1.

The nurse would monitor a patient using sodium bicarbonate to treat gastric hyperacidity for signs and
symptoms of:
*

1 point

A. Metabolic alkalosis

B. Hyperkalemia

C. Hypercalcemia

D. Metabolic acidosis

2. The home health care nurse is caring for a client with cancer who is complaining of acute pain. The
most appropriate determination of the client’s pain should include which assessment?
*

1 point

A. Nonverbal cues from the client

B. The nurse’s impression of the client’s pain

C. The client’s pain rating

D. Pain relief after appropriate nursing intervention

3. The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and
determines that the client is experiencing respiratory acidosis. Which result validates the nurse’s
findings?
*

1 point

A. pH 7.25, PCO2 50 mm Hg

B. pH 7.35, PCO2 40 mm Hg

C. pH 7.50, PCO2 52 mm Hg

D. pH 7.52, PCO2 28 mm Hg

4. A client who is found unresponsive has arterial blood gases drawn and the results indicate the
following: pH is 7.15, PCO2 is 58 mm Hg, and HCO3 is 23 mEq/L. The nurse interprets the results as
indicating which condition?
*

1 point

A. Respiratory acidosis, uncompensated

B. Metabolic acidosis, compensated

C. Metabolic acidosis, uncompensated

D. Respiratory acidosis, compensated

5. Which of the following evaluation does the nurse make when the venipuncture site has an observable
swelling and is tender and cool to touch?
*

1 point

A. An infection has developed

B. Bleeding into the surrounding tissue has occurred

C. The IV site was infiltrated

D. A phlebitis is developing

6. A client who is receiving a continuous intravenous therapy is complaining of sudden dyspnea, cough,
and tachycardia. The nurse auscultates crackles bilaterally. In determining what action to take next,
which of the following factors should the nurse consider?
*

1 point

A. The client is apprehensive about receiving continuous IV fluids

B. The client has developed a respiratory infection or pneumonia

C. The client is exhibiting signs of hypervolemia

D. The client is experiencing internal bleeding

7. The nurse is having a hard time reading the written medication order of a physician. What is her BEST
nursing action?
*

1 point

A. Call the physician who ordered the medication.

B. Ask the head nurse to read it.

C. Ask the client the medications he regularly takes.

D. Obtain all the medications from the client’s table and compare names.

8. Nurse Lily reads the therapeutic sheet of a 24.2-lb pediatric patient, gentamicin sulfate 2mg/kg q8h IV.
The medicine vial reads 20mg/10mL. How much gentamicin in milliliters will be given to the patient
within 24 hours?

*
1 point

A. 33 mL

B. 6 mL

C. 11 mL

D. 24 mL

9. Mannitol 1g/kg/day was prescribed to a 7-year-old patient with meningitis. The patient weighs 30 lbs.
How much mannitol should the nurse give?
*

1 point

A. 30 g

B. 60 mg

C. 20 mg

D. 14 g

10. Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes
continuous gentle bubbling in the suctio
*

1 point

A. Do nothing, because this is an expected finding

B. Immediately clamp the chest tube and notify the physician

C. Check for an air leak because the bubbling should be intermittent

D. Increase the suction pressure so that the bubbling becomes vigorous

11. In a chest drainage system the nurse notice a presence of intermittent bubbling in the water seal
chamber. Which of the following is the appropriate action:
*

1 point

A. Change the chest tube drainage system

B. Document the findings

C. Check for an air leak

D. Notify the MD In a chest drainage system

12. What is the ethical principle that was violated if you divulge patient information?
*
1 point

A. right to privacy

B. right to confidentiality

C. fidelity

D. beneficence

13. After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage.
When caring for this patient, the nurse must:
*

1 point

A. Monitor fluctuations in the water-seal chamber

B. Clamp the chest tube once every shift

C. Encourage coughing and deep breathing

D. Milk the chest tube every 2 hours

14. A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patient’s
condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated.
When the high pressure alarm on the mechanical ventilator, alarm sounds, the nurse starts to check for
the cause. Which condition triggers the high pressure alarm?
*

1 point

A. Kinking of the ventilator tubing

B. A disconnected ventilator tube

C. An endotracheal cuff leak

D. A change in the oxygen concentration without resetting the oxygen level alarm

15. what is the priority nursing action for a patient with pneumonia and a pulse oximeter reading of
85%?
*

