1.

One hour after admission to the post anesthesia care unit (PACU), the postoperative patient
has become very restless. What is the nurse's first action?
A. Assess the oxygen saturation level
B. Administer pain medication as ordered
C. Call the surgeon to assess the patient
D. Assess for bladder distention

2. Patient asks nurse what does this "thing" do and why do i have to use it. Nurse explains that
using this thing (incentive spirometer)
A. "The spirometer will help prevent blood clots"
B. "The spirometer will help your lungs expand."
C. "The spirometer will improve blood flow in your lungs."
D. "The spirometer will help you cough effectively."

3. After abdominal surgery, the patient complains of severe gas pains and states, "I have not
had bowels in 3 days." What is the appropriate nursing intervention?
A. Call the physician for an order for a laxative
B. Reinsert a nasogastric tube
C. Provide the ordered prn Morphine
D. Have the patient ambulate frequently

4. A patient with emphysema reports social isolation. What should the nurse encourage
patient to do? A. Participate in community activities B. Ask the patient's physician for an anti
anxiety agent C. Verbalize his or her thoughts and feelings D. Join a support group for people
with emphysema

5. he patient's abdominal incision is draining a small amount of pinkish color secretion. How
nurse document this finding on the patient's record?
A. Small amount of bloody drainage noted on dressings.
B. Small amount of serosanguineous drainage noted on dressings.
C. Small amount of serous drainage noted on dressings.
D. Small amount of sanguineous drainage noted on dressings.

6. What interventions should the nurse carry out to reduce postoperative pain and promote
comfort to surgical patient? (Select all that apply)
A. Control or remove noxious stimuli in the environment.
B. Instruct the patient in relaxation techniques.
C. Use ice to reduce and prevent swelling as indicated
D. Encourage activity and exercise to point of fatigue
E. Use pillows to assist to a position of comfort

7. A postoperative patient is in the post-anesthesia care unit (PACU) and reports having pain of
8 on a scale of 10. What is the best nursing action?
A. Consult with the anesthesia care provider to manage the pain while the patient is still in
PACU
B. Have the nurses on the surgical unit to assess the patient and administer pain medication
as appropriate
C. Look at the routine post-operative orders and administer the pain medicine that is ordered.
D. Sep up the Patient Controlled Analgesia (PCA) machine and push the button for the patient
as needed.
8. The nurse is changing the patient's dressing on the second postoperative day and notes a
small amount of serosanguineous drainage. What is the nurse's best action?
A. Cover the incision with a transparent dressing
B. Culture the drainage and leave the incision open to air
C. Cleanse the suture line and apply a sterile dressing
D. Notify the surgeon to assess the patient

9. What is the priority nursing intervention for the patient in the Post Anesthesia Care Unit
(PACU) who reports, "I think I am going to vomit"
A. Continue to monitor the vital signs
B. Place a cool cloth on the patient's forehead
C. Give the antiemetic as ordered
D. Turn the patient on their side

10. A patient with a history of asthma is admitted to the emergency department with dyspnea,
respiratory rate of 35 breaths per minute, nasal flaring, use of accessory muscles, and greatly
diminished breath sounds. What action should the nurse take first?
A. Initiate oxygen therapy and reassess the patient in 10 minutes
B. Encourage the patient to relax and breathe slowly
C. Draw blood for arterial blood gas analysis and send the patient for a chest X-ray
D. Administer bronchodilators as ordered

11. The patient is 7 hours post-op and has not voided. What should the nurse do first?
A. Call the surgeon stat and report the lack of voiding
B. Insert an indwelling urinary catheter
C. Determine when the last pain medication was given
D. Palpate for presence of the bladder above the symphysis pubis

12. One hour after the administration of ondansetron hydrochloride (Zofran) (antiemetic), the
nurse determines that the medication has been effective and documents this in the patient's
record. What phase of the nursing process is illustrated?
A. Diagnosis
B. Evaluation
C. Planning
D. Assessment

13. The nurse is caring for several patients on the postoperative unit. Which patient does the
nurse determine has the highest risk of respiratory complications after general anesthesia?
A. Young adult with a body mass index of 40
B. Middle-aged woman taking a daily cholesterol lowering medication
C. Middle-aged man with a deviated nasal septum
D. Older woman taking a medication for hypertension

14. The nurse is caring for a patient who had abdominal surgery 3 days ago. The patient tells
the nurse, "I felt something 'come apart' when I coughed." What is the nurse's best response?
A. "That is a normal feeling in the incision whenever you are moving"
B. "Be sure to splint the incision with a pillow or your hands when you cough"
C. "Lie down flat on the bed with your knees u and let me examine your incision"
D. "It is good you are coughing and deep-breathing to prevent pneumonia"
15. What is the best assessment the nurse should use to validate a patient's pain?
A. Physiologic indicators, such as elevated vital signs
B. A pain rating by someone who knows the patient well
C. Facial grimacing and crying
D. The patient's self-report of pain

16. A patient reports pain 8 hours after surgery. The patient has already received an opioid
within the past 2 hours. What should the nurse do?
A. Give the ordered pain medication early
B. Call the surgeon immediately
C. Assess the pain further
D. Document the finding in the chart

17. A postoperative patient has atelectasis in the left lung confirmed by chest x-ray. What
priority intervention should the nurse plan to include in the patient's care?
A. Monitoring oxygen saturation hourly
B. Assessing the breath sounds every two hours
C. Monitoring respiratory rate rhythm twice a shift
D. Encouraging use of the incentive spirometer hourly E. Changing positions every three hours

18. A patient is prescribed albuterol (Proventil, Ventolin) via metered-dose inhaler (MDI), two
puffs every 4 hours. What should the nurse teach the patient about potential adverse effects of
this drug?
A. Pedal edema
B. Wheezing
C. Irregular Heartbeat
D. Constipation

19. Two days after surgery, a patient refuses a PRN dose of analgesic for fear of becoming
"hooked". How should the nurse respond?
A. "Occurrence of side effects warrants the discontinuing of medication"
B. "Research has shown it is impossible to become hooked on PRN narcotics"
C. "Short-term use of narcotics is not likely to cause a person to become dependent on them"
D. "Patients who do not take PRN medications are more likely to become dependent on
narcotics"

