RAY A.

GAPUZ REVIEW SYSTEM

By Dr. Ray A. Gapuz, RN,DSc.

1. The nurse is assigned to care for a child with juvenile idiopathic arthritis (JIA). What is the child’s priority
problem?
1. Acute pain
2. Potential difficulty with everyday tasks
3. Impaired mobility causing potential injury
4. Negative view of body because of activity intolerance

2. The nurse is caring for a client who is going to have an arthrogram involving the use of a contrast medium.
Whichaction by the nurse is the priority?
1. Determining the presence of client allergies
2. Asking if the client has any last-minute questions
3. Telling the client to try to void before leaving the unit
4. Emphasizing to the client the importance of remaining still during the procedure

3. The nurse is caring for a client who had an orthopedic injury of the leg requiring surgery and application of a
cast.Postoperatively, which nursing assessment is of highest priority?
1. Monitoring for heel breakdown
2. Monitoring for bladder distention
3. Monitoring for extremity shortening
4. Monitoring for loss of blanching ability of toe nail beds

4. The nurse is conducting a health screening clinic. The nurse interprets that which client participating in the
screening isthe highest priority client to provide instruction to lower the risk of developing respiratory
disease?
1. A 36-year-old who works with pesticides
2. A 40-year-old smoker who works in a hospital
3. A 25-year-old who does woodworking as a hobby
4. A 50-year-old smoker who has cracked asbestos lining on the basement pipes in her home

5. A client with acute kidney injury has an elevated blood urea nitrogen (BUN). The client is experiencing
difficulty remembering information because of uremia. Which interventions should the nurse use when
communicating with thisclient?
Select all that apply:
1. Give simple, clear directions.
2. Include the family in discussions related to care.
3. Give thorough, lengthy explanations of procedures.
4. Explain treatments using understandable language.
5. Use as many teaching methods as available to provide discharge instructions.

6. A client is resuming a diet after a Billroth II procedure. To minimize complications from eating, which actions
shouldthe nurse teach the client to do?
Select all that apply:
1. Lay down after eating
2. Eat a diet high in protein
3. Drink liquids with meals
4. Eat six small meals per day
5. Eat concentrated sweets between meals only
7. The nurse is counseling the family of a client who has terminal cancer about palliative care. The nurse
explains thatwhich are goals of palliative care?
Select all that apply:
1. Delays death
2. Offers a support system
3. Provides relief from pain
4. Enhances the quality of life
5. Focuses only on the client, not the family
6. Manages symptoms of disease and therapies

8. The nurse is developing a care plan for an older client being admitted to a long-term care facility. Which
informationshould the nurse use to plan interventions for this client?
Select all that apply:
1. Most older clients are incontinent.
2. Older clients are at risk for dehydration.
3. Depression is a normal part of the aging process.
4. Age-related skin changes require special monitoring.
5. Older clients are at risk for complications of immobility.
6. Confusion and cognitive changes are common findings in the older population.

9. The nurse is caring for a client who is 33 weeks pregnant and has premature rupture of the membranes
(PROM). Which should the nurse expect to be part of the plan of care?
Select all that apply:
1. Perform frequent biophysical profiles.
2. Monitor for elevated serum creatinine
3. Monitor for manifestations of infection.
4. Teach the client how to count fetal movements.
5. Use strict sterile technique for vaginal examinations.
6. Inform the client about the need for tocolytic therapy.

10. A client comes into the health care clinic stating that she thinks she has restless leg syndrome. The nurse
assesses theclient and determines that which data are characteristics of this disorder?
Select all that apply:
1. A heavy feeling in the legs
2. Burning sensations in the limbs
3. Symptom relief when lying down
4. Decreased ability to move the legs
5. Symptoms that are worse in the morning
6. Feeling the need to move the limbs repeatedly

11. The nurse in a rehabilitation center is planning the client assignments for the day. Which client has needs
that can bemost safely met by the unlicensed assistive personnel (UAP)?
1. A client on strict bed rest for whom a 24-hour urine specimen is being collected
2. A client scheduled for transfer to the hospital for coronary artery bypass surgery
3. A client scheduled for transfer to the hospital for an invasive diagnostic procedure
4. A client who is going through rehabilitation after undergoing a below-the-knee amputation (BKA)

