1. Which client statement indicates potential obstructive sleep apnea? a) "I have so much trouble getting to sleep at night." b) "I wake up feeling just as tired as I did when I went to bed." c) "I wake up persistently during the night, over and over." d) "I can't breathe when I lie flat in the bed.".
2. Which statement indicates that the client does not understand teaching about radiation therapy for laryngeal cancer? a) "I will avoid exposing my skin to sunlight during treatment." b) "I will purchase a wig so that my appearance will be close to normal." c) "I will rest my voice and communicate by writing for the next 2 months." d) "I will not shave until all the redness and peeling of the skin on my face and neck is gone.".
3. Which is the nurse's priority intervention for a confused client who is to start oxygen therapy? a) Determine which method of oxygen delivery the client will best tolerate. b) Instruct the client about the importance of leaving the oxygen delivery device on. c) Explain to the client that he will not be allowed to smoke while receiving oxygen. d) Monitor the client's ability to tolerate removal of oxygen while eating.
4. Which statement by the nurse indicates an accurate understanding of tuberculosis (TB) as a disease process? a) "The risk of transmitting TB will be reduced after the client has had drug therapy for 6 weeks." b) "A definitive diagnosis of TB can be made using a chest x-ray." c) "Conclusive evidence of TB can be found through physical examination of the chest." d) "The TB client can have a negative skin test if he is immunocompromised.".
5. The nurse is instructing a group of new nurses on the ventilator bundle approach to the prevention of ventilator-associated pneumonia (VAP). What intervention is emphasized in this approach? a) Keep the client's head of the bed elevated to 90 degrees. b) Change the ventilator circuit every 8-hour shift. c) Perform meticulous oral care at least every 24 hours. d) Continuously remove subglottic secretions.
6. Which assessment finding alerts the nurse to the possibility of a pleural effusion and empyema? a) Wheezing on exhalation on the side with the broken ribs b) Absence of fremitus at and below the site of injury c) Crepitus of the skin around the site of injury d) Absence of gastric motility.
7. Which client is at greatest risk for the development of a pulmonary embolism? a) A young adult athlete who lifts weights and was diagnosed with a pneumothorax yesterday. b) A middle-aged woman who has used oral contraceptives for the past 15 years and who had abdominal surgery yesterday for cancer c) A middle-aged woman who has fragile capillaries and bruises very easily. d) An older man who caught his right hand in a piece of machinery and has five broken fingers, with extensive soft tissue damage.
8. What precaution will the nurse teach a client who is being discharged on sodium warfarin (Coumadin)? a) "Decrease your intake of sodium." b) "Your blood-clotting time will decrease." c) "Increase your intake of multiple vitamins." d) "Avoid aspirin and aspirin-containing drugs.".
9. The client at risk for ARDS has become cyanotic and diaphoretic. Which is the nurse's priority assessment? a) Measuring pulse oximetry b) Auscultating breath sounds bilaterally c) Measuring the blood pressure in both arms d) Comparing the current electrocardiographic tracing with the baseline measurement.
10. A client is scheduled to have a surgical procedure that will require endotracheal intubation and mechanical ventilation for several days postoperatively. What will the nurse tell the client about postoperative communication? a) "You will be sedated and won't need to communicate." b) "I will call the anesthesiologist to discuss your concerns." c) "We will use a variety of strategies to make sure that your needs are meet." d) "You will have to use gestures to communicate.".
11. Which action will the nurse take to improve the quality of the electrocardiographic rhythm transmission to the monitoring system? a) Apply lotion to the client's chest before attaching the chest leads. b) Remove the hair from the chest area before attaching the chest leads. c) Instruct the client not to wear any clothing made from synthetic fabrics during the test. d) Apply skin protectant to area prior to placing electrode.
12. What will the nurse administer to a client with sustained supraventricular tachycardia? a) Atropine (Atropine) b) Epinephrine (Adrenalin) c) Lidocaine (Xylocaine) d) Diltiazem (Cardizem).
13. Which client is most at risk for atrial fibrillation? a) A middle-aged client who takes an aspirin daily b) A client 3 days postcoronary artery bypass surgery c) An older adult client post-carotid endarterectomy d) An older adult with diabetes mellitus and hypertension.
14. A client with heart failure develops an increase in preload. Which mechanism contributes to this increase? a) A reduction in sympathetic stimulation b) Stimulation of coronary baroreceptors c) Activation of the renin-angiotensin-aldosterone system d) Arterial vasodilation and subsequent increase in oxygen consumption.
15. A client with a history of myocardial infarction calls the clinic to report the onset of a cough that is troublesome only at night. What direction will the nurse give to the client? a) "Come to the clinic for evaluation." b) "Increase fluid intake during waking hours." c) "Use an over-the-counter cough suppressant before going to sleep." d) "Use two pillows to facilitate drainage of postnasal secretions.".
