111aaarnnow PDF
111aaarnnow PDF
111aaarnnow PDF
2. Nurse Gail places a client in a four-point restraint following orders from the physician.
The client care plan should include:
3. A male client who has severe burns is receiving H2 receptor antagonist therapy. The
nurse In-charge knows the purpose of this therapy is to:
4. The doctor orders hourly urine output measurement for a postoperative male client. The
nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml;
9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?
5. Tony, a basketball player twist his right ankle while playing on the court and seeks care
for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which
statement by Tony suggests that ice application has been effective?
6.The physician prescribes a loop diuretic for a client. When administering this drug, the
nurse anticipates that the client may develop which electrolyte imbalance?
a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia
7.She finds out that some managers have benevolent-authoritative style of management.
Which of the following behaviors will she exhibit most likely?
8. Nurse Amy is aware that the following is true about functional nursing
9.Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"
a. Single order
b. Standard written order
c. Standing order
d. Stat order
10.A female client with a fecal impaction frequently exhibits which clinical manifestation?
a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools
11.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper
visualization, the nurse should position the client's ear by:
12. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole.
She is aware that one of the following is unassociated with this condition?
a. Excessive fetal activity.
b. Larger than normal uterus for gestational age.
c. Vaginal bleeding
d. Elevated levels of human chorionic gonadotropin.
13. A pregnant client is receiving magnesium sulfate for severe pregnancy induced
hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium
gluconate is:
14. During vaginal examination of Janah who is in labor, the presenting part is at station
plus two. Nurse, correctly interprets it as:
15. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that
warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is:
a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR
17. A trial for vaginal delivery after an earlier caesareans, would likely to be given to a
gravida, who had:
a. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at
39 weeks pregnancy was positive.
b. First and second caesareans were for cephalopelvic disproportion.
c. First caesarean through a classic incision as a result of severe fetal distress.
d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a
vertex presentation.
18.Nurse Ryan is aware that the best initial approach when trying to take a crying toddler’s
temperature is:
19.Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the
nurse do to prevent trauma to operative site?
20. Which action should nurse Marian include in the care plan for a 2 month old with heart
failure?
21.Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5
months. The nurse should advise her to include which foods in her infant’s diet?
22. 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?
23. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse
should:
a. Plan care so the client can receive 8 hours of uninterrupted sleep each night.
b. Monitor vital signs every 2 hours.
c. Make sure that the client takes food and medications at prescribed intervals.
d. Provide milk every 2 to 3 hours.
24. 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?
25. A client undergone ileostomy, when should the drainage appliance be applied to the
stoma?
26. A client undergone spinal anesthetic, it will be important that the nurse immediately
position the client in:
27.While monitoring a male client several hours after a motor vehicle accident, which
assessment data suggest increasing intracranial pressure?
28.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms
may appear first?
29. A male client has active tuberculosis (TB). Which of the following symptoms will be
exhibit?
a. Chest and lower back pain
b. Chills, fever, night sweats, and hemoptysis
c. Fever of more than 104°F (40°C) and nausea
d. Headache and photophobia
30. 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?
a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease (COPD)
d. Emphysema
31. 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?
a. Asthma attack
b. Respiratory arrest
c. Seizure
d. Wake up on his own
32. 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?
a. Ascites
b. Nystagmus
c. Leukopenia
d. Polycythemia
34. Norma, with recent colostomy expresses concern about the inability to control the
passage of gas. Nurse Oliver should suggest that the client plan to:
35. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse
would evaluate that the instructions were understood when the client states, “I should:
36. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and
electrolyte imbalances. The client is somewhat confused and complains of nausea and
muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance,
the nurse would expect to:
a. Administer Kayexalate
b. Restrict foods high in protein
c. Increase oral intake of cheese and milk.
d. Administer large amounts of normal saline via I.V.
37. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV
fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should
set the flow to provide:
a. 18 gtt/min
b. 28 gtt/min
c. 32 gtt/min
d. 36 gtt/min
38.Terence suffered form burn injury. Using the rule of nines, which has the largest percent
of burns?
39. Herbert, a 45 year old construction engineer is brought to the hospital unconscious after
falling from a 2-story building. When assessing the client, the nurse would be most
concerned if the assessment revealed:
a. Reactive pupils
b. A depressed fontanel
c. Bleeding from ears
d. An elevated temperature
40. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker.
