Post Test 2

1. Which client would be the highest risk for injury?

a. A 3-month-old in an infant seat sitting on a coffee table
b. A 2-year-old playing in the living room unattended by an adult
c. A 2-1 /2-year-old with a tracheostomy playing outside in the backyard
d. A 7-year-old who goes to after school care in a 38-year-old home
This age of child puts everything in their mouth so they could put an object in the tracheostomy. This creates a risk for airway
obstruction. Option #1 is not a priority to Option #3 due to the possibility of airway obstruction. Option #2 is a concern but not
a priority. Option #4 is incorrect because while this home may have older paint which would present a risk with lead poisoning,
this age of child does not have a tendency to put objects in the mouth.

2. A client is admitted to a general medicine unit and the lab technician arrives to draw the lab blood tests that were ordered.
After the technician leaves, the nurse enters the room to find drops of blood on the floor and on the wall by the needle
container. When considering the safety of the hospital clients, what is the best nursing action?
a. Call the laboratory supervisor and report the poor technique used by the technician.
b. Make a note for the unit manager to discuss the break in technique with the laboratory supervisor.
c. Call housekeeping to come immediately to clean and disinfect the area where the blood was dropped.
d. Have the laboratory technician return to the unit and clean up the area contaminated with the blood.
It is everyones responsibility to maintain a safe environment. This break in universal precautions should be reported
immediately to the laboratory supervisor so the technician can be identified and the problem corrected. The unit manager
may also be notified in order to follow up regarding how the lab supervisor corrected the problem. The area can be cleaned by
blotting the blood with paper towels and spraying the area with disinfectant spray designated for body fluid spills.

3. A client has colon cancer and a descending colostomy was done. How is the best way for the nurse to determine if the
client understands .and can perform her own care?
a. Have the client explain to the nurse all of the steps necessary to carry out the colostomy irrigation.
b. With the nurse performing the irrigation, have the client direct the nurse regarding how to do it.
c. Construct a written test and have the client complete it. Then discuss with the client the questions missed.
d. With the nurse present, have the client independently carry out the colostomy irrigation herself.
The best way to determine if the client understands the teaching is to encourage the client to perform a return demonstration
of the procedure. Option #1 is correct to do prior to the procedure. However, it does not determine if the client can carry out
the procedure correctly.

4. An important assessment to obtain in a client who requires home oxygen therapy is:
a. amount of oxygen required within a 24-hour period.
b. maintenance of the equipment.
c. the clients knowledge base about home oxygen therapy.
d. adequate personnel to monitor the oxygen therapy.
It is important that the client on home oxygen therapy demonstrate an adequate knowledge base about oxygen. This will
prevent any, injury to the client.

5. A client was admitted yesterday to the trauma intensive care unit (ICU) with a gunshot wound of the neck. He has a cervical
level (C4) spinal cord injury. He is tearful and constantly complains of discomfort and needing to be suctioned. The nurse
understands that his attention-seeking behaviors may be due to:
a. anger and frustration.
b. awareness of vulnerability.
c. increased social isolation.
d. increased sensory stimulation.
The client is experiencing an increased awareness of physical vulnerability due to the spinal cord injury. The client is trying to
determine who is consistent and trustworthy for meeting his significant physical needs. Options #1, #3, and #4 may come later.

6. After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a 5-year-old is admitted
to the ER. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments
should the nurse report to the physician 3 hours after admission?
a. The obtunded state she is in
b. Clear fluid draining from her right ear
c. The characteristics of the lacerations
d. Slight withdrawal of extremities in response to painful stimuli
Clear fluid from the ear indicates a rupture of the meninges and presents a potential complication of meningitis. Option #1 is
no change. Option #3 is not a priority over Option #2. Option #4 is not an assessment change.

7. To promote safety, the nurse would implement which action in obtaining a blood specimen from a client with hepatitis B?
a. Clean area with antiseptic solution
b. Wear a pair of clean gloves.
c. Apply pressure to site for 5 seconds.
d. Recap needle to avoid carrying exposed needle.
Clean gloves should be worn at all times when handling any clients body fluids. Option #1 is correct but not a higher priority
over Option #2. Option #3 is incorrect because venipuncture sites of clients with hepatitis B should be held for a longer period
of time due to possibility of increased bleeding associated with an impaired liver. Option #4 is unsafe.
 8. Which observation would be most important during the first 48 hours after the admission of a client with severe anxiety?
a. What is important to the client?
b. How does the client view self?
c. In what situations does the client get anxious?
d. Who in the clients family has had mental problems?
This will provide necessary information in the baseline assessment of the clients anxiety. Options ^l, #2, and #4 are helpful
data which can be collected during treatment, but do not take priority during the first 48 hours.

9. A 72-year-old client has an order for digoxin(Lanoxin) 0.25 mg PO in the morning. At 7:00 a.m., the nurse reviews the
following information:
• apical pulse, 68
• respirations, 16
• plasma digoxin level, 2.2 ng/ml
Based on this assessment, which nursing action is appropriate?
a. Give the medication on time.
b. Withhold the medication, notify the physician.
c. Administer epinephrine 1:1000 stat.
d. Check the clients blood pressure.
Withhold the medication and notify the physician because the therapeutic plasma level of digoxin is 0.5-2.0 ng/ml. Option #3 is
not necessary at this time. Option #4 is not a priority.

