PRACTICE TEST QUESTIONS

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Practice Exam (50 questions)

1. A client who received general anesthesia returns from surgery.

Postoperatively, which nursing diagnosis takes highest priority for
this client?
a. Acute pain related to surgery
b. Deficit fluid volume related to blood and fluid loss from
surgery
c. Impaired physical mobility related to surgery
d. Ineffective airway clearance related to anesthesia

2. They physician prescribes an infusion of 2,400 ml of IV fluid over 24

hrs, with half this amount to be infused over the first 10 hrs. During
the first 10 hrs, the client should received how many milliliters of IV
fluid per hour?
a. 50 ml/hr
b. 100 ml/hr
c. 120 ml/hr
d. 240 ml/hr

3. A client with burns on his groin has developed blisters. As the client
is bathing, a few blisters break. The best action for the nurse to
take would be to:
a. Remove the raised skin because the blisters has already
taken
b. Wash the area with soap and water to disinfect it
c. Apply a weakened alcohol solution to clean the area
d. Clean the area with normal saline solution and cover it
with a protective dressing

4. Which type of evaluation occurs continuously throughout the

teaching and learning process?
a. Formative
b. Retrospective
c. Summative
d. Informative

5. A Client Self-Determination Act of 1990 requires all hospitals to

inform clients of advance directives. What should the nurse tell the
 client about such directives as living wills and health care power of
attorney?
a. They guide the client’s treatment in certain health care
situations
b. They can’t provide DNR orders for clients with terminal
illnesses
c. They allow physicians to make decisions about treatment
d. They permit physicians to give verbal DNR orders

6. Which laboratory test result is the most important indicator of

malnutrition in a client with a wound?
a. Serum potassium level
b. Lymphocyte count
c. Albumin level
d. Differential count

7. The nurse is administering two drugs concomitantly to a client.

Which interaction occurs when two drugs with the same qualitative
effects produce response when given together greater than either
drug produces when given alone?
a. Tolerance
b. Antagonism
c. Hyporeactivity
d. Synergism

8. The nurse is giving nutritional counseling to the mother of a child

with celiac disease. Which statement by the mother would indicate
understanding?
a. My son can’t eat wheat, rye, oats or barley
b. My son needs a diet rich in gluten
c. My son must avoid potatoes, rice and cornstarch
d. My son can safely eat frozen and packaged foods

9. To assess effectiveness of incentive spirometry, the nurse can use a

pulse oximeter to monitor the client’s:
a. O2 saturation
b. Hgb level
c. Partial pressure of CO2 (PaCO2)
d. Partial pressure of O2 (PaO2)

10. After assessing a client, the nurse formulates relevant nursing

diagnoses. Which of the following is a complete nursing diagnosis
statement?
a. Ineffective airway clearance r/t mucus plugs and
nonreproductive cough
 b. Hyperventilation r/t anxiety
c. Tachycardia
d. Shortness of breath r/t anxiety

11. The nurse is caring for a 3-year old child admitted to the
pediatric unit with acetaminophen (Tylenol) poisoning. The nurse
administers syrup of ipecac by acetylcysteine (Mucomyst) every 4
hrs. for 72 hrs. Which laboratory findings confirm the effectiveness
of the drug therapy?
a. Alanine aminotransferase and aspartate
aminotransferase
b. Creatinine kinase-MB
c. Blood urea nitrogen and serum creatinine
d. Complete blood count

12. Which intervention should the nurse try first for a client who
exhibits signs of sleep disturbance?
a. Administer sleeping medication before bedtime
b. Ask the client each morning to describe the quality of sleep
during the previous night
c. Teach the client relaxation technique, such as guided
imagery, meditation, and progressive muscle relaxation
d. Provide the client with normal sleep aids such as
pillows, back rubs and snacks

13. During gentamicin therapy, the nurse should monitor a client’s:

a. Serum potassium level
b. Serum glucose level
c. Partial thromboplastin time (PTT)
d. Serum creatinine level