Which information given by the nurse shows her knowledge deficit about the artificial
cardiac pacemaker?
a. take the pulse rate once a day, in the morning upon awakening
b. May be allowed to use electrical appliances
c. Have regular follow up care
d. May engage in contact sports
41.The nurse is ware that the most relevant knowledge about oxygen administration to a
male client with COPD is
42.Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are
inserted, and one-bottle water-seal drainage is instituted in the operating room. In the
postanesthesia care unit Tonny is placed in Fowler's position on either his right side or on
his back. The nurse is aware that this position:
43. What is Nurse John likely to note in a male client being admitted for alcohol withdrawal?
a. Perceptual disorders.
b. Impending coma.
c. Recent alcohol intake.
d. Depression with mutism.
44. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it “doesn’t
help” and refuses to take it. What should the nurse say or do?
45. Dervid, an adolescent has a history of truancy from school, running away from home
and “barrowing” other people’s things without their permission. The adolescent denies
stealing, rationalizing instead that as long as no one was using the items, it was all right to
borrow them. It is important for the nurse to understand the psychodynamically, this
behavior may be largely attributed to a developmental defect related to the:
a. Id
b. Ego
c. Superego
d. Oedipal complex
46. In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows
that succinylcoline (Anectine) will be administered for which therapeutic effect?
a. Short-acting anesthesia
b. Decreased oral and respiratory secretions.
c. Skeletal muscle paralysis.
d. Analgesia.
47. Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar
disorder is:
a. Serve the client a bowl of soup, buttered French bread, and apple slices.
b. Increase calories, decrease fat, and decrease protein.
c. Give the client pieces of cut-up steak, carrots, and an apple.
d. Increase calories, carbohydrates, and protein.
48.What parental behavior toward a child during an admission procedure should cause
Nurse Ron to suspect child abuse?
a. Flat affect
b. Expressing guilt
c. Acting overly solicitous toward the child.
d. Ignoring the child.
49.Nurse Lynnette notices that a female client with obsessive-compulsive disorder washes
her hands for long periods each day. How should the nurse respond to this compulsive
behavior?
a. By designating times during which the client can focus on the behavior.
b. By urging the client to reduce the frequency of the behavior as rapidly as possible.
c. By calling attention to or attempting to prevent the behavior.
d. By discouraging the client from verbalizing anxieties.
50.After seeking help at an outpatient mental health clinic, Ruby who was raped while
walking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three months
later, Ruby returns to the clinic, complaining of fear, loss of control, and helpless feelings.
Which nursing intervention is most appropriate for Ruby?
1. Nurse Betty is assigned to the following clients. The client that the nurse would see first
after endorsement?
2. Nurse Gail places a client in a four-point restraint following orders from the physician.
The client care plan should include:
3. A male client who has severe burns is receiving H2 receptor antagonist therapy. The
nurse In-charge knows the purpose of this therapy is to:
4. The doctor orders hourly urine output measurement for a postoperative male client. The
nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml;
9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?
5. Tony, a basketball player twist his right ankle while playing on the court and seeks care
for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which
statement by Tony suggests that ice application has been effective?
a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia
7.She finds out that some managers have benevolent-authoritative style of management.
Which of the following behaviors will she exhibit most likely?
8. Nurse Amy is aware that the following is true about functional nursing
9.Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"
a. Single order
b. Standard written order
c. Standing order
d. Stat order
10.A female client with a fecal impaction frequently exhibits which clinical manifestation?
a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools
11.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper
visualization, the nurse should position the client's ear by:
13. A pregnant client is receiving magnesium sulfate for severe pregnancy induced
hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium
gluconate is:
14. During vaginal examination of Janah who is in labor, the presenting part is at station
plus two. Nurse, correctly interprets it as:
15. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that
warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is:
a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR
17. A trial for vaginal delivery after an earlier caesareans, would likely to be given to a
gravida, who had:
a. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at
39 weeks pregnancy was positive.
b. First and second caesareans were for cephalopelvic disproportion.
c. First caesarean through a classic incision as a result of severe fetal distress.
d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a
vertex presentation.
18.Nurse Ryan is aware that the best initial approach when trying to take a crying toddler’s
temperature is:
19.Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the
nurse do to prevent trauma to operative site?
20. Which action should nurse Marian include in the care plan for a 2 month old with heart
failure?
21.Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5
months. The nurse should advise her to include which foods in her infant’s diet?
22. 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?
23. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse
should:
a. Plan care so the client can receive 8 hours of uninterrupted sleep each night.
b. Monitor vital signs every 2 hours.
c. Make sure that the client takes food and medications at prescribed intervals.
d. Provide milk every 2 to 3 hours.
