A patient comes to the emergency room with a possible pneumothorax.

The nurse should assess for

which of the following?

1. Rapid respirations.

2. Deep, rapid respirations.

3. Respiratory depression.

4. Periods of hyperpnea alternating with periods of apnea.

Strategy: Think about each answer.

1) CORRECT— describes tachypnea
2) hyperpnea; causes include metabolic acidosis, diabetic ketoacidosis
3) occurs with drug overdose
4) Cheyne-Stokes respirations; crescendo breathing; cause is cerebral lesion
The nurse prepares a client for a barium enema. It is MOST important for the nurse to include which of
the following instructions?

1. “Your stool will be light-colored for 2 to 3 days after the test.”

“Once the test is over and you go to the toilet, you will be able to resume normal
2.
activities.”

3. “The x-ray table will be tilted so you can assume various positions.”

4. “During the test, it is crucial that you take slow, deep breaths through your mouth.”

Strategy: “MOST important” indicates priority.

1) accurate information but not the most important
2) after the rectal tube is removed and client evacuates the bowels, additional x-rays are taken;
due to the bowel prep and procedure, most clients require a period of rest after the test
3) accurate information but not the most important; reassure client that he will be secure on the
table during the x-rays
4) CORRECT— for test to be successful, client must retain barium; as barium is introduced,
client may have the urge to defecate; slow, deep breathing will help ease the discomfort
The nurse counsels a client newly diagnosed with hypertension. Which of the following statements, if
made by the client to the nurse, indicates that teaching is successful?
 1. "If I feel dizzy when I wake up, I will skip my morning blood-pressure pill."

2. "I will switch from lifting weights at the health club to doing aerobics."

3. "I will be sure to take chlorothiazide (Diuril) every night before I go to bed."

4. "I will take hot baths or go to the sauna to relax if I feel tension coming on."

Strategy: "Teaching is successful" indicates correct information.

(1.) medication needs to be taken on a regular basis; instruct to rise slowly from lying and sitting
positions; if severely bothered by dizziness, contact physician
(2.) CORRECT—regular aerobic exercises are usually recommended; isometric exercises such
as heavy weight-lifting and rowing are contraindicated, can cause a dangerous rise in blood
pressure due to a vasovagal response during intense isometric muscle contraction
(3.) thiazide diuretic; nighttime dosing will interfere with sleep by requiring frequent urination
(4.) not best; antihypertensives (and diuretics) commonly cause hypotension and heat can
facilitate hypotension
An older client diagnosed with emphysema becomes restless and confused. The nurse should take which
of the following actions?

1. Encourage the client to perform pursed lip breathing.

2. Check the client’s temperature.

3. Assess the client’s potassium level.

4. Increase the oxygen flow rate to 5 L/min.

Strategy: Determine whether it is appropriate to assess or implement.

1) CORRECT— prevents collapse of lungs; helps patient control rate and depth of breathing
2) confusion probably due to decreased oxygenation
3) confusion not due to potassium imbalance
4) should receive low oxygen flow to prevent CO 2 narcosis
The nurse cares for a client 1 day after abdominal surgery. The nurse notes that the client is 5 ft, 3 in tall;
weighs 210 lb; BP 130/80; pulse 76; and respirations 14/min. The client complains of pain, and the
nurse administers meperidine (Demerol) 75 mg. and promethazine (Phenergan) 50 mg IM. Two hours
later the client reports no relief from the pain. Which of the following actions by the nurse is MOST
appropriate?
 1. Assess the client’s mental status.

2. Contact the physician.

3. Observe the abdominal wound.

4. Explain to the client that abdominal wounds are painful.

Strategy: “MOST appropriate” indicates priority

1) pain is defined as “whatever the person says it is” ; no indication that client has altered mental
status
2) CORRECT— meperidine is effective for 2.5 to 3 hours and is equivalent to 5 to 7.5 mg of
morphine; first goal of drug therapy is to match client need with the drug; physician may have to
change prescription; increased dose of 25 to 50% should be administered until there is a 50%
reduction in pain or the client reports pain relief
3) clients with abdominal wounds have more severe, steady wound pain; an infected wound will
cause pain but it is too soon for infection
4) abdominal wounds are painful; nurse should ensure that the client is receiving the correct
medication and dose to relieve acute pain

A young adult is admitted to the hospital with a diagnosis of catatonic schizophrenia. When the nurse
places the patient’s hand over his head, it remains in that position. The nurse identifies that this is

1. conversion hysteria.

2. waxy flexibility.

3. dystonic reaction.

4. neurasthenia.

Strategy: Think about each answer.

1) motor or sensory neurological symptoms with no identifiable physiological cause
2) CORRECT— abnormal posturing; catatonic schizophrenia causes sudden loss of animation
and a tendency to remain motionless in a stereotyped position
3) muscle spasms of any muscles of the body
4) unexplained chronic fatigue with nervousness, anxiety, and irritability
The home care nurse visits a client receiving chlordiazepoxide (Librium). The nurse is MOST concerned
if which of the following is observed?

1. Shuffling gait and rigidity.

2. Drowsiness and blurred vision.

3. Photosensitivity and jerky movements.

4. Hypertension and slurred speech.

Strategy: “MOST concerned” indicates something is wrong.

1) side effects of antipsychotic drugs
2) CORRECT— Librium is an antianxiety; additional side effects include constipation, slurred
speech, dermatitis, anorexia, polyuria, pancytopenia, and thrombocytopenia; administer after
meals or with milk to decrease GI irritation
3) side effects of antipsychotic drugs
4) side effects of MAO inhibitor
The nurse in the psychiatric day hospital program cares for a patient diagnosed with recurrent
depression. The referring therapist recommends a cognitive therapy approach. The nurse doing the
initial assessment knows it is MOST important to focus the assessment on which of the following?

1. The patient’s use of language.

2. The patient’s insight into the depression.

3. The patient’s socialization history and skills.

4. The patient’s attitude toward medications.

Strategy: "MOST important" indicates that discrimination is required to answer the question.
(1.) CORRECT—cognitive viewpoint on depression sees it as stemming from errors in
thinking, which may be negative, illogical, and/or irrational; language is used in thought as well
as in speech; speech or writing is used to express thoughts and thereby is an indicator of the
patient’s automatic thoughts, their schemata or cognitive structure about themselves and the
world, and their cognitive distortions
(2.) emphasis on insight is prominent in traditional psychoanalytic and psychodynamic therapies
(3.) emphasis on socialization is prominent in behavioral therapies, milieu therapies, and some
interpersonal psychotherapies
 (4.) emphasis on medications is prominent in biochemical and psychologic therapies
The nurse cares for a client receiving hemodialysis three times per week. Today the client’s potassium is
6.5 mEq/L. The physician orders sodium polystyrene sulfonate (Kayexalate) 15 g PO today. Because the
client finds the taste unpleasant, the client asks if the medication can be added to orange juice. Which of
the following responses by the nurse is MOST appropriate?

1. Inform client that orange juice is likely to increase the blood sugar.

2. Explain to client that orange juice is contraindicated with this medication.

3. Remind the client that additions to diet supersede the prescribed regulations.

4. Discuss with the client the importance of managing her kidney disease.

Strategy: “MOST appropriate” indicates discrimination is required to answer the question.

1) true statement, but the priority is managing the hyperkalemia
2) CORRECT— Kayexalate is a cationic exchange resin used to treat hyperkalemia; normal
potassium is 3.5 to 5.0 mEq/L
3) the rationale is related to the hyperkalemia and not the specific dietary restrictions; exchanges
can be made if the client wanted the orange juice and hyperkalemia did not exist
4) is relevant for health problem; may have forgotten about the chemistry of orange juice;
obviously needs reinforcement of prior teaching; current issue is the relationship between orange
juice and hyperkalemia
The nurse discusses diet with the mother of a child being treated for deep partial thickness burns on her
legs. Which of the following meals should the nurse suggest?

1. Chicken leg, broccoli, Jell-O, and lemonade.

2. Cheeseburger, fruit-flavored yogurt, carrots, and milk.

3. Cottage cheese, canned peaches, crackers, and apple juice.

Scrambled eggs, hashed brown potatoes, banana, and orange

4.
juice.

