1. Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement?
a. A 34 year-old post operative appendectomy client of five hours who is complaining of pain.
b. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
c. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.
d. A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid.
2. Nurse Gail places a client in a four-point restraint following orders from the physician. The client care plan should include:
a. Assess temperature frequently.
b. Provide diversional activities.
c. Check circulation every 15-30 minutes.
d. Socialize with other patients once a shift.
3. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge knows the purpose of this therapy is to:
a. Prevent stress ulcer
b. Block prostaglandin synthesis
c. Facilitate protein synthesis.
d. Enhance gas exchange
4. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?
a. Increase the I.V. fluid infusion rate
b. Irrigate the indwelling urinary catheter
c. Notify the physician
d. Continue to monitor and record hourly urine output
5. Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests that ice application has been effective?
a. “My ankle looks less swollen now”.
b. “My ankle feels warm”.
c. “My ankle appears redder now”.
d. “I need something stronger for pain relief”
6.The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?
7.She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely?
a. Have condescending trust and confidence in their subordinates.
b. Gives economic and ego awards.
c. Communicates downward to staffs.
d. Allows decision making among subordinates.
8. Nurse Amy is aware that the following is true about functional nursing
a. Provides continuous, coordinated and comprehensive nursing services.
b. One-to-one nurse patient ratio.
c. Emphasize the use of group collaboration.
d. Concentrates on tasks and activities.
9.Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"
a. Single order
b. Standard written order
c. Standing order
d. Stat order
10.A female client with a fecal impaction frequently exhibits which clinical manifestation?
a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools
11.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper visualization, the nurse should position the client's ear by:
a. Pulling the lobule down and back
b. Pulling the helix up and forward
c. Pulling the helix up and back
d. Pulling the lobule down and forward
12. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociated with this condition?
13. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is:
14. During vaginal examination of Janah who is in labor, the presenting part is at station plus two. Nurse, correctly interprets it as:
15. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is:
16. Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A nursing action that must be initiated as the plan of care throughout injection of the drug is:
17. A trial for vaginal delivery after an earlier caesareans, would likely to be given to a gravida, who had:
18.Nurse Ryan is aware that the best initial approach when trying to take a crying toddler’s temperature is:
19.Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to prevent trauma to operative site?
20. Which action should nurse Marian include in the care plan for a 2 month old with heart failure?
21.Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months. The nurse should advise her to include which foods in her infant’s diet?
22. Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action?
23. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should:
24. A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?
25. A client undergone ileostomy, when should the drainage appliance be applied to the stoma?
26. A client undergone spinal anesthetic, it will be important that the nurse immediately position the client in:
27.While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?
28.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first?
29. A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit?
30. Mark, a 7-year-old client is brought to the emergency department. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has
a nonproductive cough. He recently had a cold. Form this history; the client may have which of the following conditions?
31. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have
which of the following reactions?
32. A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging?
33. Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for the systemic side effect of:
34. Norma, with recent colostomy expresses concern about the inability to control the passage of gas. Nurse Oliver should suggest that the client plan to:
35. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, “I should:
36. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte imbalances. The client is somewhat confused and complains of nausea and muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance, the nurse would expect to:
37. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:
38.Terence suffered form burn injury. Using the rule of nines, which has the largest percent of burns?
39. Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:
40. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?
41.The nurse is ware that the most relevant knowledge about oxygen administration to a male client with COPD is
42.Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Tonny is placed in Fowler's position on either his right side or on his back. The nurse is aware that this position:
43. What is Nurse John likely to note in a male client being admitted for alcohol withdrawal?
a. Perceptual disorders.
b. Impending coma.
c. Recent alcohol intake.
d. Depression with mutism.
44. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it “doesn’t help” and refuses to take it. What should the nurse say or do?
a. Withhold the drug.
b. Record the client’s response.
c. Encourage the client to tell the doctor.
d. Suggest that it takes awhile before seeing the results.
45. Dervid, an adolescent has a history of truancy from school, running away from home and “barrowing” other people’s things without their permission. The adolescent denies stealing, rationalizing instead that as long as no one was using the items, it was all right to borrow them. It is important for the nurse to understand the psychodynamically, this behavior may be largely attributed to a developmental defect related to the:
d. Oedipal complex
46. In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows that succinylcoline (Anectine) will be administered for which therapeutic effect?
a. Short-acting anesthesia
b. Decreased oral and respiratory secretions.
c. Skeletal muscle paralysis.
47. Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar disorder is:
a. Serve the client a bowl of soup, buttered French bread, and apple slices.
b. Increase calories, decrease fat, and decrease protein.
c. Give the client pieces of cut-up steak, carrots, and an apple.
d. Increase calories, carbohydrates, and protein.
48.What parental behavior toward a child during an admission procedure should cause Nurse Ron to suspect child abuse?
a. Flat affect
b. Expressing guilt
c. Acting overly solicitous toward the child.
d. Ignoring the child.
49.Nurse Lynnette notices that a female client with obsessive-compulsive disorder washes her hands for long periods each day. How should the nurse respond to this compulsive behavior?
a. By designating times during which the client can focus on the behavior.
b. By urging the client to reduce the frequency of the behavior as rapidly as possible.
c. By calling attention to or attempting to prevent the behavior.
d. By discouraging the client from verbalizing anxieties.
50.After seeking help at an outpatient mental health clinic, Ruby who was raped while walking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three months later, Ruby returns to the clinic, complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most appropriate for Ruby?
a. Recommending a high-protein, low-fat diet.
b. Giving sleep medication, as prescribed, to restore a normal sleepwake cycle.
c. Allowing the client time to heal.
d. Exploring the meaning of the traumatic event with the client.
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