20. The patient was given 15 mg of morphine IM for post surgical pain. One hour later, the
patient is sleeping and has a respiratory rate of 10 breaths/min. What is the nurse's first
action?
A. Administer naloxone (Narcan) IV push
B. Administer oxygen by nasal cannula
C. Arousing the patient by calling his or her name
D. Documenting the findings and continuing to monitor

21. The nurse is working in the post anesthesia care unit (PACU) and receives a patient from
the operating room (OR). What does the nurse assess first?
A. Patient's nasogastric tube
B. Hemovac drain at the incision site
C. Patient's urinary catheter
D. Patient's endotracheal tube
22. What should the nurse include in the plan of care for a patient with patient-controlled
epidural anesthesia (PCEA)?
A. Change the epidural dressing daily
B. Assess but do not disturb the epidural dressing
C. Use septic technique when handling the epidural catheter
D. Apply an antibiotic ointment to the site BID

23. Which assessment finding is cause for concern in a patient who has taken 4 grams of
acetaminophen (Tylenol) to relieve back pain?
A. Increased liver function tests
B. Gastrointestinal bleeding
C. Difficulty with urination
D. Decreased respiratory rate

24. Which instruction should the nurse give a patient who has a patient-controlled analgesia
device (PCA) after abdominal surgery?
A. "Push the button when you first feel pain instead of waiting until pain is severe"
B. "Instruct you visitor to press the button for you when you are sleeping"
C. "Try to go as long as you possibly can before you press the button"
D. "Push the button every 15 minutes whether you feel pain that time or not"

25. The nurse empties the Jackson-Prat drainage bulb. What nursing intervention ensures
correct functioning of the drain?
A. Connection to to a drainage bag and clamping it off
B. Irrigating it with normal saline
C. Compressing it and then plugging it to establish suction
D. Connection it to low intermitted suction

26. The nurse assess a patient who has received morphine sulfate. The patient blood pressure
is 90/50 mm Hg; pulse rate 58 beats per minute; respiratory rate 4 beats per minute. What
drug should the nurse prepare to administer?
A. Flumazenil (Romazicon)
B. Meperidine (Demerol)
C. Ondansetron hydrochloride (Zofran)
D. Naloxone hydrochloride (Narcan)

27. The nurse empties the Jackson-Prat drainage bulb. What nursing intervention ensures
correct functioning of the drain?
A. Connection to to a drainage bag and clamping it off
B. Irrigating it with normal saline
C. Compressing it and then plugging it to establish suction
D. Connection it to low intermitted suction

28.A nurse is assessing a surgical patient's vital signs 8 hours after surgery. Before surgery,
the blood pressure (BP) was 120/80 mm Hg and on admission tot he medical-surgical unit the
BP was 110/80 mmHg. The patient's BP is now 90/7- mm Hg. What should the nurse do first?
A. Check the intake and output record
B. Administer pain medication
C.Notify the surgeon immediately
D. Elevate the head of the bed
29. What is the priority nursing assessment upon the patient's admission to the Post
Anesthesia Care Unit (PACU)
A. Patient's level of consciousness and hanging IV fluid level
B. Vital signs and ABCs, beginning with the respiratory system
C. Patient identification using attached ID band with two identifiers
D. The surgical interventional procedure performed and OR number

30. For the patient who is experiencing post operative pain on post-op day 2, what medicate
should the nurse plan to administer
A. Acetaminophen (Tylenol)
B. Morphine Sulfate
C. Acetylsalicylic Acid (Aspirin)
D. Ibuprofen (Advil)

31. Following surgery, a patient has difficulty getting out of bed, walking and coughing and
deep breathing. Although patient-controlled analgesia (PCA) is in place, it is rarely used. What
statement is the best way for the nurse to address this concern with the patient?
A. "I noticed you use very little pain medication. You must be very brave and strong. But
without pain medication you will get weaker, bot stronger."
B."I can understand why you are reluctant to use pain medication. Many people feel the same
way. Yet, without pain relief, you can get atelectasis, pneumonia and blood clots"
C. "I noticed you don't use much pain medication. If you don't push that button, I will. You need
that medicine. Don't worry about getting addicted. It won't happen"
D. "I noticed you haven't used your pain medication very often since your surgery. Im
wondering if you are hesitant to use the PCA medication"

32. What intervention should the nurse implement to prevent pulmonary emboli from forming
in the post-operative patient?
A. Massage the patient's lower legs every four hours
B. Encourage the patient to cough and deep breath
C. Have the patient perform leg exercises every hour whole awake
D. Have the patient wear anti embolism stockings only when out of bed

33. The patient has a Salem Sump nasogastric tube (NGT) connected to low intermitted
suction whose "pigtail" is draining stomach contents. What should the nurse do?
A. Clamp the pigtail to prevent gastric leakage
B. Insert 30 mL of air into the pigtail to spear the drainage
C. Call the surgeon to check placement of the NGT
D. Increase the suction to high continuous suction

34. The nurse is caring for a patient is the post anesthesia care unit (PACU) 2 hours after
abdominal surgery. The nurse auscultates the patient's abdomen and notes that there are no
bowel sounds. What action should the nurse take?
A. Palpate the bladder and measure abdominal girth
B. Document the finding and continue to monitor
C. Insert a nasogastric tube to low intermittent suction
D. Position the patient of the left side with the bed flat
35. The post-operative patient has been transferred from the Post Anesthesia Care Unit
(PACU) to the medical-surgical unit. What should the nurse do first?
A. Assess airway and oxygenation
B. Check the dressing for any drainage
C. Provide pain medication as ordered
D. Perform a neurological check

36. The nurse's abdominal assessment of a post-operative patient reveals the patient's
abdomen is flat, non distended, and no bowel sounds are audible. What is the best explanation
of the finding?
A. Exposure of the patient to the cold operating room causes bowel sounds to stop
B. Permanent loss of bowel sounds occurs with certain types of abdominal surgery
C. Due to the effects of general anesthesia, the patient has a paralytic ileus
D. Bowel sounds are absent as a result of the narcotics given for pain control