1 point

A. do nothing it is normal

B. report to the doctor

C. give oxygen

D. assess VS
16. The physician has ordered a urine specimen for vanillymandelic acid (VMA) levels in a client with
severe uncontrolled hypertension. Which foods would interfere with VMA test results?
*

1 point

A. Whole grain breads and cereals

B. Chocolate pudding and gelatins

C. Spinach and kale

D. Beef and beef products

17. The nurse is supervising an LPN/LVN who is administering an enema to a patient. During the
administration, it is MOST important for the LPN/LVN to take which of the following actions?
*

1 point

A. Place the solution 20 inches above the anus.

B. Adjust the temperature of the solution.

C. Insert the tube six inches.

D. Position the patient left side-lying (Sim’s) with knee flexed.

18. A nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into
the urethra, urine begins to flow into the tubing. At this point, the nurse:
*

1 point

A. Immediately inflates the balloon

B. Withdraws the catheter approximately 1 inch and inflates the balloon

C. Inserts the catheter until resistance is met and inflates the balloon

D. Inserts the catheter 2.5to5cm and inflates the balloon

19. In preparing a teaching plan regarding colostomy irrigations, the nurse should include which of the
following?
*

1 point

A. The colostomy needs to be irrigated at the same time every day.

B. Irrigate the colostomy after meals to increase peristalsis.

C. Insert the catheter about 10 inches into the stoma.

D. The solution should be very warm to increase dilation and flow.

20. Which of the following best indicates that the client understands teaching about stoma care?
*

1 point

A. The client asks questions about skin preparations for the stomal site.

B. The client is able to repeat the stoma care instructions.

C. The client performs proper skin care and applies a stomal bag.

D. The client asks for additional literature regarding management of a stoma.

21. The nurse assesses a client with an ileostomy for possible development of which of the following
acid-base imbalances?

1 point

A. Respiratory acidosis

B. Metabolic acidosis

C. Metabolic alkalosis

D. Respiratory alkalosis

22. A client with COPD has a knowledge deficit related to positions used to breathe more easily. The
nurse plans to teach the client to:
*

1 point

A. Lie on the side with the head of the bed at a 45 degree angle

B. Sit bolt upright in bed with the arms crossed over the chest

C. Sit on the edge of the bed with the arms leaning on an over bed table

D. Sit in a reclining chair tilted slightly back with the feet elevated

23. To assist a blind client with ambulation, the nurse should walk:
*

1 point

A. To the side and slightly in front of the client while the client holds onto the nurse’s arm

B. To the front of the client while the client holds on to the nurse’s arm

C. To the front of the client while the nurse holds on to the client’s arm

D. T o the side of the client while the nurse holds onto the client’s arm
24. The nurse is monitoring the fluid status of a 63-year-old woman receiving IV fluids following surgery.
Which of the following symptoms would suggest to the nurse that the patient has fluid volume
overload?
*

1 point

A. Temperature 101°F (38.3°C), BP 96/60, pulse 96 and thready.

B. Cool skin, respiratory crackles, pulse 86 and bounding.

C. Complaints of a headache, abdominal pain, and lethargy.

D. Urinary output 700 cc/24 h, CVP of 5, and nystagmus.

25. A woman has returned from surgery after a right mastectomy with an IV of 0.9% NaCl infusing at 100
cc/hour into her left forearm. Several hours later, the IV infiltrates. The nurse is supervising a student
nurse preparing to insert a new peripheral intravenous catheter. The nurse would intervene in which of
the following situations?
*

1 point

A. The student nurse selects a site where the veins are soft and elastic.

B The student nurse selects a site on the distal portion of the left arm.

C. The student nurse selects a site close to the joint to provide for stability.

D The student nurse holds the skin taut to stabilize the vein.

26. The LPN is monitoring a client receiving an IV of Nipride in D5W. the IV bag has a foil covering, and
the nurse notes that the IVF has s light brownish tint. The nurse should:
*

1 point

A. Discard the solution

B. Obtain a bag of normal saline

C. Cover both the solution bag and the IV tubing with foil

D. Do nothing because the solution is expected to be a light brown in color.

27. A nurse is caring for a client who recently had a bowel resection. The client has a hemoglobin level
of 8 g/dl and hematocrit of 30%. Dextrose 5%in half NSS (D5 ½ NSS) is infusing through a triple-lumen
central catheter at 125ml/hour. The primary care provider’s orders include:

Gentamicin (Garamycin)80 mg IV piggyback in 50 ml dextrose 5% in water (D5W) over 30 minutes

Ranitidine (Zantac) 50 mg IV in 50 ml D5W piggyback over 30 minutes

One unit of 250ml of packed RBCs over 3 hours

NGT flushes with 30ml NSS every 2 hours

How many mL should the nurse document as the total intake for the8-hour shift?

