PRACTICE TEST QUESTIONS

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Q & A RANDOM – 16
Question Number 1 of 40
The nurse is caring for a client with a hemopneumothorax. The client
has a chest tube. The nurse would expect which of the following color
of drainage

A) Red
B) Yellow
C) Clear
D) Brown
Your response was "A". The correct answer is A: Red
"Hemo" implies a bloody pneumothorax, therefore red drainage

Question Number 2 of 40
The nurse is caring for a client with a pneumothorax. The nurse
expects the client to have a chest tube inserted because
".
It will drain the purulent drainage from the empyema that
A)
caused it
It is the appropriate post-operative treatment for a
B)
pneumothorax
It will increase the intrathoracic pressure, restoring it back to
C)
normal
It will drain air out of the thorax, restoring normal intrathoracic
D)
pressure
Your response was "A". The correct answer is D: It will drain air out of
the thorax, restoring normal intrathoracic pressure

With a pneumothorax, which is not the result of a surgical procedure,

normal intrathoracic pressure increases as a result of the opening in
the thorax which allows outside air to rush in and "collapse" the lung;
therefore, draining the air out of the thoracic cage reduces that
increased intrathoracic pressure and restores it to normal - essentially
re-inflating the collapsed lung.

Question Number 3 of 40
A client with a terminal condition is admitted to the nursing unit. The
initial action by the nurse would be to
 A) Ensure the client is free from pain, nausea, or dyspena
B) refer the client's family to the chaplain
discuss the options for advance directions with the client and
C)
family
D) collaborate with the multidisciplinary team members
Your response was "A". The correct answer is A: Ensure the client is
free from pain, nausea, or dyspena The client should be kept as
comfortable and free from pain, nausea, or dyspnea as possible. After
the immediate needs of the client are met, any of the other choices
would be appropriate.

Question Number 4 of 40
A pregnant women is advised to increase her protein and Vitamin C to
meet the needs of the growing fetus. Which diet best meets the
client’s needs?

A) Scrambled egg, hash browned potatoes, large nectarine

B) 3oz. chicken, 1/2 C. corn, lettuce salad, small banana
C) 1 C. macaroni, 3/4 C. peas, glass whole milk, medium pear
D) Beef, 1/2 C. lima beans, glass of skim milk, 3/4 C. strawberries
Your response was "A". The correct answer is D: Beef, ½ C. lima
beans, glass of skim milk, ¾ C. strawberries
Beef and beans are an excellent source of protein as is skim milk.
Strawberries are a good source of Vitamin C.

Question Number 5 of 40
The RN is planning the care of a 79-year-old client with skin abrasions
from a fall in the home. What aspect of this client's care is the primary
responsibility of the nurse?

A) Identification of a change in skin color

B) Report the finding of any break in the skin
C) Assessment of the integumentary condition
D) Apply lotion to unaffected areas
Your response was "A". The correct answer is C: Assessment of the
integumentary condition
The RN is ultimately responsible for thorough, ongoing assessment and
evaluation of integument for this client. Because the nurse is
responsible for all care-related decisions, only implementation tasks
that do not require independent judgment can be delegated
Question Number 6 of 40
Which management style best demonstrates the end of the continuum
of management behaviors referred to by Douglas McGregor as theory
Y? The manager

is responsible for motivation of employees towars the

A)
organizational goals
assumes employees are self-motivated and want to work
B)
toward organizational and personal goals
takes a hands-off attitude and makes no decisions for
C)
employees
organizes teams of staff and gives compensation to the team
D)
rather than individual success
Your response was "A". The correct answer is B: assumes employees
are self-motivated and want to work toward organizational and
personal goals McGregor''s theory placed management behaviors on a
continuum, with Y being a set of propositions that describes managers
as supporting people who naturally work for organizational and
personal goals

Question Number 7 of 40
The nurse, while assessing a 2 day-old newborn, notices that the
breasts are enlarged bilaterally with a white, thin discharge. What
action should the nurse do next?

