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Text Mode – Text version of the exam 1. Nurse Michelle should know that the drainage is normal 4 days after a sigmoid colostomy when the stool is:
2. Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia?
3. A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse?
4. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by:
5. Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action?
6. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should:
7. A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?
8. A client undergone ileostomy, when should the drainage appliance be applied to the stoma?
9. A client undergone spinal anesthetic, it will be important that the nurse immediately position the client in:
10.While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?
11.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first?
12. A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit?
13. Mark, a 7-year-old client is brought to the emergency department. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He recently had a cold. Form this history; the client may have which of the following conditions?
14. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have which of the following reactions?
15. A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging?
16. Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to administration of this medication?
17. Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to:
18. Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by:
19. Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication:
20. Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover:
21. When caring for a female client who is being treated for hyperthyroidism, it is important to:
22. Nurse Kris is teaching a client with history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:
23. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client following a:
24. A 55-year old client underwent cataract removal with intraocular lens implant. Nurse Oliver is giving the client discharge instructions. These instructions should include which of the following?
25. George should be taught about testicular examinations during:
26. A male client undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. Nurse Trish first response is to:
27. Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne- Strokes respirations. Cheyne-strokes respirations are:
28. Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:
29. The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and breath sounds aren’t audible. The reason for this change is that:
30. Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should:
31. After insertion of a cheat tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?
32. Nurse Maureen is talking to a male client, the client begins choking on his lunch. He’s coughing forcefully. The nurse should:
33. Nurse Ron is taking a health history of an 84 year old client. Which information will be most useful to the nurse for planning care?
34. When performing oral care on a comatose client, Nurse Krina should:
35. A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He’s being hydrated with L.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F (39.4°C) a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may have which of the following conditions?
36. Nurse Oliver is working in a out patient clinic. He has been alerted that there is an outbreak of tuberculosis (TB). Which of the following clients entering the clinic today most likely to have TB?
37. Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is aware that which of the following reasons this is done?
38. Kennedy with acute asthma showing inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated with which of the following classes of medication right away?
39. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema and cyanotic nail beds. Based on this information, he most likely has which of the following conditions?
40. The treatment for patients with leukemia is bone marrow transplantation. Which statement about bone marrow transplantation is not correct?
41. After several days of admission, Francis becomes disoriented and complains of frequent headaches. The nurse in-charge first action would be:
42. During routine care, Francis asks the nurse, “How can I be anemic if this disease causes increased my white blood cell production?” The nurse in-charge best response would be that the increased number of white blood cells (WBC) is:
43. Diagnostic assessment of Francis would probably not reveal:
44. Robert, a 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency embolectomy. Six hours later, the nurse isn’t able to obtain pulses in his left foot using Doppler ultrasound. The nurse immediately notifies the physician, and asks her to prepare the client for surgery. As the nurse enters the client’s room to prepare him, he states that he won’t have any more surgery. Which of the following is the best initial response by the nurse?
45. During the endorsement, which of the following clients should the on-duty nurse assess first?
46. Honey, a 23-year old client complains of substernal chest pain and states that her heart feels like “it’s racing out of the chest”. She reports no history of cardiac disorders. The nurse attaches her to a cardiac monitor and notes sinus tachycardia with a rate of 136beats/minutes. Breath sounds are clear and the respiratory rate is 26 breaths/minutes. Which of the following drugs should the nurse question the client about using?
47. A 51-year-old female client tells the nurse in-charge that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?
48. A 35-year-old client with vaginal cancer asks the nurse, “What is the usual treatment for this type of cancer?” Which treatment should the nurse name?
49. Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean?
50. Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?
51. A 37-year-old client with uterine cancer asks the nurse, “Which is the most common type of cancer in women?” The nurse replies that it’s breast cancer. Which type of cancer causes the most deaths in women?