1 point

A. 1470ml

B. 470ml

C. 1380 ml

D. 1370 ml

28. A client with an IV line in place complains of pain at the insertion site. Assessment of the site reveals
a vein that’s red, warm and hard. Which of the following actions should the nurse take?
*

1 point

A. Assess iv site

B. Remove iv cannula

C. Restart iv cannula

D. Report to doctor

29. After suffering an acute MI, w client with history of type I diabetes is prescribed metoprolol
(Lopressor) IV. Which nursing interventions are associated with IV administration of metorpolol?
*

1 point

A. Assess respiratory rate

B. Watch out for hypoglycaemia

C. Mix with d5w

D. Report to doctor

30. A client who is receiving a blood transfusion experiences a hemolytic reaction. The nurse would
anticipate which of the following assessment findings?
*

1 point

A. Hypotension, backache, low back pain, fever.

B. Wet breath sounds, severe shortness of breath.

C. Chills and fever occurring about an hour after the infusion started.

D. Urticaria, itching, respiratory distress.

31. The client has been receiving a blood transfusion for approximately 30 minutes. Which of these
assessments, if made by the nurse, would indicate an anaphylactic reaction?
*

1 point

A. Hypotension.

B Chills.

C. Respiratory wheezing.

D. Lower back discomfort.

32. The nurse is supervising the staff caring for four clients receiving blood transfusions. Which of the
four clients should the nurse see FIRST?
*

1 point

A. A client complaining of a headache.

B. A client vomiting.

C. A client complaining of itching.

D. A client with neck vein distention.

33. The LPN is assisting the RN with preparation for administering a transfusion of whole blood. Which
action by the nurse predisposes the client to the development of hyperkalemia?
*

1 point

A. Allowing the blood to warm to room temperature

B. Administering blood that is 24 hours old

C. Administering blood with 18-gauge needle

D. Filling the drip chamber below the level of the filter

34. Which of the following is most important to have on hand during a blood transfusion?
*

1 point

A. An alternative IV line

B. Diphenhydramine
C. Acetaminophen

D. A tourniquet

35. A 48-year-old man with an endotracheal tube needs suctioning. Which of the following statements is
an accurate description of how the nurse should perform the procedure?
*

1 point

A. Insert the suction catheter four inches into the tube. Apply suction for 30 seconds, using a twirling
motion as the catheter is withdrawn.

B. Hyperoxygenate the client and then insert the suction catheter into the tube. Suction while you
remove the catheter using a back and forth motion.

C. Explain the procedure to the patient. Insert the catheter while gently applying suction, and withdraw
using a twisting motion.

D. Insert the suction catheter until resistance is met, then withdraw it slightly. Apply suction
intermittently as the catheter is withdrawn.

36. What is the expected height of an enema solution?

*

1 point

A. 10 inches

B. 8 inches

C. 25 inches

D. 22 inches

37. A volunteer nurse on the ward tells the nurse that one of the patients on the ward is a neighbor and
asks about the patient’s condition. Which information should the nurse discuss with the volunteer?
*

1 point

A. Determine how well she knows the patient before talking with the volunteer

B. Tell the volunteer the patient’s condition in layman’s term

C. Ask the patient if it is all right to talk with the volunteer

D. Explain that patient information is on the need to know basis only

38. The nurse finds an unopened vial of morphine sulfate lying on the cabinet in a patient’s room. What
is the most appropriate action for the nurse to take first?
*

1 point
A. Secure the vial and return the medication to stock for the future use.

B. Remove the vial from the patient’s bedside and notify the nurse supervisor

C. Check with the other nurses to see if their patients have morphine orders and administer the
medication to another patient to avoid waste.