Strategy: Evaluate the nutrients in each menu.

1) chicken leg and broccoli contain protein
2) CORRECT— all foods contain protein except for carrots; burn injury requires high-protein
diet
3) only cottage cheese contains some protein
 4) eggs contain protein, potatoes contain some protein
The nurse performs a physical assessment on a patient diagnosed with bulimia nervosa. Which of the
following findings warrant an IMMEDIATE referral to the physician?

1. Bilateral parotid gland enlargement.

2. A hoarse voice that is barely audible.

3. Grey to black eroded teeth with foul odor.

4. Multiple papulopustular skin eruptions on face, chest, and back.

Strategy: "IMMEDIATE referral" indicates a complication.

(1.) hallmark sign of chronic vomiting; glands become clogged with foreign matter; not priority
(2.) CORRECT—at high risk for tracheoesophageal fistula from esophageal tear; laryngitis is
danger sign
(3.) sign of chronic vomiting; gastric acid erodes teeth; needs eventual dental referral
(4.) sign of acne vulgaris related to bingeing on junk foods
The nurse obtains a health history from a 72-year-old Caucasian female. It is MOST important for the
nurse to ask which of the following questions?

1. “What kind of coffee do you drink?”

2. “When did your mother go through menopause.”

3. “Is there a family history of osteoporosis?”

4. “Do you take calcium supplements?”

Strategy: “MOST important” indicates priority.

1) client at risk to develop osteoporosis; excessive caffeine intake is a risk factor; caffeine should
be ingested in moderation
2) primary osteoporosis occurs in woman after menopause; prevention is the key
3) no known familial relationship
4) CORRECT— small-framed non-obese Caucasian women are at risk; not only has a 72-year-
old woman lost bone mass, but the elderly also absorb calcium less efficiently; should take
regular calcium supplements
The charge nurse on the medical unit reviews physician’s orders for four newly admitted patients. The
nurse should question which of the following orders?

1. A CT scan for a patient with suspected intracranial bleeding.

2. A bone imaging study for a patient with multiple myeloma.

3. A chest X-ray for a patient with a positive tuberculin skin test.

4. An upper GI tract endoscopy for a patient with cirrhosis.

Strategy: "Nurse should question" indicates a complication.

(1.) appropriate order; computed tomography (CT) scanning used to identify extent of a brain
injury, including intracranial bleeding and presence of lesions requiring surgery, such as epidural
or subdural hematomas
(2.) CORRECT—every contrast medium has a risk for causing reactions; benefit vs. risk should
be considered; multiple myeloma involves overproduction of plasma cells, with resultant
destruction of bone and of bone marrow products; multiple myeloma is unique as a neoplastic
condition that is better detected with a plain radiograph than with a nuclear scan; if a bone scan is
done, false-negative results occur
(3.) appropriate order; chest x-ray is appropriate follow-up to a positive PPD to further diagnose
possible TB
(4.) appropriate order; upper GI tract endoscopy, especially esophagogastroduodenoscopy,
examines the esophagus, stomach, and duodenum to identify factors that can complicate the care
of a patient with cirrhosis, such as esophageal varices or gastric or duodenal irritation,
ulcerations, or bleeding
The nurse instructs a client receiving clozapine (Clozaril). The nurse knows that teaching has been
successful if the patient verbalizes which of the following?

1. I will contact the health care provider if I have a sore throat and fever.

2. I am taking Clozaril because I have an anxiety disorder.

3. I will frequently monitor my blood glucose level.

4. I can breast feed my baby while taking the medication.

Strategy: “Teaching is effective” indicates correct information.

1) CORRECT— medication has the potential to suppress bone marrow and cause
agranulocytosis; fatal side effect in 1–2% of patients
 2) is an antipsychotic used for the treatment of schizophrenia; health care provider will monitor
and report WBCs once weekly for first 6 months of therapy; if stable will monitor every 2 weeks
thereafter
3) health care provider will monitor CBC; drug will be discontinued if WBCs fall below
2,000/mm 3
4) excreted in breast milk; breast feeding contraindicated
The nurse cares for a client receiving 40 drops per minute of D 5 W. The IV set delivers 10 drops per ml.
If the nurse begins infusing 1,000 ml of D 5 W at 12 noon, how many milliliters of D 5 W will be
remaining at 3:30 PM? Type the correct answer into the blank.

Strategy: Do the math.

Correct answer: 160

3.5 hr × 60 min/hr = 210 min

210 min × 4 ml/min = 840 ml
1,000 ml – 840 ml = 160 ml left at 3:30 PM
As a nurse prepares to assist a physician with an epidural patch for a client with a postlumbar puncture
headache, the client tells the nurse he is an illegal alien. Which of the following actions should the nurse
perform NEXT?

1. Position the client in a side lying position.

2. Notify immediate supervisor of the client’s citizenship status.

3. Notify the appropriate federal officials.

4. Place client in upright position.

Strategy: “NEXT” indicates priority.

1) CORRECT— appropriate position for procedure; citizenship status is not the priority
2) staff nurse does not address citizenship status; current need is proper position for procedure,
along with equipment/supplies
3) agency would need to decide who should make contact; questions of privacy and
confidentiality exist
 4) more likely to result in severe headache; headache represents excessive loss of cerebral spinal
fluid, resulting in brain settling while in upright position
The nurse in the neurology unit cares for a patient diagnosed with a cerebrovascular accident (CVA)
with hemiplegia and dysphagia. As discharge approaches, the nurse discusses nutritional planning with
the patient’s wife. Which of the following statements, if made by the wife to the nurse, indicates that
further teaching is necessary?

1. "I will have him sit up for 20 minutes before he eats and about an hour afterward."

2. "Casseroles are one of my favorite things to make, and he loves them."

3. "I will plan to prepare six meals a day rather than our usual three."

4. "A peanut butter sandwich and glass of milk at midday is easy and nutritious."

Strategy: "Further teaching is necessary" indicates incorrect information.

(1.) appropriate action; sitting, particularly in high Fowler’s position at 90 degrees, lessens
aspiration risk by utilizing the pressure of gravity to pass food through the stomach and into the
duodenum; sitting before a meal allows for a rest period before eating, which helps minimize
fatigue and therefore helps the patient’s desire to eat and enhances swallowing efforts
(2.) appropriate action; swallowing usually easiest with semisolid foods of medium consistency
(3.) appropriate action; six small meals versus three large ones can increase swallowing-muscle
strength and are easier to digest
(4.) CORRECT—incorrect action; peanut butter is to be avoided because it is sticky in the
mouth and the throat; most milk products are avoided because they produce mucus
The nurse cares for a client receiving IV antibiotics every 8 hours for the past 4 days. The antibiotic is
mixed in D 5 W. The nurse determines that a post-infusion phlebitis has occurred if which of the
following is observed?

1. Tenderness at the IV site.

2. Increased swelling at the insertion site.

3. Area around the IV site is reddened with red streaks.

4. Fluid is leaking around the IV catheter.

Strategy: Think about each answer.

1) tenderness occurs with phlebitis but is not specific to it
 2) may indicate either infiltration or phlebitis
3) CORRECT— reddened, warm area noted around insertion site or on path of vein;
discontinue IV, apply warm, moist compresses, restart IV at new site
4) not indicative of phlebitis
A client is admitted to the hospital with a diagnosis of acute myocardial infarction. The client’s husband
tells the nurse his wife has been drinking heavily for the past 4 years. The nurse should observe for
which of the following symptoms?

1. Insomnia, hyperactivity, and decreased appetite.

2. Lack of energy, withdrawn, and sense of failure.

3. Watery eyes, cramps, and tremors.

4. Hyper-alert, startles easily, and anorexia.

Strategy: Think about the answers.

1) symptoms of withdrawal from cannabis derivatives
2) symptoms of depression
3) symptoms of narcotic withdrawal
4) CORRECT— symptoms of early withdrawal from alcohol; other symptoms include
increased pulse, anxiety, tremors, insomnia, hallucinations
The nurse observes the mother of an adult patient, who is newly admitted with bacterial meningitis,
crying softly in the waiting area. The mother says to the nurse, "My father died of meningitis when I was
a child and it was awful. Now my child may die of the same thing." Which of the following is the BEST
initial response by the nurse?

