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers
compressions by pushing down on the chest to a depth of:

A. 1 inch
B. 1½ inches
C. 2 inches
D. 4 inches - C. 2 inches

1131. The nurse is administering cardiopulmonary resuscitation (CPR) to an

adult client. Which compression-ventilation ratio is correct?

A. 15:1
B. 15:2
 C. 20:2
D. 30:2 - D. 30:2

1132. A pediatric nurse finds a hospitalized child unresponsive. A quick

assessment reveals that the child is not breathing and does not have a pulse.
The nurse initiates cardiopulmonary resuscitation (CPR). How many chest
compressions per minute does the nurse deliver?

A. 15
B. 30
C. 50
D. 100 - D. 100

1133. A nurse attending a recertification course in basic life support (BLS) for
healthcare professionals is practicing BLS on an infant mannequin. Where does
the nurse place the fingers to assess the infant's pulse?

A. Neck
B. Wrist
C. Behind the knee
D. Antecubital fossa of the arm - D. Antecubital fossa of the arm

1134. A nurse is working in the emergency department. Which client should be

assessed first?

A. A client with new-onset dizziness

B. A client admitted with a recent ear injury
C. A client who has been experiencing nausea and vomiting for 12 hours
D. A client with new-onset atrial fibrillation with a rate of 118 beats/min - D. A
client with new-onset atrial fibrillation with a rate of 118 beats/min

1135. A nurse is having dinner at a restaurant when a man sitting at the next
table collapses and falls to the floor. The nurse yells for help and quickly
assesses the client, noting that the client is not breathing and does not have a
pulse. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and
the restaurant manager rushes to the scene with an automatic external
defibrillator (AED). What should the nurse do next?

A. Use the AED

B. Stop the resuscitation efforts
C. Perform CPR until emergency medical services arrives
D. Check for a pulse for 30 seconds before continuing CPR - A. Use the AED

1136. A client with cancer of the larynx is receiving external radiation therapy of
the neck. Which side effect related specifically to the site of irradiation does the
nurse tell the client to expect?
 A. Diarrhea
B. Dyspnea
C. Headache
D. Dysphagia - D. Dysphagia

1137. The nurse has instructed a client who is about to begin external radiation
therapy in how to maintain optimal skin integrity during therapy. Which statement
by the client indicates a need for further instruction?

A. "I need to keep the sun off the radiation site."

B. "I can use over-the-counter cortisone cream on the radiation site if it gets
red."
C. "I need to be careful not to wash off the marks that the radiologist made on
my skin."
D. "I need to wash the skin at the radiation site with a mild soap and water
and pat it dry." - B. "I can use over-the-counter cortisone cream on the
radiation site if it gets red."

1138. A nurse develops a nursing care plan for a client with a sealed radiation
implant. Which stipulation does the nurse include in the plan?

A. Visitors must be limited to one half-hour per day.

B. Visitors must remain at least 2 feet from the client.
C. A dosimeter badge must be placed on the client's bedside stand.
D. The client may be maintained in a semiprivate room as long as the client
uses a commode. - A. Visitors must be limited to one half-hour per day.

1139. A female client who has undergone placement of a sealed radiation

implant asks the nurse whether she can take a walk around the nursing unit. How
should the nurse respond to the client's request?

A. "Short walks are OK."

B. "You need to stay in your room for now."
C. "Yes, it's fine to take a walk around the nursing unit."
D. "Do you think that a walk around the unit will tire you out?" - B. "You need
to stay in your room for now."

1140. A nurse answers the call bell of a client who has been fitted with an
internal cervical radiation implant, and the client states that she thinks that the
implant has fallen out. The nurse checks the client and sees the implant lying in
the bed. Which action should the nurse take first?

A. Calling the health care provider

B. Reinserting the implant into the client's vagina
C. Picking up the implant with gloved hands and placing it in sterile water
 D. Using long-handled forceps to place the implant in a lead container - D.
Using long-handled forceps to place the implant in a lead container

1141. A client who experienced a brain attack (stroke) exhibits right-sided

unilateral neglect. The nurse caring for this client plans to place the client's
personal care items:

A. Within the client's reach on the left side

B. Within the client's reach on the right side
C. Just out of the client's reach on the left side
D. Just out of the client's reach on the right side - B. Within the client's reach
on the right side

1142. A client who is recovering from a brain attack (stroke) has residual
dysphagia. Which measure does the nurse plan to implement at mealtimes?