37. A patient is prescribed fluticasone (Flovent) via metered-dose inhaler (MDI) BID. What
actions indicate the patient is using the MDI correctly? (Select all that apply)
A. The patient waits 5 minutes between puffs
B. The mouth is rinsed with water after administration
C. the inhaler is held upright
D. The patient lies supine for 15 minutes following administration
E. The patient breathes in quickly and shallowly

38. A post-operative patient who is on bed rest asks why intermittent compression devices are
needed. How should the nurse respond?
A. "These are more comfortable than compression stockings"
B. "These remind you to keep still and avoid around too much"
C. "These will improve the arterial circulation in your body"
D. "These help prevent clot formation in your legs while you are inactive"

39. A patient with asthma reports "not being able to take deep breaths." The nurse auscultates
decreased breath sounds in the bases and no wheezes. What is the nurse's best action?
A. Have the patient cough forcefully
B. Encourage the patient to stay calm and take deep breaths
C. Assess the patient's oxygen saturation
D. Document the findings and continue to monitor

40. The nurse is evaluating a patient's response to medication therapy to asthma. The patient
has a peak flowmeter reading in the yellow zone. What does the nurse do next?
A. Nothing: this is an acceptable range
B. Assist the patient to use a reliever (rescue) inhaler
C. Assess the patient's lungs
D. Teach the patient to take deeper breaths

41. The nurse is teaching a patient with asthma about self-management. Which statement by
the nurses the best?
A. Keep a daily symptoms and intervention diary
B. Establish your personal best peak expiratory flow during an attack
C. Note your symptoms when you don't take your medications
D. Exercise before and after taking inhalers and compare tolerance
42. A patient with emphysema has a respiratory rate of 24 breaths per minute, bilateral
crackles, and is coughing but unable to expectorate sputum. Which nursing diagnosis is the
priority for the patient?
A. Impaired Gas Exchange r/t ventilation-perfusion mismatch
B. Ineffective Airway Clearance r/t inability to expectorate sputum
C. Risk for Decreased Cardiac Output secondary to for pulmonale
D. Ineffective Breathing Pattern r/t increased work of breathing

43. What statement but the nurse indicated the understanding of the administration of oxygen
to the patient with emphysema?
A. High oxygen concentration will cause coughing and dyspnea
B. Administration of oxygen is contraindicated in patients who use bronchodilators
C. High oxygen concentration may inhibit the hypoxic stimulus to breathe
D. Increased oxygen use will cause the patient to become dependent on the oxygen

44. What outcome is appropriate for the patient with emphysema who has been discharged to
home?
A. The patient states he will call the health care provider if dyspnea on exertion occurs
B. The patient promises to do pursed-lip breathing at home if short of breath
C. The patient states he will use oxygen via nasal cannula at 5 L/minute
D. The patient verbalizes actions to reduce and manage pain

45. When instructing patient on how to decrease the risk of chronic obstructive pulmonary
disease (COPD). What should the nurse emphasize?
A. Avoid exposure to people with known respiratory infections
B. Abstain from cigarette smoking
C. Participate regularly in aerobic exercises
D. Maintain a high protein diet

46. A patient is seen at the clinic for a routine physical examination. After the patient is
assessed for evidence of peripheral vascular disease, the nurse explains that which of the
following tests is typically used to assist in the diagnosis?
A. Allen's Test
B. Ankle brachial pressure index.
C. Cardiac Stress Test.
D. Echocardiogram

47. A patient has been diagnosed with left-sided congestive heart failure, and is confused
about the return of oxygenated blood from the lungs. To clarify the confusion, the nurse
explains all chambers of the heart dealing with blood circulation. The nurse is correct when
she tells the client:
A. Blood flows into the left ventricle which pumps it out against high resistance into the
systemic circulation.
B. The blood moves to the left ventricle, which pumps blood into the lungs.
C. The heart consists of 5 chambers.
D. The left atrium receives oxygenated blood from the lungs.
E. The right atrium receives deoxygenated blood from the body tissues.
48. A patient recovering from a MI has been in bed for 6 days. The patient now complains of
calf pain. The nurse should first:
A. Administer pain medication as ordered.
B. Assess the calf for redness warmth and swelling.
C. Massage the calf to relieve the muscle cramp.
D. Observe the patient walking.

49. The nurse is caring for a patient in the early stages of heart failure. The family is curious
as to how the body adapts to heart failure. The nurse knows that during the early stages of
heart failure, which specific compensatory mechanisms occur?
A. Decreased cardiac output inhibits the release of ADH by the pituitary gland.
B. Hypotension stimulates the baroreceptors to increase sympathetic activity.
C. Hypotension stimulates the baroreceptors to decrease sympathetic activity.
D. Impaired renal perfusion inhibits aldosterone release.

50. The nurse is assessing a patient with atrial fibrillation and a rapid ventricular rate. The
nurse would expect to see:
A. Distended juglar veins.
B. Dizziness and hypotension.
C. Hypertension and headache.
D. Lower extremity pain.

51. The nurse is caring for a patient scheduled to undergo a mitral valve replacement. The
nurse should monitor for which complication of mitral stenosis?
A. Left-sided heart failure.
B. MI
C. Pulmonary Hypertension
D. Respiratory Alkalosis

52. A nurse is assessing a patient who has longstanding hypertension. The nurse know that
complications of hypertension are possibly arising when which of the following signs are
noted?
A. Dyspnea during activity
B. Fatigability
C. Recurrent episodes of severe headache.
D. Trace proteins in the urinalysis.

53. The nurse is evaluating a 52 year old male for risk factors for CAD. The patient is
overweight, male, and smokes a pack a day. The nurse questions the patient about other risk
factors including:
A. A history of atherosclerotic heart disease.
B. A history of diabetes.
C. A history of gout.
D. Elevated HDL levels.

54. The nurse is knowledgeable about sinoatrial node dysrhythmias if she selects which of the
following causes of sinus tachycardia? Select all that apply.
A. Emotional and physical stress
B. Fever
C. Heart Failure
D. Increased Intracranial pressure
55. An ICU nurse is providing continuing health education to new nurses in the unit. Which
statements made by the nurse are correct?
A. Dysrhythmias can decrease the heart's ability to pump effectively but cannot cause death.
B. Dysrhythmias result from disturbances in the automaticity, conduction, and re-entry of
impulses.
C. If the SA node fails to fire, in a normal heart, the AV node should take over the pacemaker
function.
D. Normal sinus rhythm is the usual heart rhythm is the usual heart rhythm, beginning in the
AV node.
E. The most serious complication of a dysrhythmia is MI. 6. The SA node is the pacemaker of
the heart.