1. "The outlook for meningitis is much better now than it was back then."

2. "I can have the chaplain come speak with you if you would like."

3. "This must be bringing back a lot of memories."

4. "Not necessarily. You can’t make that assumption."

Strategy: "BEST" indicates discrimination is required to answer the question.

(1.) CORRECT—directly responds to the mother’s expressed concerns; gives factual
information (family teaching) of which the mother may not have been aware and which may help
alleviate some of her distress
 (2.) passing the buck; premature; nurse should be able to respond to the mother
(3.) not best; nice empathic statement that reflects the obvious and provides opening for further
discussion
(4.) while factual, it blocks further communication by not encouraging the mother to express
herself further; also, the word "assumption" has a judgmental tone
The nurse cares for a client diagnosed with moderate flail chest. The nursing care plan should include
which of the following interventions?
Select all that apply:

1. Monitor client’s vital signs for shock.

2. Maintain Pler-evac drainage system.

3. Administer pain medication at regular intervals.

4. Encourage client to turn, cough, and breathe deep.

5. Monitor ABGs.

Strategy: Determine the outcome of each answer. Is it desired?

1) CORRECT— treat hypovolemia immediately
2) required for pneumothorax
3) CORRECT— caused by blunt chest trauma and is extremely painful
4) CORRECT— promotes lung expansion
5) CORRECT— assess for hypoxemia and hypercapnia
The nurse cares for a 4-year-old child diagnosed with epiglottitis. It is MOST important for the nurse to
take which of the following actions?

1. Instruct a nursing assistant to take the child to the x-ray department.

2. Use a padded tongue blade to assess the child’s gag reflex.

3. Obtain a blood culture and arterial blood gases (ABGs) as ordered.

4. Apply a pulse oximeter and start an IV.

Strategy: “MOST important” indicates priority.

 1) epiglottitis is inflammation of the epiglottis and can be life-threatening; a professional should
be with the child at all times
2) Never insert a tongue blade into the mouth of a child diagnosed with epiglottitis; gag reflex
can cause complete obstruction of the airway
3) crying can cause obstruction of airway
4) CORRECT— treatment includes moist air and IV antibiotics to decrease epiglottal swelling;
pulse oximeter measures oxygen saturation to determine the need for supplemental oxygen
The nurse in the emergency department (ED) assesses a patient diagnosed with tonic-clonic epilepsy.
The patient’s spouse states that the patient has been taking phenytoin (Dilantin) as prescribed but has not
been feeling well lately. Which of the following observations of the patient MOST concerns the nurse?

1. Reddish-brown urine, and the patient complains of constipation.

2. Acne, hirsutism, gingival hyperplasia.

3. Ataxia, slurred speech, nystagmus.

4. The left arm is in a sling and the patient walks with a limp.

Strategy: "MOST concerns the nurse" indicates a complication. Discrimination is required to

answer the question.
(1.) common occurrences with Dilantin; may turn urine pink, red, or reddish-brown, and is a
harmless effect; constipation or diarrhea may occur with Dilantin
(2.) seen with long-term Dilantin therapy; meticulous personal and professional dental care can
help prevent or ameliorate gingival hypertrophy; acne and hirsutism may require referral to a
dermatologist; patient may also benefit from psychological counseling related to body image
(3.) CORRECT—these are common signs of Dilantin overdose/toxicity; usual therapeutic
concentration of the drug in the plasma is 10–20 g/mL; nystagmus is usually evident at >20
g/mL, and ataxia and slurred speech are usually evident at >30 g/mL
(4.) may indicate osteomalacia, which may occur with Dilantin unless sufficient vitamin D is
given; Dilantin interferes with normal vitamin D metabolism
The home care nurse makes an initial visit to a client diagnosed with heart failure. The client takes
digoxin (Lanoxin) 0.25 mg daily and furosemide (Lasix) 40 mg daily. It is MOST important for the
nurse to intervene if the client states which of the following?

1. "I take my digoxin in the morning."

2. "I eat a dish of ice cream for dessert every night."

3. "I take herbal licorice to keep my stomach ulcer from coming back."
 4. "I take the furosemide (Lasix) at night."

Strategy: "MOST important" indicates that discrimination is required to answer the question.
(1.) appropriate action; cardiac glycoside
(2.) high in fat; not priority for nurse to intervene
(3.) CORRECT—licorice can increase potassium loss and may cause digoxin toxicity
(4.) should take in the morning to prevent diuresis from interfering with sleep; priority is the
ingestion of licorice
The nurse instructs a patient about Kegel exercises to manage urinary stress incontinence. Which of the
following statements, if made by the patient to the nurse, indicates that teaching is effective?

1. "I will do the exercises for longer periods than required."

2. "When it is time to do the exercises, I will sit down."

3. "I will hold my breath as I am tightening my muscles."

4. "When I do the contractions I will pretend I am trying to stop passing gas."

Strategy: "Teaching is effective" indicates correct information.

(1.) should not overdo the exercising of these muscles, pelvic muscle fatigue may result; two or
three times a day is recommended
(2.) exercises best done while sitting, standing, and lying down in order to make the muscles the
strongest
(3.) incorrect action; breathing should be relaxed and normal during muscle contraction
(4.) CORRECT—weakened pelvic floor muscles can cause urinary incontinence; contracting
these muscles strengthens them; pretending to be keeping intestinal gas or flatus from escaping
automatically use these muscles
A patient with a history of assault is admitted involuntarily to the locked psychiatric unit. As the nurse
begins the admission interview, the patient angrily yells, "Get away from me, you racist bigot!" Which
of the following actions by the nurse is MOST appropriate?

1. Inform the patient that the nurse will return in 30 minutes.

Ask another nurse of the same ethnic background as the patient to complete the
2.
interview.

3. Remain sitting quietly with the patient until the patient is ready to cooperate.
 4. Ignore the patient’s comment and continue the interview.

Strategy: "MOST appropriate" indicates discrimination is required to answer the question.

(1.) CORRECT—history of assault makes this patient potentially violent, nurse’s safety always
comes first; give patient space and time to calm down
(2.) inappropriate; will only validate patient’s remark and set the stage for staff splitting
(3.) inappropriate at this time; patient needs time alone to grasp situation
(4.) may intensify patient’s anger and make the nurse the target of violence
The nurse cares for a client hospitalized for treatment of uncontrollable aggressive impulses. Which of
the following observations is MOST important for the nurse to record before beginning a behavior
modification plan?

1. The client tells each nurse that she is his favorite nurse.

2. The client is flirtatious with female members of the staff.

3. The client threatened to hit two other clients within 2 hours.

4. The client appears insincere and superficial in his interactions.

Strategy: “MOST important indicates discrimination is required to answer the question

1) example of manipulative behavior
2) example of manipulative behavior
3) CORRECT— concrete evidence of aggressive behavior; intercede early, continue
nonthreatening behavior, restrain client to protect himself and others
4) not related to aggression
The home care nurse assesses a client diagnosed with hypertension. The client’s blood pressure is
180/100 mm Hg. The nurse questions the client about compliance with medication. Which of the
following responses by the client indicates to the nurse that the client is taking the prescribed
medication?
“I take my medication every morning. If my blood pressure is high, I take another
1.
dose in the evening.”
“I take my medication every day at the same time regardless of how I feel. I have
2.
not missed any doses.”
“I take my medication every day and make sure that I drink a large amount of liquid
3.
with each dose.”

4. “If I miss the morning dose of medication, I take two pills in the evening.”
 Strategy: Think about what the words mean.
1) client should not add extra doses of medication
2) CORRECT— describes how antihypertensives should be taken; because the client is taking
medication appropriately, health care provider should be notified
3) important to monitor fluid balance
4) should take medication as prescribed
The office nurse observes a student nurse assess the blood flow in a patient diagnosed with hypertension
and peripheral arterial disease (PAD) using a Doppler ultrasound device. The nurse should intervene if
which of the following is observed?
The student nurse holds the probe at a 45-degree angle to the artery being
1.
assessed.