A. Giving the client thin liquids

B. Alternating liquids with solids
C. Giving foods that are primarily liquid
D. Placing food in the affected side of the client's mouth - B. Alternating
liquids with solids

1143. A nurse is teaching a client who is experiencing homonymous

hemianopsia after a brain attack (stroke) about measures to overcome the deficit.
The nurse tells the client to:

A. Wear eyeglasses 24 hours a day

B. Wear a patch on the affected eye
C. Turn the head to scan the lost visual field
D. Keep all objects in the impaired field of vision - C. Turn the head to scan
the lost visual field

1144. A nurse is providing home care instructions to a client with Parkinson

disease about measures to avoid rigidity and to overcome tremor and
bradykinesia. The nurse tells the client to:

A. Sit in soft, deep chairs

B. Rock back and forth to start movement
C. Exercise in the evening to combat fatigue
D. Perform tasks with only the hand that has the tremor - B. Rock back and
forth to start movement

1145. A client with a spinal cord injury suddenly complains of a pounding

headache. The nurse quickly assesses the client and notes that the client is
diaphoretic, that his blood pressure has increased, and that his heart rate has
 slowed. Suspecting that the client is experiencing autonomic dysreflexia, the
nurse elevates the head of the client's bed and immediately:

A. Documents the event

B. Notifies the healthcare provider
C. Checks the client's bladder for distention
D. Checks to see whether the client has a prescription for an
antihypertensive - C. Checks the client's bladder for distention

1146. A nurse is monitoring a client who has just undergone radical neck
dissection. The nurse notes that the client's blood pressure has dropped from
132/84 to 90/50 mm Hg and that the pulse has increased from 78 to 96
beats/min. On the basis of these findings, the nurse immediately:

A. Suctions the client

B. Obtains a pulse oximeter
C. Contacts the health care provider
D. Increases the rate of the client's intravenous (IV) solution - C. Contacts the
health care provider

1147. An emergency department (ED) nurse receives a telephone call from

emergency medical services and is told that a client who has sustained severe
burns of the face and upper arms is being transported to the ED. Which action
does the nurse, preparing for the arrival of the client, plan to implement first?

A. Inserting a Foley catheter

B. Initiating an intravenous (IV) line
C. Cleansing the burn wound
D. Administering 100% humidified oxygen - D. Administering 100%
humidified oxygen

1148. A nurse is assessing a client with AIDS for signs of Pneumocystis jiroveci
infection. Which sign of the infection is the earliest manifestation?

A. Fever
B. Dyspnea at rest
C. Dyspnea on exertion
D. Nonproductive cough - D. Nonproductive cough

1149. A client arrives at the emergency department with reports of a headache,

hives, itching, and difficulty swallowing. The client states that he took ibuprofen
(Motrin) 1 hour earlier and believes that he is experiencing an allergic reaction to
this medication. After ensuring that the client has a patent airway, which
intervention does the nurse prepare the client for first?

A. Administration of normal saline solution

 B. Administration of an intravenous (IV) glucocorticoid
C. Administration of pain medication to relieve the client's headache
D. Administration of a subcutaneous injection of epinephrine (Adrenalin) - D.
Administration of a subcutaneous injection of epinephrine (Adrenalin)

1150. A client is found to have AIDS. What is the nurse's highest priority in
providing care to this client?

A. Providing emotional support to the client

B. Discussing the cause of AIDS with the client
C. Instituting measures to prevent infection in the client
D. Identifying risk factors related to contracting AIDS with the client - C.
Instituting measures to prevent infection in the client

1151. A client who sustained a fracture of the left arm requires the application of
a plaster cast. The nurse tells the client that the procedure for applying the cast
involves:

A. Administering a local anesthetic to the fractured arm

B. Soaking the left arm in a warm-water bath for 2 hours before cast
application
C. Debriding any open wounds and applying antibiotic ointment before the
cast material is applied
D. Applying soft padding and stockinette over the fractured arm, followed by
the application of the cast material - D. Applying soft padding and
stockinette over the fractured arm, followed by the application of the cast
material

1152. A client has just had a plaster leg cast applied, and the nurse has given
the client instructions on cast care. Which statement by the client indicates
theneed for further instruction?