12. Which client could the nurse delegate to the unlicensed assistive personnel (UAP)?
1. A client who needs teaching regarding the use of an incentive spirometer
2. A client who needs to have a urine specimen collected for a clean catch urine
3. A client who needs reinforcement of a dressing covering an abdominal incision
4. A client who needs assessment of a newly identified area of pressure over the right hip
13. The registered nurse (RN) is creating a plan for the assignments for the day and is leading a team
composed of a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Based on
licensure, which client is mostappropriate to assign to the LPN?
1. A client with dementia
2. A 1-day postoperative mastectomy client
3. A client who requires some assistance with bathing
4. A client who requires some assistance with ambulation

14. The nurse has been assigned to care for a client recovering at home from a disabling lung infection. While
obtaininga nursing history, the nurse learns that the infection is probably the result of human
immunodeficiency virus (HIV) contracted through homosexual activity. The nurse is morally opposed to
homosexuality and cannot care for the client. The nurse then leaves the client’s home. Which is acceptable
regarding the nurse’s actions?
Select all that apply:
1. The nurse has the moral right to leave the client’s home at any time.
2. The nurse has a legal right to inform the client of any barriers to providing care.
3. The nurse has a duty to protect self from client care situations that are morally repellent.
4. The nurse has a duty to provide competent care to assigned clients in a nondiscriminatory manner.
5. The nurse has the right to refuse to care for any client on religious grounds if competent care
coverage is arranged

15. The nurse is preparing to administer a first dose of pentamidine isethionate (Pentam 300) intravenously to
a client.Before administering the dose, which safety mea- sure should the nurse consider for this client?
1. Assign to a private room
2. Establish a supine position
3. Place on respiratory precautions
4. Assist to a semi-Fowler’s position

16. The nurse is planning care for a client with acute glomerulonephritis. Which action should the nurse
instruct theunlicensed assistive personnel (UAP) to take in the care of the client?
1. Ambulate the client frequently.
2. Encourage a diet that is high in protein.
3. Monitor the temperature every 2 hours.
4. Remove the water pitcher from the bedside

17. The nurse has completed discharge teaching with the parents of a child with glomerulo nephritis. Which
statement bythe parents indicates that further teaching is necessary?
1. “We’ll check our child’s blood pressure every day.”
2. “We’ll test our child’s urine for albumin every week.”
3. “It’ll be so good to have our child back in tap-dancing classes next week.”
4. “We’ll be sure that our child eats a lot of vegetables and does not add extra salt to food.

18. A client with glomerulonephritis is at risk of developing acute kidney injury. Which is a sign of this
complication?
1. Bradycardia
2. Hypertension
3. Decreased cardiac output
4. Decreased central venous pressure

19. A client with benign prostatic hyperplasia undergoes transurethral resection of the prostate (TURP). The
nurse shouldrequest which solution from the pharmacy so it is available postoperatively for continuous
bladder irrigation (CBI)?
1. Sterile water
2. Sterile normal saline
3. Sterile Dakin’s solution
4. Sterile water with 5% dextrose
20. The client scheduled for a transurethral resection prostatectomy (TURP) has listened to the surgeon’s
explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be
removed. The nurse should tell the client that the prostate will be removed through which location?
1. The urethra
2. A lower abdominal incision
3. An upper abdominal incision
4. An incision made in the perineal area

21. The nurse is caring for a client with heart failure who has a magnesium level of 0.75 mg/dL. Which action
should thenurse take?
1. Monitor the client for irregular heart rhythms.
2. Encourage the intake of antacids with phosphate.
3. Teach the client to avoid foods high in magnesium.
4. Provide a diet of ground beef, eggs, and chicken breast

22. The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor. Which action
should thenurse take?
1. Prepare for defibrillation.
2. Continue to monitor the rhythm.
3. Notify the health care provider immediately.
4. Prepare to administer lidocaine hydrochloride (Xylocaine)

23. The nurse hears the alarm sound on the telemetry monitor, looks at the monitor, and notes that the client
is in ventricular tachycardia. The nurse rushes to the client’s room. Upon reaching the client’s bedside,
which action should thenurse take first?
1. Call a code.
2. Prepare for cardioversion.
3. Prepare to defibrillate the client.
4. Check the client’s level of consciousness

24. A client is in ventricular tachycardia and the health care provider prescribes intravenous (IV) lidocaine
(Xylocaine).The nurse should dilute the concentrated solution of lidocaine with which solution?
1. Lactated Ringer’s 3. 5% Dextrose in water
2. Normal saline 0.9% 4. Normal saline 0.45%