52. Antonio with lung cancer develops Horner’s syndrome when the tumor invades the ribs and affects the sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should note:
53. Vic asks the nurse what PSA is. The nurse should reply that it stands for:
54. What is the most important postoperative instruction that nurse Kate must give a client who has just returned from the operating room after receiving a subarachnoid block?
55. A male client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?
56. During a breast examination, which finding most strongly suggests that the Luz has breast cancer?
57. A female client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis sites for cancer cells?
58. Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?
59. Nurse Cecile is teaching a female client about preventing osteoporosis. Which of the following teaching points is correct?
60. Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings for contraindications for this procedure. Which finding is a contraindication?
61. Mr. Rodriguez is admitted with severe pain in the knees. Which form of arthritis is characterized by urate deposits and joint pain, usually in the feet and legs, and occurs primarily in men over age 30?
62. A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old client with stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of saline solution. How many milliliters per hour should be given?
63. A 76-year-old male client had a thromboembolic right stroke; his left arm is swollen. Which of the following conditions may cause swelling after a stroke?
64. Heberden’s nodes are a common sign of osteoarthritis. Which of the following statement is correct about this deformity?
65. Which of the following statements explains the main difference between rheumatoid arthritis and osteoarthritis?
66. Mrs. Cruz uses a cane for assistance in walking. Which of the following statements is true about a cane or other assistive devices?
67. A male client with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:
68. Nurse Len should expect to administer which medication to a client with gout?
69. Mr. Domingo with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client’s hypertension is caused by excessive hormone secretion from which of the following glands?
70. For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wetto- dry dressing change every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry dressings used for this client?
71. Nurse Zeny is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find?
72. A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
73. A female client tells nurse Nikki that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client’s efforts, the nurse should check:
74. Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a diabetic client at 7 a.m. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction?
75. The adrenal cortex is responsible for producing which substances?
76. On the third day after a partial thyroidectomy, Proserfina exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a lifethreatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
77. Which laboratory test value is elevated in clients who smoke and can’t be used as a general indicator of cancer?
78. Francis with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia?
79. In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says:
80. When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction?
81. Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
82. After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina suspects the client is experiencing anaphylactic shock. What should the nurse do first?
83. Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
84. A 23-year-old client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that adaptive immunity is provided by which type of white blood cell?
85. In an individual with Sjögren’s syndrome, nursing care should focus on:
86. During chemotherapy for lymphocytic leukemia, Mathew develops abdominal pain, fever, and “horse barn” smelling diarrhea. It would be most important for the nurse to advise the physician to order:
87. A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:
88. A complete blood count is commonly performed before a Joe goes into surgery. What does this test seek to identify?
89. While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?
90. When taking a dietary history from a newly admitted female client, Nurse Len should remember that which of the following foods is a common allergen?
91. Nurse John is caring for clients in the outpatient clinic. Which of the following phone calls should the nurse return first?
92. Nurse Sarah is caring for clients on the surgical floor and has just received report from the previous shift. Which of the following clients should the nurse see first?
93. Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for treatment of Grave’s disease. The nurse would be most concerned if which of the following was observed?
94. Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. To assist with pain relief, the nurse should take which of the following actions?
95. Nurse Tina prepares a client for peritoneal dialysis. Which of the following actions should the nurse take first?
96. Nurse Jannah teaches an elderly client with right-sided weakness how to use cane. Which of the following behaviors, if demonstrated by the client to the nurse, indicates that the teaching was effective?
97. An elderly client is admitted to the nursing home setting. The client is occasionally confused and her gait is often unsteady. Which of the following actions, if taken by the nurse, is most appropriate?
98. Nurse Evangeline teaches an elderly client how to use a standard aluminum walker. Which of the following behaviors, if demonstrated by the client, indicates that the nurse’s teaching was effective?
99. Nurse Deric is supervising a group of elderly clients in a residential home setting. The nurse knows that the elderly are at greater risk of developing sensory deprivation for what reason?
100. A male client with emphysema becomes restless and confused. What step should nurse Jasmine take next?
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