A. "I may feel cool while the cast is drying."

B. "I shouldn't use anything to scratch underneath the cast."
C. "If I smell any odor from the cast, I should call the doctor."
D. "I can dry the cast faster if I use a hairdryer on the hot setting." - D. "I can
dry the cast faster if I use a hairdryer on the hot setting."

1153. A client with a leg fracture who has been placed in skeletal traction is
transported to the orthopedic unit after surgery. Which finding would indicate the
need to contact the orthopedic specialist?

A. The traction knots are intact.

B. The traction weights are hanging freely.
C. The clamps on the traction frame are tight.
 D. The traction ropes are unable to move over the pulleys. - D. The traction
ropes are unable to move over the pulleys.

1154. Buck extension traction is applied to the right leg of a client who sustained
a right hip fracture. Which intervention should the nurse include in the plan of
care?

A. Assessing the pin sites at least every 8 hours

B. Removing the traction weights to provide skin care
C. Applying lanolin to the skin of the right leg once per shift
D. Checking the skin integrity of the right leg at least every 8 hours - D.
Checking the skin integrity of the right leg at least every 8 hours

1155. A nurse provides home care instructions to a client with a below-the-knee

amputation (BKA) about residual limb and prosthesis care. Which statement by
the client indicates a need for further instruction?

A. "I should wear a sock over my stump."

B. "I can wash my leg with a mild soap."
C. "I need to check my leg for irritation every day."
D. "I'll put lotion on my leg a few times a day." - D. "I'll put lotion on my leg a
few times a day."

1156. A nurse provides instructions to a client with rheumatoid arthritis about

joint exercises that are important to prevent deformity and reduce pain. Which
statement by the client indicates the need for further instruction?

A. "I should always maintain good posture."

B. "I should stop my exercises if I get tired."
C. "I should avoid all exercise when my joints are inflamed."
D. "Doing range-of-motion exercises every day will ease the pain." - C. "I
should avoid all exercise when my joints are inflamed."

1157. A nurse provides instructions to a client about measures to prevent an

acute attack of gout. The nurse determines that the client needs additional
instructions if the client states:

A. "It's important for me to drink a lot of fluids."

B. "A fad diet or starvation diet can cause an acute attack."
C. "I don't need medication unless I'm having a severe attack."
D. "Physical and emotional stress can cause an attack." - C. "I don't need
medication unless I'm having a severe attack."
1158. A nurse is providing instructions to an unlicensed assistive personnel
(UAP) about effective measures for communicating with a hearing-impaired
client. The nurse instructs the UAP to:

A. Raise his voice when talking to the client

B. Talk directly into the client's impaired ear
C. Be cordial and smile when talking to the client
D. Face the client when talking, keeping the hands away from the mouth - D.
Face the client when talking, keeping the hands away from the mouth

1159. A stapedectomy is performed on a client with otosclerosis. During the

preparations for discharge, which home care instruction does the nurse give the
client?

A. Expect excessive ear drainage for about 2 weeks.

B. Avoid rapidly moving the head and bending over for at least 3 weeks.
C. Rinse the ear canal at least twice a day to clear out any excess drainage.
D. It is all right to shower as long as the ear dressing is changed immediately
after the shower - B. Avoid rapidly moving the head and bending over for
at least 3 weeks.

1160. A nurse provides home care instructions to a client with Ménière disease
about measures to control and treat vertigo. The nurse should tell the client to:

A. Limit sodium in the diet

B. Increase fluid intake to at least 3000 mL/day
C. Lie down when vertigo occurs and keep a light on in the room
D. Move the head from the right to the left when vertigo occurs to determine
the extent of its effects - A. Limit sodium in the diet

1161. A client is transported to the recovery area of the ambulatory care unit
after cataract surgery. In which position does the nurse place the client?