24. 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?
25. A client undergone ileostomy, when should the drainage appliance be applied to the
stoma?
26. A client undergone spinal anesthetic, it will be important that the nurse immediately
position the client in:
27.While monitoring a male client several hours after a motor vehicle accident, which
assessment data suggest increasing intracranial pressure?
28.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms
may appear first?
30. 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?
a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease (COPD)
d. Emphysema
31. 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?
a. Asthma attack
b. Respiratory arrest
c. Seizure
d. Wake up on his own
32. 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?
a. Ascites
b. Nystagmus
c. Leukopenia
d. Polycythemia
34. Norma, with recent colostomy expresses concern about the inability to control the
passage of gas. Nurse Oliver should suggest that the client plan to:
35. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse
would evaluate that the instructions were understood when the client states, “I should:
36. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and
electrolyte imbalances. The client is somewhat confused and complains of nausea and
muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance,
the nurse would expect to:
a. Administer Kayexalate
b. Restrict foods high in protein
c. Increase oral intake of cheese and milk.
d. Administer large amounts of normal saline via I.V.
37. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV
fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should
set the flow to provide:
a. 18 gtt/min
b. 28 gtt/min
c. 32 gtt/min
d. 36 gtt/min
38.Terence suffered form burn injury. Using the rule of nines, which has the largest percent
of burns?
39. Herbert, a 45 year old construction engineer is brought to the hospital unconscious after
falling from a 2-story building. When assessing the client, the nurse would be most
concerned if the assessment revealed:
a. Reactive pupils
b. A depressed fontanel
c. Bleeding from ears
d. An elevated temperature
40. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker.
Which information given by the nurse shows her knowledge deficit about the artificial
cardiac pacemaker?
a. take the pulse rate once a day, in the morning upon awakening
b. May be allowed to use electrical appliances
c. Have regular follow up care
d. May engage in contact sports
41.The nurse is ware that the most relevant knowledge about oxygen administration to a
male client with COPD is
42.Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are
inserted, and one-bottle water-seal drainage is instituted in the operating room. In the
postanesthesia care unit Tonny is placed in Fowler's position on either his right side or on
his back. The nurse is aware that this position:
43. What is Nurse John likely to note in a male client being admitted for alcohol withdrawal?
a. Perceptual disorders.
b. Impending coma.
c. Recent alcohol intake.
d. Depression with mutism.
44. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it “doesn’t
help” and refuses to take it. What should the nurse say or do?
45. Dervid, an adolescent has a history of truancy from school, running away from home
and “barrowing” other people’s things without their permission. The adolescent denies
stealing, rationalizing instead that as long as no one was using the items, it was all right to
borrow them. It is important for the nurse to understand the psychodynamically, this
behavior may be largely attributed to a developmental defect related to the:
a. Id
b. Ego
c. Superego
d. Oedipal complex
46. In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows
that succinylcoline (Anectine) will be administered for which therapeutic effect?
a. Short-acting anesthesia
b. Decreased oral and respiratory secretions.
c. Skeletal muscle paralysis.
d. Analgesia.
47. Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar
disorder is:
a. Serve the client a bowl of soup, buttered French bread, and apple slices.
b. Increase calories, decrease fat, and decrease protein.
c. Give the client pieces of cut-up steak, carrots, and an apple.
d. Increase calories, carbohydrates, and protein.
48.What parental behavior toward a child during an admission procedure should cause
Nurse Ron to suspect child abuse?
a. Flat affect
b. Expressing guilt
c. Acting overly solicitous toward the child.
d. Ignoring the child.
49.Nurse Lynnette notices that a female client with obsessive-compulsive disorder washes
her hands for long periods each day. How should the nurse respond to this compulsive
behavior?
a. By designating times during which the client can focus on the behavior.
b. By urging the client to reduce the frequency of the behavior as rapidly as possible.
c. By calling attention to or attempting to prevent the behavior.
d. By discouraging the client from verbalizing anxieties.
50.After seeking help at an outpatient mental health clinic, Ruby who was raped while
walking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three months
later, Ruby returns to the clinic, complaining of fear, loss of control, and helpless feelings.
Which nursing intervention is most appropriate for Ruby?
a. Recommending a high-protein, low-fat diet.
b. Giving sleep medication, as prescribed, to restore a normal sleepwake cycle.
c. Allowing the client time to heal.
d. Exploring the meaning of the traumatic event with the client.