56. A client has been admitted to the unit for treatment of dehydration. During the initial
meeting of the client and the nurse, which nursing action is most appropriate?
A. Evaluate the client's response to treatment thus far.
B. Establish the outcomes of hospitalization for the client.
C. Tell the client that the provider will explain what to expect in the hospital.
D. Determine the preliminary client needs upon discharge.

57. The nurse would perform which activity that relates to the evaluation phase of the nursing
process during client care?
A. Ambulate a client 20 feet down the hallway.
B. Question a client about family medical history.
C. Assess a client's progress toward a desired outcome.
D. Assign a nursing diagnosis to an identified need.

58. The nurse is caring for a client who was admitted from the operating room following a
traumatic amputation sustained during a motor vehicle accident. The client is awake upon
arrival to the nursing unit and is hemodynamically stable at this time. The nurse monitors
which elements of complete blood count as indicators of potential complications? Select all
that apply.
A. Total white blood cell count.
B. Neutrophils
C. Eosinophils
D. Red blood cells.
E. Platelets

59. The nurse is caring for a client admitted with a diagnosis of "rule out acute myocardial
infarction" (AMI). When reviewing the client's laboratory data, the nurse concludes that which
laboratory report is diagnostic for an AMI?
A. Elevations in troponin T and I.
B. Elevated total cholesterol.
C. Elevated total creatine kinase.
D. Decrease in myoglobin.

60. The nurse is caring for a client diagnosed with acute renal failure. Which numeric values
best represent this client's anticipated arterial blood gas results?
A. pH 7.48, pCO2 37, HCO3 29.
B. pH 7.34, pCO2 49, HCO3 23.
C. pH 7.27, pCO2 38, HCO3 19.
D. pH 7.46, pCO2 30, HCO3 25.
61. The nurse is caring for a client newly diagnosed with renal failure. What serum laboratory
value should the nurse use as the most specific indicator of the effectiveness of the
treatment?
A. Potassium level 5.0.
B. Blood urea nitrogen BUN 40.
C. Creatinine level
D. Urine specific gravity 1.010

62. Which factor should the nurse consider when assessing the medication needs of a client
with type 1 diabetes mellitus who is being admitted to the nursing unit? Select all that apply:
A. The client's exercise pattern
B. The client's acute illness condition.
C. Nutritional status of the client
D. The length of time the client has been diagnosed with diabetes.
E. Allergies previously reported.

63. The nurse is caring for a client in the short procedure unit (SPU) following a bronchoscopy
using moderate (conscious) sedation. Prior to discharging the client, the nurse verifies that the
client has achieved which priority outcome?
A. Verbalizes symptoms of late complications.
B. Demonstrates an intact gag reflex.
C. Remains afebrile for up to 2 postop days.
D. Reports being thirsty and asks for oral fluids.

64. The nurse is caring for a client diagnosed with right middle lobe pneumonia. The nurse
should perform which intervention to mobilize secretions?
A. Administer antibiotics as ordered.
B. Limit fluids to IV only.
C. Place the client in a prone position to increase alveolar expansion.
D. Assist client to use incentive spirometry.

65. The nurse is performing a physical assessment on a patient with an aortic dissection.
Which of the following should the nurse avoid during the physical assessment?
A. Auscultation of the abdominal aorta.
B. Deep palpation of the abdomen.
C. Inspection of the abdomen.
D. Repositioning the patient to the side.

66. The nurse is caring for a patient that just underwent a bronchoscopy. The nurse should
complete which of the following interventions?
A. Administer midazolam IV for conscious sedation.
B. Administer vecuronium IV.
C. Confirm the return of a gag reflex before advancing diet.
D. Encourage large amounts of fluids.

67. The nurse is caring for a patient after a total laryngectomy. It is the most important for the
nurse to do which of the following?
A. Initiate a liquid diet.
B. Keep the head of the bed flat.
C. Keep the tracheostomy cuff deflated.
D. Suction the patient's tracheostomy every 30 minutes.
68. The nurse is assessing a patient with asthma exacerbation for signs of worsening disease.
Which of the following would indicate that the patient's asthma exacerbation is worsening?
A. Diminished breath sounds
B. Expiratory and inspiratory wheezes.
C. Less than 80% of predicted forced expiratory volume.
D. Loud wheezes.

69. The nursing diagnosis for a patient with pneumonia is ineffective airway clearance r/t
increased sputum production. Which is an appropriate goal for this patient?
A. The patient will maintain a patent airway AEB the absence of dyspnea.
B. The patient will maintain an open airway AEB no complaints of pain.
C. The patient will maintain an open airway AEB by tachypnea.
D. The patient's airway will remain free of obstruction.

70. A patient is admitted to the hospital for a pulmonary embolism. The nurse assesses the
patient knowing that which of the following is commonly reported? Select all that apply.
A. Anxiety
B. Hemoptysis
C. New dyspnea on exertion or rest.
D. Slow progressing dyspnea
E. Sudden chest pain

71. The nurse is informing a patient about postural drainage. To facilitate clearing of the lungs,
the nurse should position the patient based on which assessment?
A. Auscultation
B. Inspection of chest
C. Percussion of thorax
D. X-ray

72. A client is admitted to the medical department due to pneumonia associated with
influenza. Which of the following interventions promotes airway patency? Select all that apply.
A. Apply chest physiotherapy
B. Frequent Turning
C. Increase fluid intake
D. Provide a quiet environment
E. Schedule activities after treatments.

73. Which statements made by the nurse while taking a nursing history would elicit the
greatest amount of client data?
A. Did your pain begin recently?
B. You said the pain started yesterday?
C. Can you tell me more about how the pain began?
D. The pain isn't bad right now is it?