25. The nurse is preparing to administer amiodarone (Cordarone) intravenously. To provide a safe
environment, the nurseshould ensure that which specific item is in place for the client before
administering the medication?
1. Oxygen therapy
2. Oxygen saturation monitor
3. Continuous cardiac monitoring
4. Noninvasive blood pressure cuff

26. A client remains in atrial fibrillation with rapid ventricular response despite pharmacological intervention.
Synchronous cardioversion is scheduled to convert the rapid rhythm. What action should the nurse plan to
take to ensuresafety and prevent complications of this procedure?
1. Cardiovert the client at 360 joules.
2. Sedate the client before cardioversion.
3. Ensure that emergency equipment is available.
4. Check that the defibrillator is set on the synchronous mode
27. The nurse working on an adult nursing unit is told to review the client census to determine which clients
could bedischarged if there are a large number of admissions from a newly declared disaster. The nurse
determines that the clients with which problems would need to remain hospitalized?
Select all that apply:
1. Laparoscopic cholecystectomy
2. Fractured hip, pinned 5 days ago
3. Diabetes mellitus with blood glucose at 180 mg/dL
4. Ongoing ventricular dysrhythmias while receiving procainamide
5. Newly delivered postpartal client with a blood pressure of 146/94 and 2+ proteinuria

28. A spouse of a client who is scheduled for the insertion of an implantable cardioverter- defibrillator (ICD)
expressesanxiety about what would happen if the device discharges during physical contact. What
information should the nurse provide to the spouse?
1. Physical contact should be avoided when- ever possible.
2. The spouse would not feel or be harmed by the countershock.
3. The shock would be felt, but it would not cause the spouse any harm.
4. A warning device sounds before counter- shock, so there is time to move away.

29. A client is admitted to the hospital with a myocardial infarction and is not experiencing chest pain at this
time. The nurse reviews the electrocardiogram (ECG) rhythm strip, notes that the PR intervals are 0.16
seconds, and determines that which is the appropriate interpretation?
1. A normal finding
2. An abnormal finding
3. An impending reinfarction
4. First-degree atrioventricular (AV) block

30. The nurse is providing emergency treatment for a client in ventricular tachycardia and is preparing to
defibrillate theclient. Which nursing action provides for the safest environment during a defibrillation
attempt?
1. Ensuring that no lubricant is on the paddles
2. Placing the charged paddles one at a time on the client’s chest
3. Holding the client’s upper torso stable while the defibrillation is performed
4. Performing a visual and verbal check that all assisting personnel are clear of the client and the
client’s bed

31. A client with unstable ventricular tachycardia (VT) loses consciousness and becomes pulseless after an
initial treatment with a dose of lidocaine (Xylocaine) intravenously. Which item should the nurse caring for
the clientimmediately obtain?
1. A pacemaker
2. A defibrillator
3. A second dose of lidocaine
4. An electrocardiogram machine

32. A client has been defibrillated at 360 joules (monophasic) and the attempts to convert the ventricular
fibrillation (VF)were unsuccessful. Based on an evaluation of the situation, the nurse determines that which
action would be best?
1. Terminating the resuscitation effort
2. Preparing for the administration of sodium bicarbonate intravenously
3. Performing cardiopulmonary resuscitation (CPR) for 5 cycles or about 2 minutes
4. Performing cardiopulmonary resuscitation (CPR) for 5 minutes, then defibrillatingthree more times at
400 joules
33. A client who is taking an antipsychotic is preparing for discharge. To facilitate health promotion for this
client, whatinstruction should the nurse provide?
1. Avoid prolonged exposure to the sun.
2. Adhere to a strict tyramine-restricted diet.
3. Recognize the signs and symptoms of a relapse of depression.
4. Have therapeutic blood levels drawn because the medication has a narrow therapeutic range.

34. The nurse is reviewing the record of a client who was admitted to the hospital for diagnostic studies after a
faintingspell. The nurse notes that the client is receiving olanzapine (Zyprexa). Which disorder or condition
should the nurse suspect in the client?
1. History of schizophrenia
2. History of diabetes mellitus
3. History of diabetes insipidus
4. History of coronary artery disease

35. The nurse caring for a client taking clozapine (Clozaril) for the treatment of a schizophrenic disorder
reviews the laboratory studies that have been prescribed for the client. Which laboratory study is the
priority to monitor for an adverse effect associated with the use of this medication?
1. Platelet count
2. Cholesterol level
3. Blood urea nitrogen
4. White blood cell count

36. A manic client is placed in a seclusion room after an outburst of violent behavior that involved a physical
assault onanother client. Which intervention should the nurse include in her plan of care before seclusion?
1. Ask the client if she understands why the seclusion is necessary.
2. Remain silent because verbal interaction would be too stimulating.
3. Tell the client that she will be allowed to come out when she can behave.
4. Inform the client that she is being secluded to help her regain her self-control

37. The nurse is preparing a plan of care for a client diagnosed with mania. Which interventions should be
included in theplan of care?
Select all that apply:
1. Place the client in seclusion.
2. Ignore any client complaints.
3. Use a firm and calm approach.
4. Use short and concise explanations and statements.
5. Remain neutral and avoid power struggles and value judgments.
6. Firmly redirect energy into more appropriate and constructive channels.