10. A client is ordered cefoxitin (Mefoxin) 2 gm. IV piggyback in 100 cc 5% Dextrose in water. The primary IV is 5% Dextrose in
lactated ringers infusing by gravity. Which safety measure should be included in the administration of this medication?
a. The medication should be administered slowly at 20-25 cc/hr.
b. The primary IV solution should be changed.
c. The piggyback infusion bag should be hung higher than the primary infusion.
d. An infusion pump must be obtained prior to administration.
When using a gravity drip, the piggyback fluid level should be higher than the primary infusion. Option #1 is incorrect
because the antibiotic should be administered within one hour. Options #2 and #4 are not necessary for safe infusion.

11. When exploring ways to effectively manage the budget, the nurse will most likely find that she will have to set goals for the
unit. What would be an appropriate goal for the unit?
a. Decrease overhead by limiting supplies utilized to operate the unit.
b. Stabilize the total work force by utilizing only part-time employees with limited working hours.
c. Develop an incentive program that will demonstrate cost-effective measures to maintain the overall budget.
d. Participate in open-forums to discuss the issues of budget management on a consistent basis.
Developing an incentive program to maintain revenue will involve the whole unit. This will also give accountability and
responsibility back to the staff on the unit. Option #1 may be counterproductive. Option #2 may de crease quality of care.
Option #4 may be useful and secondary to Option #3.

12. A client is to be taking the tricyclic antidepressant medication imipramine (Tofranil) at home following discharge. The nurse
should instruct the client to report which symptoms immediately?
a. Sore throat, fever, increased fatigue, vomiting, diarrhea
b. Dry mouth, nasal stuffiness, weight gain
c. Rapid heartbeat, frequent headaches, yellowing of eyes or skin
d. Weakness, staggering gait, tremor, feeling of being drunk
These are possible side effects of Tofranil which can be resolved by changing the dosage or changing the medication. Option #2
describes side effects of antidepressants which the client can learn to manage at home without changing the medication.
Options #3 and #4 describe side effects of a different category of medications.

13. The physician has just informed a client that an amputation of the leg is needed. The client is crying as you enter the room.
Which technique that the nurse can utilize is the most therapeutic?
a. Sit with client quietly until crying stops; then inquire about feelings.
b. Ask what is causing client to feel so badly.
c. Comfort by hugging and tell client not to worry.
d. Try to distract by talking about her family.
Being with the client as acknowledgement and dealing with impending loss demonstrates the nurses acceptance of the clients .
need to grieve. Allowing the client time to cry and then asking to describe feelings demonstrates the nurse is willing to listen
and validate the clients feelings. Option #2 is not acknowledging the situation requiring an amputation. Option #3 might be
somewhat premature and uncomfortable unless both participants in the relationship find touching acceptable. It is
inappropriate to tell her not to worry. Option #4 is avoidance of the situation.

14. The client is admitted with cerebrovascular accident (CVA) and has facial paralysis. Nursing care should be planned to
prevent which complication?
a. Inability to talk
b. Inability to swallow
c. Inability to open the affected eye
d. Corneal abrasion
The client will be unable to close his eye voluntarily. When the facial nerve (cranial nerve VII) is affected, the lacrimal gland
will no longer supply secretions that protect the eye. Options #1, #2, and #3 may occur, but nursing care cannot prevent them.

15. Which statement by a client indicates an understanding of the cause of herpes zoster?
a. "I will avoid exposure to children with German measles."
b. "I had the chickenpox in grammar school."
c. "Using a condom during intercourse will be necessary."
d. "I will bathe more often than in the past."
Herpes zoster (shingles) is a reactivation of latent varicella (chickenpox) which has an ^increased frequency rate among
adults with weakened immune systems. Option #1 is not correlated with measles. Option #3 is incorrect because this is not a
sexually-transmitted disease. Option #4 is incorrect because the problem is not related to hygiene.

16. The nurse has been caring for a schizophrenic client receiving haloperidol (Haldol) IM. She notices the following new
symptoms in the client:
• high fever
• tachycardia
• muscle rigidity
• incontinence
These findings suggest that the client is experiencing:
a. tardive dyskinesia.
b. Parkinsons syndrome.
c. acute dystonic reaction.
d. neuroleptic malignant syndrome.
This severe reaction to antipsychotic medication occurs in clients who are severely ill as a result of dopamine blockage in the
hypothala-mus. Option #1 would be characterized by abnormal facial and tongue movements. Option #2 would be
characterized by tremors, rigidity, and shuffling gait. Option #3 would be characterized by severe muscle contractions of the
head and neck.

17. Which technique is best for obtaining a urine specimen for a culture and sensitivity from a client with an existing indwelling
catheter?
a. Clean the drain of the collection bag with an antiseptic before filling the specimen container.
b. Obtain the specimen from the drainage bag in the morning.
c. Using a sterile syringe with a small gauge needle, aspirate urine from the catheter port.
d. If the catheter has been in place for 48 hours, replace it before obtaining the specimen.
Indwelling catheters have a port for the withdrawal of sterile urine specimens. Options #1 and #2 will not provide a sterile
specimen from the collection bag. Option #4 is not necessary.

