Professional Documents
Culture Documents
1. A pregnant woman who is at term is admitted to the birthing unit in active labor. The
client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with
hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her
contractions. Which of the following is the most important aspect of nursing
intervention at this time?
A. Timing and recording length of contractions.
B. Monitoring.
C. Preparing for an emergency cesarean birth.
D. Checking the perineum for bulging.
2. A client who hallucinates is not in touch with reality. It is important for the nurse to:
A. Isolate the client from other patients.
B. Maintain a safe environment.
C. Orient the client to time, place, and person.
D. Establish a trusting relationship.
3. The nurse is caring to a child client who has had a tonsillectomy. The child complains
of having dryness of the throat. Which of the following would the nurse give to the
child?
A. Cola with ice
B. Yellow noncitrusJello
C. Cool cherry Kool-Aid
D. A glass of milk
4. The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-old
client. The nurse caring to the client provides instructions that the nasal spray must be
used exactly as directed to prevent the development of:
A. Increased nasal congestion.
B. Nasal polyps.
C. Bleeding tendencies.
D. Tinnitus and diplopia.
5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be
assigned to care for the client must institute appropriate precautions. The nurse should:
A. Place the client in a private room.
B. Wear an N 95 respirator when caring for the client.
C. Put on a gown every time when entering the room.
D. Don a surgical mask with a face shield when entering the room.
6. Which of the following is the most frequent cause of noncompliance to the medical
treatment of open-angle glaucoma?
A. The frequent nausea and vomiting accompanying use of miotic drug.
B. Loss of mobility due to severe driving restrictions.
12. The staff nurse on the labor and delivery unit is assigned to care to a primigravida
in transition complicated by hypertension. A new pregnant woman in active labor is
admitted in the same unit. The nurse manager assigned the same nurse to the second
client. The nurse feels that the client with hypertension requires one-to-one care. What
would be the initial actionof the nurse?
A. Accept the new assignment and complete an incident report describing a shortage of
nursing staff.
B. Report the incident to the nursing supervisor and request to be floated.
C. Report the nursing assessment of the client in transitional labor to the nurse
manager and discuss misgivings about the new assignment.
D. Accept the new assignment and provide the best care.
13. A newborn infant with Down syndrome is to be discharged today. The nurse is
preparing to give the discharge teaching regarding the proper care at home. The nurse
would anticipate that the mother is probably at the:
A. 40 years of age.
B. 20 years of age.
C. 35 years of age.
D. 20 years of age.
14. The emergency department has shortage of staff. The nurse manager informs the
staff nurse in the critical care unit that she has to float to the emergency department.
What should the staff nurse expect under these conditions?
A. The float staff nurse will be informed of the situation before the shift begins.
B. The staff nurse will be able to negotiate the assignments in the emergency
department.
C. Cross training will be available for the staff nurse.
D. Client assignments will be equally divided among the nurses.
15. The nurse is assigned to care for a child client admitted in the pediatrics unit. The
client is receiving digoxin. Which of the following questions will be asked by the nurse
to the parents of the child in order to assess the clients risk for digoxin toxicity?
A. Has he been exposed to any childhood communicable diseases in the past 2-3
weeks?
B. Has he been taking diuretics at home?
C. Do any of his brothers and sisters have history of cardiac problems?
D. Has he been going to school regularly?
16. The nurse noticed that the signed consent form has an error. The form states,
Amputation of the right leg instead of the left leg that is to be amputated. The nurse
has administered already the preoperative medications. What should the nurse do?
A. Call the physician to reschedule the surgery.
B. Call the nearest relative to come in to sign a new form.
A. Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have
frequency associated with fever, pain on voiding, or blood in the urine, call your
doctor/nurse-midwife.
B. Placental progesterone causes irritability of the bladder sphincter. Your symptoms
will go away after the baby comes.
C. Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids to
1L/daily.
D. Frequency is due to bladder irritation from concentrate urine and is normal in
pregnancy. Increase your daily fluid intake to 3L.
23. Which of the following will help the nurse determine that the expression of hostility
is useful?