A) Notify the healthcare provider within that shift

B) Ask about medications taken during pregnancy
C) Record the findings while thinking that they are "normal"
D) Obtain fluid to check for glucose by dextrastix
Your response was "A". The correct answer is C: Record the findings as
"normal" Newborn infants of both sexes may have engorged breasts
and may secrete milk during the first few days and weeks after birth

Question Number 8 of 40
The nurse is caring for a client with chronic renal failure on
hemodialysis 3 times a week. The client becomes confused and
irritable 6 hours before his next treatment. Which of these items might
explain the reason for the client’s behavior?

A) Elevated blood urea nitrogen (BUN)

B) Potassium loss
C) Calcium depletion
 D) Metabolic alkalosis
Your response was "B". The correct answer is A: Elevated blood urea
nitrogen (BUN) Confusion and irritability are signs of renal
encephalopathy secondary to elevated levels of BUN and creatinine in
the blood. Other options do not explain the client’s behavior.
Potassium levels are generally high in renal failure. Side effects of
calcium depletion manifest as abdominal and muscle cramping and
hyperactive reflexes. Metabolic acidosis not alkalosis is seen in renal
failure.

Question Number 9 of 40
The client’s self-esteem is most damaged by the nurse’s

A) Anger
B) Indifference
C) Disapproval
D) Fear
Your response was "A". The correct answer is B: Indifference Positive
connectedness/caring objectivity characterizes therapeutic
relationships and is incongruent with indifference

Question Number 10 of 40
A nurse consistently ignores the call lights clients who practice
alternative lifestyles. The nurse's behavior is an example of

A) Discrimination
B) Prejudice
C) Stereotyping
D) Cultural insensitivity
Your response was "B". The correct answer is A: Discrimination The
differential treatment of individuals because they belong to a minority
group. Generally refers to the limiting of opportunities, choices, or life
experiences because of prejudices about individuals, cultures, or social
groups.

Question Number 11 of 40
The nurse is performing a cardiac assessment on a client. The nurse
knows that the correct order of blood flow through the valves of the
heart is

A) Tricuspid, pulmonary, mitral, aortic

 B) Aortic, mitral, tricuspic, pulmonary
C) Pulmonary, aortic, mitral, tricuspid
D) Mitral, pulmonary, tricuspic, aortic
Your response was "A". The correct answer is A: Tricuspid, pulmonary,
mitral, aortic
The correct pathway of blood flow through the valves of the heart is:
tricuspid, pulmonary, mitral, aortic.

Question Number 12 of 40
A client has just joined a health care maintenance organization (HMO)
and asks for information about the payment obligations with this plan.
The most accurate description of health care costs is that the client
will be charged

A) Only for services provided by specialists

B) A flat rate for each service rendered
C) A pre-determined fee for all services
D) The usual and customary fee for services
Your response was "B". The correct answer is C: A pre-determined fee
for all services An HMO plan is a plan that provides for all services
based on a flat rate. During the specified period of enrollment, all
health care services are provided with no additional fees.

Question Number 13 of 40
The nurse is caring for a mother who has just delivered a stillborn
baby. What would be the most therapeutic comment by the nurse to
this grieving mother?

A) "You are young and will have other children."

B) "Nature has a way of getting rid of the imperfect."
C) "Tell me about your pregnancy experience."
D) "You have an angel in heaven watching over you now."
Your response was "B". The correct answer is C: "Tell me about your
pregnancy experience." The nurse must help the mother actualize the
loss by encouraging her to talk about it. Advice and cliches are not
comforting
Question Number 14 of 40
Two hours after the normal spontaneous vaginal delivery of a woman,
who is gravida 4 para 4, the nurse notes that the fundus is boggy and
displaced slightly above and to the left of the umbilicus. What is the
initial nursing action?