2. The student nurse presses firmly while moving the probe proximal to distal.

3. The student nurse applies lukewarm gel over the vessel to be assessed.

4. The student nurse marks the pulse locations with a waterproof pen.

Strategy: "Nurse should intervene" indicates an incorrect action.

(1.) probe should be at a 45-degree angle for the best signals
(2.) CORRECT—pressing snugly or excessively can compress the artery, abolishing the signal;
direction of movement, if done, should be distal to proximal
(3.) conductive gel applied to the skin to decrease resistance to sound transmission; it also
protects the crystals in the probe, which are what transmit and receive signals; warming the gel is
important because if the gel were cold it would promote vasoconstriction, making it difficult to
detect a signal
(4.) facilitates locating the pulses for repeated assessments
The nurse prepares a patient for discharge after treatment for AIDS and candida esophagitis. Which of
the following statements, if made by the patient, indicates that the nurse’s discharge teaching is
effective?

1. “I should not share my father’s razor.”

2. “I should not use the same bathroom as my parents.”

3. “I should not eat with my parents at the same table.”

4. “I should not wash my clothes with my parents’ clothes.”

 Strategy: “Teaching is effective” indicates a true statement.
1) CORRECT— AIDS transmitted through contact with blood and body fluids, could
contaminate blade with blood.
2) only necessary if too ill to observe good hygiene, or profuse diarrhea, fecal incontinence, or
altered behavior secondary to CNS dysfunction; virus found in very low concentration in urine
and feces
3) not transmitted through casual contact
4) virus does not survive for long periods of time outside body, hot water and detergent destroy
virus in the laundry; if clothing heavily soiled with blood and/or body fluids wash separately
using dilute solution of sodium hypochlorite, or household bleach and water
The nurse administers a tube feeding to a patient with a baseline decreased mental status. Immediately
after completing the tube feeding, it is MOST important for the nurse to place the client in which of the
following positions?

1. Supine with the head of the bed elevated 45°.

2. Supine with the lower extremities elevated on pillows.

3. High Fowler’s or semi-Fowler’s position.

4. On the right side with the head of the bed elevated.

Strategy: Determine the outcome of each answer. Is it desired?

1) placing patient on right side promotes emptying of the stomach and prevents aspiration
2) at risk for aspirating
3) place on right side
4) CORRECT— promotes emptying of stomach while preventing aspiration
The nurse reviews the charting by a student nurse after the student nurse performs a routine physical on
a healthy adult. The nurse determines that the student nurse properly inspected the client’s anterior chest
if which of the following entries is found in the client’s chart?

1. "Diaphragmatic excursion equal bilaterally measuring 4 cm."

2. "Smooth, symmetrical chest expansion noted."

3. "Vesicular breath sounds present over lung periphery."

"Ribs sloping downward with symmetric interspaces and a costal angle within 90
4.
degrees."
 Strategy: Think about each answer.
(1.) diaphragmatic excursion percussed on posterior chest wall
(2.) palpated over anterior chest wall
(3.) auscultated on anterior, posterior, and lateral chest
(4.) CORRECT—inspection of anterior chest includes shape and configuration of the chest,
facial expression, level of consciousness, color and condition of skin, and quality of respirations
The home care nurse receives a phone call from the caregiver for a client diagnosed with AIDS. The
caregiver states that she has the flu and is afraid that she is going to give the client an infection. Which
of the following actions should the nurse take FIRST?
Instruct the caregiver to wear a well fitting surgical mask that covers the mouth and
1.
nose.

2. Assess whether the caregiver is frequently washing her hands before providing care.

3. Determine if there is someone else available to provide care for the client.

4. Inform the caregiver to clean the client’s bathroom daily.

Strategy: “FIRST” indicates priority.

1) appropriate action if infected caregiver must provide care to the client; priority is to prevent
the client from being exposed to infection
2) appropriate action; because of the client being immunocompromised, should not be exposed to
sick people
3) CORRECT— priority is to prevent client’s exposure to infection; if that is not possible,
actions should be aimed at reducing the client’s risk (caregiver wearing mask and frequently
washing hands)
4) appropriate action when caring for a client who is immunocompromised; priority in this
situation is to find an uninfected person to provide care
The nurse cares for clients on the psychiatric unit. Before administering medication to a client, the nurse
asks him to state his name. The client responds, “I am Jesus Christ.” Which of the following actions
should the nurse take FIRST?

1. Ask two nursing assistants to stand by in the area.

2. Request that the hospital chaplain speak to the client.

3. Look at the client’s armband.

 4. Determine if the client ate his lunch.

Strategy: Determine the outcome of each answer.

1) nursing assistants not needed; priority is identifying client before giving medications
2) passing the buck
3) CORRECT— remember the five rights of medication administration
4) some medications have to be given before or after meals; priority is identifying the client so
medications can be given
The nurse prepares for the admission of a patient diagnosed with diabetes and a latex allergy. The only
private room on the unit is occupied by a patient diagnosed with tuberculosis. The nurse should take
which of the following actions when assigning the new patient to a room on the unit?
Transfer a patient diagnosed with tuberculosis to a room with a patient diagnosed
1.
with bronchitis, and then clean the private room for the patient with latex allergy.
Admit the patient diagnosed with latex allergy to a room with a patient diagnosed
2.
with Parkinson’s disease, and treat both patients as being latex-sensitive.
Admit the patient diagnosed with latex allergy to a room with a patient diagnosed
3.
with diverticulitis, and keep the beds and all equipment at least 3 feet apart.
Admit the patient diagnosed with latex allergy to a room with a patient diagnosed
4.
with diabetes who has a Foley catheter and is receiving oxygen.

Strategy: Determine the outcome of each answer. Is it desired?

(1.) private room is best for a patient with latex allergy; however, a patient with active
tuberculosis must be placed on airborne precautions in a private, negative air-pressure room with
the door closed; the air is vented directly to the outside of the building or filtered before it is
recirculated
(2.) CORRECT—private room is best for a patient with latex allergy; if a private room is not
available, then all patients in the room with the patient with latex allergy must be treated as
though they too were latex-sensitive; latex-free environment is essential for treatment of patients
having latex allergy
(3.) 3 feet separation between patient and others is appropriate for droplet precautions, not latex
allergy
(4.) not safe; although both patients have diabetes and might have something in common, the
Foley catheter and the oxygen equipment are usually latex; also, staff caring for the catheter are
likely to use latex gloves and other supplies for that patient and for others they care for; patient
with latex allergy requires a latex-free environment
For the past 3 days, an 8-year-old child has come to the school nurse’s office complaining of
"stomachaches." The school nurse notes that the abdominal pain subside when the child overhears the
nurse contact the child’s parent at work. It is MOST important for the nurse to take which of the
following actions?

1. Ask the child what the child eats for breakfast and dinner

2. Ask the child to describe life at home.

3. Report this event to social services.

4. Ask the parents how the child behaves prior to school.

Strategy: "MOST important" indicates discrimination is required to answer the question.

(1.) incorrect assessment, frequent stomach upset in children is suggestive of anxiety
(2.) question too broad, child still thinks in concrete terms
(3.) need further assessment data before taking this action
(4.) CORRECT—need to validate anxiety, especially separation anxiety; child may be worrying
about parents and is relieved when nurse talks to the parent
The nurse cares for clients on the psychiatric unit. One of the clients has committed suicide, and the staff
members meet to discuss the incident. The nurse understands the staff is meeting for which of the
following reasons?

1. Participate in the hospital administration’s review of the client’s records.

2. Determine who will speak to the client’s family members.

3. Allow the staff to ventilate feelings and review the case.

4. Ascertain who was responsible for the incident.

Strategy: Think about each answer.

1) administration will review the client’s records and staff actions; not the purpose of the
meeting
2) not the purpose of the meeting
3) CORRECT— in-hospital successful suicide can be emotionally distressing to staff; meeting
allows for a shared experience to explore and express feelings
4) case will be reviewed, but primary purpose of meeting is to allow staff to ventilate
The nurse cares for children at summer camp. Which of the following children presenting at the
infirmary should the camp nurse see FIRST?
 A child diagnosed with hemophilia who is complaining of a headache and has slurred
1.
speech.