D. Contact the organization’s security department and have it investigate the crime scene.

39. On nursing rounds, a patient is found lying on the floor. Which statement would be most appropriate
for the nurse to document in the patient’s medical record?
*

1 point

A. “It is most likely that the patient attempted to climb over the side rails and fell”.

B. “Upon entering the room, the patient was found lying on the floor.”

C. “The patient had been restless all evening and was trying to get out of bed”.

D. “The presence of a bed alarm could have prevented the fall.”

40. After signing an informed consent form, the patients states, “I have changed my mind and do not
want to have the procedure done.” Which action would be most appropriate for the nurse to take first?
*

1 point

A. Remind the patient that a signed informed consent form is a legally binding document.

B. Notify the surgeon that the patient wishes to withdraw informed consent for the procedure.

C. Contact the operating room and tell the personnel there the patient’s surgery has been cancelled.

D. Proceed with preparation of the patient for the surgical procedure

41. The nurse is unable to find coverage to leave the floor for a personal appointment outside the
hospital. The nurse decides to leave her scheduled shift an hour early without permission and
notification of the charge nurse. The patients assigned to the nurse are in stable condition. What type of
legal tort could apply to the situation?
*

1 point

A. Patient abandonment.

B. Battery.

C. Intentional infliction of emotional distress.

D. Slander.
42. During what Tanner Stage of Sexual Maturation is breast budding seen among women adolescents?
*

1 point

A. Stage I

B. Stage II

C. Stage III

D. Stage IV

43. In assessing the client’s condition, Nurse Marie is aware that the most important determinant of the
percent of fluid loss in infants and younger children is
*

1 point

A. Capillary refill >2 secs

B. Decreased level of consciousness

C. Weight

D. Decreased skin turgor

44. Nurse Marie should assess for which early sign of dehydration in this client?
*

1 point

A. Tachycardia

B. Dry mucous membranes

C. Prolonged capillary refill

D. Sunken fontanelles

45. Nurse Marie inserted an IV access at the left cephalic vein of the client. To secure the IV access site,
she should:
*

1 point

A. Use a padded board to secure the extremity

B. Restrain all four extremities

C. Restrain the extremity to the bed’s side rail

D. Allow the extremity to be loose

46. Which of these is not a purpose of the nursing process?
*

1 point

A. It offers a plan of care to a patient that is organized according to the goals set by the nurse.

B. It helps nurses identify a client’s health status, and actual or potential health care problems.

C. It delivers specific nursing interventions for the client to be able to meet his identified needs.

D. It diagnoses and treats human responses to actual or potential health problems.

47. Which of the following principles does the nurse use in selecting interventions for the care plan?
*

1 point

A. Always select independent interventions when possible.

B. Actions should address the etiology of the nursing diagnosis.

C. There is one best intervention for each goal or outcome.

D. Interventions should be “doing,” not just “monitoring.”

48. Implementation is related to other steps of the nursing process. Which of the following statements is
true regarding the relationship of the implementing phase to other phases?
*

1 point

A. After implementing, the nurse moves towards the diagnosing phase.

B. The data that the nurse gathered during assessment are reassessed in the implementing phase.

C. The nurse’s need for actual involvement of members from other health disciplines in implementing
occurs during the planning phase.

D. Evaluation can begin after all interventions have been carried out.

49. Which of the following parameters should Nurse Chloe pay close attention to during and after
Abdominal Paracentesis?
*

1 point

A. Bleeding at the paracentesis site

B. Skin color

C. Blood pressure

D. Level of consciousness
50. Nurse Chloe should first double-check with the physician which laboratory parameter before they
proceed with the liver biopsy?
*

1 point

A. Aspartate Aminotransferase

B. Prothrombin Time

C. Serum albumin

D. Hemoglobin

Fundamentals of Nursing (Evaluative Exam)

[email protected] Switch account

* Indicates required question

GENERAL INSTRUCTIONS: Read and analyze the questions carefully before answering. Select the SINGLE
BEST ANSWER/RESPONSE and choose the letter that correspond to your answer.