74. A nurse is revising the client goals and interventions in the nursing care plan. What
information enables the nurse to make relevant revisions?
A. Knowledge of the hospital's standards of care.
B. Medical assessment and written prescriptions.
C. Health care team conferences.
5. Validation of the effectiveness of nursing interventions.
75. The nurse would assess for hyperkalemia in a client with which of the following problems?
A. Renal failure.
B. Nausea and vomiting.
C. Excessive laxative use.
D. Loop diuretic use.

76. A nurse has been assigned the following clients on the day shift. In updating their plans of
care, which client would have both Risk for Ineffective Breathing Pattern and Risk for Impaired
Gas Exchange as a priority diagnoses?
A. A newly admitted 32-year-old female with exacerbation of myasthenia gravis.
B. A second day post-op 66 year old client who underwent femoropopliteal bypass grafting.
C. A 56 year old client admitted for an appendectomy.
D. An 82 year old client with non-metastic prostate cancer.

77. The nurse is caring for a client on digoxin. Which electrolyte abnormality should the nurse
be concerned about regarding the risk of digoxin toxicity?
A. Sodium 132 mEq/L
B. Potassium 3.0 mEq/L
C. Magnesium 1.0 mEq/L
D. Calcium 9.2 mEq/L

78. The nurse is preparing the client for an ultrasound of the gallbladder. Which statement
would be the most important to prepare the client for the test?
A. You will have food and fluids restricted for 4 to 8 hours prior to the test.
B. Stool in the bowel may cause a reporting of inaccurate findings.
C. There is no special preparation for this procedure. You may eat and drink as usual.
D. You will be asked to drink a solution of radionuclide 2 hours prior to the procedure.

79. A client has recently returned to the nursing unit following a bronchoscopy and is
requesting a glass of water. What should the nurse's initial assessment before meeting this
request?
A. Determine if the client is able to ambulate without assistance.
B. Ensure that the side rails are up on the client's bed.
C. Determine if the client is received a local anesthetic during the procedure.
D. Ensure that the call light is within the client's reach.

80. The nurse is caring for a client who has an oxygen dose decreased to 2L/min by nasal
cannula. Shortly after this change, the client reports feeling short of breath (SOB). The nurse
determines that the current pulse oximetry reading reveals an oxygen saturation of 71%. What
would be the nurse's initial intervention?
A. Closely monitor the client's condition and increase the oxygen concentration to 15/L min.
B. Place the client in a semi-Fowler's position and continue to monitor.
C. Do nothing; the drop in oxygen concentration is expected with the change in oxygen being
delivered.
D. Sit the client up, assess the client's respiratory status and notify the health care provider
immediately.
81. The nurse is assisting with prioritization of admission, discharge, and triage of acutely ill
clients. Which client would require continued monitoring in the the ICU? Select all that apply.
A. Client with terminal cancer in the process of dying.
B. Client with congestive heart failure and chronic renal failure who develops an exacerbation
of the heart failure.
C. Hemodynamically unstable client who requires vasoactive drugs to maintain blood
pressure.
D. Client with metastatic lung disease who develops a pneumonia.

82. What is most appropriate for the nurse to do when interviewing an older patient?
A. Ensure all assistive devices are in place.
B. Interview the patient and caregiver together.
C. Perform the interview before administering analgesics.
D. Move on to the next question if the patient does not respond quickly.

83. Which assessment findings would alert the nurse to possible elder mistreatment (select all
that apply)?
A. Agitation
B. Depression
C. Weight gain
D. Weight loss
E. Hypernatremia

84. A 67-year-old woman who has a long-standing diagnosis of incontinence is in the habit of
arriving 20 minutes early for church in order to ensure that she gets a seat near the end of a
row and close to the exit so that she has ready access to the restroom. Which tasks of the
chronically ill is the woman demonstrating (select all that apply)?
A. Controlling symptoms
B. Preventing social isolation
C. Preventing and managing a crisis
D. Denying the reality of the problem
E. Adjusting to changes in the course of the disease

85. A 70-year-old man has just been diagnosed with chronic obstructive pulmonary disease
(COPD). At what point should the nurse begin to include the patient's wife in the teaching
around the management of the disease?
A. As soon as possible
B. When the patient requests assistance from his spouse and family
C. When the patient becomes unable to manage his symptoms independently
D. After the patient has had the opportunity to adjust to his treatment regimen

86. A nurse who is providing care for an 81-year-old female patient recognizes the need to
maximize the patient's mobility during her recovery from surgery. What accurately describes
the best rationale for the nurse's actions?
A. Continued activity prevents deconditioning.
B. Pharmacokinetics are improved by patient mobility.
C. Lack of stimulation contributes to the development of cognitive deficits in older adults.
D. Regularly scheduled physical rehabilitation provides an important sense of purpose for
older patients.
87. Which criterion must a 65-year-old person meet in order to qualify for Medicare funding?
A. Being entitled to Social Security benefits
B. A documented absence of family caregivers
C. A validated need for long-term residential care
D. A history of failed responses to standard medical treatments

88. A male patient has a history of hypertension and type 1 diabetes mellitus. Because of
these chronic illnesses, the patient exercises and eats the healthy diet that his wife prepares
for him. Which factors will most likely have a positive impact on his biologic aging (select all
that apply)?
A. Exercise
D. Diabetes
C. Social support
D. Good nutrition
E. Coping resources

89.A 60-year-old female patient has had increased evidence of dementia and physical
deterioration. What would be the best assistance to recommend to her caregiver husband who
is exhausted?
A. Long-term care
B. Adult day care
C. Home health care
D. Homemaker services

90. What should be included when planning care for an older adult?
A. Patient priorities should be the only focus of care.
B. Additional time related to declining energy reserves
C. Reduction of disease and problems should be the focus.
D. Tobacco cessation will help the patient cope with other illnesses.