A) Assess lochia for color and amount

B) Monitor pulse and blood pressure
C) Call the health care provider immediately
D) Ask the woman to empty her bladder
Your response was "A". The correct answer is D: Ask the woman to
empty her bladder A full bladder can displace the uterus and prevent
contraction. After the woman empties the bladder, the fundus should
be assessed again.

Question Number 15 of 40
A client is admitted for placement of a suprapubic catheter. Which
statement by the client indicates a misunderstanding of care?

A) "I will change the urine bag as needed."

B) "I will be sure to sit up or move around as much as I can."
"I will take the medication to prevent infection only when the
C)
urine gets to be cloudy."
"I plan to get lots of bottled water since it is easier to have
D)
nearby."
Your response was "A". The correct answer is C: "I will take the
medication to prevent infection only when the urine gets to be cloudy."

Prophylactic antibiotics are given continuously. Sitting up enhances the

drainage of urine to prevent stasis in the kidney and bladder.
Adequate fluid intake will prevent crystallization of the urine and stone
formation. Routine changing of the urine bag, as needed is
appropriate.

Question Number 16 of 40
The best action to establish correct placement of a gastric tube is for
the nurse to

A) aspirate for the color and pH test

B) inject air while listening for the gastric gurgle
C) check the results of the X-ray of tube placement
D) measure the residual volume then reinsert the aspirate
Your response was "A". The correct answer is A: aspirate for the color
and pH test All of the options are safe actions. However checking the
color and pH are the best actions for verification of tube placement

Question Number 17 of 40
If the nurse notes cloudy drainage 2 days post insertion of a Tenckhoff
catheter for peritoneal dialysis, what other data does the nurse need
to collect before reporting this finding?

The correct response is "C".

A) bowel sounds
B) breath sounds
C) temperature
D) urine output
Your response was "A".

The correct answer is C: temperature

This finding indicates potential infection so temperature is essential to

evaluate before notification of the care provider.

Question Number 18 of 40
The nurse is caring for a client with a T-tube following a
cholecystectomy, one-day postoperatively. The nurse would expect
which the following color of drainage from the client's T-tube

The correct response is "C".

A) Brown
B) Yellow
C) Green
D) Orange
Your response was "A". The correct answer is C: Green

Bile, which is green, is the expected drainage from a T-tube.

Question Number 19 of 40
Parents of a 4 year-old boy have just been informed that their son has
a congenital neurologic demyelinating disorder that is terminal. The
nurse evaluates their reaction to be in which phase of the crisis
process?
 A) Pre-crisis phase
B) Impact phase
C) Crisis phase
D) Resolution phase
Your response was "A". The correct answer is B: Impact phase The
impact of crisis is indicative of high levels of stress, sense of
helplessness, confusion, disorganization, and the inability to apply
problem solving behavior.

Question Number 20 of 40
The nurse admits a 50 year-old client with a 3 day history of fever,
flank pain, and elevated blood pressure. Which of the following data
obtained in the admission interview alerts the nurse that this may be
acute glomerulonephritis?

A) Travel to a foreign country

B) Sore throat 3 weeks ago
C) Type 1 diabetes since age 15
D) History of mild hypertension
Your response was "A". The correct answer is B: Sore throat 3 weeks
ago In the majority of cases of acute glomerulonephritis there is a
history of a group beta streptococcal infection of the throat preceding
the onset by 2-3 weeks. The other options do not suggest acute
glomerulonephritis

Question Number 21 of 40
The nurse is assigned to an adolescent unit. Which of these groups of
needs would the nurse expect to have to deal with that day?