A. Supine
B. Semi-Fowler
C. On the side that has undergone surgery
D. Prone on the side that has undergone surgery - B. Semi-Fowler

1162. A nurse is providing discharge instructions to a client after outpatient

surgery for cataract removal. The nurse determines that the client needs
additional instructions if the client indicates that he will:

A. Limit activity for 24 hours

B. Take acetaminophen for discomfort
C. Leave the eye patch in place until he has been seen by the health care
provider
 D. Expect to experience pain, nausea, and vomiting after the procedure - D.
Expect to experience pain, nausea, and vomiting after the procedure

1163. During a client's yearly eye examination, the nurse checks the intraocular
pressure. The nurse notes that the pressure in the right eye is 12 mm Hg and 19
mm Hg in the left. The nurse tells the client:

A. That he has glaucoma in the left eye

B. That he has glaucoma in the right eye
C. That the intraocular pressure in both eyes is normal
D. That he needs to increase his fluid intake, because the pressure in the
right eye is low - C. That the intraocular pressure in both eyes is normal

1164. A nurse provides home care instructions to a client after a scleral buckling
procedure. The nurse should tell the client:

A. To maintain strict bedrest for 48 hours

B. To expect bloody drainage on the eye dressing
C. That vision will be perfectly clear immediately after surgery
D. That redness and swelling of the eyelids and conjunctiva are expected - D.
That redness and swelling of the eyelids and conjunctiva are expected

1165. A nurse receives a telephone call from a neighbor, who says that her child
was just hit in the eye with a swing. The nurse rushes to the neighbor's house
and notes that the child has sustained a contusion of the eye. The nurse advises
the child's mother to immediately:

A. Call an ambulance
B. Call an optometrist
C. Apply ice to the affected eye
D. Irrigate the eye with cool water - C. Apply ice to the affected eye

1166. A client arrives in the emergency department for treatment of a surface

injury sustained when sand blew into the eye. Which action does the nurse take
first?

A. Assessing the client's vision

B. Placing ice on the eye
C. Removing the sand particles
D. Irrigating the eye with sterile saline solution - A. Assessing the client's
vision

1167. A client with chronic kidney disease is undergoing his first hemodialysis
treatment, and the nurse is monitoring the client for signs of disequilibrium
syndrome. For which signs of this syndrome does the nurse monitor the client?
 A. Fever and tachycardia
B. Headache and confusion
C. Bradycardia and hypothermia
D. Irritability and generalized weakness - B. Headache and confusion

1168. A hospitalized client with chronic renal failure has returned to the nursing
unit after a hemodialysis treatment. Which parameters contained in the
predialysis and postdialysis documentation does the nurse utilize to determine if
the procedure was effective?

A. Weight and BUN

B. Blood pressure and weight
C. Potassium and creatinine levels
D. Blood urea nitrogen (BUN) and creatinine levels - B. Blood pressure and
weight

1169. A nurse is caring for a hospitalized client who is undergoing peritoneal

dialysis. The nurse notes that the outflow is less than the inflow on the first
exchange. What should the nurse do first?

A. Irrigate the catheter

B. Reposition the client
C. Check the system for kinks
D. Hang the second exchange and continue to monitor the outflow - C.
Check the system for kinks

1170. A client has an arteriovenous fistula in place for hemodialysis. What

should the nurse do to assess the patency of the fistula?

A. Irrigate the fistula with 3 mL of normal saline solution

B. Infuse 50 mL of normal saline once per 24 hours
C. Palpate for a vibrating sensation at the fistula site
D. Flush the fistula with 1 mL of heparin solution once per shift - C. Palpate
for a vibrating sensation at the fistula site

1171. A nurse is administering care to a client with angina pectoris who is

attached to a cardiac monitor. The monitor alarm sounds, and the nurse notes
the rhythm shown here. How does the nurse interpret the rhythm?

A. Atrial fibrillation
B. Sinus tachycardia
C. Sinus bradycardia
D. Ventricular tachycardia - D. Ventricular tachycardia
1172. A nurse is monitoring a client after transurethral resection of the prostate
for benign prostatic hypertrophy. The client has a bladder irrigation infusing, and
the urine output is a light cherry color. The nurse performs a follow-up
assessment 1 hour later and notes that the urine output is now bright red in color
with clots and that the client's blood pressure has dropped. Which action by the
nurse is appropriate?

A. Contacting the health care provider

B. Continuing to monitor the client
C. Increasing the flow rate of the intravenous (IV) solution
D. Placing pressure on the bladder to aid expulsion of any additional clots -
A. Contacting the health care provider

1173. A nurse is monitoring a client with deep vein thrombosis (DVT) for signs of
pulmonary embolism. For which sign of DVT, the most common, does the nurse
assess the client?