A. Expression of anger dissipates the energy.
B. Energy from anger is used to accomplish what needs to be done.
C. Expression intimidates others.
D. Degree of hostility is less than the provocation.
24. The nurse is providing an orientation regarding case management to the nursing
students. Which characteristics should the nurse include in the discussion in
understanding case management?
A. Main objective is a written plan that combines discipline-specific processes used to
measure outcomes of care.
B. Main purpose is to identify expected client, family and staff performance against the
timeline for clients with the same diagnosis.
C. Main focus is comprehensive coordination of client care, avoid unnecessary
duplication of services, improve resource utilization and decrease cost.
D. Primary goal is to understand why predicted outcomes have not been met and the
correction of identified problems.
25. The physician orders a dose of IV phenytoin to a child client. In preparing in the
administration of the drug, which nursing action is not correct?
A. Infuse the phenytoin into a smaller vein to prevent purple glove syndrome.
B. Check the phenytoin solution to be sure it is clear or light yellow in color, never
cloudy.
C. Plan to give phenytoin over 30-60 minutes, using an in-line filter.
D. Flush the IV tubing with normal saline before starting phenytoin.
26. The pregnant woman visits the clinic for check up. Which assessment findings will
help the nurse determine that the client is in 8-week gestation?
A. Leopold maneuvers.
B. Fundal height.
C. Positive radioimmunoassay test (RIA test).
D. Auscultation of fetal heart tones.
27. Which of the following nursing intervention is essential for the client who had
pneumonectomy?
33. The ambulance team calls the emergency department that they are going to bring a
client who sustained burns in a house fire. While waiting for the ambulance, the nurse
will anticipate emergency care to include assessment for:
A. Gas exchange impairment.
B. Hypoglycemia.
C. Hyperthermia.
D. Fluid volume excess.
34. Most couples are using natural family planning methods. Most accidental
pregnancies in couples preferred to use this method have been related to unprotected
intercourse before ovulation. Which of the following factor explains why pregnancy may
be achieved by unprotected intercourse during the preovulatory period?
A. Ovum viability.
B. Tubal motility.
C. Spermatozoal viability.
D. Secretory endometrium.
35. An older adult client wakes up at 2 oclock in the morning and comes to the nurses
station saying, I am having difficulty in sleeping. What is the best nursing response to
the client?
A. Ill give you a sleeping pill to help you get more sleep now.
B. Perhaps youd like to sit here at the nurses station for a while.
C. Would you like me to show you where the bathroom is?
D. What woke you up?
36. The nurse is taking care of a multipara who is at 42 weeks of gestation and in
active labor, her membranes ruptured spontaneously 2 hours ago. While auscultating
for the point of maximum intensity of fetal heart tones before applying an external fetal
monitor, the nurse counts 100 beats per minute. The immediate nursing action is to:
A. Start oxygen by mask to reduce fetal distress.
B. Examine the woman for signs of a prolapsed cord.
C. Turn the woman on her left side to increase placental perfusion.
D. Take the womans radial pulse while still auscultating the FHR.
37. The nurse must instruct a client with glaucoma to avoid taking over-the-counter
medications like:
A. Antihistamines.
B. NSAIDs.
C. Antacids.
D. Salicylates.
38. A male client is brought to the emergency department due to motor vehicle
accident. While monitoring the client, the nurse suspects increasing intracranial
pressure when:
A. Client is oriented when aroused from sleep, and goes back to sleep immediately.
B. Blood pressure is decreased from 160/90 to 110/70.
C. Client refuses dinner because of anorexia.
D. Pulse is increased from 88-96 with occasional skipped beat.
39. The nurse is conducting a lecture to a class of nursing students about advance
directives to preoperative clients. Which of the following statement by the nurse js
correct?
A. The spouse, but not the rest of the family, may override the advance directive.
B. An advance directive is required for a do not resuscitate order.
C. A durable power of attorney, a form of advance directive, may only be held by a
blood relative.
D. The advance directive may be enforced even in the face of opposition by the
spouse.
40. A client diagnosed with schizophrenia is shouting and banging on the door leading
to the outside, saying, I need to go to an appointment. What is the appropriate
nursing intervention?