A) Independence, confidence, narcissism

B) Interest in sports, competition, being right
C) Privacy, autonomy, peer interactions
D) School performance, reading, journal writing
Your response was "A". The correct answer is C: Privacy, autonomy,
peer interactions Adolescents display the need for privacy, autonomy
and peer interaction concurrent with an evolving sense of identity

Question Number 22 of 40
A client states: "I do not want to be interrupted for breakfast because
it interferes with my meditation time." What is the next action for the
nurse to take?
 A) Contact the client's health care provider
B) Contact the nutritionist or dietitian
C) Consult with the nurse manager to get suggestions
D) Talk with the client to workout a mutual plan
Your response was "B". The correct answer is D: Talk with the client to
workout a mutual plan

The nurse should talk with the client to determine how the practice of
meditation can be incorporated into the breakfast schedule. Respect
for differences must be incorporated into a client''s plan of care

Question Number 23 of 40
The RN is caring for a client immediately after a cholecystectomy.
Which of these tasks can the RN safely ask an unlicensed assistive
personnel (UAP) to document?

A) Amount of output into the drainage collection device

B) Changes in abdominal distention
C) Amount of drainage on the surgical dressing
D) The check for the return of bowel sounds or passing flatus
Your response was "A". The correct answer is A: Amount of output into
the drainage collection device The emptying, measuring and recording
of drainage from a postoperative drain may be delegated to unlicensed
assistive personnel who have demonstrated competence in performing
this task. While the RN is responsible for all care-related decisions,
delegation of tasks not requiring independent judgment is appropriate.

Question Number 24 of 40
While performing a dialysate exchange for a client on peritoneal
dialysis, which finding would alert the nurse that the client has
developed an acute complication?

A) Pulse 86 and blood pressure 112/74

B) Respiration rate of 30 with rales (use bibasilar)
C) Client sleeps throughout fluid exchange
D) Catheter dressing saturated with clear fluid
Your response was "A". The correct answer is B: Respiration rate of 30
with rales (use bibasilar) The development of an increased respiratory
rate with rales indicates fluid overload, which is an acute complication
of peritoneal dialysis. In option 1 the vital signs are normal. Sleeping
throughout the fluid exchange is normal and indicates the client is
comfortable. Clear fluid on the dressing around the catheter indicates
leakage of the dialysate fluid and can be controlled instilling less fluid
with each exchange

Question Number 25 of 40
An 8 year-old child is admitted to the child mental health unit for
evaluation. After the mother’s departure, the client cries and refuses
to eat dinner. The best approach by the nurse is to

A) Offer to play with the child

Remind the child of the expectation to eat some or all of the
B)
dinner
Tell the child that privileges will be denied for uncooperative
C)
behavior
Discuss with the child that the parents will be upset if
D)
cooperation is not given
Your response was "A". The correct answer is A: Offer to play with him
Play is both distracting and an avenue for a child’s communication.
Play facilitates mastery of feelings.

Question Number 26 of 40
A client is admitted with the diagnosis of testicular cancer. Which
factor in the client’s history would be associated with the disease?

A) Seminal vesiculitis
B) Undescended testis
C) Epididymitis
D) Sexual relations at an early age
Your response was "A". The correct answer is B: Undescended testis

A history of undescended testis or cryptorchidism is a known risk

factor

Question Number 27 of 40
While obtaining the history of a 2 week-old infant during the well-baby
exam, the nurse finds that the neonatal screening for phenylketonuria
(PKU) was done when the infant was less than 24 hours-old. What is
the priority nursing action?

A) Schedule the infant for a repeat test in 2 weeks

B) Obtain a repeat blood test at this point
C) Contact the hospital of birth for the results
D) Document that the test results are pending
Your response was "A". The correct answer is B: Obtain a repeat blood
test at this point Testing for PKU is most reliable when protein has
been ingested. A repeat blood specimen must be obtained by the third
week of life if the initial specimen was taken from an infant less than
24 hours-old

Question Number 28 of 40
The nurse assists in the insertion of a chest tube. The nurse must
apply which type of dressing after the application of sterile vaseline
gauze around the tube and sterile gauze over the vaseline gauze?