91. Aging primarily affects the _________of drugs.

A. excretion
B. absorption
C. metabolism
D. distribution

92. A nurse is caring for an adult who sustained a severe traumatic brain injury following a
motor vehicle accident. Once the patient recovers from the acute aspects of this injury and is
no longer ventilator-dependent, discharge planning would include that this patient will be
transferred to what type of practice setting?
A. Assisted living
B. Acute rehabilitation
C. Long-term acute care
D. Skilled nursing facility

93. A nurse with an associate or baccalaureate degree who meets licensing requirements is
qualified to practice as:
A. a nurse practitioner.
B. a certified specialist.
C. an entry-level generalist.
D. an advanced practice nurse.
94. When nurses disagree about the effectiveness of a commonly used nursing intervention,
the best evidence for solving the question related to an intervention is:
A. a systematic review of randomized controlled trials.
B. a qualitative research study with a large sample size.
C. a methodological Internet search using key medical terms.
D. Anecdotal evidence retrieved from two or more case studies.

95. A 40-year-old female patient is being prepared for discharge home after a laparoscopic
cholecystectomy. Which team member can be assigned to complete a discharge assessment
and provide patient teaching for post-discharge care?
A. Registered nurse (RN)
B. Nursing technician (NT)
C. Unlicensed assistive personnel (UAP)
D. Licensed practical/vocational nurse (LPN/LVN)

96. The nurse is caring for a patient dependent on a mechanical ventilator. In order to reduce
the risk of developing pneumonia, the nurse should do which of the following? Select all that
apply.
A. Administer prophylactic antibiotics.
B. Keep the head of the bed above 30 degrees.
C. Perform oral care at least every 4 hours.
D. Reposition the patient every 2 hours.

97. A patient is complaining of increased shortness of breath. The nurse observes a

respiratory rate of 24 on 3LPM of oxygen via nasal cannula. Which of the following actions
should be done initially?
A. Administer a bronchodilator as ordered.
B. Conduct a comprehensive respiratory assessment.
C. Increase oxygen flow rate
D. Notify the physician

98. The nurse is caring for a postoperative patient at risk for pneumonia. What interventions
should be implemented to reduce the risk of pneumonia? Select all that apply.
A. Coughing
B. Early ambulation
C. Frequent repositioning
D. Incentive spirometry 6. Limiting fluids

99. The nurse is caring for a patient suspected of having lung cancer. The physician performs
a bronchoscopy to obtain a biopsy. Which of the following should be reported to the physician?
A. Bronchospasm
B. Cough
C. Dark red sputum
D. Drowsiness

100. The nurse is caring for a patient with a GI bleed who is SOB but has clear lung sounds and
an oxygen saturation of 98%. Which of the following is the most probably cause for the
patient's symptoms?
A. A psychiatric disorder
B. Heart failure
C. Hematologic problem
D. Poor perfusion to the extremities
101. The nurse assesses a patient suspected of having a pleural effusion. Which of the
following are the most common clinical manifestations of this condition?
A. Dry, nonproductive cough and crackles over the affected area.
B. Dry, nonproductive cough and diminished breath sounds.
C. Productive cough and crackles over the affected area.
D. Productive cough and diminished breath sounds over the affected area.

102. Which type of transmission based precaution technique should the nurse implement for
the client diagnosed with bacterial meningitis?
A. Standard
B. Airborne
C. Enteric
D. Droplet

103. A postoperative client with emphysema is receiving oxygen at 2L/min via nasal cannula
when the client reports SOB. The spouse asks the nurse to increase the oxygen to help the
client breathe easier. Which response by the nurse is most appropriate?
A. I have a better technique; I will switch him to 100% non-rebreather mask.
B. Higher concentration of oxygen may decrease breathing and cause more difficulty.
C. I think you should leave for an hour; its just anxiety and rest will improve your breathing.
D. This is an indication that he is in pain; I will treat that.

104. The home health nurse is assessing an adolescent who has frequent school absences
because of acute asthma attacks. Assessment reveals mild inspiratory wheezes and current
oxygen saturation (SaO2) of 98%. The client can answer questions in full sentences and
accurately demonstrates the use of inhalers. After documenting this data, what would be the
next best action by the nurse?
A. Report to home health agency that client has adequate knowledge of how to manage
disease.
B. Question family members to determine if they know CPR in the event of a respiratory
emergency.
C. Perform environmental assessment to identify asthma triggers.
D. Report the situation to the Department of Youth Services for truancy and possible neglect.

105. The nurse is teaching a client with newly diagnosed emphysema how to manage the
disease. The client asks how pursed lip breathing helps the emphysema. What would be the
best response by the nurse?
A. It prevents air sacs in the longs from trapping air.
B. It decreases the pressure in the airways.
C. The resistance on exhalation increases the muscle strength in the diaphragm.
D. It helps slow down respiratory rate.

106. The nurse is caring for a client diagnosed with pneumothorax which is being treated with
a chest tube to re-expand the lung. Which actions are appropriate for the nurse to take when
caring for this client? Select all that apply.
A. Clamp chest tube when assisting client from bed to chair.
B. Report fluctuations in water seal section of chest drainage system.
C. Maintain an occlusive dressing, such as petrolatum gauze around chest tube at insertion
site.
D. Gently massage chest tubes hourly to promote drainage.
E. Encourage client to maintain a high Fowler's position.
107. The nurse is caring for a 68 year old client who is scheduled for discharge later that day.
An arterial blood gas done the previous morning reveals a PaO2 of 87 mmHg. The client has a
respiratory rate of 22 and clear lungs and reports no shortness of breath. What should be the
nurses response?
A. Call the health care provider to report to PaO2
B. Monitor the client more closely because a physiological abnormality is beginning
C. Do nothing because a PaO2 of 87 is normal in an older adult
D. Call the family and tell them to anticipate that the discharge will be canceled

108. When teaching a client scheduled for bedside thoracentesis, what would the nurse
explain is the primary purpose of this procedure?
A. It is used to obtain pleural tissue for evaluation
B. It is used to determine the stage of a lung tumor
C. It is used to withdraw fluid from the pleural space
D. It is used to directly examine the pleural space

109. The nurse is caring for a client just admitted with a diagnosis of pulmonary cystic fibrosis
(CF). What would be the priority goal when planning care for this client?
A. Improving airway clearance
B. Removing allergens from the environment
C. Eliminating foods that are known to cause intolerance
D. Preparing client for the CF-specific sweat test