A. Tell the client that he cannot bang on the door.
B. Ignore this behavior.
C. Escort the client going back into the room.
D. Ask the client to move away from the door.
41. Which of the following action is an accurate tracheal suctioning technique?
A. 25 seconds of continuous suction during catheter insertion.
B. 20 seconds of continuous suction during catheter insertion.
C. 10 seconds of intermittent suction during catheter withdrawal.
D. 15 seconds of intermittent suction during catheter withdrawal.
42. The clients jaw and cheekbone is sutured and wired. The nurse anticipates that the
most important thing that must be ready at the bedside is:
A. Suture set.
B. Tracheostomy set.
C. Suction equipment.
D. Wire cutters.
43. A mother is in the third stage of labor. Which of the following signs will help the
nurse determine the signs of placental separation?
A. The uterus becomes globular.
B. The umbilical cord is shortened.
C. The fundus appears at the introitus.
D. Mucoid discharge is increased.
44. After therapy with the thrombolytic alteplase (t-PA. , what observation will the
nurse report to the physician?
A. 3+ peripheral pulses.
B. Change in level of consciousness and headache.
C. Occasional dysrhythmias.
D. Heart rate of 100/bpm.
45. A client who undergone left nephrectomy has a large flank incision. Which of the
following nursing action will facilitate deep breathing and coughing?
A. Push fluid administration to loosen respiratory secretions.
B. Have the client lie on the unaffected side.
C. Ill give the medicine if my child gets into some plant bulbs.
D. Ill give the medicine if my child gets into some vitamin pills.
77. To assess if the cranial nerve VII of the client was damaged, which changes would
not be expected?
A. Drooling and drooping of the mouth.
B. Inability to open eyelids on operative side.
C. Sagging of the face on the operative side.
D. Inability to close eyelid on operative side.
78. The community health nurse makes a home visit to a family. During the visit, the
nurse observes that the mother is beating her child. What is the priority nursing
intervention in this situation?
A. Assess the childs injuries.
B. Report the incident to protective agencies.
C. Refer the family to appropriate support group.
D. Assist the family to identify stressors and use of other coping mechanisms to prevent
further incidents.
79. The nurse in the neonatal care unit is supervising the actions of a certified nursing
assistant in giving care to the newborns. The nursing assistant mistakenly gives a
formula feeding to a newborn that is on water feeding only. The nurse is responsible for
the mistake of the nursing assistant:
A. Always, as a representative of the institution.
B. Always, because nurses who supervise less-trained individuals are responsible for
their mistakes.
C. If the nurse failed to determine whether the nursing assistant was competent to take
care of the client.
D. Only if the nurse agreed that the newborn could be fed formula.
80. The nurse is assigned to care for a client with urinary calculi. Fluid intake of 2L/day
is encouraged to the client. the primary reason for this is to:
A. Reduce the size of existing stones.
B. Prevent crystalline irritation to the ureter.
C. Reduce the size of existing stones
D. Increase the hydrostatic pressure in the urinary tract.
81. The nurse is counseling a couple in their mid 30s who have been unable to
conceive for about 6 months. They are concerned that one or both of them may be
infertile. What is the best advice the nurse could give to the couple?
A. it is no unusual to take 6-12 months to get pregnant, especially when the partners
are in their mid-30s. Eat well, exercise, and avoid stress.
B. Start planning adoption. Many couples get pregnant when they are trying to adopt.
C. Consult a fertility specialist and start testing before you get any older.
D. Have sex as often as you can, especially around the time of ovulation, to increase
your chances of pregnancy.
82. The nurse is caring for a cient who Is a retired nurse. A 24-hour urine collection for
Creatinine clearance is to be done. The client tells the nurse, I cant remember what
this test is for. The best response by the nurse is:
A. It provides a way to see if you are passing any protein in your urine.
B. It tells how well the kidneys filter wastes from the blood.
C. It tells if your renal insufficiency has affected your heart.
D. The test measures the number of particles the kidney filters.
83. The nurse observes the female client in the psychiatric ward that she is having a
hard time sleeping at night. The nurse asks the client about it and the client says, I
cant sleep at night because of fear of dying. What is the best initial nursing response?