16. Which statement made by a client would alert the nurse to the possibility of right-sided heart failure? a) "I sleep with four pillows at night." b) "My shoes fit really tight." c) "I wake up coughing every night." d) "I have trouble catching my breath.".
17. Which assessment finding alerts the nurse to the possibility of pulmonary edema in an older adult? a) Confusion b) Dysphagia c) Sacral edema d) Irregular heart rate.
18. What clinical manifestation alerts the nurse to the possibility that the client's mitral stenosis has progressed? a) The client's oxygen saturation is 92%. b) The client has dyspnea on exertion. c) The client has a systolic crescendo-decrescendo murmur. d) The client experiences a loss of strength in the upper extremities.
19. A client with hyperlipidemia who is being treated with dietary fat restrictions and an exercise program asks the nurse why his serum lipid levels are still elevated. What activity by the nurse is most appropriate? a) Developing a very low-fat diet that the client will adhere to b) Explaining familial tendencies in hyperlipidemia c) Referring the client to a registered dietitian for weight loss d) Educating the client on antihyperlipidemic medications.
20. What specific instructions should the nurse give to the client with atherosclerosis who is attempting to stop cigarette smoking with the use of a nicotine patch? a) “Abruptly discounting this patch can cause high BP” b) “Abruptly discontinuing this patch can cause nausea and vomiting” c) “Smoking while using this patch increased the risk of respiratory infections” d) “Smoking while using this patch increases the risk of health failure”.
21. With hypertension has been prescribed clonidine hydrochloride (Catapres). Which
…. Will the nurse give to this client?
a) Take this medication at bedtime.” b) Call your health care provider if a rash develops.’ c) “You will need to have your blood counts monitored regularly.” d) “Take this medication by puncturing the capsule and placing the liquid contents.
22. A client with chronic peripheral arterial disease and claudication tells the nurse that burning pain often awakens him from sleep. What is the nurse's interpretation of this change? a) The client has inflow disease. b) The client has outflow disease. c) The client's disease is worsening. d) The client's disease is stable.
23. Which nursing action is indicated for the client who has developed compartment syndrome after aortoiliac bypass graft surgery for peripheral arterial disease?
a) Performing passive range-of-motion exercise on the affected limb to increase flexibility. b) Preparing the client for return to the operative suite for surgical correction. c) Medicating the client for pain and placing the client in a knee-chest position. d) Loosening the dressing and elevating the extremity to the level of the heart.
24. Which monitoring technique being performed by a new graduate nurse should be questioned in the client with an unrepaired abdominal aortic aneurysm? a) Measurement of abdominal girth. b) Observation of abdominal wall movement c) Auscultation of any area of the abdomen d) Palpation of the abdominal midline area.
25. A client has been admitted with a gastrointestinal ulcer. The client is NPO and has a nasogastric tube in place connected to low suction. What form of shock should the nurse monitor this client for? a) Distributive shock b) Obstructive shock c) Cardiogenic shock d) Hypovolemic shock .
26. The nurse is taking the history of a client with suspected CAD who has had episodes of chest discomfort while mowing the lawn. Because the chest discomfort subsides when the client rests, the nurse correlates this with which condition? a) Variant angina b) Stable angina c) Do you notice any changes in your memory d) Do you bruise easily.
28. Which instruction is most important for the nurse to include in the client's discharge plan after a splenectomy? a) Avoid crowds b) Avoid fruit and raw vegetables c) You will be at an increased risk for developing allergies d) Do not play contact sports.
30. The nurse is planning care for a client who has a platelet count of 30,000/mm3. Which intervention does the nurse include in this client's plan of care? a) Oxygen by nasal cannula b) Bleeding Precaution c) Isolation Precautions d) Vital signs every 4 hours.
31. Which identification mean should the nurse use to ensure that a blood transfusion administered to the correct client? a.) Ask the client whether his or her name is the one on the blood product tag. b.) Ask the client's spouse if the client is supposed to have a transfusion. c.) Compare the name and ID number on the blood product tag with the name and ID number on the client's ID band. d.) Compare the unit and room number of the client with the unit and room number listed on the blood product tag.
32. For which clinical manifestation in the client with a history of complex partial seizures will the nurse assess? a) Automatisms b) Blank staring c) Sudden loss of muscle tone d) Brief jerking of the extremities.
33. The nurse is caring for a client with a history of epilepsy who suddenly begins to experience a tonic-clonic seizure and loses consciousness. What is the nurse's priority action? a) Restrain the client's extremities. b) Turn the client's head to the side. c) Take the client's blood pressure. d) Place an airway into the client's mouth.