A. Cough
B. Hemoptysis
C. Diaphoresis
D. Pleuritic chest pain - D. Pleuritic chest pain

1174. A nurse is caring for a client who has undergone resection of an

abdominal aortic aneurysm (AAA). Which action should the nurse implement to
prevent graft occlusion?

A. Monitoring urine output

B. Monitoring bowel sounds
C. Checking pedal pulses distal to the graft site
D. Limiting elevation of the head of the bed to 45 degrees - D. Limiting
elevation of the head of the bed to 45 degrees

1175. A client who experiences frequent episodes of chest pain is admitted to

the hospital for cardiac monitoring. The client suddenly complains of chest pain,
and the nurse obtains a 12-lead electrocardiogram (ECG). Which finding would
the nurse expect to note in the event of an ischemic episode?

A. Peaked T waves
B. ST-segment depression
C. Widened QRS complex
D. An isolated premature ventricular contraction (PVC) - B. ST-segment
depression

1176. The wife of a client with angina pectoris calls the health care provider's
office and reports to the nurse that her husband is experiencing chest pain and
 has taken 2 sublingual nitroglycerin tablets 5 minutes apart, with no relief. The
nurse tells the client's wife to:

A. Have her husband rest and, if no relief is obtained, call back

B. Discuss the situation with the doctor, who will call her as soon as he gets
into the office
C. Call Emergency Medical Services to take her husband to the emergency
department (ED) immediately
D. Give her husband a third tablet and, if no relief is obtained, call an
ambulance to have him transported to the ED - C. Call Emergency
Medical Services to take her husband to the emergency department (ED)
immediately

1177. A cardiac monitor alarm sounds, and a nurse notes a straight line on the
monitor screen. The nurse immediately:

A. Calls a code
B. Assesses the client
C. Checks the cardiac leads and wires
D. Obtains a rhythm strip from the monitor device - B. Assesses the client

1178. The emergency department nurse assesses a client who has a diagnosis
of left-sided heart failure. Which findings does the nurse expect to note?Select all
that apply.

A. Dyspnea
B. Dependent edema
C. Neck vein distention
D. Abdominal distention
E. Crackles on auscultation of the lungs - A. Dyspnea

1179. A nurse provides instructions to a client with chronic obstructive

pulmonary disease (COPD) about the positions that are most effective in
alleviating dyspnea. Which statement by the client indicates a need for further
instruction?

A. "I should sit up in my recliner."

B. "I should lie on my right side in bed."
C. "I should sit on the side of my bed and lean on the overbed table."
D. "I should stand with my back and hips against the wall and my shoulders
bent slightly forward." - B. "I should lie on my right side in bed."

1180. A nurse has admitted a client with a diagnosis of tuberculosis (TB) to the
nursing unit. Which finding that confirms the diagnosis does the nurse expect to
see documented in the client's record?
 A. Night sweats and a low-grade fever
B. Positive result on an acid-fast bacillus smear
C. Cough and expectoration of mucopurulent sputum
D. A tuberculin skin test result that indicates 5 mm of redness - B. Positive
result on an acid-fast bacillus smear

1181. A ventilator's low exhaled volume (low-pressure) alarm sounds, and the
nurse rushes to the client's room and quickly assesses the client. The client
appears to be having respiratory difficulty. The nurse should first:

A. Call a code
B. Suction the client
C. Call the anesthesiologist
D. Manually ventilate the client, using a resuscitation bag - D. Manually
ventilate the client, using a resuscitation bag

1182. A nurse is caring for a client in the intensive care unit (ICU) who is being
mechanically ventilated. As the nurse prepares medications, the client suddenly
becomes anxious and pulls out the endotracheal tube. The nurse assesses the
client for spontaneous breathing and then:

A. Prepares for reintubation

B. Restrains the client's wrists
C. Calls the rapid response team (RRT)
D. Administers an antianxiety medication to the client - A. Prepares for
reintubation

1183. The nurse teaches a client with gastroesophageal reflux disease (GERD)
about measures to prevent reflux during sleep. The nurse determines that the
client needs additional instructions if the client states:

A. "I should take an antacid at bedtime."

B. "I should sleep flat on my right side."
1184. C "The histamine antagonist will help me."
1185. D. "I should avoid eating in the 3 hours before bedtime." - B. "I should
sleep flat on my right side."