38. The nurse reviews the client’s health care record and notes that the client is taking hydrochloride (Aricept).
Understanding the purpose of this medication, the nurse suspects this client has which medical problem?
1. Dementia
2. Seizure disorder
3. History of schizophrenia
4. Obsessive-compulsive disorder

39. The nurse is providing instructions to the spouse of a client who is taking tacrine (Cognex) for the
management ofmoderate dementia associated with Alzheimer’s disease. Which instruction should the
nurse give to the spouse?
1. Not to administer the medication with food.
2. If a dose is missed, double up on the next dose.
3. If a change in the color of the stools occurs, notify the health care provider.
4. If flulike symptoms occur, it is necessary to notify the health care provider immediately
40. A client with chronic kidney disease has an indwelling peritoneal catheter in the abdomen for peritoneal
dialysis. While bathing, the client spills water on the abdominal dressing covering the abdomen. Which
action should the nurseperform immediately?
1. Change the dressing.
2. Reinforce the dressing.
3. Flush the peritoneal dialysis catheter.
4. Scrub the catheter with povidone-iodine.

41. The client with chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a
daily doseof enalapril (Vasotec). When should the nurse plan to administer this medication?
1. During dialysis
2. Just before dialysis
3. The day after dialysis
4. Upon return from dialysis

42. The nurse develops a care plan for a client receiving hemodialysis who has an arteriovenous (AV) fistula in
the rightarm. The nurse includes which interventions in the plan to protect the AV fistula?
Select all that apply:
1. Assess pulses and circulation proximal to the fistula.
2. Palpate for thrills and auscultate for a bruit every 4 hours.
3. Check for bleeding and infection at hemodialysis needle insertion sites.
4. Avoid taking blood pressure or performing venipuncture in the extremity.
5. Instruct the client not to carry heavy objects or anything that compresses the extremity.
6. Instruct the client not to sleep in a position that places his or her body weight on top of the
extremity.

43. The nurse is admitting to the nursing unit a client who has an arteriovenous (AV) fistula in the right arm for
hemodialysis. Which strategy should the nurse plan to implement to best prevent injury to the site?
1. Applying an allergy bracelet to the right arm
2. Placing an alert bracelet per agency procedure on the client’s right arm
3. Putting a large note about the access site on the front of the medical record
4. Telling the client to inform all caregivers who enter the room about the presence of the access site.

44. The nurse manager of a hemodialysis unit observes a new nurse preparing hemodialysis on a client with
chronic kidney disease. The nurse manager should note the new nurse needs further teaching and
intervene if which action iscarried out by the new nurse?
1. Uses sterile technique for needle insertion
2. Wears full protective clothing such as goggles, mask, gown, and gloves
3. Covers the connection site with a bath blanket to enhance extremity warmth
4. Puts on a mask and gives one to the client to wear during connection to the machine

45. The experienced nurse watches a novice nurse performing hemodialysis on a client. The novice nurse is
drinkingcoffee and eating a doughnut next to the hemodialysis machine while talking with the client about
the client’s week. Which action should the experienced nurse take?
1. Get a cup of coffee and join in on the conversation.
2. Determine whether or not the client would like a cup of coffee.
3. Admire the therapeutic relationship the novice nurse has with the client.
4. Ask the novice nurse to refrain from eating and drinking in the client area

46. The nurse is performing an assessment on a client with a diagnosis of chronic angina pectoris who is
receiving sotalol (Betapace) 80mg orally twice daily. Which assessment finding indicates that the client is
experiencing an adverse effect ofthe medication?
1. Dry mouth 3. Diaphoresis
2. Palpitations 4. Difficulty swallowing
47. The nurse is assessing a client who is being treated with a beta-adrenergic blocker. Which assessment
findings wouldindicate that the client may be experiencing dose- related side effects of the medication?
Select all that apply:
1. Dizziness 4. Sexual dysfunction
2. Bradycardia 5. Cardiac dysrhythmias
3. Reflex tachycardia