110. Which arterial blood gas report would the nurse expect in a client with advances chronic
obstructive pulmonary disease (COPD)?
A. pH: 7.55, PaCO2 30mmHg, PaO2 80 mmHg, HCO3 -24 mEq/L
B. pH: 7.4, PaCO2 40 mmHg, PaO2 94 mmHg, HCO3 -22 mEq/L
C. pH: 7.38, PaCO2: 45 mmHg, PaO2: 88mmHg, HCO3: -24 mEq/L
D. pH: 7.30, PaCO2: 60 mmHg, PaO2: 70 mmHg, HCO3: -30 mEq/L

111. The nurse considers that which concept should have priority for discussion during
discharge teaching for client who has chronic bronchitis?
A. Fluid restriction
B. Smoking cessation
C. Avoidance of crowds
D. Side effects of drug therapy

112. A client diagnosed with HIV has returned to the clinical 72 hours after a tuberculin skin
test was given and there is an induration of 6 mm at the administration site. Thee client is
visibly upset and states, "I can't believe I have TB!" Which statement by the nurse is most
appropriate?
A. "Don't worry, this is a good result. At least it is not 10 mm."
B. "The doctor will prescribe ionized for you to take for the next 3 months."
C. "This finding does not confirm TB; it may indicate a recent exposure to tuberculosis"
D. "We'll need to do a chest x-ray. This may be false positive because your history of HIV"
113. The nurse is caring for a client with a tracheostomy tube. The nurse keeps which concept
in mind while caring for this client?
A. Client must be suctioned as needed using clean technique
B. Tracheotomy tube must be capped to allow client to eat by mouth.
C. The oxygen or air needs to be humidified
D. Saline can be inserted into the tracheotomy tube before suctioning if secretions are thick

114. The registered nurse (RN) has an unlicensed assistive person (UAP) assigned to help with
the clients. Which task can the RN delegate to the UAP? Select all that apply.
A. Perform routine measurement of clients peak expiratory flow rate
B. Switch supplemental oxygen from face mask for nasal cannula
C. Teach the client how to use the incentive spirometer
D. Administer nebulizer treatment for the client with recurrent asthma exacerbation
E. Ambulate a client who has had a chest tube removed 8 hours prior.

115. A client has a right chest tube post-thoracotomy. When assessing the client to ambulate,
the nurse should use what measure to maintain functioning of the closed chest drainage
system?
A. Keep collection device below the level of the chest
B. Clamp the chest tube before assisting the client out of bed
C. Milk chest tube when client returns to bed to re-establish airway
D. Connect collection device to a portable suction machine.

116. A client is brought to the ED after his motor vehicle crashed into a tree. Which finding
suggests to the nurse that the client has experienced a tension pneumothorax?
A. Tachypnea
B. Hypotension
C. Tracheal deviation
D. Unilateral wheezing

117. The nurse is assessing a client on admission who reports a gradual increase in shortness
of breath over at least the past 6 months. If the client denied a history of smoking, why would
the nurse ask about exposure to secondhand smoke?
A. Clients with secondhand smoking exposure typically present with difficulty breathing
B. Secondhand smoke causes acute airway obstruction
C. This form of smoking is more likely to cause lung cancer
D. The nurse wants to estimate the risk for smoke inhalation within the client's immediate
environment

118. When auscultating breath sound in the client with an acute asthma exacerbation, the
nurse uses which pieces of information to help interpret and plan for the severity of asthma?
Select all that apply.
A. The presence or absence of cough
B. The presence or absence of bilateral wheezing
C. The presence of absence of unilateral wheezing
D. The duration of the expiratory phase
E. The rate of respirations.
119. When assessing a patient who underwent pericardiocentesis, the nurse notes a
decreased blood pressure, distended neck veins, and clear lung sounds. The nurse suspects
that the client has developed which of the following?
A. Heart failure
B. Cardiac tamponade
C. Pericarditis
D. Cardiomyopathy

120. A 54-year old male client was recently diagnosed with subset bacterial endocarditis
(SBE). The nurse determines that the client understands the discharge teaching when he
makes which statement?
A. " I need a referral to a dietician to understand a low sodium diet"
B. "I have to call my doctor so I can get antibiotics before seeing a dentist"
C. "Can I take the antibiotics as a pill now"
D. "If i quit smoking, it will help the endocarditis"

121. The nurse on a cardiac unit is caring for a client admitted with an acute exacerbation of
heart failure. The nurse concluded that the client's condition is worsening after noting which
client data during assessment?
A. Normal sinus rhythm that becomes sinus tachycardia
B. Urine drainage is increased in amount
C. Onset of a cough with pink-frothy sputum
D. Presence of dyspnea at rest

122. A client is scheduled for coronary angiography. In reviewing the client's record, which
significant finding would the nurse report to the health care provider before the diagnostic
procedure?
A. A client reported an allergy to iodine.
B. Client's electrocardiogram shows atrial fibrillation
C. Potassium level is 4,0 mEq/L
D. Client has a history of chronic renal failure

123. The nurse is implementing a discharge teaching plan for a client newly diagnosed with
FH. When discussing fluid status with the client, the nurse would explain the importance of
doing which of the following?
A. Restricting fluid intake to approximately 800 mL/day
B. Taking a single extra dose of diuretic is there is decreased urination for several days
C. Recording body weight every day before breakfast and report a weight gain of 3 or more
pounds in a week
D. Keeping track of daily output and calling healthcare provider if it is less than 1 L on any day

124. A client is getting ready to go home after acute myocardial infarction. The client is asking
questions about the prescribed medications, and wants to know why metoprolol was
prescribed. The nurse's best response would be which of the following?
A. "You heart was beating too slowly, and metoprolol increases your heart rate"
B. Lopressor helps to increase the blood supply to the heart by dilating the coronary arteries"
C. Lopressor helps make your heart beat stronger to supply more blood to your body
D. Lopressor slows your heart rate and decrease the amount of work it has to do so it can heal
125. A client is taking digoxin and furosemide for HF. The nurse approved of which of the
following client selections that is the best menu choice for this client?
A. Chicken with baked potato and cantaloupe
B. Ham and cheese omelet with low-cholesterol egg substitute
C. Grilled cheese sandwich with pan browned potatoes
D. Pizza with low fat mozzarella cheese and pepperoni