2. A child diagnosed with type 1 diabetes who is nervous, pale, and sweating.

3. A child diagnosed with asthma who is complaining of a sore throat and restlessness.

A child diagnosed with leukemia was stung by a bee and is complaining of feeling hot
4.
and itchy all over.

Strategy: Remember the ABCs.

(1.) very serious, but not first; indicates cerebral bleeding; requires prompt evaluation and
treatment
(2.) possible hypoglycemic reaction; not priority
(3.) potential problem; inflammation contributes to airways becoming more reactive; colds and
infections can precipitate and/or aggravate asthmatic exacerbations; restlessness can indicate
anxiety, respiratory difficulty, boredom, etc.
(4.) CORRECT—probable sign of anaphylactic reaction, which can proceed quickly to loss of
consciousness, angioedema, bronchiolar constriction, pulmonary edema
A 21-year-old college student diagnosed with asthma falls on the running track while preparing for a
track meet. Use of the inhaler restores breathing and equilibrium. Since this is the third time this has
occurred in 3 weeks, the college health center nurse is called to the scene. The student is conscious,
alert, and oriented. Blood pressure is 120/82 mm Hg, pulse is 84 bpm, and respirations are 14/min. The
coach asks the student to go to the emergency department to obtain medical evaluation to assess whether
continued training is safe. The student refuses to seek medical evaluation. It is MOST appropriate for the
nurse to take which of the following actions?
Contact the student’s parents to obtain consent for hospital evaluation and any
1.
needed treatment.
Call an ambulance and ask the student who he wants to accompany him to the
2.
hospital.

3. Tell the student he does not have to seek medical evaluation if he does not want to.

Suggest the coach remove the student from the training roster unless the student
4.
consents to be medically evaluated.

Strategy: "MOST appropriate" indicates that discrimination is required to answer the question.
(1.) student has the right to refuse treatment; he is of legal age, living away from home,
conscious and oriented
(2.) student has the right to refuse treatment
 (3.) CORRECT—student is of legal age to refuse treatment; even if he were not, he is living
away from home so may be considered an emancipated minor with rights equivalent to legal age;
a competent adult can refuse emergency treatment, and that refusal must be respected by all
(4.) may be appropriate response to the coach but nurse should direct comments to the student,
who has the right to refuse treatment
The nurse asks the nursing assistant to perform soapsuds enemas for a patient scheduled for a diagnostic
test. The nurse should

1. observe the returns from the enemas in the patient’s bedside commode.

2. ask the nursing assistant to describe the returns from the enemas.

3. ask the patient to describe the returns from the enemas.

4. palpate the patient’s abdomen, noting firmness and tenderness.

Strategy: Determine the outcome of each answer. Is it desired?

1) performing an enema is a standard, unchanging procedure that can be delegated to the nursing
assistant; responsibility and authority for performing the task (function, activity, decision) is
transferred to another individual; it is the nurse’s responsibility to describe clear outcomes;
observing returns is a part of the task delegated and should be performed by the nursing assistant
2) CORRECT— describing returns from the enema is a part of the responsibilities delegated;
nurse should monitor performance and results according to established goals
3) inappropriate; this information should be reported by the nursing assistant
4) should be performed by the RN if patient complains of tenderness or the nursing assistant
identifies a problem with the procedure
A patient is to receive 1,000 cc of TPN infused over a 24-hour period. When it is time for the nurse to
change the solution, there is 200 cc remaining in the bottle. Which of the following actions, if taken by
the nurse, is MOST appropriate?

1. Quickly infuse the remaining solution over the next half-hour.

2. Slowly infuse the remaining solution over the next two hours.

3. Change the infusion as scheduled.

4. Call the physician for further instructions.

Strategy: Determine the outcome of each answer.

 1) too rapid; would cause hyperglycemia and hyperosmolar diuresis
2) should hang no longer than 24 h; slowing rate will cause rebound hypoglycemia
3) CORRECT— decrease the chance of infection; unused solution always discarded; site of
catheter changed every 4 weeks, change IV tubing and filers every 24 h
4) “passing the buck”
A patient is discharged from the orthopedic unit after receiving treatment for low-back pain. The nurse
counsels the patient about how to prevent further back injury. Which of the following statements, if
made by the patient to the nurse, indicates correct understanding of appropriate preventive measures?
"It is all right to reach up for things, but if I am picking something up from the floor,
1.
I will squat rather than bend and reach down."

2. "I will sleep on my side or abdomen rather than lie flat on my back."

3. "If my back starts to hurt, I will immediately stop what I am doing."

"I will sit as far back from the pedals on my car as my legs can comfortably stretch,
4.
and I will use a firm backrest."

Strategy: All parts of the answer must be correct for the answer to be correct.
(1.) partially correct; it is not safe to strain to reach things
(2.) prone (abdomen) position should be avoided in order to maintain proper body alignment
(3.) CORRECT—pain is the body’s signal that there is a potential for physical harm and that the
patient needs to withdraw from the pain-producing situation
(4.) to prevent back strain when driving a car, patient should sit close to the pedals, in part to
avoid knee and hip extension; a seat belt and firm backrest should be used for back support
The nurse cares for patients in the emergency department (ED). Which of the following patients should
the nurse see FIRST?

1. A patient complaining of a dry cough for several weeks with frequent night sweats.

A patient who complains of vaginal spotting and reports that her last menstrual
2.
period was 2 weeks ago.
A patient complaining of right upper quadrant abdominal pain with nausea and
3.
vomiting.
A patient complaining of burning epigastric pain that radiates to the mid-chest when
4.
the patient is lying flat.

Strategy: Determine the MOST unstable patient.

(1.) CORRECT—classic symptoms of tuberculosis; place in room with negative air pressure or
fit with an appropriate mask to prevent spread of the disease until evaluation confirms that
patient is free of disease
 (2.) likely experiencing breakthrough bleeding at ovulation, though other possibilities range from
an infectious process to cervical cancer; no emergent intervention is required at this time
(3.) important to alleviate patient’s symptoms; preventing spread of infection to other patients,
visitors, and staff takes precedence
(4.) likely experiencing symptoms of acid reflux; instruct patient to keep the head of the bed
elevated; possibly offer medication intervention
The nurse assesses a client during the client’s first prenatal visit. The nurse determines that the client is
at 6 weeks’ gestation. The nurse identifies which of the following as a probable sign of pregnancy?

1. Amenorrhea.

2. Positive urine pregnancy test.

3. Urinary frequency.

4. Fetal heart tone auscultated by Doppler.

Strategy: Think about each answer.

1) presumptive sign of pregnancy; presumptive signs are felt by the woman, such as
nausea/vomiting, breast sensitivity, fatigue, quickening
2) CORRECT— probable signs are observed by the examiner; uterine enlargement, souffle and
contractions, positive urine pregnancy test, Hegar’s sign, Chadwick’s sign
3) presumptive sign; can also be caused by UTI
4) positive sign of pregnancy; palpation of fetal movement; sonogram of fetus
The nurse assumes care of a patient just returning from surgery after a total abdominal hysterectomy.
When the nurse questions the patient about her pain, the patient rates her pain as 4 out of 10 on the pain
scale. Which of the following interventions by the nurse is MOST appropriate?

1. Assist the patient to a more comfortable position and encourage her to sleep.

2. Administer narcotic pain medications as ordered.

3. Encourage the patient to watch television or read a book.

4. Continue to monitor the patient for pain.

Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?
1) nonpharmacologic interventions such as repositioning and rest are appropriate alternatives;
however, moderate pain should be more aggressively addressed
 2) CORRECT— there is a known etiology for the pain (surgery), so it is most appropriate to
provide pain medications immediately for moderate pain and use other methods as adjunct
therapy
3) distraction may be appropriate adjunct therapy; unrealistic intervention immediately post
anesthesia
4) providing no intervention for the patient’s report of moderate pain is an unacceptable solution
The nurse observes that a physician has ordered 100 cc D 5 W with KCl 80 mEq to infuse in 0.5 hour.
Which of the following actions should the nurse take FIRST?

1. Assess the client’s urinary output.

2. Ensure the patency of the client’s IV.

3. Request an order for IV Lidocaine.

4. Contact the physician.

Strategy: “FIRST” indicates priority.