18. A client is ordered to take metronidazole (Flagyl) PO TID at home. Which client statement indicates a knowledge deficit and
need for teaching?
a. "I'll be sure to take this medication with meals."
b. "I'll call my physician if my skin becomes itchy."
c. "I'll limit my, alcohol intake to two drinks per day."
d. "I understand that my urine may become brown-colored and is normal."
Metronidazole (Flagyl) will produce a disulfiram-like (Antabuse) reaction if any form of alcohol is used. Options #1, #2, and #4
indicate an understanding of the concepts related to taking this medication.

19. The nurse's assessment of a client who abuses cocaine includes:

a. bradycardia, miosis, hypertension.
b. mydriasis, abdominal cramps, excessive salivation.
c. hypotension, bradycardia, abdominal cramps.
d. hypertension, tachycardia, tremor.
Cocaine elevates the blood pressure and pulse along with causing a fine tremor. Cardiac arrhythmias can occur, especially
with the use of crack cocaine. Excessive salivation and bradycardia are not found with cocaine abuse.

20. Which technique should be used in the administration of heparin sodium (Heparin)?
a. Gently massage the injection site.
b. Do not aspirate after inserting the needle.
c. Use a 1-inch, 18-20 gauge needle
d. Administer the medication at the deltoid muscle.
Aspirating the syringe with a subcutaneous heparin solution can cause bruising.Option #1 is incorrect because the heparin
injection site should not be rubbed. Option #3 is incorrect because the needle is too long. Option #4 is incorrect because the
medication should be given subcutaneously.

21. A nursing unit is implementing a project involving changes in the way the unit is managed. The nursing manager on the unit
continues to have problems with a team member that has been very disruptive regarding the implementation of the project.
What is the best approach for the nurse manager in handling this situation?
a. Call the unit supervisor and advise her of the problems with the team member and ask her how to handle the
situation.
b. Privately meet with the team member, review her behavior, and determine if she is aware of the impact her
behavior has on he unit.
c. Involve the other members of the team in attempting to discourage the disruptive team members behavior.
 d. Counsel with the disruptive team member and ask her why she is not happy working on this unit.
It is important to determine what the problem is with the disruptive team member. The best way to do that is in private.
Review with her the disruptive behavior and attempt to determine the source of the problem. If this does not solve the
situation, then the supervisor should be notified. Option #2 better describes the solution than does Option #4. Other team
members should not be brought into the situation.

22. A client is experiencing a severe panic attack and has threatened to hurl another client on the unit. The nurse would expect
to administer which PRN medication as ordered?
a. Chlorpromazine (Thorazine)
b. Lithium carbonate (Lithane)
c. Haloperidol (Haldol)
d. Phenytoin (Dilantin)
Haldol is particularly effective in reducing assaultive behavior associated with severe anxiety. Option #1 is more likely to be
used as a PRN when a client is experiencing agitation associated with schizophrenia. Option #2 is an antimanic drug. Option
#4 is an anticonvulsant medication.

23. The nurse should teach the mother of a newborn which concept regarding umbilical cord care?
a. Apply a sterile gauze dressing with petroleum jelly to cord.
b. Position diaper over the umbilicus to maintain dryness.
c. Clean cord with alcohol several times a day and expose to air frequently.
d. Apply erythromycin ointment to cord several times a day to prevent infection.
This will encourage drying and assist in preventing infection. Option #1 is appropriate for circumcision care. Option #2 will
keep the area moist. Diaper should be placed below the umbilicus. Option #4 is incorrect because the antibiotic ointment is not
necessary.

24. An extremely agitated client is receiving rapid neuroleptization with haloperidol (Haldol) IM every 30 minutes while in the
psychiatric emergency room. The most important nursing intervention is to:
a. monitor vital signs, especially blood pressure every 30 minutes.
b. remain at clients side for reassurance.
c. tell client name of medication and its effect.
d. monitor anticholinergic effects of medication.
While all of these nursing interventions are necessary during rapid neuroleptization, monitoring vital signs is of utmost impor-
tance to assure client safety and physiological integrity. Rapid neuroleptization is a pharmacological intervention used to
rapidly diminish severe symptoms which accompany acute psychosis. The alpha-adrenergic blockade of peripheral vascular
system lowers blood pressure and causes postural hypotension. Options #2 and #4 are secondary. Option #3 may be done later.

25. Two of the complications of Tetralogy of Fallot that should be included in the teaching plan would include:
a. pulmonary valve and aortic stenosis.
b. ventricular septal defect and pulmonary valve hypertrophy.
c. atrial septal defect and left ventricular hypertrophy.
d. right ventricular hypertrophy and overriding aorta.
The four physical defects of the heart in Tetralogy of Fallot include overriding aorta, right ventricular hypertrophy,
ventricular septal defect, and pulmonary valve stenosis. Options #1, #2, and #3 include incorrect information.