A. It must be frightening for you to feel that way. Tell me more about it.
B. Dont worry, you wont die. You are just here for some test.
C. Why are you afraid of dying?
D. Try to sleep. You need the rest before tomorrows test.
84. In the hospital lobby, the registered nurse overhears a two staff members
discussing about the health condition of her client. What would be the appropriate
action for the registered nurse to take?
A. Join in the conversation, giving her input about the case.
B. Ignore them, because they have the right to discuss anything they want to.
C. Tell them it is not appropriate to discuss such things.
D. Report this incident to the nursing supervisor.
85. The client has had a right-sided cerebrovascular accident. In transferring the client
from the wheelchair to bed, in what position should a client be placed to facilitate safe
transfer?
A. Weakened (L) side of the cient next to bed.
B. Weakened (R) side of the client next to bed.
C. Weakened (L) side of the client away from bed.
D. Weakened (R) side of the cient away from bed.
86. The child client has undergone hip surgery and is in a spica cast. Which of the
following toy should be avoided to be in the childs bed?
A. A toy gun.
B. A stuffed animal.
C. A ball.
D. Legos.
87. The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10 units (IV or IM)
must be given to a client after birth fo the fetus. The nurse is correct to explain that
oxytocin:
A. Minimizes discomfort from afterpains.
B. Suppresses lactation.
C. Promotes lactation.
D. Maintains uterine tone.
88. The nurse in the nursing care unit is aware that one of the medical staff displays
unlikely behaviors like confusion, agitation, lethargy and unkempt appearance. This
behavior has been reported to the nurse manager several times, but no changes
observed. The nurse should:
A. Continue to report observations of unusual behavior until the problem is resolved.
B. Consider that the obligation to protect the patient from harm has been met by the
and did not know the hospitals policy concerning telephone orders. The nurse was also
unfamiliar with the doctor and the client. Therefore the nurse should not take the order
unless A. no one else is available and B. it is an emergency situation.
12. C. The nurse is obligated to inform the nurse manager about changes in the
condition of the client, which may change the decision made by the nurse manager.
13. A. Perinatal risk factors for the development of Down syndrome include advanced
maternal age, especially with the first pregnancy.
14. B. Assignments should be based on scope of practice and expertise.
15. B. The child who is concurrently taking digoxin and diuretics is at increased risk for
digoxin toxicity due to the loss of potassium. The child and parents should be taught
what foods are high in potassium, and the child should be encouraged to eat a highpotassium diet. In addition, the childs serum potassium level should be carefully
monitored.
16. A. The responsible for an accurate informed consent is the physician. An exception
to this answer would be a life-threatening emergency, but there are no data to support
another response.
17. D. Asking the client to cough and take a deep breath will help determine if the chest
tube is kinked or if the lungs has reexpanded.
18. B. Every event that exposes a client to harm should be recorded in an incident
report, as well as reported to the appropriate supervisors in order to resolve the current
problems and permit the institution to prevent the problem from happening again.
19. D. One of the earliest signs of digoxin toxicity is Bradycardia. For a toddler, any
heart rate that falls below the norm of about 100-120 bpm would indicate Bradycardia
and would necessitate holding the medication and notifying the physician.
20. B. This option is least threatening.
21. D. In preparing the client for discharge that is receiving prednisone, the nurse
should caution the client to (A. take oral preparations after meals; (B. remember that
routine checks of vital signs, weight, and lab studies are critical; (C. NEVER STOP OR
CHANGE THE AMOUNT OF MEDICATION WITHOUT MEDICAL ADVICE; (D. store the
medication in a light-resistant container.
22. A. Progesterone also reduces smooth muscle motility in the urinary tract and
predisposes the pregnant woman to urinary tract infections. Women should contact
their doctors if they exhibit signs of infection. Kegel exercise will help strengthen the
perineal muscles; limiting fluids at bedtime reduces the possibility of being awakened by
the necessity of voiding.
23. B. This is the proper use of anger.
24. C. There are several models of case management, but the commonality is
comprehensive coordination of care to better predict needs of high-risk clients,
decrease exacerbations and continually monitor progress overtime.
25. A. Phenytoin should be infused or injected into larger veins to avoid the
discoloration know as purple glove syndrome; infusing into a smaller vein is not
appropriate.