Transparent tape over the top and bottom horizontal edges of

A)
the gauze
Adhesive tape over the entire gauze with all edges covered with
B)
the tape
C) Elastic adhesive tape over the vertical edges of the gauze
D) Any kind of tape over the gauze in a criss-cross or "X" manner
Your response was "A". The correct answer is B: Adhesive tape over
the entire gauze with all edges covered with the tape An occlusive
dressing which means all of the gauze as well as all of the edges being
covered, is necessary to prevent air from entering the thorax. Regular
adhesive tape is preferred since it is more dense and resistent to air
flow.

Question Number 29 of 40
The RN is doing initial discharge teaching to a 65 year-old female
client with renal calculi. Which of the following should be included as
dietary recommendations to prevent recurrence?

A) Consume foods high in vitamin E

B) Reduce dietary calcium
C) Increase sources of vitamin C
D) Increase protein levels
Your response was "A". The correct answer is B: Reduce dietary
calcium

Dietary restrictions of calcium and purines aid in the prevention of

recurrence of renal calculi. Dietary recommendations for prevention of
kidney stones include restricting protein to 60 g/day to decrease
urinary excretion of calcium and uric acid. There is no evidence that
increasing vitamins E or C affects or prevents the formation of urinary
stones.

Question Number 30 of 40
In a client with mitral regurgitation the nurse would expect to see
which of the following signs and symptoms?

A) Low red blood cell count

B) Exertional dyspnea
C) Crushing chest pain
D) Elevated white blood cell count
Your response was "A". The correct answer is B: Exertional dyspnea
Fluid retention and diminished heart function cause exterional dyspnea
in clients with mitral regurgitation as heart failure worsens. This is due
to a rise in left atrial pressure and subsequent pulmonary and venous
congestion

Question Number 31 of 40
Which entry on a client's progress notes is the most complete?

A) Demerol 75mg administered for severe abdominal pain

B) Client expresses anxiety about a low salt diet
C) Dark green drainage 100 ml from nasogastric tube this shift
D) Client's urinary output adequate for the past shift
Your response was "A". The correct answer is C: Dark green drainage
100ml from nasogastric tube this shift Entries in client records need to
be complete, accurate and factual. Reimbursement from third party
payers is facilitated when records are accurate, reliable and valid.

Question Number 32 of 40
Nurse colleagues are discussing their practice during lunch. Which
statement is correct?

The employing agency is ultimately responsible to provide

A)
practice guidelines for licensed nurses.
B) Each state has specific regulations to license RNs and PNs
The federal government ensures the safety of clients by defining
C)
the scope of nursing practice.
"The national nurses’ associations work collaboratively to
D)
update the social policy statement for nursing.”
Your response was "A". The correct answer is B: State governmental
agency This is the only correct statement. State governmental
agencies license nurses in each state.

Question Number 33 of 40
Which of these statements, made by a client who had a mastectomy 2
months ago, indicates a need for additional assessment associated
with the impact of an alteration in body-image?

"It really isn't much of a problem for me, I never had large
A)
breasts anyway."
"I plan to volunteer to work with others who have had
B)
mastectomies in Reach for Recovery."
"I guess it's time for me to quit wearing a bikini at my age
C)
anyway."
D) "I only look at myself in the mirror after I am fully dressed."
Your response was "A". The correct answer is D: "I only look at myself
in the mirror after I am fully dressed." An inability to look at the
incision or surgical site is associated with possible denial or anger
during the process of coping with a loss. This indicates that a problem
area for this client is body image. The other statements reflect
movement towards acceptance of the loss of a “normal” figure

Question Number 34 of 40
The RN is responsible for the care of a client who is 2 days post-
reconstructive nasal surgery. Which task can be safely delegated to an
unlicensed assistive personnel (UAP)?

A) Ask the client if the medication for pain worked

B) Observe for restlessness or a change in breathing
C) Remind the client to report increased discomfort
D) Suggest that the client ask for medication every few hours
Your response was "A". The correct answer is C: Remind the client to
report increased discomfort The person to whom the activity is
delegated must be capable of performing it. It is within the role of the
UAP to reinforce the nurse’s teaching about pain management.