26. A client has been diagnosed with metastatic colon and brain cancer. She states, "The physician is wrong. I don't feel that
sick." What is the best interpretation of her statement?
a. She is unable to cope with her imminent death.
b. Her reaction is an abnormal response.
c. Her statement is a common denial response of the grief process.
d. Her statement needs further exploration before interpretation.
The clients response is indicative of the first stage of the grief process associated with . life-threatening disease. Option #1 is
incorrect because there is not enough information to determine if the client is unable to cope. Option #2 is incorrect because
the response is normal. Option #4 may help later.

27. Which action by the nurse is most appropriate when a client requests that a nurse on a previous shift not care for him
again?
a. Document the issue on an incident report.
b. Inform the nurse manager of the incident.
c. Explain to the client the nurse was having a bad day.
d. Address the clients concerns with the charge nurse.
As a client advocate, the nurse needs to intervene to assure the clients request is met. The issue needs to be discussed with the
charge nurse so that accurate communication occurs between the shifts and personnel involved. Option #1 is inappropriate.
Option #2 should occur, but after the charge nurse is advised of the situation. Option #3 is making excuses and not addressing
the issue.

28. Which assessment would be important to include in the history of a 7-year-old with glomerulonephritis?
a. Strep throat 12 days ago
b. Weight loss with diarrhea
c. Increase in fluid intake and voiding frequently
d. Decrease in energy with an increased need for sleep
There is a 10-14 day latent period between group A beta hemolytic streptococcal infection and the onset of signs of glomeru
lonephritis. Option #2 includes signs of hypovolemia. Option #3 includes signs of diabetes mellitus. Option #4 is not specific to
a particular diagnosis.

29. A child admitted with failure to thrive has a positive sweat test. The nurse would anticipate which of the following changes
in the child's plan of care first?
a. Administration of replacement enzymes
b. Administration of oxygen
c. A salt-restricted diet
d. Initiation of intravenous therapy
A positiye sweat test is diagnostic for cystic fibrosis and will need enzyme replacement. Option #2 is incorrect because there is
no data to indicate the child is having pulmonary problems. Option #3 is incorrect because salt is increased in the diet. Option
#4 is incorrect because there is no need for IV therapy based on the data.

30. A client is receiving furosemide (Lasix) 40 mg IV bid. Prior to administering the medication, the nurse should check for:
a. muscle weakness.
b. metabolic acidosis.
c. hyperkalemia.
d. hypertension.
The major symptoms of hypokalemia are muscle weakness and atony. Option #2 is incorrect because hypokalemia
accompanies metabolic alkalosis. Option #3 is incorrect because hypokalemia would be the problem. Option #4 is not a side
effect.

31. The nurse's best response to a preschool child who asks if he is going to die is:
a. "Everyone dies sometime."
b. "Don't be silly. You get stronger every day."
c. "You sound concerned. Tell me what made you ask that question."
d. "You are eating so much better and getting out of bed sometimes."
Exploring what happened to cause the client to ask the question would assist the nurse in answering questions. Options #1, #2
and #4 do not explore the clients feelings.

32. The infant had a myelomeningocele repair. The parents acceptance is observed by the home care nurse when they:
a. state the infant will outgrow this problem in time.
b. have the neighbor do bidder expression.
c. measure the head circumference daily.
d. discuss the expectation of child walking in one year.
Parents participation in care may be the first sign of acceptance. Measuring the head circumference is important due to the
risk of hydrocephalus following surgery, but even simple care like bathing the child, could bring acceptance. Option #1 is
incorrect because the child has a chronic problem. Option #2 indicates parents lack of interest and inability to care for child.
Option #4 shows a lack of understanding about myelomeningocele.

33. Before administering the MMR (Measles, Mumps and Rubella) vaccine to a 15-month-old toddler, the nurse should check
with the mother about:
a. sibling reaction to immunizations.
b. allergies to eggs or neomycin.
c. allergies in family members to medications.
d. diarrhea in this client a week ago without temperature.
Allergies to MMR come from egg, foul, and neomycin due to the growth of the live virus on egg embryo. Option #1 is incorrect
because there is no absolute relationship between the siblings allergic responses. Option #3 is not relevant to this vaccination.
Option #4 is more significant for oral polio administration.

34. When assessing orientation to person, place and time for an elderly hospitalized client, which principle should be
understood by the nurse?
a. Short-term memory is more efficient than long-term memory.
b. The stress of an unfamiliar environment may cause confusion.
c. A decline in mental status is a normal part of aging.
d. Learning ability is reduced during hospitalization of the elderly client.
The stress of an unfamiliar situation or environment may lead to confusion among the elderly. Option #1 is incorrect because
long-term memory is more efficient than short-term. Options #3 and #4 are not affected by aging. The elderly client may be
slower at doing things.

35. Which nursing action is a priority for a child admitted with a positive stool culture for Salmonella?
a. Change diet to clear liquids.
b. Initiate intravenous fluids.
c. Place child in enteric isolation.
d. Apply cloth diapers.
Enteric isolation prevents the transmission of Salmonella to other individuals. Options #1, #2, and #4 may be appropriate but
are not a priority over Option #3 which will prevent transmission.