1. A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes
a papular lesion on the perineum. Which initial action is most appropriate?
*

1 point

a. Document the finding

b. Report the finding to the doctor

c. Prepare the client for a C-section

d. Continue primary care as prescribed

2. A client with a diagnosis of HPV is at risk for which of the following?

*

1 point

a. Hodgkin's lymphoma

b. Cervical cancer

c. Multiple myeloma
d. Ovarian cancer

3. During the initial interview, the client reports that she has a lesion on the perineum. Further
investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most
likely source of the lesion is:
*

1 point

a. Syphilis

b. Herpes

c. Gonorrhea

d. Condylomata

4. A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which

laboratory finding is associated with HELLP syndrome?*

1 point

a. Elevated blood glucose

b. Elevated platelet count

c. Elevated creatinine clearance

d. Elevated hepatic enzymes

5. Which observation in the newborn of a diabetic mother would require immediate nursing
intervention?*

1 point

a. Crying

b. Wakefulness

c. Jitteriness

d. Yawning

6. The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side
effects associated with drug therapy. An expected side effect of magnesium sulfate is:
*

1 point

a. Decreased urinary output

b. Hypersomnolence

c. Absence of knee jerk reflex

d. Decreased respiratory rate

7. A gravida III para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy.
Which observation would the nurse be expected to make after the amniotomy?
*

1 point

a. Fetal heart tones 160bpm

b. A moderate amount of straw-colored fluid

c. A small amount of greenish fluid

d. A small segment of the umbilical cord

8. The client is having fetal heart rates of 90–110bpm during the contractions. The first action the nurse
should take is:*

1 point

a. Reposition the monitor

b. Turn the client to her left side

c. Ask the client to ambulate

d. Prepare the client for delivery

9. In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should
expect:*

1 point

a. A painless delivery

b. Cervical effacement

c. Infrequent contractions

d. Progressive cervical dilation

10. A vaginal exam reveals a footling breech presentation. The nurse should take which of the following
actions at this time?*

1 point

a. Anticipate the need for a Caesarean section

b. Apply the fetal heart monitor

c. Place the client in Genu Pectoral position

d. Perform an ultrasound exam

11. As the client reaches 8cm dilation, the nurse notes late decelerations on the fetal monitor. The FHR
baseline is 165–175bpm with variability of 0–2bpm. What is the most likely explanation of this pattern?*

1 point

a. The baby is asleep.

b. The umbilical cord is compressed.

c. There is a vagal response.

d. There is uteroplacental insufficiency.

12. The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action
would be to:
*

1 point

a. Notify her doctor

b. Start an IV of pitocin

c. Reposition the client

d. Prepare patient for an UTZ to make the finding more accurate

13. Which of the following is a characteristic of a reassuring fetal heart rate pattern?
*

1 point

a. A fetal heart rate of 170–180bpm

b. A baseline variability of 25–35bpm

c. Ominous periodic changes

d. Acceleration of FHR with fetal movements

14. The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a
diagnosis of ectopic pregnancy?
*

1 point

a. Painless vaginal bleeding

b. Abdominal cramping

c. Throbbing pain in the upper quadrant

d. Sudden, stabbing pain in the lower quadrant

15. The client with hyperemesis gravidarum is at risk for developing:
*

1 point

a. Respiratory alkalosis without dehydration

b. Metabolic acidosis with dehydration

c. Respiratory acidosis without dehydration

d. Metabolic alkalosis with dehydration

16. The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to
be:*

1 point

a. Hypoglycemic, small for gestational age

b. Hyperglycemic, large for gestational age

c. Hypoglycemic, large for gestational age

d. Hyperglycemic, small for gestational age

17. The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in
the postpartum client with:*

1 point

a. Diabetes

b. Positive HIV

c. Hypertension

d. Thyroid disease

18. A client telephones the emergency room stating that she thinks that she is in labor. The nurse should
tell the client that labor has probably begun when:*

1 point

a. Her contractions are 2 minutes apart.

b. She has back pain and a bloody discharge.

c. She experiences abdominal pain and frequent urination.

d. Her contractions are 5 minutes apart.

19. The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal
development. Which characteristic is associated with babies born to mothers who smoked during
pregnancy?*
1 point

a. Low birth weight

b. Large for gestational age

c. Preterm birth, but appropriate size for gestation

d. Growth retardation in weight and length

20. The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A
negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be
administered:*

1 point

a. Within 72 hours of delivery

b. Within 1 week of delivery

c. Within 2 weeks of delivery

d. Within 1 month of delivery

21. For the client who is using oral contraceptives, the nurse informs the client about the need to take
the pill at the same time each day to accomplish which of the following?*

1 point

a. Decrease the incidence of nausea

b. Maintain hormonal levels

c. Reduce side effects

d. Prevent drug interactions

22. When teaching a client about contraception. Which of the following would the nurse include as the
most effective method for preventing sexually transmitted infections?*