14. Why shouldn’t the nurse palpate both carotid arteries at one
time?
a. The pulse can’t be assessed accurately unless the arteries are
palpated one at a time
b. It may cause transient hypertension
c. It may cause severe bradycardia
d. It may cause severe tachycardia

15. A client twists the right ankle while playing basketball and seeks
care for ankle pain and swelling. After the nurse applies ice tot the
ankle for 30 minutes, which statement by the client suggests that
ice application has been effective?
a. I need something stronger for pain relief
b. My ankle looks less swollen now
c. My ankle appears redder now
 d. My ankle feels very warm

16. The nurse reviews the ABG values of a client admitted with
pneumonia: pH 7.51; PaCO2 28 mmHg; and HCO3 24mEq/L. What
do these values indicate?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

17. A client who suffered a stroke has a nursing diagnosis of

Ineffective airway clearance. The goal of care for this client is to
mobilize pulmonary secretions. Which intervention would help meet
this goal?
a. Repositioning the client every 2 hrs
b. Restricting fluids to 1,000 ml/24 hrs
c. Administering O2 by nasal cannula as ordered
d. Keeping the head of the bed at 30-degree angle

18. On admission, the client has the following ABG values: PaO2 50
mmHg, PaCO2 70 mmHg, pH 7.20, HCO3 28 mEq/L. Based on
these values, the nurse should formulate which nursing diagnosis
for this client?
a. Risk for deficient fluid volume
b. Deficient fluid volume
c. Impaired gas exchange
d. Metabolic acidosis

19. Before preparing a client for surgery, the nurse assists in

developing a teaching plan. What is the primary purpose of
preoperative teaching?
a. To determine whether the client is psychologically ready for
the surgery
b. To express concerns to the client about the surgery
c. To reduce the risk of postoperative complications
d. To explain the risks and obtain informed consent

20. The nurse encourages a client with a would to consume foods

high in Vit C because this vitamin:
a. Restores the inflammatory response
b. Enhances O2 transport to tissues
c. Reduces edema
d. Enhances protein synthesis

21. A client with AIDS develops Pneumocytosis carinii pneumonia.

Which nursing diagnosis has the highest priority?
 a. Impaired gas exchange
b. Impaired oral mucous membranes
c. Imbalanced nutrition: Less than body requirements
d. Activity intolerance

22. A pediatric nurse is asked to work temporarily (float) in the ICU

because there are few clients in the pediatric unit. The nurse has
never worked in ICU and has no critical care experience. Which
action is most appropriate for this nurse?
a. Refuse to float to ICU
b. Notify the nursing supervisor that she feels unqualified
and untrained for the assignment
c. Go to ICU and take a total client assignment, ask the critical
care nurses for assistance when necessary
d. Go to ICU, tell the ICU nurses she has never worked in ICU,
and let the nurses decide what tasks she can perform

23. The nurse-manager of an outpatient physical medicine and

rehabilitation facility isn’t satisfied with the policies and procedures
governing discharge planning. The manager knows other managers
at several similar facilities that are regarded as the “best” in the
country. As part of a continuous quality-improvement process, the
nurse-manager decides to take which steps?
a. Contact the nurse-managers at the best facilities and
compare their discharge planning policies with those of
her facility
b. Ask her staff nurses to investigate discharge policies and
procedures at other outpatient rehabilitation facilities and
provide recommendation for changes
c. Contact the nurse-managers at the best facilities and ask for
their policies and procedures so she can adopt them
d. Ask the staff nurses to perform a task force for the review
and revision of the discharge policies and procedures
currently in use.