1) decreased renal function can cause hyperkalemia
2) severe pain and tissue necrosis may occur because of extravasation
3) lidocaine used for treatment of ventricular dysrhythmia
4) CORRECT— rate of IV administration should be no faster than 20 mEq/h; contact physician
to clarify order
The nurse observes a nursing assistant care for a client after abdominal surgery. The nursing assistant
supports the client’s leg as the client flexes and bends the knee. The nurse identifies that the client is
engaged in which of the following therapeutic exercises?

1. Passive.

2. Active-assistive.

3. Active.

4. Resistive.

Strategy: Think about each answer.

1) exercise is carried out by nurse without help from the client
2) CORRECT— nurse supports distal part while client actively takes the joint through range-of-
motion
 3) exercise is carried out by the client without help from the nursing staff; will increase muscle
strength
4) active exercise that is carried out independently by client; client works against resistance to
increase muscle power
The nurse in the medical clinic cares for a client diagnosed with hyperthyroidism treated with
radioactive iodine I-130. When caring for the client, it is MOST important for the nurse to be alert for
which of the following?

1. Irritability, weight loss, nausea, vomiting, postural hypotension.

2. Numbness and tingling of toes and fingers, painful muscle spasms.

3. Lethargy, sensitivity to cold, dry skin, weight gain, depression.

4. Frequent urination, excessive thirst, excessive hunger.

Strategy: "MOST important" indicates discrimination may be required to answer the question.
(1.) indicate primary adrenal insufficiency
(2.) indicate tetany, which results from hypocalcemia
(3.) CORRECT—indicate hypothyroidism, which is a complication of I-130 therapy
(4.) indicate diabetes
The nurse cares for clients in the intensive care unit (ICU). During the shift, the nurse received a phone
call stating a client diagnosed with a head trauma is to be admitted. Since there are no empty beds, the
nurse anticipates which of the following clients may be transferred to the step-down neurological unit?

1. A client diagnosed with bacterial meningitis and Glasgow Coma Scale of 7.

A client 1 day postoperative after a transsphenoidal craniotomy with a possible

2.
cerebrospinal leak.

3. A client diagnosed with a stroke 4 days ago with confusion.

4. A client with a head injury with seizures.

Strategy: Determine the most stable client.

1) indicates comatose state; unstable
2) risk of ICP; unstable
3) CORRECT— risk of second stroke reduced; focus is on rehabilitation
4) unstable client
The nurse cares for clients in the long-term care facility. The nurse recognizes which of the following
signs/symptoms may indicate that a client has developed dementia?

1. Impaired motor skills, lack of coordination, and mood changes.

2. Confusion, delirium, and hallucinations.

3. Weight loss, fatigue, and hopelessness.

4. Poor judgment, memory deficit, and irritability.

Strategy: Think about each answer.

1) may be the result of a CVA
2) describes delirium; rapid onset secondary to physical illness
3) symptoms of depression
4) CORRECT— characteristic symptoms of dementia; may also see apathy, indifference,
pacing, restlessness, and agitation
The nurse assists with the insertion of a central venous catheter. During the insertions, the nurse notes
that the tip of the monitor device brushes the underside of the sterile field. Which of the following
actions, if taken by the nurse, is MOST appropriate?

1. Wipe the tip with alcohol before connecting to the system.

2. Notify the physician of the occurrence.

3. Back-flush the catheter for several seconds before connecting.

Obtain a new monitor device and prepare for a second

4.
attempt.

Strategy: Determine the outcome of each answer.

1) equipment is contaminated; obtain new equipment
2) priority is to obtain new equipment
3) equipment is contaminated
4) CORRECT— if equipment becomes contaminated during sterile procedure, obtain new
equipment; the edge of the field is considered contaminated
The nurse instructs a client during the third trimester about the signs and symptoms of impending labor.
The nurse determines that teaching is effective if the client states which of the following?
 “I will call the health care provider when my contractions are 3-4 minutes apart and I
1.
have bloody show.”
“I will call the health care provider when my contractions occur every 5 minutes for
2.
an hour.”

3. “I will call the health care provider when I pass my mucous plug.”

4. “I will call the health care provider when I feel the increased pelvic pressure.”

Strategy: “Teaching is effective” indicates a correct statement.

1) contractions every 3–4 min indicates active labor; fetus should be evaluated before the active
phase of labor; bloody show is considered a sign of labor, may expel it 24–48 hours before the
onset of labor
2) CORRECT— contractions that last continuously for an hour generally indicate labor; in true
labor, contractions are regular with decreasing intervals between contractions, contractions
increase in intensity and duration, intensity usually increases with walking, cervix dilates and
effaces
3) mucous plug can be expelled up to 2 weeks before onset of labor; client may not notice it
4) lightening occurs when the fetus settles into the pelvic inlet; this often occurs 2 weeks before
labor in a primipara woman and during labor in a multipara woman
The parish nurse observes children at a church picnic. Which of the following observations would
MOST concern the nurse?
The spine of a 2-month-old boy is flexed forward and rounded when he is held in a
1.
seated position.
The legs of an 18-month-old bend outward at the knees when the child stands and
2.
walks.
The legs of a 4-year-old girl touch at the knees when she stands with feet spread
3.
apart.
The arms of a 14-year-old girl appear different in length and she has a slight limp
4.
during ambulation.

Strategy: "MOST concern" indicates that something is wrong.

(1.) normal; spine is rounded or C-shaped in infants younger than 3 months of age due to the
thoracic and pelvic curves; during the third and fourth months the cervical curve develops, and

by to 18 months the lumbar curve develops

(2.). normal for a toddler; it is called genu varum and referred to as bowleg; caused by lateral
bowing of the tibia and lasts until all leg and lower back muscles are well developed, usually by
2 years of age
 (3.) normal for a child of 2 to 7 years of age; it is called genus valgum and referred to as knock-
knee
(4.) CORRECT—this is possible scoliosis, a spinal curvature deformity that is most noticeable
during the growth spurt in preadolescence
Following a left above-knee amputation with delayed prosthesis fitting, the nurse instructs the client
about the importance of lying prone. Which of the following responses by the client indicates to the
nurse that teaching is successful?
“I need to lie on my stomach to keep from getting a flexion contracture of my left
1.
hip.”

2. “Lying flat keeps my blood flowing and prevents my stump from swelling.”

3. “I need to lie on my stomach to prevent a pressure sore on my hips.”

4. “I will always elevate my stump when I am in a chair to keep it from swelling.”

Strategy: Determine the outcome of each answer. Is it desired?

1) CORRECT— prone position provides maximum extension of the hip joint and prevents hip
flexion contracture; if hip flexion contracture occurs, it is very difficult to correctly fit or use a
prosthesis
2) lying prone prevents hip contracture; wrap stump with elastic bandage to shape; reduce edema
and keep dressing in place; encourage client to roll from side to side
3) not the reason for the prone position; begin active range of motion and strengthening exercises
for arms
4) lie prone to prevent hip contracture; instruct about stump care
The physician prescribes ampicillin 125 mg IM q6h for a 76-year-old woman. The injection site selected
by the nurse should depend on which of the following?

1. The size of the muscle mass.

2. The total number of injections ordered.

3. The position of the patient in bed.

4. The gauge of the needle.

Strategy: Determine how each answer relates to an IM injection.

 1) CORRECT— must be injected deeply into large muscle mass; injection too close to nerve or
blood vessel causes neurovascular damage; best site for adult upper outer quadrant of buttocks,
best site for children midlateral thigh
2) would not determine site; with multiple injections, sites should be rotated
3) safety is most important consideration, not comfort
4) varies with type of medication, not site of injection or size of person
The nurse on the cardiac unit notes that a patient recovering from a myocardial infarction appears
worried and irritable. When asked about his thoughts, the patient replies, "I’m worried about my
business. You know, I own a restaurant and I’m not there. I’m used to working 6 days a week, at least
12 hours a day. I’m worried about how things are going there now, and I’m worried about whether I will
be able to handle the stress once I’m back there." Which of the following responses by the nurse is
BEST?
Give him a list of complementary therapies related to relaxation and say, "Pretend
1.
this is a menu. Which of these would you like to order for yourself?"
"You might find it interesting to attend the cardiac cooking class the dietitian gives
2.
before you are discharged."
"Who is supposed to be taking care of the restaurant while you are here in the
3.
hospital?"
Hand the patient the TV control and say, "Sometimes when I have a lot on my mind,
4.
I watch a movie. It makes me feel better."