126. The nurse is caring for a client with a diagnosis of restrictive cardiomyopathy. When
planning this client's care, which of the following would be the most appropriate nursing
diagnosis?
A. Fear related to new onset of symptoms
B. Hopelessness related to lack of cure and debilitating symptoms
C. Deficient knowledge related to medication regime
D. Activity intolerance related to decreased cardiac output

127. he nurse working on a cardiac telemetry unit prepared to use an external pacemaker after
noting that an assigned client has a blood pressure of 70/52 and has developed which cardiac
dysrhythmia that is amenable to this therapy? Select all that apply.
A. Ventricular fibrillation
B. Atrial fibrillation
C. Ventricular tachycardia
D. Second-degree heart block
E. Third-degree heart block

128. A client is prescribed sublingual nitroglycerine for the treatment of angina pectoris. The
nurse concludes that what response from the client indicates understanding of this
medication?
A. "My health care provider gave me a year's supply of nitroglycerine tablets"
B. "I will carry my nitro tabs in the inside pocket of my jacket, so they are always close"
C. "I usually take 3 of my nitro tabs at the same time. I find that they work better that way"
D. "I have a small metal labeled case for a few nitro tabs that I carry with me when I go out"

129. The nurse is caring for a client with a diagnosis of first-degree heart block. The nurse
anticipates that the client's cardiac rhythm strip will reveal which of the following? Select all
that apply.
A. Number of QRS complexes are half the number of P waves
B. PR interval is consistent
C. QT interval is prolonged
D. P wave rate is usually slower than the QRS rate 5. PR interval is prolonged

130. The nurse is caring for a client who has just returned from the cardiac catheterization lab
following a precautions transluminal coronary angioplasty (PTCA). The client is receiving a
continuous infusion of heparin. The urine is now tea colored. What action should the nurse
take next?
A. Notify the health care provider and ask for an order for an aPTT
B. Monitor the urine for any additional change in color
C. Assess the insertion site for bleeding and measure pulse and blood pressure
D. Ask the client if there is any chest pain
131. The nurse is caring for client being discharged after valve replacement surgery using a
St. Jude mechanical vale. The nurse is reviewing the instructions for the client's follow-up care
and determines that the client understands the instructions when the client makes which
statement?
A. I will take warfarin for 2 months and get my blood drawn every week until I stop taking the
drug
B. I will remind the doctor to give me a prescription for anticoagulant medication every time I
go to the dentist
C. I will need to take anticoagulant medication for the rest of my life
D. I won't take any anticoagulant medication or blood thinners because they may cause a
problem with my new valve

132. The nurse is caring for a client on the second postoperative day after a coronary artery
bypass surgery. The client has a nursing diagnosis of Impaired Gas Exchange. Which action
would the nurse take to best assist the client with this diagnosis?
A. Assist the client with deep breathing and vigorous coughing every hour
B. Ensure that client uses the incentive spirometer every hour
C. Pre-medicate client before ambulation
D. Auscultate lungs once a shift

133. A client who just underwent cardiac catheterization insists on getting up to go to the
bathroom to urinate immediately after returning to his room. What would the nurse's best
response be?
A. "You can't walk yet. You may be too weak after the procedure and may fall"
B. "If you bend your leg, you will risk bleeding from the insertion site. It is an artery, and it
could lead to complications"
C. "If you get out of bed you may have an arrhythmia from the catheterization. Your heart has
to rest after this procedure"
D. "The doctor has ordered that you stay on bed rest for the next 6 hours. It is important that
you follow these orders"

134. The nursing is caring for aliment admitted to the ED with chest pain. He reports that chest
pain developed while mowing the lawn and he stopped and rested on the sofa, which is typical
for him. This time the pain was not relieved by rest so he came to the ED. The chest pain is
relieved following administration of 2 sublingual nitroglycerine tabs. The nurse draws which
conclusion about the clients status?
A. Client most likely has stable angina
B. Client has a knowledge deficit because he did not take his sublingual nitro
C. Client most likely has unstable angina
D. Client most likely has acute MI

135. The nurse is assessing a client at 7:30 am on a day when the client has a cardiac stress
test scheduled for 11:30. The client reports that no breakfast was delivered this morning and
the client is hungry. When is the nurse's best action?
A. Bring client coffee and toast
B. Explain that client should have no food the morning of the cardiac stress test
C. Call nutrition department and get the client's regular full breakfast
D. Have nursing assistant get the client cereal with milk and orange juice
136. A hospitalized client has continuous electrocardiographic (ECG) monitoring, and monitors
shows that the rhythm suddenly changed to ventricular tachycardia (VT). Upon entering the
room, the nurse notes that client is awake and alert and speaks to the nurse. What are priority
actions that the nurse should take? Select all that apply.
A. Administer intravenous lidocaine according to emergency protocol
B. Obtain the defibrillator and defibrillate the client
C. Quickly assess the client's blood pressure and pulse
D. Administer a precordial thumb 5. Ask the unit secretary to telephone the clients family

137. The physician has diagnosed acute MI on the basis of electrocardiogram (ECG) changes
for a client in the ED. The nurse assesses the client frequently, and notes that the client seem
forgetful, and periodically asks the nurse to explain the ECG and noninvasive blood pressure
monitors. The nurse concluded that the client's response is most likely due to which of the
following reasons?
A. Client is showing signs of very early Alzheimer's disease
B. Client is showing signs of fear and anxiety
C. Nurses in the ER are busy and provide explanations that they are short
D. Memory lapses are coming with clients experiencing MI

138. Mrs. Chua a 78 year old client is admitted with the diagnosis of mild chronic heart failure.
The nurse expects to hear when listening to client’s lungs indicative of chronic heart failure
would be:
A. Stridor
B. Crackles
C. Wheezes
D. Friction rubs

139. Patrick who is hospitalized following a myocardial infarction asks the nurse why he is
taking morphine. The nurse explains that morphine:
A. Decrease anxiety and restlessness
B. Prevents shock and relieves pain
C. Dilates coronary blood vessels
D. Helps prevent fibrillation of the heart

140. Which of the following should the nurse teach the client about the signs of digitalis
toxicity?
A. Increased appetite
B. Elevated blood pressure
C. Skin rash over the chest and back
D. Visual disturbances such as seeing yellow spots