1186. A client is found to have viral hepatitis, and the nurse provides home care
instructions to the client. The nurse should tell the client to:

A. Maintain strict bed rest

B. Limit the intake of alcohol
C. Take acetaminophen for discomfort
D. Eat small frequent meals that are low in fat and protein and high in
carbohydrates - D. Eat small frequent meals that are low in fat and protein
and high in carbohydrates
1187. An emergency department nurse is caring for a client with acute
pancreatitis who will be admitted to the hospital. Into which position that will ease
the abdominal pain does the nurse assist the client?

A. Prone
B. Supine with the legs straight
C. With the knees drawn up to the chest
D. Side-lying with the head of the bed flat - C. With the knees drawn up to the
ches

1188. A nurse is developing a plan of care for a client with a new diagnosis of
Graves disease. Which intervention does the nurse include in the plan?

A. Keeping the room warm

B. Placing extra blankets on the client
C. Providing a high-calorie, high-protein diet
D. Encouraging frequent ambulation and activities - C. Providing a high-
calorie, high-protein diet

1189. A nurse is teaching a client with diabetes mellitus who requires insulin
about methods of preventing diabetic ketoacidosis (DKA) when the client is ill.
The nurse tells the client to:

A. Contact the health care provider if a fever over 102° F occurs

B. Refrain from eating or drinking during periods of vomiting
C. Take the prescribed insulin dose even if he is unable to eat
D. Contact the health care provider when the premeal blood glucose value is
greater than 350 mg/dL - C. Take the prescribed insulin dose even if he is
unable to eat

1190. A home care nurse visits a pregnant client with a diagnosis of mild
preeclampsia. During the assessment, the client tells the nurse that she has had
an upset stomach and pain in the epigastric area. The nurse most appropriately:

A. Contacts the client's health care provider

B. Tells the client to avoid lying flat
C. Instructs the client to eat a small portion of food every 2 to 3 hours
D. Administers an antacid to the client and tell her to take a dose every 6
hours - A. Contacts the client's health care provider

1191. A nurse is conducting an assessment of a client with mild preeclampsia.

Which sign indicates improvement in the client's condition?

A. Complaint of headache
B. Trace protein in the urine
 C. Blood pressure 148/94 mm Hg
D. Blood urea nitrogen (BUN) of 40 mg/dL (14.2 mmol/L) - B. Trace protein in
the urine

1192. A nurse is monitoring a client who is in the active phase of labor and has
been experiencing contractions that are coordinated but weak. Which
assessment finding indicates to the nurse that the client may be experiencing
hypotonic contractions?

A. Fetal hypoxia
B. Discomfort with each contraction
C. Increased frequency and longer duration of contractions
D. Contractions that can be indented easily with fingertip pressure at their
peak - D. Contractions that can be indented easily with fingertip pressure
at their peak

1193. A nurse in the labor room is performing a vaginal assessment of a

pregnant client who is in active labor. The nurse notes that the umbilical cord is
protruding from the vagina and immediately:

A. Pushes the cord gently back into the vagina

B. Prepares the client for cesarean delivery
C. Places the client in the knee-chest position
D. Prepares to administer a tocolytic medication - C. Places the client in the
knee-chest position

1194. A woman in labor suddenly complains of abdominal tenderness and pain

and states that she felt as though "something ripped." For which manifestations
does the nurse, suspecting uterine rupture, assess the client? Select all that
apply.

A. Bradypnea
B. Severe chest pain
C. Absence of fetal heart tones
D. Increased blood pressure
E. Increased frequency of uterine contractions - B. Severe chest pain
1195. C. Absence of fetal heart tones

1196. A client in the third trimester of pregnancy is experiencing painless vaginal

bleeding, and placenta previa is suspected. For which intervention does the
nurse prepare the client?

A. An ultrasound examination
B. Internal fetal monitoring
C. Administration of oxytocin (Pitocin)
D. A manual (digital) pelvic examination - A. An ultrasound examination
1197. A nurse is reading the medical record of a pregnant client in the second
trimester with a diagnosis of abruptio placentae. Which clinical manifestation of
the disorder does the nurse expect to see documented?