Strategy: "BEST" indicates that discrimination is required to answer the question.

(1.) CORRECT—patient needs to learn to relax, both to prevent and to cope with stressors of
the job and avoid further physiologic damage; relaxation strategies also part of cardiac
rehabilitation program; providing a list of possible complementary therapies gives the patient
choices
(2.) valid idea; relates to patient’s professional life, but does not address expressed concerns
(3.) assessment to elicit factual information related to one of the patient’s current concerns, but
by itself does not offer coping options; also, does not respond to emotional tone and is rather
closed-ended
(4.) distraction can be a valid stress management technique at times; however, this response does
not respond directly enough to the content and tone of patient’s concerns
The nurse instructs the mother of a toddler about appropriate foods for her 2-year-old child. It is MOST
important for the nurse to make which of the following suggestions?

1. Provide the child with finger foods.

2. Allow the child to eat favorite foods.

3. Encourage a diet high in protein.

 4. Limit the number of snacks offered to the child.

Strategy: Topic of question is unstated.

1) CORRECT— toddler is working to develop autonomy; finger foods offer the child the
necessary independence for this stage
2) parents’ responsibility to offer a variety of nutritionally sound foods
3) needs carbohydrates for energy
4) toddlers eat small amounts of food; offer nutritionally sound snacks
The nurse instructs a client diagnosed with COPD about how to perform pursed lip breathing. Which of
the following statements by the client to the nurse indicates further teaching is necessary?

1. “I will tighten my stomach muscles as I finish breathing out.”

2. “I will take twice as long to breathe out as I did to breathe in.”

3. “I will breathe in deeply through my nose, hold it, and then breathe out.”

4. “I will pretend I am whistling when I breathe out.”

Strategy: “Further teaching is necessary” indicates incorrect information.

1) using abdominal muscles helps to squeeze out all of the air
2) appropriate action; exhalation should be at least twice as long as inhalation; mild resistance of
partially opposed lips prolongs exhalation and increases airway pressure
3) CORRECT— incorrect action; breath should never be held during pursed lips breathing
4) ensures slow, soft, and steady exhalation
A sequential compression device (SCD) is ordered for a patient recovering from a retropubic
prostatectomy. It will be the first time for the nurse to apply such a device. Which of the following
statements by the nurse to the nursing manager best reflects correct understanding of the proper
procedure?
"I will wrap the sleeves snugly, but I will be certain I can fit one finger between each
1.
one and the leg."

2. "I will put the antiembolism stockings on before I wrap and secure the sleeves."

"I will start by positioning each sleeve under the leg so that the opening is at the
3.
ankle."
"I will measure the circumference of the midcalf and the midthigh to ensure that the
4.
sleeves are the correct size."
 Strategy: Determine the outcome of each answer. Is it desired?
(1.) incorrect action; need to be able to fit two fingers, not just one, between the sleeve and the
leg; correct fit prevents irritation to the leg; it also allows for the device to reach adequate
inflation pressure and prevents slipping out of position when deflation occurs; the fit can be
checked by inserting two fingers in the knee opening
(2.) CORRECT—correct action; it is acceptable, though not essential, to apply antiembolism
stockings prior to applying the sequential compression device sleeves; the stockings can decrease
the itching, sweating, and heat that can build up under the plastic sleeves and thereby cause
discomfort and skin irritation
(3.) incorrect action; the opening should be at the knee (in front) and at the popliteal pulse point
(in back)
(4.) incorrect action for sequential compression device; circumference of the thigh is measured at
the gluteal fold; correct sleeve size ensures proper fit and function
The nurse is working with a battered woman who is living in a domestic violence shelter after having
left her partner. The woman states to the nurse, “I don’t know what I keep doing wrong to get beaten this
way.” Which of the following responses by the nurse is BEST?

1. “Can you remember what you said or did just before he hit you?”

2. “Let’s focus on getting your face and ribs healed first.”

3. “We can help you when you’re ready; you do not deserve to be abused.”

4. “Only your husband can tell us what made him lose his temper.”

Strategy: “BEST response” indicates discrimination is required to answer the question correctly.
1) yes/no question is nontherapeutic; implies that the woman did something wrong to cause the
abuse
2) closed statement is nontherapeutic; focuses on physical healing; emotional work should not be
delayed if the woman indicates a willingness to start
3) CORRECT— reflective statement is therapeutic, also provides information; should offer
support and a path to help, coupled with reinforcement that the woman does not deserve to be
abused
4) focus is on the husband, not the patient; gives power to the abuser to place blame on the
victim, and implies to the woman that she is to blame
The nurse cares for patients on the medical/surgical unit. After receiving report, which of the following
patients should the nurse see FIRST?
 A 22-year-old admitted 8 hours ago with viral gastroenteritis who is complaining of
1.
nausea, vomiting, and diarrhea.
A 42-year-old 24 hours post-thyroidectomy who is complaining of a headache and
2.
pain at the incision site.
A 50-year-old admitted 72 hours ago for chronic renal failure with a urinary output of
3.
220 mL in 8 hours and hands and feet that are edematous.
A 64-year-old admitted yesterday for hypertension, congestive heart failure, and
4.
digitalis toxicity with frequent PVCs (premature ventricular complexes).

Strategy: Determine the LEAST stable patient.

(1.) potential electrolyte imbalance; need to monitor
(2.) pain at incision site is expected outcome; headache needs further investigation; not priority
(3.) indicates sodium retention, which is an expected finding in chronic renal failure; output
needs to be evaluated but is not an immediate threat
(4.) CORRECT—indicates potassium imbalance (hypokalemia); dysrhythmias
(cardiac/circulatory problem) can rapidly deteriorate to ventricular tachycardia or sudden death
The nurse cares for a client receiving carbidopa/levodopa (Sinemet). Which of the following statements,
if made by the client’s wife to the nurse, indicates the medication is effective?

1. “My husband has gained 2 pounds in the last month.”

2. “My husband gets fewer upper respiratory infections.”

3. “My husband’s tremors have disappeared.”

4. “My husband is better able to ambulate.”

Strategy: Think about the answers.

1) Sinemet is used to treat symptoms of Parkinson’s disease; weight gain does not evaluate
effectiveness of medication
2) does not indicate effectiveness of medication; instruct patient to take immediately before
meals; high-protein meals may impair effectiveness of medication
3) medication is not a cure and tremors do not disappear
4) CORRECT— reduces rigidity and bradykinesis and facilitates client’s mobility
A 24-year-old woman at 10 weeks’ gestation becomes nauseated each day around 4 P.M. Which of the
following interventions is MOST appropriate for the nurse to suggest to the client?

1. Limit lunch to soft foods and fruit before 2 p.m.

 2. Eat several pretzels around 3:30 p.m.

3. Take an antacid around 3:30 p.m.

4. Lie down and rest around 2 p.m.

Strategy: All the answer choices are implementations. Evaluate the outcome of each answer
choice. Is it desired?
1) implementation; does not provide requirements for healthy pregnancy
2) CORRECT— implementation; should eat dry carbohydrate food 30 minutes to 1 hour before
getting out of bed; remain in bed until the feeling of nausea subsides; alternate dry carbohydrate
with fluids such as hot tea, milk, or coffee; avoid eating fried, spicy, or gas-forming foods; eat
small, frequent meals
3) implementation; heartburn due to displacement of stomach by the enlarging uterus; take low
sodium antacid; occurs in second and third trimesters
4) implementation; will not prevent nausea; fatigue common in first trimester
The nurse returns to the desk in the prenatal clinic and finds four phone messages. Which of the
following messages should the nurse return FIRST?

1. A multigravida at 12 weeks’ gestation experiencing heavy white vaginal discharge.

2. A primigravida at 17 weeks’ gestation states that she has not felt the baby move.

A primigravida at 22 weeks’ gestation complains of feeling dizzy and clammy when

3.
lying on her back.
A multigravida at 32 weeks’ gestation experiencing malaise and bilateral dependent
4.
and facial edema.