36. After a client is admitted with pregnancy-induced hypertension (PIH), which is the most important nursing action?
a. Start an IV
 b. Measure vital signs.
c. Administer magnesium sulfate.
d. Notify lab to draw the blood.
It is imperative to do a baseline assessment in order to successfully evaluate the treatment. Options #1 and #4 are not priority
actions. Option #3 is correct but not a priority to Option #2.

37. The nurse is aware that which of the following assessment findings would support a diagnosis of Cushing's syndrome?
a. Hypotension
b. Thin facial features
c. Well-developed arm and leg muscles
d. Central or truncal-type obesity
The client with Cushing's will have abnormal fat distribution which causes a central or truncal type obesity. Option #1 is
incorrect because the client tends to have increased blood pressure. Option #2 is incorrect because the client will have a moon
face. Option #3 is incorrect because the extremities will be thin.

38. A nurse would anticipate assessing which initial side effects from a client undergoing chemotherapy?
a. Alopecia and purpura
b. Anorexia and weight loss
c. Nausea and vomiting
d. Coughing and shortness of breath
The most common side effects of chemotherapy are nausea and vomiting. Options #1 and #4 are typically later findings.
Option #2 can be a result of Option #3.

39. For the immobile client, which nursing assessment indicates a need for intervention?
a. Drainage from the Foley catheter is clear, with a pH of 6.5.
b. The clients skin blanches over the scapular areas.
c. Bilateral chest excursion is present.
d. The client drinks three glasses of orange juice everyday.
Blanching or hyperemia that does not disappear in a short time is a warning sign of pressure ulcers. Option #1 is normal urine.
Option #3 is a normal respiratory assessment finding. Option #4 is irrelevant.

40. To evaluate for adverse reactions of a narcotic injection, the nurse would observe:
a. elevated temperature.
b. hypertension.
c. decreased pulse rate.
d. increased respirations.
Narcotics can cause a decrease in heart rate. Option #1 is irrelevant. Option #2 is incorrect because hypotension will result.
Option #4 is incorrect because respiratory depression will result.

41. What would be the most appropriate action for the nurse to take after noting the sudden appearance of a fixed and dilated
pupil in a neuro client?
a. Reassess in five minutes.
b. Check clients visual acuity.
c. Lower the head of the clients bed.
d. Call the physician.
A fixed and dilated pupil represents a neurological emergency. Option #1 does not take action necessary for the immediate
situation. Option #2 cannot accurately be evaluated with increased ICP. Option #3 would increase the intracranial pressure.

42. In developing discharge plans with the family of the client in stage four Parkinson's disease, it is most important for the
nurse to include which activities?
a. Ambulate twice daily.
b. ROM to all extremities four times a day.
c. Hobbies and games such as knitting and putting puzzles together.
d. Encourage and provide writing materials.
In stage four Parkinsons disease, the client is immobile. Option #1 is incorrect because the client would be unable to ambulate.
Options #3 and #4 are incorrect because the client cannot perform activities which require small muscle dexterity.

43. Which statement made by the client in sickle cell crisis indicates a need for further teaching?
a. "My pain is from poor circulation due to sickling of the cells."
b. "I will need to see a genetic counselor when I get married."
c. "I have a trip planned to snow ski in 3 weeks."
d. "I need to stay away from strenuous activities."
The mountains are low in oxygen concentration which, along with increased activity, would contribute to sickling of the cells.
Options #1, #2, and #4 indicate a correct understanding.

44. Which statement made by a client who is prescribed Allopurinol (Zyloprin) has an appropriate understanding of how to
safely take the medication? "I will:
a. take the medication 60 minutes prior to meals."
b. drink 2.5-3 liters of fluid per day."
c. increase my intake of vitamin C."
 d. continue eating oatmeal and a slice of whole wheat toast for breakfast."
Fluids are imperative to decrease the side effects of a gout attack or renal stones. Option #1 is incorrect because the drug
should be taken following meals due to nausea and vomiting. Option #3 will increase the likelihood of renal calculi formation.
Option #4 is high in purine which is a precursor to uric acid. This counteracts the purpose of administering the medication.

45. Which statement made by the client indicates a correct understanding of client-controlled epidural analgesia (PCA)?
a. "If I start feeling drowsy, I should notify the nurse."
b. "This button will give me enough to kill the pain whenever I want it."
c. "If I start itching, I need to call the nurse."
d. "This medicine will make me feel no pain."
A common side effect of narcotics used in epidural pain management is itching? Options #2 and #4 are incorrect. Option #1 is
secondary.

46. What is the initial nursing priority for an infant admitted to the pediatric unit with possible Hemophilus influenzae
meningitis?
a. Encourage fluids to prevent dehydration.
b. Restrain child appropriately to maintain integrity of IV site.
c. Place child in respiratory isolation.
d. Encourage parents to hold and rock infant to promote comfort.
To prevent the spread of the infection, the client is placed in respiratory isolation for at least 24 hours after implementation of
antibiotic therapy. Option #1 is incorrect because the fluids are determined by client status. Fluids are usually limited to
prevent cerebral edema. Option #2 is appropriate but is not a priority to Option #3. Option #4 would cause discomfort to the
clients head.