1 point

a. Spermicides

b. Diaphragm

c. Condoms

d. Vasectomy

23. When preparing a woman who is 2 days postpartum for discharge, recommendations for which of
the following contraceptive methods would be avoided?*

1 point
a. Diaphragm

b. Female condom

c. Oral contraceptives

d. Rhythm method

24. For which of the following clients would the nurse expect that an intrauterine device would not be
recommended?*

1 point

a. Woman over age 35

b. Nulliparous woman

c. Promiscuous young adult

d. Postpartum client

25. A client in her third trimester tells the nurse, “I’m constipated all the time!” Which of the following
should the nurse recommend?*

1 point

a. Daily enemas

b. Laxatives

c. Increased fiber intake

d. Decreased fluid intake

26. The client tells the nurse that her last menstrual period started on January 14 and ended on January
20. Using Nagele’s rule, the nurse determines her EDD to be which of the following?*

1 point

a. September 27

b. October 21

c. November 7

d. December 27

27. When taking an obstetrical history on a pregnant client who states, “I had a son born at 38 weeks
gestation, a daughter born at 30 weeks gestation and I lost a baby at about 8 weeks,” the nurse should
record her obstetrical history as which of the following?*

1 point

a. G2 T2 P0 A0 L2
b. G3 T1 P1 A0 L2

c. G3 T2 P0 A0 L2

d. G4 T1 P1 A1 L2

28. When preparing to listen to the fetal heart rate at 12 weeks’ gestation, the nurse would use which of
the following?*

1 point

a. Stethoscope placed midline at the umbilicus

b. Doppler placed midline at the suprapubic region

c. Fetoscope placed midway between the umbilicus and the xiphoid process

d. External electronic fetal monitor placed at the umbilicus

29. When developing a plan of care for a client newly diagnosed with gestational diabetes, which of the
following instructions would be the priority?*

1 point

a. Dietary intake

b. Medication

c. Exercise

d. Glucose monitoring

30. A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the following would be the
priority when assessing the client?*

1 point

a. Glucosuria

b. Depression

c. Hand/face edema

d. Dietary intake

31. A client 12 weeks’ pregnant come to the emergency department with abdominal cramping and
moderate vaginal bleeding. Speculum examination reveals 2 to 3 cms cervical dilation. The nurse would
document these findings as which of the following?*

1 point

a. Threatened abortion

b. Imminent abortion
c. Complete abortion

d. Missed abortion

32. Which of the following would be the priority nursing diagnosis for a client with an ectopic
pregnancy?*

1 point

a. Risk for infection

b. Pain

c. Knowledge Deficit

d. Anticipatory Grieving

33. Before assessing the postpartum client’s uterus for firmness and position in relation to the umbilicus
and midline, which of the following should the nurse do first?*

1 point

a. Assess the vital signs

b. Administer analgesia

c. Ambulate her in the hall

d. Assist her to urinate

34. Which of the following should the nurse do when a primipara who is lactating tells the nurse that
she has sore nipples?*

1 point

a. Tell her to breastfeed more frequently

b. Administer a narcotic before breast feeding

c. Encourage her to wear a nursing brassiere

d. Use soap and water to clean the nipples

35. The nurse assesses the vital signs of a client, 4 hours’ postpartum that are as follows: BP 90/60;
temperature 100.4ºF; pulse 100 weak, thready; R 20 per minute. Which of the following should the
nurse do first?*

1 point

a. Report the temperature to the physician

b. Recheck the blood pressure with another cuff

c. Assess the uterus for firmness and position

d. Determine the amount of lochia

36. The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which of the following
assessments would warrant notification of the physician?*

1 point

a. A dark red discharge on a 2-day postpartum client

b. A pink to brownish discharge on a client who is 5 days postpartum

c. Almost colorless to creamy discharge on a client 2 weeks after delivery

d. A bright red discharge 5 days after delivery

37. A postpartum client has a temperature of 101.4ºF, with a uterus that is tender when palpated,
remains unusually large, and not descending as normally expected. Which of the following should the
nurse assess next?*