Strategy: Determine the most unstable client.

1) leukorrhea caused by hyperplasia of vaginal mucosa, normal finding
2) normal finding for primigravida
3) vena cava syndrome; instruct client to lie on side
4) CORRECT— symptoms of pre-eclampsia that require evaluation
The home health nurse visits an elderly client who is diagnosed with diabetes and osteoporosis. The
client lives with her daughter in a two-story home. Which of the following statements by the daughter
MOST concerns the nurse?

1. "Mother loves a hot bath with her favorite bath oil."

 2. "Mother seems to taking more of an interest in the things going on around her."

3. "I sometimes feel guilty leaving her alone, even if it is just for half an hour."

4. "I am not sure what we are going to do when winter comes."

Strategy: "MOST concerns" indicates a complication.

(1.) CORRECT—safety risk; oils in the bath water can result in slippery shower or bathtub
surfaces; mother is at risk for falling due to osteoporosis
(2.) positive occurrence; reflects an interest in life
(3.) may indicate that daughter may be excessively locked into the caregiver role; caregiving
feelings and options should be explored
(4.) should further assess daughter’s concern about winter; not of greatest concern
A child is admitted to the pediatric cardiology unit after presenting in the emergency department with
symptoms of sudden chest pain and dizziness. A diagnosis of supraventricular tachycardia (SVT) is
made. If the child experiences another episode of chest pain and dizziness, what is the BEST action for
the pediatric nurse to take?
Place the child in a supine position with arms to the side, and elevate the foot of the
1.
bed.
Instruct the child to assume a squatting position with the arms wrapped around the
2.
legs.
Encourage the child to lie on the side and picture walking through a meadow,
3.
breathing in slowly through the nose and out through the mouth.
Ask the child to stick the thumb in the mouth, close the mouth around it, and then
4.
blow on the thumb as if it were a trumpet.

Strategy: "BEST" indicates that discrimination is required to answer the question.

(1.) useful for increasing venous return in peripheral vascular disease (PVD)
(2.) position assumed by children with congential heart disease, particularly Tetralogy of Fallot,
in an effort to relieve hypoxia, especially when exercising
(3.) imagery and relaxed controlled breathing can help decrease anxiety and increase relaxation
and sense of control; no particular reason to lie on either side
(4.) CORRECT—form of vagal or Valsalva maneuver, which can reverse SVT; blowing should
occur for 30–60 seconds; other possible vagal maneuvers include ice to the face, holding the
breath and then bearing down, massaging the carotid artery on only one side of the neck; if vagal
maneuvers do not work, IV adenosine (Adenocard or Adenoscan), an antidysrhythmic agent,
may be given
The nurse reviews the history obtained from a client with degenerative joint disease (DJD) of the right
hip. The nurse identifies which of the following as risk factors for developing degenerative joint
disease?
Select all that apply.

1. Client had a transurethral resection of the prostate (TURP) 2 years ago.

2. Client worked as a carpet installer for 40 years.

3. Client is a 65-year-old male, height 6 ft, weight 280 lb.

4. Client was diagnosed with diabetes mellitus 10 years ago.

5. Client had a myocardial infarction at age 37.

Strategy: Determine how each answer relates to degenerative joint disease.

1) no relationship with prostatic hypertrophy and joint disease
2) CORRECT— occupation that causes increased mechanical stress to joints, also would be 60+
years old
3) CORRECT— seen after age 60 years, obesity causes stress to weight-bearing joints
4) CORRECT— metabolic diseases (diabetes mellitus, Paget’s disease) and blood disorders
(hemophilia) can cause joint degeneration
5) myocardial infarction is caused by coronary artery disease
The home care nurse makes an initial visit for an elderly client diagnosed with heart failure,
hypertension, and osteoarthritis. The nurse asks the client if she is experiencing any pain caused by the
arthritis. The client admits to being in pain. Which of the following actions should the nurse take
NEXT?

1. “What has worked to relieve your pain in the past?”

2. “What have you taken today to relieve the pain?”

3. “Does it help to take a warm bath?”

4. “Does your physician know you are experiencing pain?”

Strategy: “NEXT” indicates priority.

1) priority is to determine what patient is doing now to relieve the pain
 2) CORRECT— if client is in pain, priority is to determine what client is doing now to relieve
the pain
3) yes/no question; when assessing, nurse should ask broad, open-ended questions
4) yes/no question; nurse should complete assessment of client’s pain
A patient receives isoniazid (INH), rifampin (Rifadin), and ethambutol (Myambutol). Which of the
following statements, if made by the patient to the nurse, MOST concerns the nurse?

1. "I seem to be becoming color-blind—I can’t see green."

2. "My urine and sweat are reddish-orange."

3. "Sometimes I wonder what I did to deserve all this."

4. "My big toe has started hurting so I can hardly walk."

Strategy: "MOST concerns" indicates that discrimination is required to answer the question.
(1.) CORRECT—a major common adverse effect of ethambutol is optic neuritis, with reduced
visual activity; lessened ability to see green is a possible initial sign
(2.) discoloration of body fluids—urine, sweat, tears, feces, and sputum—is a harmless side
effect of rifampin (Rifadin); patient should be warned, though, that soft contact lenses may be
permanently stained and therefore should not be worn; the stain will wash out of clothing
(3.) psychosocial; does indicate need for further exploring patient’s thoughts and emotions
regarding causation and management of disease process, including assessing for possible
depression, as medications prescribed indicate patient has tuberculosis
(4.) hyperuricemia can occur with pyrazinamide (PZA), resulting in acute gout symptoms, such
as severe pain in the great toe; this indicates that the drug should be discontinued
A patient receiving phenelzine sulfate (Nardil) is diagnosed with Cushing syndrome and found to be
hypokalemic. Which of the following foods is BEST for the nurse to recommend the patient add to the
diet?

1. Banana and raisin fruit salad.

2. Spinach and tuna fish salad.

Whole-wheat bread and cream

3.
cheese.

4. Guacamole and brown rice.

Strategy: "BEST" indicates discrimination is required to answer the question.

 (1.) high in potassium, but bananas are also high in tyramine; when tyramine is ingested with a
monoamine oxidase inhibitor (MAOI) such as Nardil, it can cause a hypertensive crisis
(2.) CORRECT—both are high in potassium and neither is contraindicated with monoamine
oxidase inhibitors (MAOI); most vegetables are acceptable with MAOIs
(3.) not high in potassium; whole-wheat bread is likely to have yeast, which is contraindicated
with MAOIs; cream cheese is one of a few cheeses that is acceptable with MAOIs
(4.) avocados high in potassium and tyramine; when ingested with an MAOI such as Nardil, can
cause a hypertensive crisis; brown rice is an acceptable grain with an MAOI because it does not
contain yeast
The nurse cares for a client diagnosed with tuberculosis. The nurse should follow which of the following
transmission-based precautions?

1. Standard precautions.

2. Airborne precautions.

3. Droplet precautions.

4. Contact precautions.

Strategy: Think about each answer.

1) barrier precautions used for all clients to prevent nosocomial infections
2) CORRECT— used with pathogens transmitted by airborne route
3) used with pathogens transmitted by infectious droplets
4) contact precautions required for all client care activities that require physical skin-to-skin
contact or those that require contact with contaminated inanimate objects in the client’s
environment
The nurse cares for a client experiencing alcohol withdrawal delirium. The client tells the nurse that
bugs are crawling on the walls in the room. Which of the following actions by the nurse is MOST
appropriate?

1. Place a can of insecticide within the client’s field of vision.

2. Turn on the lights and remain with the client.

3. Distract the client with simple activities.

4. Dim the lights and encourage the client to rest.

Strategy: Determine the outcome of each answer. Is it desired?
1) validates hallucination
2) CORRECT— client with alcohol withdrawal delirium may experience delusions and
hallucinations; place the client in a quiet, well-lighted room and stay with the client to interpret
the environment
3) not appropriate for a client experiencing alcohol withdrawal
4) do not leave the client alone; place in well-lighted room