26. C. Serum radioimmunoassay (RIA. is accurate within 7days of conception. This test
is specific for HCG, and accuracy is not compromised by confusion with LH.
27. D. Surgery and anesthesia can increase mucus production. Deep breathing and
coughing are essential to prevent atelectasis and pneumonia in the clients only
remaining lung.
28. B. Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophiliA. and
conjunctivitis from Chlamydia.
29. D. The client may perceive this as avoidance, but it is more important to redirect
back to the client, especially in light of the manipulative behavior of drug abusers and
adolescents.
30. C. It describes a democratic process in which all members have input in the clients
care.
31. A. Contraction of the milk ducts and let-down reflex occur under the stimulation of
oxytocin released by the posterior pituitary gland.
32. B. In case management, the nurse assumes total responsibility for meeting the
needs of the client during the entire time on duty.
33. A. Smoke inhalation affects gas exchange.
34. C. Sperm deposited during intercourse may remain viable for about 3 days. If
ovulation occurs during this period, conception may result.
35. B. This option shows acceptance (key concept) of this age-typical sleep pattern
(that of waking in the early morning).
36. D. Taking the mothers pulse while listening to the FHR will differentiate between
the maternal and fetal heart rates and rule out fetal Bradycardia.
37. A. Antihistamines cause pupil dilation and should be avoided with glaucoma.
38. A. This suggests that the level of consciousness is decreasing.
39. D. An advance directive is a form of informed consent, and only a competent adult
or the holder of a durable power of attorney has the right to consent or refuse
treatment. If the spouse does not hold the power of attorney, the decisions of the
holder, even if opposed by the spouse, are enforced.
40. C. Gentle but firm guidance and nonverbal direction is needed to intervene when a
client with schizophrenic symptoms is being disruptive.
41. C. Suctioning is only done for 10 seconds, intermittently, as the catheter is being
withdrawn.
42. D. The priority for this client is being able to establish an airway.
43. A. Signs of placental separation include a change in the shape of the uterus from
ovoid to globular.
44. B. This could indicate intracranial bleeding. Alteplase is a thrombolytic enzyme that
lyses thrombi and emboli. Bleeding is an adverse effect. Monitor clotting times and
signs of any gastrointestinal or internal bleeding.
45. D. Because flank incision in nephrectomy is directly below the diaphragm, deep
breathing is painful. Additionally, there is a greater incisional pull each time the person
moves than there is with abdominal surgery. Incisional pain following nephrectomy
generally requires analgesics administration every 3-4 hours for 24-48 hours after
surgery. Therefore, turning, coughing and deep-breathing exercises should be planned
to maximize the analgesic effects.
46. B. Under high estrogen levels, during the period surrounding ovulation, the cervical
mucus becomes thin, clear, and elastic (spinnbarkeit), facilitating sperm passage.
47. D. After surgery for a ruptured appendix, the client should be placed in a semiFowlers position to promote drainage and to prevent possible complications.
48. C. Directing and evaluation of staff is a major responsibility of a nursing manager.
49. A. The recommended procedure for administering eyedrops to any client calls for
the drops to be placed in the middle of the lower conjunctival sac.
50. B. Thirst and restlessness indicate hypovolemia and hypoxemia. Internal bleeding is
difficult to recognized and evaluate because it is not apparent.
51. C. Erythema toxicum is the normal, nonpathological macular newborn rash.
52. D. The family needs to understand what brain death is before talking about organ
donation. They need time to accept the death of their family member. An environment
conducive to discussing an emotional issue is needed.
53. A. Bending from the waist in pregnancy tends to make backache worse.
54. B. Support and limit setting decrease anxiety and provide external control.
55. C. The stoma drainage bag is applied in the operating room. Drainage from the
ileostomy contains secretions that are rich in digestive enzymes and highly irritating to
the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin
exposed to these enzymes even for a short time becomes reddened, painful and
excoriated.
56. B. It is the most accurate statement of physiological facts for a 28-day menstrual
cycle: ovulation at day 14, egg life span 24 hours, sperm life span of 72 hours.