A. Uterine tenderness
B. Lack of uterine activity
C. Painless vaginal bleeding
D. Constipation - A. Uterine tenderness

1198. A nurse assessing a client in the fourth stage of labor notes that the
uterine fundus is firmly contracted and is midline at the level of the umbilicus. On
the basis of this finding, the nurse most appropriately:

A. Records the findings

B. Massages the fundus
C. Contacts the health care provider
D. Helps the mother void - A. Records the findings

1199. Mastitis is diagnosed in a client who recently gave birth. The nurse tells
the woman that:

A. Wearing a bra will increase the discomfort

B. Antibiotics are not usually used to treat this disorder
C. Breastfeeding must be discontinued until the condition resolves
D. Moist heat will increase circulation and may be used before the breasts
are emptied - D. Moist heat will increase circulation and may be used
before the breasts are emptied

1200. A mother calls the clinic and tells the nurse that her newborn's umbilical
cord site looks red and swollen. The nurse should tell the mother:

1201. A .That this is a normal occurrence

1202. B. To bring the newborn to the clinic
1203. C. To increase the number of cord site cleanings each day
1204. D. To place an ice pack on the cord for 10 minutes three times a day - B.
To bring the newborn to the clinic

1205. A nurse provides instructions to the mother of a newborn with

hyperbilirubinemia who is being breastfed. The nurse determines that the mother
understands the instructions if the mother says that she will:

A. Bottle feed only

B. Breastfeed the newborn every 2 to 3 hours
C. Provide water feedings between breast feedings
 D. Feed her newborn less frequently until the bilirubin level drops - B.
Breastfeed the newborn every 2 to 3 hours

1206. A nurse in the newborn nursery is monitoring a neonate born to a mother

with diabetes mellitus. For which finding does the nurse monitor the neonatemost
closely?

A. Hypercalcemia
B. Hyperglycemia
C. Hypobilirubinemia
D. Respiratory distress syndrome - D. Respiratory distress syndrome

1207. A nurse is assessing a newborn for fetal alcohol syndrome (FAS). Which
finding would the nurse expect to note in the newborn?

A. Greater-than-average length
B. Higher-than-normal birth weight
C. Short palpebral fissures and a flat midface
D. Greater-than-average head circumference - C. Short palpebral fissures
and a flat midface

1208. A nurse is preparing a teaching plan for the parents of an infant with a
ventricular peritoneal shunt. Which instruction does the nurse plan to include?

A. Call the health care provider if the infant is lethargic.

B. Expect increased urine output with the shunt.
C. Call the health care provider if the anterior fontanel bulges when the infant
cries.
D. Position the infant on the side of the shunt for sleep. - A. Call the health
care provider if the infant is lethargic.

1209. A nurse in a newborn nursery receives a telephone call from the delivery
room and is told that a newborn with spina bifida (meningomyelocele type) will be
transported to the nursery. Which item does the nurse, preparing for the arrival of
the newborn, make a priority of placing at the newborn's bedside?

A. Flashlight
B. Sterile dressing
C. Cardiac monitor
D. Blood pressure cuff - B. Sterile dressing

1210. A nurse is assessing a child with increased intracranial pressure who has
been exhibiting decorticate posturing. The nurse notes extension of the upper
and lower extremities, with internal rotation of the upper arms and wrists and the
knees and feet. The nurse determines that the child's condition:
 A. Indicates improved neurological status
B. Indicates decreased intracranial pressure
C. Indicates deterioration in neurological function
D. Is unchanged from the previous neurological assessment - C. Indicates
deterioration in neurological function

1211. An ambulatory care nurse is providing home care instructions to the

mother of a child who had a tonsillectomy. The nurse determines that the
motherneeds further instruction if she indicates that she will:

A. Avoid giving citrus juices to her child

B. Have her child use a straw to make drinking easier
C. Give acetaminophen (Tylenol) to her child for discomfort
D. Give her child extra fluids to relieve a foul odor from the mouth - B. Have
her child use a straw to make drinking easier

1212. A home care nurse has provided instructions to the father of a child with
croup regarding treatment measures. Which statement by the father indicates a
need for further instruction?