47. Which statement by a client indicates that the client is using the defense mechanism of conversion?
a. "I love my family with all my heart, even though they don't love me."
b. "I could not take my final exams because I was unable to write."
c. "I don't believe I have diabetes. I feel perfectly fine."
d. "If my wife was a better housekeeper, I wouldn't have such a problem."
The client has converted his anxiety over school performance into a physical symptom that interferes with his ability to
perform. Option #1 may be reaction formation. Option #3 is denial. Option #4 is projection.

48. Which statement indicates parental understanding about the cause of their newborn's diagnosis of cystic fibrosis?
a. "The gene came from my husbands side of the family."
b. "The gene came from my wife’s side of the family."
c. "There is a 50 percent chance that our next child will have the disease."
d. "Both my husband and I carry a recessive trait for cystic fibrosis."
Cystic fibrosis is inherited by an autosomal recessive trait. Both parents are carriers of the abnormal gene. There is a 25
percent chance of passing the gene on to any of their offspring. Options #1, #2, and #3 are inaccurate.

49. Prior to mixing different types of insulin, the nurse should:

a. rotate the vial at least 1 minute between both hands.
b. gently shake each vial for at least 1 minute.
c. throw away all cloudy color insulin.
d. take the vials out of the refrigerator for 30 minutes
Rotating resuspends the modified insulin preparations and helps to warm the medication. Option #2 causes bubbles and foam
which can alter the dose. Option #3 is incorrect because longer acting insulins are supposed to be cloudy. Option #4 is incor-
rect because insulin does not have to be refrigerated as long as it is at normal room temperature.

50. Which diversional activity is most appropriate for a 12-year-old client recovering from a sickle-cell crisis?
a. Walking in the hall 20 minutes 2 times a day
b. Watching the cartoon channel all day
c. Talking to best friend on the telephone
d. Putting together large-pieced wooden puzzles
This will conserve energy and still meet psycliosocial needs of peer involvement. Option #1 will not conserve much needed
energy. Option #2 is an isolating activity and is not age appropriate. Option #4 is appropriate for preschool children.

51. Which nursing observation indicates an early complication of hypoxemia in a child with epiglottis?
a. Tachycardia
b. Cyanosis
c. Circumoral pallor
d. Difficulty swallowing
The heart rate correlates with hypoxemia and is an early finding along with restlessness. Options #2 and #3 would be late signs.
Option #4 is a sign of epiglottitis.

52. Which action observed by the nurse would indicate a clients ability to care for his own colostomy?
a. Irrigating the colostomy with 2000 ml of warm tap water
b. Changing the appliance twice a day
c. Inserting the irrigating tube 6 into the stoma
d. Fitting the appliance securely around the edge of the stoma
The appliance should fit easily around the stoma and protect the skin. Option #1 is incorrect because no more than 1000 ml of
irrigation fluid should ever be used. Option #2 is incorrect because the appliance should only be changed when it begins to
leak or becomes dislodged. Option #3 is incorrect because the catheter should not be inserted over 4 into the stoma.

53. Which nursing action is most appropriate when an infant is admitted for fever, poor feeding, irritability, and a bulging
fontanel?
a. Perform neuro checks every four hours.
b. Place the client in respiratory isolation.
c. Monitor clients urine output closely.
d. Encourage fluid intake.
These are classic signs of meningitis, and the client should be isolated from other clients. Options #1 and #3 are appropriate
but are not a priority over Option #2 when the client is first admitted. Option #4 is inappropriate for this situation.

54. Which nursing action is a priority for a newborn with a myelomeningocele?

a. Elevate the head of the bed to decrease intracranial pressure.
b. Immediately intubate the infant to decrease the potential for respiratory distress.
c. Position the infant supine to prevent damage to the sac.
d. Cover the sac with sterile, warm, moist compresses to maintain asepsis.
Prevention of infection is critical for this infant. The head of the infants bed should remain flat unless otherwise ordered.
Option #2 is irrelevant to this situation. Option #3 is of utmost importance, but to do this, the infant must be prone or on his
side.

55. Which statement made by a client indicates a correct understanding of the side effects of phenazopyridine hydrochloride
(Pyridium)? "My medicine:
a. will make me urinate more frequently."
b. should be taken only at bedtime."
c. will cause my urine to become orange."
d. should be taken before meals."
The drug may change the urine to an orange color. Option #1 is not accurate because this drug is not a diuretic. It has a local
anesthetic action on the urinary tract mucosa. Options #2 and #4 are incorrect because the drug should be taken after meals.

56. Which recommendation by the nurse would offer the greatest support to a newly diagnosed AIDS client and his family?
a. Avoid all contact with anyone except immediate family.
b. Speak to a representative from the local AIDS support group.
c. Stop all sexual activity immediately.
d. Begin chemotherapy as soon as possible.
The establishment of a support system from the beginning is very important to any terminally ill client, especially with a
disease like AIDS that is associated with a social stigma. Option #1 is incorrect because general isolation is not necessary. The
client does need education regarding exposure to infectious agents. Option #3 is not necessary as long as precautions are taken
to prevent spreading the disease. Option #4 is inappropriate to the situation.