24. A client, age 75, is admitted to the facility. Because of the

client’s age, the nurse should modify the assessment by:
a. Shortening it
b. Talking in a loud voice
c. Addressing the client by the first name
d. Allowing extra time for the assessment

25. A child with rheumatic fever complains of painful joints. What

nonpharmacologic measures should the nurse use to reduce the
child’s pain?
a. Perform gentle passive ROM exercise
 b. Gently massage the painful joints
c. Use a bed cradle to keep linens off the child’s joints
d. Encourage the child to change position in bed every 2 hrs

26. When a central venous catheter dressing becomes moist or

loose, what should the nurse do first?
a. Draw a circle around the moist spot and note the date and
time
b. Notify the physician
c. Remove the catheter, check for catheter integrity, and send
the tip for the culture
d. Remove the dressing, clean the site, and apply a new
dressing

27. The nurse is assessing a client’s abdomen. Which examination

technique should the nurse use first?
a. Auscultation
b. Inspection
c. Percussion
d. Palpation

28. The client is to receive an IV infusion of 3,000 ml of dextrose

and normal saline solution over 24 hrs. The nurse observes that the
rate is 150 ml/hr. if the solution runs continuously at this rate, the
infusion will be completed in:
a. 12 hrs
b. 20 hrs
c. 24 hrs
d. 50 hrs

29. Each morning, the nurse-manager assigns clients and additional

tasks for the staff nurses to complete that day. During the shift, a
crisis develops and one staff nurse doesn’t complete the additional
task. The next day, the nurse-manager reprimands this nurse.
When the nurse tries to explain, the nurse-manger interrupts,
saying that the tasks should have been completed anyway. Which
leadership style is the nurse-manager exhibiting?
a. Democratic
b. Permissive
c. Laissez-faire
d. Authoritarian

30. In planning a presentation that advocates a decrease in the

client-to-nurse ratio from 8:1 to 6:1, a nurse should emphasize its
effect on:
a. Institutional resources
 b. Standards of practice
c. Client-care quality
d. Nursing recruitment

31. The nurse is performing a preoperative assessment. Which

statement by the client would alert the nurse to the presence of risk
factors for postoperative complications?
a. I haven’t been able to eat anything solid for the past 2 days
b. I’ve never had surgery before
c. I had an operation 2 years ago, and I don’t want to have
another one
d. I’ve cut my smoking down from two packs to one pack
a day

32. The nurse uses a stethoscope to auscultate a client’s chest.

Which statement about a stethoscope with a bell and diaphragm is
true?
a. The bell detects high-pitched sounds best
b. The diaphragm detects high-pitched sounds best
c. The bell detects thrills best
d. The diaphragm detects low-pitched sounds best

33. Which of the following is an appropriate nursing diagnosis?

a. Administer a sedative at bedtime
b. Pupils round, reactive to light and accommodation
c. Client will demonstrate subcutaneous injection independently
d. Impaired gas exchange

34. When following standard precautions, the nurse’s responsibility

is to:
a. Wear gloves for all contact with the client
b. Consider all body substances potentially infectious
c. Place a body substance isolation sign on the client’s door
d. Wear gloves and a gown if the client is in respiratory isolation

35. As the nurse helps a client ambulate, the client says, “I had
trouble sleeping last night.” Which action should the nurse take
first?
a. Recommending warm milk or a warm shower at bedtime
b. Gathering more information about the sleep problem
c. Determining whether the client is worried about something
d. Finding out whether the client is taking medication that may
impede sleep.

36. Why would the nurse be interested in a client’s dietary history

when administering drugs?
 a. Vegetarian diets can cause more adverse drug reactions than
diets containing meat
b. The number of calories consumed can alter a drug’s
metabolism
c. Dietary intake can alter the effectiveness of some
drugs
d. High sodium diets can increase the half-life of some drugs

37. A newly hired charge nurse assesses the staff nurses as

competent individually but ineffective and nonproductive as a team.
In addressing her concern, the charge nurse should understand that
the usual reason for such a situation is:
a. Unhappiness about the change in leadership
b. Unexpressed feelings and emotions among the staff
c. Fatigue from overwork and understaffing
d. Failure to incorporate staff in decision making

38. The label of a drug package reads “meperidine hydrochloride

(Demerol), 50 mg/ml.” how many milliliters would the nurse give a
client for a 30mg dose?
1.6 ml
1 ml
0.6 ml
0.5 ml