A. "I should put a steam vaporizer in her room."

B. "I'll take her out into the cool, humid night air."
C. "I can open the freezer door and encourage her to breathe in the cool air."
D. "I can run the hot water in my bathroom and cuddle her in the steamy
room." - A. "I should put a steam vaporizer in her room."

1213. A nurse is caring for a hospitalized child with a diagnosis of Kawasaki

disease. During the subacute phase, the nurse monitors the child closely for:

A. Bleeding
B. A high fever
C. Failure to thrive
D. Signs of congestive heart failure (CHF) - D. Signs of congestive heart
failure (CHF)

1214. A nurse has been assigned to care for an infant with tetralogy of Fallot.
The infant suddenly exhibits rapid, deep respirations; irritability; and cyanosis.
The nurse determines that the infant is experiencing a hypercyanotic episode
and immediately:

A. Calls a code
B. Holds the infant in an upright position
C. Places the infant in the knee-chest position
D. Contacts the respiratory therapy department - C. Places the infant in the
knee-chest position
1215. A nurse is conducting the initial assessment of a child with rheumatic
fever. Which question does the nurse ask the parents to elicit information specific
to the development of the disease?

A. "Has he had any loss of appetite?"

B. "Has he complained of a backache recently?"
C. "Has he been excessively tired or lethargic?"
D. "Has he had a sore throat in the last few months?" - D. "Has he had a sore
throat in the last few months?"

1216. A nurse is obtaining subjective data from the mother of a child admitted to
the hospital with a diagnosis of intussusception. Which occurrence does the
nurse expect the mother to report?

A. Scleral jaundice
B. Projectile vomiting
C. Hard, pale stools
D. Bloody mucus stools and diarrhea - D. Bloody mucus stools and diarrhea

1217. A nurse provides dietary instructions to the mother of a child with celiac
disease. Which food does the nurse tell the mother to include in the child's diet?

A. Rice
B. Wheat cereal
C. Rye crackers
D. Oatmeal biscuits - A. Rice

1218. A child with a diagnosis of pertussis (whooping cough) is being admitted to

the pediatric unit. As soon as the child arrives to the unit, the nurse first:

A. Weighs the child

B. Takes the child's temperature
C. Attaches the child to a pulse oximeter
D. Administers the prescribed antibiotic - C. Attaches the child to a pulse
oximeter

1219. A nurse is assessing a 12-month-old child with iron-deficiency anemia.

Which finding does the nurse expect to note in this child?

A. Lethargy
B. Bradycardia
C. Hyperactivity
D. Reddened cheeks - A. Lethargy

1220. A nurse is caring for a child with newly diagnosed type 1 diabetes mellitus
who is receiving insulin. The child suddenly exhibits tachycardia and beings to
 sweat and tremble, and the nurse determines that the child is experiencing a
hypoglycemic reaction. The nurse would immediately give the child:

A. A sugar cube
B. A teaspoon of sugar
1221. C . ½ cup of diet cola
1222. D. ½ cup of fruit juice - D. ½ cup of fruit juice

1223. A nurse is reviewing the assessment findings and laboratory results of a

child with a diagnosis of new-onset glomerulonephritis. Which finding would the
nurse expect to note?

A. Hypertension
B. Low serum potassium
C. Increased creatinine level
D. Cloudy yellow urine - A. Hypertension

1224. A home care nurse is providing instructions to the mother of a 3-year-old

with hemophilia regarding care of the child. Which statements by the mother
indicate a need for further instructions? Select all that apply.

A."I will be so glad when my baby outgrows all of this bleeding."

B."I need to cancel all of the dental appointments that I've made for him."
C."If he gets a cut, I should hold pressure on it until the bleeding stops."
D."I should check the house for any household items that could fall over
easily."
E. "I should move furniture with sharp corners out of the way and pad the
corners of the furniture." - A. "I will be so glad when my baby outgrows all
of this bleeding."
1225. B. "I need to cancel all of the dental appointments that I've made for him."

1226. The alarm on a client's cardiac monitor goes off, and the nurse rushes to
the client's bedside and finds the client unconscious. After noting the following
rhythm on the monitor, the nurse immediately:

A. Checks for a radial pulse

B. Assesses the client's neurological status
C. Increases the flow rate of the client's intravenous infusion
D. Begins cardiopulmonary resuscitation (CPR) - B. Assesses the client's
neurological status