48. A client has been taking nadolol (Corgard) for the past month. Which finding would indicate a therapeutic
effect of themedication?
1. The client is afebrile.
2. The client has clear breath sounds.
3. The client reports no episodes of headache.
4. The client has a blood pressure of 118/72 mm Hg

49. The nurse provides home care instructions to a client with cancer who has an implanted vascular access
port. Which statement by the client indicates the need for further teaching?
1. “I should keep the site clean and dry.”
2. “I should pump the port daily to maintain patency.”
3. “If the site becomes red, I will notify my health care provider.”
4. “The port will need to be flushed with saline to maintain patency.

50. A pregnant client diagnosed with mitral valve prolapse is prescribed anticoagulant therapy during
pregnancy. Thenurse reviews the client’s medical record, expecting to note that which medication is
prescribed?
1. Oral intake of warfarin (Coumadin) daily
2. Intravenous infusion of heparin sodium daily
3. Subcutaneous administration of terbutaline daily
4. Subcutaneous administration of heparin sodium daily

51. The nurse is planning to assist with obtaining a set of arterial blood gas measurements for a client. Which
itemsshould the nurse plan to provide to optimally maintain the integrity of the specimen?
1. A syringe that contains a preservative
2. A heparinized syringe and a bag of ice
3. A heparinized syringe and a preservative
4. A syringe that contains a preservative and a bag of ice

52. A client is receiving heparin sodium by continuous intravenous infusion. Which adverse effect of this
therapy shouldthe nurse monitor the client?
1. Tinnitus 3. Increased pulse rate
2. Ecchymoses 4. Decreased blood pressure

53. A client with a ruptured intracranial aneurysm in which surgery is contraindicated is still maintained on bed
rest withsubarachnoid precautions in place. The nurse should question which medication if it is prescribed
for this client?
1. Nicardipine (Cardene SR) 3. Docusate sodium (Colace)
2. Heparin sodium (Heparin) 4. Aminocaproic acid (Amicar)

54. When preparing the client with a spinal cord injury who is experiencing bladder spasms and reflex
incontinence fordischarge to home, the nurse should provide which instruction to prevent the problem?
1. “Avoid caffeine in your diet.”
2. “Take your temperature every day.”
3. “Limit your fluid intake to 1000mL per 24 hours.”
4. “Catheterize yourself every 2 hours as needed to prevent spasm
55. A primigravida client comes to the clinic and has been diagnosed with a urinary tract infection. She
repeatedlyverbalizes concern regarding the safety of the fetus. What should the nurse address first?
1. Client’s fear
2. Prescribing a sedative
3. Instructions regarding improved hygiene
4. Instructions regarding medication compliance

56. Which actions should the nurse implement to prevent ventilator-associated pneumonia (VAP) in the client
who is intubated and on mechanical ventilation?
1. Practice meticulous hand hygiene.
2. Maintain the head of the bed elevation at 10 degrees.
3. Perform suctioning of oral cavity secretions every 4 hours.
4. Have the respiratory therapist change the ventilator circuit tubing every 4 hours

57. The nurse is caring for the client with silicosis who has massive pulmonary fibrosis. The nurse monitors the
client foremotional reactions related to the chronic respiratory disease. Which emotional reaction, if
expressed by the client, indicates a need for immediate intervention?
1. Anxiety 3. Suicidal ideation
2. Depression 4. Ineffective coping

58. The nurse is monitoring the function of a client’s chest tube. The chest tube is attached to a chest drainage
system. Thenurse notes that the fluid in the water-seal chamber is below the 2-cm mark. What should the
nurse determine based on this finding?
1. There is a leak in the system.
2. Suction should be added to the system.
3. This is caused by client pneumothorax.
4. Water should be added to the chamber.

59. A client is experiencing pulmonary edema as an exacerbation of chronic left-sided heart failure. The nurse
shouldassess the client for what manifestation?
1. Weight loss
2. Bilateral crackles
3. Distended neck veins
4. Peripheral pitting edema

60. The nurse prepares a client who has a right pleural effusion for a thoracentesis; however, the client
experiences severe dizziness when sitting upright. Which alternate position should the nurse assist the
client into to maintain safety during the procedure?
1. Right side-lying with the head of the bed flat
2. Prone with the head turned toward the affected side
3. Sims ’position with the head of the bed elevated 45 degrees
4. Left side-lying with the head of the bed elevated 45 degrees