34. Which statement indicates that the family has a good understanding of the changes in motor movement associated with this disease? a) "I can never tell what she's thinking. She hides behind a frozen face." b) "She drools all the time so I just can't take her out anywhere." c) "I think this disease makes her nervous. She perspires all the time." d) "She has trouble chewing so I will offer bite-sized portions.".
36. Which postoperative complaint voiced by a client who had a discectomy 6 hours ago priority action? a) Fatigue b) Thirst c) Restlessness d) Inability to void.
37. A nurse is caring for a client experiencing spinal shock after a spinal cord injury. Which clinical manifestation indicates the resolution of spinal shock? a. The return of reflex activity b. Normalization of the pupillary reflex c. Return of bowel and bladder continence d. Tingling in the extremities below the lesion.
38. A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/95 mm Hg. Which is the nurse’s first action? a. Palpating the area over the bladder for distention b. Placing the client in the Trendelenburg position c. Administering oxygen via a nasal cannula d. Performing carotid massage.
39. A nurse notes reddened areas over the hips and sacrum of a client with paraplegia from a spinal cord injury. Which is the nurses best action? a. Rubbing the areas with an oil-based lubricant b. Performing hip flexion and extension range-of-motion (ROM) exercises c. Repositioning the client so that the reddened area does not bear weight d. Ensuring that the client sits in a chair at least once each shift.
40. The nurse monitors for which complication in a client with compression of the pituitary gland by a brain tumor? a. SIADH b. Syncope c. Diabetes mellitus d. Pulmonary edema.
41. A client comes to the emergency department with periorbital ecchymosis of the right eye. Which is the nurse's priority inyaction? a.) Apply an ice pack to the affected eye. b.) Patching the eye to prevent eye movement c.) Assessing the client’s vision in both eyes d.) irrigating the affected eye with normal saline.
43. Which assessment alerts the nurse to the possible presence of a cataract in a client? a.) Loss of central vision. b.) Loss of peripheral vision. c.) Dull aching in the eye and brow areas. d.) Blurred vision and reduced color perception.
44. The nurse is caring for a client with external otitis. Which assessment finding indicates to the nurse that the client's infection has worsened? a.) The client now reports tinnitus and vertigo at night. b.) The client now has a positive Rinne test, with AC > BC. c.) The tympanic membrane is pearly gray with white patches. d.) The auricular lymph nodes have increased in size over the last 24 hours.
45. The nurse is caring for a client with otitis media and notes purulent drainage in the ear canal during the physical assessment. Which is the nurse's priority intervention? a.) Obtaining a specimen of the drainage for culture. b.) Irrigating the ear canal with sterile normal saline. c.) Gently examine the client's ear with an otoscope. d.) Placing a cotton ball in the ear canal to absorb the drainage.
46. The nurse is caring for a client with Ménière's disease. The client asks the nurse how to prevent another acute episode from occurring. Which is the nurse's best response? a.) Stop or reduce cigarette smoking." b.) Use aspirin rather than acetaminophen (Tylenol) for pain." c.) Reduce the quantity of saturated fats in your diet." d.) Avoid crowds and people with upper respiratory infection.".
47. The nurse is caring for a 132-lb client with an ear infection who is to receive amoxicillin, 40 mg/kg/day in divided doses every 8 hours. The nurse will administer ____ mg/dose of amoxicillin to the client.
132 lb × (1 kg/2.2 lb) = 60 kg
60 kg × (40 mg/day) = 2400 mg/day)/3 =
a.) 800 b.) 750 c.) 880 d.) 700.
48. Which serum electrolyte values alert the nurse to the possibility of hyperaldosteronism? a.) Serum sodium 150 mmol/L, serum potassium 2.5 mmol/L. b.) Serum sodium 140 mmol/l, serum potassium 5.0 mmol/l. c.) Serum sodium 130 mmol/l, serum potassium 2.5 mmol/l. d.) Serum sodium 130 mmol/l, serum potassium 7.5 mmol/l.
49. A client presents with elevations in triiodothyronine (T3) and thyroxine (T4), and a decrease in thyroid stimulating hormone levels (TSH). Which is the nurse's priority intervention? a) Administer levothyroxine (Synthroid). b) Administer liothyronine (Cytomel). c) Monitor the apical pulse. d) Assess for Trousseaus' sign.
50. Which statement made by the client indicates the need further teaching about injection site selection and rotation of insulin? a.) “The abdominal site is best because it is closest to the pancreas” (it is best because of better absorption). b.) I can reach my thigh the best, so I will use different areas of the same thigh”. c.) By rotating the sites in one area, my chance of having tissue increases or decreases is less.” d.) If I change injection sites from the thigh to the arm, the rate of absorption will be different.”.