57. Which question would best aid the nurse in assessing the orientation of a client on the psychiatric unit?
a. "Who is the president of the United States?"
b. "Do you remember my name?"
c. "What is your name?"
d. "What time is it?"
This is a specific question related to the orientation of the person. Option #1 is incorrect because some well-oriented people do
not know the answer to this question depending upon their age, educational level, etc. Option #2 is irrelevant. Option #4 is •
incorrect because without consulting a watch or clock, most well-oriented people cannot answer this question.

58. In performing a nursing audit, the nurse is evaluating the nursing documentation. Which should be present in the charting
for a client receiving total parenteral nutrition (TPN)?
a. Weight, blood glucose, I&O
b. Amount of blood withdrawn for lab studies
c. Position during dressing change
d. CVP reading obtained during infusion to TPN
Daily weights, blood glucose, and I&O evaluate the effectiveness of TPN. Option #2 is unnecessary. Option #3 may be charted
but is secondary to #1. Option #4 is incorrect. The CVP should not be determined with TPN infusing.

59. Which client statement indicates a need for more information regarding oral contraceptives?
a. "I will need check-ups every six months."
b. "I should take the pill the same time each day."
c. "If I forget a pill one day, I should take it when I remember. Then take the next pill as scheduled the next day."
d. "If I miss 2 pills, I will take them when I remember and continue the normal schedule."
If 2 pills are missed, they should be taken. Howeyer another form of contraception for the remainder of the month should be
used. Options #1, #2, and #3 are correct and do not require more information.

60. Which assessment would be most important regarding safety for a client receiving vincristine sulfate (Oncovin)?
a. Fatigue and nausea
b. Polyphagia and polydipsia
 c. Hypotension and alopecia
d. Paresthesia and difficulties in gait
These assessments indicate a problem with peripheral neuropathy. These can result in difficulties with safety and will mandate
a change in the plan of care. Option #1 does occur but is not a priority over Option #4. Option #2 includes signs of diabetes.
Option #3 is not a priority over Option #4.

61. During morning assignments, a nurse is assigned to several clients. Which would be first to receive morning care?
a. A client with a recent appendectomy
b. A client with infectious meningitis
c. An immunosuppressed client
d. A client with COPD
WBCs are usually decreased in the immunosuppressed client which predisposes to infection. AM care should be completed on
this client first, especially before the client with meningitis. Option #1: the nurse may find it useful to provide time for a PRN
for pain to work before she begins AM care on this client. Option #4: this client would need care done slowly so as not to
fatigue him.

62. Care of a 70-year-old woman with symptoms including temperature of 103.4°F, moderate dehydration, bilateral rales in
lower lobes of lungs, and disorientation to time and place, would be based on understanding that:
a. the client is experiencing temporary delirium secondary to the infectious process.
b. the client is probably displaying early symptoms of Alzheimer's Disease.
c. old people get confused often as a normal part of the aging process.
d. a referral to a nursing home for continuing care will be necessary for this client.
Delirium, accompanied by some disorientation, is often caused by a systemic infection such as pneumonia, especially in an
older person who may be more vulnerable to illness. Options #2, #3, and #4 are premature assumptions and are not based on
the data presented.

63. A client in the ER is displaying the following symptoms:

• elevated vital signs
• hallucinations
• aggressive behavior.
The clients friend says she thinks he has been using hallucinogenic drugs. The appropriate nursing action would be to:
a. put the client in full restraints.
b. decrease environmental stimulation.
c. call the security guards.
d. administer a PRN dose of chlorpromazine (Thorazine).
The symptoms may subside with time and decreased stimulation. Options #1 and #3 are not necessary at this time. Option #4
is inappropriate.

64. The nurse is caring for a client who is taking Disulfiram (Antabuse). The nurse should caution the client to avoid the intake
of which of the following?
a. Aged cheeses
b. Liquid cough medicines
c. Chicken or beef liver
d. Yogurt or sour cream
Many liquid cough medicines have an alcohol base which will interact with the Antabuse to produce nausea and vomiting.
Options #1, #3, and #4 are foods which interact with MAO inhibitor medications.

65. The nurse is caring for a client whose identity diffusion has reached panic proportions. The client says that she is
experiencing a feeling of strangeness and unrealness about her body. The nurse recognizes this as:
a. omnipotence.
b. depersonalization.
c. denial.
d. primitive idealization.
Depersonalization, a symptom often seen in the client with borderline personality, is defined as the feeling of strangeness or
unreality about ones self. Option #1 is defined as fantasies of greatness or exaggerated importance. Option #3 is defined as
keeping disturbing thoughts and feelings out of conscious awareness. Option #4 is defined as assigning unrealistic powers to
someone on whom the client is dependent. These are all symptoms that may be seen in a client with borderline personality
disorder.

66. The nurse is caring for a client who is extremely flirtatious, charming, and willing to manipulate others. Which measure
should the nurse take?
a. Limit the clients behavior and share that information with nursing staff on all three shifts.
b. Ask another nurse to care for this particular client.
c. Document the clients behavior so that the physician will order medication to control his behavior.
d. Listen empathetically and help meet the clients needs.
A manipulative client needs firm limits, and those limits must be known and followed by all the nursing staff. If not, client will
be able to split the staff into opposing forces. Options #2, #3, and #4 are inappropriate nursing actions with this client.