39. A nurse is caring for a client with a diagnosis of Impaired gas

exchange. Which outcome us most appropriate based upon this
nursing diagnosis?
a. The client maintains a reduced cough effort to lessen fatigue
b. The client restricts fluid intake to prevent Overhydration
c. The client reduces daily activities to a minimum
d. The client has normal breath sounds in all lung fields

40. A nurse is caring for a client with a history of GI bleeding, sickle

cell disease and platelet count of 22,000/ul. The client is
dehydrated and receiving dextrose 5% in half-normal saline
solution at 150 ml/hr. the client complains of severe bone pain and
is scheduled to receive a dose of morphine sulfate. In administering
the medication, the nurse should avoid which route?
a. Oral
b. IV
c. IM
d. Subcutaneous (SC)

41. A primary nurse in the unit tells the nurse-manager that a newly
hired registered nurse needs an additional week of orientation in
 order to function effectively on the staff. Which action is most
appropriate for the nurse-manager?
a. Tell the primary nurse that the new nurse must finish
orientation in 6 weeks of a staffing shortage
b. Meet the new nurse and the primary nurse and help set
up an additional week of orientation
c. Fire the new nurse because the unit is short-staffed and
nurses who can complete the orientation process in the
normal length of time are needed
d. Schedule a staff meeting to find out if there are problems
with the orientation process

42. To give a Z-track injection, the nurse measures the correct

medication dose and then draws a small amount of air into the
syringe. What is the rationale for this action?
a. Adding air decreases pain caused by the injection
b. Adding air prevents the drug from flowing back into the
needle track
c. Adding air prevents the solution from entering a blood vessel
d. Adding air ensures that the client receives the entire dose

43. A client comes to the emergency department complaining of a

fast and irregular hearthbeat. After examining the client, the
physician gives a verbal order of digoxin (Lanoxin), 1 mg in four
divided doses over the next 24 hrs, starting the first does stat. how
should the nurse respond to this order?
a. Write and sign the order as dictated, and then repeat it
aloud for the physician’s verification
b. Verbally repeat the order to the physician for verification
c. Insist that the physician write the order, then administer the
drug
d. Refuse to carry out the order

44. The physician prescribes an infusion of 2,400 ml of IV fluid over

24 hrs with half of this amount to be infused over the first 10 hrs.
During the first 10 hrs, the client should receive how many
milliliters of IV fluid per hour?
a. 50 ml
b. 100 ml
c. 120 ml
d. 240 ml

45. A client with toxoplasmosis and cytomegalovirus is confused and

has been dislodging his IV access device. He is scheduled to receive
amphotericin B (Amphotec) IV. Which action would be most
appropriate for the nurse to take?
 a. Place bilateral wrist restraints on the client
b. Ask the physician to prescribe sedation for the client
c. Delay giving the drug until the client’s confusion ceases
d. Tell a nursing assistant to stay with the client during
the infusion

46. When leaving the room of a client with strict isolation, the nurse
should remove which protective equipment first?
a. Cap
b. Mask
c. Gown
d. Gloves

47. When should the nurse check a client with rebound tenderness?
a. Near the beginning of the examination
b. Before doing anything else
c. Anytime during the examination
d. At the end of the examination

48. Which of the following clients would qualify for hospice care?
a. A client with late-stage AIDS
b. A client with left-sided paralysis resulting from a stroke
c. A client who’s undergoing treatment for heroin addiction
d. A client who had a coronary artery bypass surgery 2 weeks
before

49. A client complains of dyspnea. To correct this problem, the nurse

should place the client in which position?
a. Trendelenburg
b. Sim’s
c. Fowler’s
d. Supine

50. A client is admitted completely immobilized by an acute

exacerbation of multiple sclerosis. Two days later, the client cries
frequently and refuses to see family members. The nurse
formulates a nursing diagnosis of hopelessness. To address this
diagnosis, the nurse should include which intervention in the care
plan?
a. Obtaining an order for sedation
b. Limiting visitors to 15 minutes per day
c. Encouraging the client to verbalize feelings
d. Reinforcing the client’s responsibility to the family