Question Number 35 of 40
A pregnant client asks the nurse about the scheduled blood test for
alpha-fetoprotein (AFP). What would be the nurse's best response?

A) "It tells us how far along your pregnancy is."

B) "The results help determine if the baby is growing normally."
C) "Placental well-being is being evaluated."
D) "Possible neurological defects may be identified."
Your response was "A". The correct answer is D: "Possible neurological
defects may be identified." A fetus with neural tube defects loses alfa-
fetoprotein (AFP) to the amniotic fluid and hence the maternal blood.
High levels in the blood indicate the possibility of defects such as spina
bifida and meningocele. Further evaluative tests are indicated if a test
is positive.

Question Number 36 of 40
An external disaster has occurred in the town. The triage nurse from
the emergency department is transported to the site and assigned to
triage the injuryed. Which of these clients would the nurse tag as a “to
be seen last” by the health care providers at the seen?

A) An infant with bilateral fractured lower legs

A middle-aged person with deep abrasions that are over 90% of
B)
the body
A teenager with small amount of bright red blood dripping out
C)
of the nose
D) An elderly person with a open fracture of the left arm
Your response was "A". The correct answer is B: A middle-aged person
with deep abrasions that are over 90% of the body The clients that are
least likely to survive are to be tagged as the “last to be seen.” Deep
abrasions are usually treated as second or third degree burns since the
fluid loss is great.

Question Number 37 of 40
During urinary catheterization in the male client it is important to
lubricate the tip of the catheter prior to insertion to

A) Reduce friction within the urethra

B) Prevent bladder distention
C) Prevent infection
D) Reduce leakage of urine around the catheter
Your response was "A". The correct answer is A: Reduce friction within
the urethra Lubrication reduces friction and eases insertion. Due to the
tortuous nature of the male urethra lubrication also reduces potential
trauma

Question Number 38 of 40
When planning the therapeutic milieu, what is the most important
factor in selecting group activities?

A) Match them to the clients' preferences

B) Consistentcy with clients’ skills
C) Achieving clients’ therapeutic goals
D) Build the skills of group participation
Your response was "A". The correct answer is C: Achieving clients’
therapeutic goals Activity groups are used to enhance the therapeutic
milieu and to meet the clinical and social needs of clients, e.g., to
minimize withdrawal and regression, to develop self care skills, etc.

Question Number 39 of 40
An internal disaster is declared in the hospital at 9:00 PM. The charge
nurse on this evening shift is asked to determine which client is a
candidate for discharge. Which of these clients should the nurse select
as a potential candidate for discharge

A middle-aged man with a history of type 2 diabetes mellitus

A)
and 1 day post diabetic ketoacidosis
A young adult with a history of asthma since age 5 who was
B) admitted at the beginning of the shift with an exacerbation of
asthma
An elderly female who is expected to die within the next day or
C)
so , is a “do not resuscitate” and has a son at the bedside
A adolescent who is a new admission of the prior shift, has been
D) diagnosed with rule out acute pancreatitis, and reported
stopped drinking alcohol 2 days ago
Your response was "A". The correct answer is A: A middle-aged man
with a history of type 2 diabetes mellitus and 1 day post diabetic
ketoacidosis The client to be discharged would be one that is most
stable with minimal risk of complications or instability. Client with
chronic disease may be better to function at home than those of acute
or a new onset of disease

Question Number 40 of 40
A nurse documents “effective use of guided imagery to change pain
from a 4 to a 1.” Which definition best describes this technique?

closure of the eyes to focus on the back of the eyelids or blank

A)
screen
B) the repetition of a word to self
C) inhalation to a count of 4 and exhalation to a count of four
D) focus on a pleasant, relaxed mental pictures
Your response was "A". The correct answer is D: focus on a pleasant,
relaxed mental pictures

Guided imagery is a technique that uses pleasant mental visuals that

can be recalled by the client to reduce stress, anxiety, or pain. Option
2 describes meditation. Option 3 is slow deep breathing.