67. One of the goals the nurse and client with Post Traumatic Stress Disorder (PTSD) mutually agreed upon is an increase in
participation in out of the apartment activities. Which recommendation will be the most therapeutic while achieving that
goal?
 a. Take a day trip with a friend.
b. Take an 11-minute bus ride alone.
c. Join a support group and participate in a victim assistance organization.
d. Take a 10-minute walk with spouse around the block.
Support groups of people who have suffered similar acts of violence can be helpful and supportive in teaching clients how to
deal with the traumatizing situation and the emotional aftermath. Options #1, #2, and #4 are all reasonable recommendations
to begin utilizing in a systematic desensitization program after the crisis period is alleviated.

68. Which client would be the first to receive morning care? A client with a diagnosis of:
a. appendectomy.
b. infectious meningitis.
c. AIDS.
d. COPD.
In an immunosuppressed client, the WBCs are usually decreased which predisposes the client to infections. It would be
important to do this clients AM care first, especially before the client with meningitis. Option #2 care is given after Option #3.
Option #1 is incorrect, but the nurse might find it helpful to medicate the client prior to giving AM care. Option #4 would need
care done in a way not to cause fatigue increase the hypoxia.

69. A charge nurse is developing the assignment for the evening shift. In a semi-private room, Client A has neutropenia. Client B
has a tracheostomy with purulent drainage and a pending C&S. Which assignment is the most appropriate?
a. Assign an experienced nurse to care for both clients in the same room.
b. Assign two nursesone nurse for Client A, and another nurse for Client Bin the same room.
c. Place Client A in a private room. Assign the same nurse to care for Client A and Client B.
d. Place Client A in a private room. Assign different nurses to care for Client A and Client B.
Infection in a neutropenic individual may cause morbidity and fatality if untreated. Place neutropenic client in a private room.
Limit and screen visitors and hospital staff with potentially communicable illnesses. Options #1, #2, and #3 may be harmful to
client A.

70. A 6-month-old infant is on Isomil and weighs fifteen pounds. Which nursing observation on a home visit would indicate a
need for further teaching?
a. The infant is sucking a pacifier.
b. The infant is crawling on the floor.
c. The father speaks sternly to the infant for pulling books from the bookcase.
d. The father gives the baby a bottle with whole milk.
A 6-month-old on a soy based formula is probably allergic to cow milk products. Many children who arc sensitive to cows milk
cannot tolerate it until the age ot2. Options #1, #2. and #3 are acceptable activities in caring for this age child.

71. An 11-month-old baby is having trouble gaining weight after discharge from the hospital. To best assess the problem, the
nurse would:
a. observe the child at mealtime.
b. inquire regarding the childs eating pattern.
c. weigh the baby each month.
d. try to feed the baby for the mother.
Direct observation of a typical mealtime will give the most information. Option #2 may or may not secure an accurate picture.
The weight should be obtained more often or on each visit as opposed to Option #3. Option #4 circumvents the routine
patterns of behavior surrounding feeding times.

72. A client has been receiving morphine sulfate 15 mg IV push for several days as pain management for severe burns. Nursing
assessment reveals a decrease in bowel sounds and slight abdominal distention. Which nursing action is the most
appropriate?
a. Recommend morphine dose be decreased.
b. Withhold pain medication.
c. Administer medication by another route.
d. Explore alternative pain management techniques.
Morphine is the drug of choice for burn pain management. When a side effect becomes apparent, exploration of alternative
techniques such as visualization become important. Option #1 might be used, but with a possible impending ileus suspected,
this option is not ideal. Options #2 and #3 are inappropriate.

73. Which assessment would be a priority for evaluating the status of a pleurevac connected to a right middle lobe chest tube?
a. Incentive spirometry
b. Breath sounds
c. Chest tube drainage
d. Chest X-ray
The chest x-ray will be able to visualize fluid and air in the pleural space. Options #1, #2, and #3 would be beneficial to
evaluate but are not as inclusive as Option #4.

74. Following hip replacement surgery, an elderly client is ordered to begin ambulation with a walker. In planning nursing care,
which statement by the nurse will best help this client?
a. "Sit in a low chair for ease in getting lip to the walker."
b. "Make sure rubber caps are present on all four legs of the walker."
 c. "Begin weight-bearing on the affected hip as soon as possible."
d. "Practice tying your own shoes before using the walker."
Intact rubber caps should be present on walker legs to prevent accidents. Options #1, #3, and #4 should be avoided for 4-6
weeks.

75. An elderly client with mild osteoarthritis needs instruction on exercising. In planning nursing care, which instruction would
best help this client?
a. Swimming is the only helpful exercise for osteoarthritis.
b. Warm-up exercises should be done prior to exercising.
c. Exercises should be done routinely even if joint pain occurs.
d. Isometric exercises are most helpful to prevent contractures.
Warm-up or stretching exercises should always be done prior to and after exercising. Option #1 is only one helpful exercise.
Option #3 is incorrect because painful joints should not be exercised. Option #4 does not involve joint movements.