Fertilization could occur from sperm deposited before ovulation.
57. C. An advocate role encourage freedom of choice, includes speaking out for the
client, and supports the clients best interests.
58. A. Abstinence will eliminate any unnecessary pain during intercourse and will reduce
the possibility of transmitting infection to ones sexual partner.
59. B. Anxiety is generated by group therapy at 9:00 AM. The ritualistic behavioral
defense of hand washing decreases anxiety by avoiding group therapy.
60. D. Denial is a very strong defense mechanism used to allay the emotional effects of
discovering a potential threat. Although denial has been found to be an effective
mechanism for survival in some instances, such as during natural disasters, it may in
greater pathology in a woman with potential breast carcinoma.
61. B. The registered nurse cannot delegate the responsibility for assessment and
evaluation of clients. The status of the client in restraint requires further assessment to
determine if there are additional causes for the behavior.
62. C. The client with chest pain may be having a myocardial infarction, and immediate
assessment and intervention is a priority.
63. B. Is correct because semen analysis requires that a freshly masturbated specimen
be obtained after a rest (abstinence) period of 48-72 hours.
64. C. Betamethasone, a form of cortisone, acts on the fetal lungs to produce
surfactant.
65. A. Secretions may have pooled above the tracheostomy cuff. If these are not
suctioned before deflation, the secretions may be aspirated.
82. B. Determining how well the kidneys filter wastes states the purpose of a Creatinine
clearance test.
83. A. Acknowledging a feeling tone is the most therapeutic response and provides a
broad opening for the client to elaborate feelings.
84. C. The behavior should be stopped. The first is to remind the staff that
confidentiality maybe violated.
85. C. With a right-sided cerebrovascular accident the client would have left-sided
hemiplegia or weakness. The clients good side should be closest to the bed to facilitate
the transfer.
86. D. Legos are small plastic building blocks that could easily slip under the childs cast
and lead to a break in skin integrity and even infection. Pencils, backscratchers, and
marbles are some other narrow or small items that could easily slip under the childs
cast and lead to a break in skin integrity and infection.
87. D. Oxytocin (Pitocin) is used to maintain uterine tone.
88. B. The submission of reports about incidents that expose clients to harm does not
remove the obligation to report ongoing behavior as long as the risk to the client
continues.
89. C. The recommended dosage of tetracycline is 25-50mg/kg/day. If the child weighs
20kg and the maximum dose is 50mg/kg, this would indicate a total daily dose of
1000mg of tetracycline. In this case, the child is being given this medication four times
a day. Therefore the maximum single dose that can be given is 250mg (1000 mg of
tetracycline divided by four doses.)
90. C. An abnormality in the uterine muscle could reduce the effectiveness of uterine
contractions and lengthen the duration of subsequent labors.
91. A. Personality disorders stem from a weak superego, implying a lack of adequate
controls.
92. C. The basal body temperature is the lowest body temperature of a healthy person
that is taken immediately after waking and before getting out of bed. The BBT usually
varies from 36.2 C to 36.3C during menses and for about 5-7 days afterward. About
the time of ovulation, a slight drop in temperature may be seen, after ovulation in
concert with the increasing progesterone levels of the early luteal phase, the BBT rises
0.2-0.4 C. This elevation remains until 2-3 days before menstruation, or if pregnancy
has occurred.
93. A. This choice implies concern for client care and self-improvement.
94. C. The first trimester is the period of organogenesis, that is, cell differentiation into
the various organs, tissues, and structures.
95. C. This response does not contradict the clients perception, is honest, and shows
empathy.
96. D. Tension on round ligament occurs because of the erect human posture and
pressure exerted by the growing fetus.
97. D. The Good Samaritan Law does not impose a duty to stop at the scene of an
emergency outside of the scope of employment, therefore nurses who do not stop are
not liable for suit.
98. C. Although reducing environment stimuli and activity is necessary for a woman
with mild preeclampsia, she will most probably have bathroom privileges.
99. B. A normal respiratory rate for a newborn is 30-40 breaths per minute.
100. D. The behavior described is likely to be symptoms of delirium tremens, or alcohol
withdrawal (often unsuspected on a surgical unit.)