1 point

a. Lochia

b. Breasts

c. Incision

d. Urine

38. Which of the following is the priority focus of nursing practice with the current early postpartum
discharge?*

1 point

a. Promoting comfort and restoration of health

b. Exploring the emotional status of the family

c. Facilitating safe and effective self-and newborn care

d. Teaching about the importance of family planning

39. Which of the following actions would be least effective in maintaining a neutral thermal environment
for the newborn?
*

1 point

a. Placing infant under radiant warmer after bathing

b. Covering the scale with a warmed blanket prior to weighing

c. Placing crib close to nursery window for family viewing

d. Covering the infant’s head with a knit stockinette

40. A client is having hyperemesis gravidarum. All of the following are recommended nursing
management to a pregnant woman, except:
*

1 point

a. Small frequent feedings

b. Carbonated beverages after eating

c. Low sodium crackers before arising in the morning

d. Increase protein intake at night

41. In the 12th week of gestation, pt. Dani completely expels the products of conception. Because the
client is Rh negative, the nurse must:
*

1 point

A. Administer RhoGAM within 72 hours.

B. Not give RhoGAM since it is not used with the birth of a stillborn.

C. Make certain that the client does not receive RhoGAM, since the gestation was only 12 weeks.

D. Make certain she receives RhoGAM on her first clinic visit.

42. Milz is admitted in active labor has only progressed from 2 cm to 3 cm in 8 hours. She is diagnosed as
having hypotonic dystocia and is given oxytocin (Pitocin) to augment her contractions. The most
important aspect of nursing at this time is:
*

1 point

A. Monitoring the FHR

B. Timing and recording the length of contractions.

C. Checking the perineum for bulging.

D. Preparing for an emergency cesarean delivery.

43. Aling Anabelle is experiencing stomach and right shoulder pain. She is diagnosed with severe
preeclampsia. She was ordered with magnesium sulfate. Which of the following would you note as the
first sign of an excessive blood magnesium level:
*

1 point

A. Distrurbance in sensorium

B. Development of cardiac dysrhyhmia

C. Increase in respiratory rate

D. Disappearance of the knee-jerk reflex

44. Dora is admitted to the hospital with vaginal staining but no pain. The client’s history reveals
amenorrhea for the last 2 months, and pregnancy confirmation by her physician after her first missed
period. She is admitted for observation with a possible diagnosis of:
*

1 point

A. Missed abortion

B. Ectopic pregnancy

C. Inevitable abortion

D. Threatened abortion

45. You discovered a loop of the umbilical cord protruding through the vagina when preparing to
perform a vaginal examination. Your most appropriate intervention is to:
*

1 point

a. Call the physician immediately

b. Place a moist clean towel over the cord to prevent drying

c. Immediately turn the client on her side and listen to the fetal heart rate.

d. Perform the vaginal examination and apply upward digital pressure to the presenting part while
having the mother assume a knee-chest position.

46. A mother is crying at baby’s bedside. The most therapeutic response by the nurse is:
*

1 point

a. “Don’t worry. Everything will be fine.”

b. “Why are you upset?”

c. “Would you like me to call the hospital chaplain?”

d. “This must be hard for you.”

47. Which of the following additional assessment findings would be most suspicious and lead the nurse
to suspect postpartum “blues” in a client who is anxious and crying?
*

1 point

a. Loss of appetite, constipation, abdominal pain

b. Despondency, loss of appetite, difficulty sleeping

c. Increased appetite, urinary retention, diarrhea

d. Poor concentration, constipation, diarrhea

48. The nurse assesses the vital signs of the client, 4 hours’ postpartum that are as follows: BP 90/60;
temperature 100.4°F; pulse 100 weak, thready; R 20 per minute. Which of the following should the nurse
do first?
*

1 point

a. Report the temperature to the physician

b. Recheck the blood pressure with another cuff

c. Assess the uterus for firmness and position

d. Determine the amount of lochia

49. It is most important for the nurse to have which drug readily available when the client is being
treated with heparin therapy for thrombophlebitis?
*

1 point

a. Calcium gluconate

b. Protamine sulfate

c. Aquamephyton

d. Ferrous sulfate

50. After 4 hours of active labor, the nurse notes that the contractions of a primigravid client are not
strong enough to dilate the cervix. Which of the following would the nurse anticipate?
*

1 point

a. Obtaining an order to begin IV oxytocin

b. Administering a light sedative to allow the patient to rest for several hours

c. Preparing for cesarean section for failure to progress

d. Increasing the encouragement to the patient when pushing begins.