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Question 1

The nurse observes a sinus rhythm pattern on the cardiac monitor of a client admitted with diarrhea and vomiting. On physical assessment, the nurse is unable to palpate a central pulse. The nurse would suspect that the client is demonstrating which of the following?

1. Pulseless electrical activity (PEA)
2. Ventricular fibrillation
3. Asystole
4. Ventricular tachycardia

Answer 1

1. Pulseless electrical activity (PEA)

PEA is associated with what appears to be a normal electrical conduction pattern but there is no mechanical pumping of the myocardium. Ventricular fibrillation, ventricular tachycardia, and asystole will not demonstrate an effective electrical conduction pattern on the cardiac monitor.

Question 2

While teaching a client about the proper administration of dipivefrine (Propine), the nurse would provide which of the following instructions?

1. Gently squeeze eyes closed for 30 seconds immediately after instillation of medication.
2. Close, but do not squeeze, eyes immediately after instillation of medication.
3. Do not blink for 30 seconds after instillation of medication.
4. Close the eyes for 1 full minute after instillation of medication.

Answer 2

3. Do not blink for 30 seconds after instillation of medication.

To promote absorption, the client should not blink for 30 seconds after the administration of dipivefrine. Options 1, 2, and 4 are incorrect for the administration of dipiveprine.

Question 3

The nursing unit is short-staffed for the shift and a registered nurse (RN) from the pediatric unit has been floated to the nursing unit. Which of the following clients should the nurse assign to the float nurse?

1. A 32-year-old client newly diagnosed with diabetes who needs dietary and medication teaching
2. A 56-year-old client newly admitted with Guillain-Barré syndrome who has severe leg weakness
3. An 86-year-old client with dementia who will be transferred to a skilled nursing facility during the shift
4. A 59-year-old client who will be returning from surgery following transurethral resection of the prostate

Answer 3

1. A 32-year-old client newly diagnosed with diabetes who needs dietary and medication teaching

Pediatric clients can be diagnosed with diabetes and the float nurse should be familiar with this health problem and could do client teaching. The nurse is not as likely to have recent experience in working with clients with Guillain-Barré syndrome or who have had prostate gland surgery. The client with dementia who is being transferred will require transfer paperwork to be completed, and the pediatric nurse may not be as familiar with these types of forms because of the pediatric population usually worked with.

Question 4

A client has experienced a near-drowning event in salt water. The nurse anticipates that one of the complications this client may experience is:

1. Heart block.
2. Renal failure.
3. Pulmonary edema.
4. Respiratory alkalosis.

Answer 4

3. Pulmonary edema.

Pulmonary edema occurs as a result of fluid shifts caused by the ingestion of the hypertonic salt water. The result is fluid collecting in the interstitial spaces causing pulmonary edema. Hypoxia, hypovolemia, and acidosis occur as a result of near-drowning incidents.

Question 5

The nurse has just read the results of a client’s tuberculin (TB) test at a health fair. An induration is apparent. The client asks what this means. The nurse’s best response would be:

1. “A positive test means that you have been exposed to the TB organism. It does not mean that you currently have active bacteria. Further testing will be needed.”
2. “A positive TB test means that you currently have active TB, and you will need to be isolated immediately.”
3. “Many false positives occur. You can expect to be retested in 6 months.”
4. “A positive TB test means that you are currently infectious and will need to be started on medication immediately.”

Answer 5

1. “A positive test means that you have been exposed to the TB organism. It does not mean that you currently have active bacteria. Further testing will be needed.”

A positive TB test means that the organism is present in the body in either an active or a dormant state. It should not be ignored nor should further testing be deferred for several months. The client can expect to be scheduled for sputum tests for the presence of the bacillus and a chest x-ray to determine the presence of lesions or active disease. Medications and isolation are not instituted until a probable or definitive diagnosis has been made.

Question 6

An anxious client begins to yell and interrupt other clients. The client’s speech is rapid and pressured. What action should the nurse take?

1. Ask the client to speak more slowly and softly.
2. Instruct the other clients to ignore this client’s behavior.
3. Point out to the client that the behavior is a sign of anxiety.
4. Remind the client of the need to use good manners when talking with other people.

Answer 6

1. Ask the client to speak more slowly and softly.

Question 7

The nurse suspects that hepatotoxicity is developing in a dark-skinned client who is on an antibiotic. In what area of the body should the nurse assess for jaundice?

1. Palms of the hands or soles of the feet
2. Hard palate of oral cavity
3. Sclera
4. Conjunctivae

Answer 7

2. Hard palate of oral cavity

Jaundice in the dark-skinned client can best be observed by assessing the hard palate. Normally fat may be deposited in the layer beneath the conjunctivae that can reflect as a yellowish hue of the conjunctivae and the adjacent sclera in contrast to the dark periorbital skin. In these clients, palms and soles may appear jaundiced, but calluses on the surface of their skin can also make the skin appear yellow.

Question 8

In assessing a hospitalized client 1 hour after receiving hydralazine (Apresoline) 20 mg PO, the nurse notes that the BP is 68/42. The client has been taking this medication for several years at home without difficulty. Which of the following factors most likely contributed to this episode of hypotension?

1. Dose is excessive for this medication.
2. Total intake for the previous 24 hours is 1,000 mL.
3. Serum potassium is 5.8 mEq/L.
4. Heart rate is 145 beats per minute.

Answer 8

2. Total intake for the previous 24 hours is 1,000 mL.

Apresoline is a vasodilator and if the client becomes dehydrated, hypotension will result. In other words, during dehydration both preload and afterload are reduced, causing the tank to get larger with less volume. The normal dose of hydralazine is 5 to 25 mg PO. Serum potassium is high but unrelated to apresoline. The increased heart rate is a reflexive response to the low cardiac output to compensate with decreased preload and afterload.

Question 9

A client with a history of heart failure suddenly exhibits shortness of breath, a respiratory rate of 30, crackles auscultated bilaterally, and frothy sputum. After telephoning the physician for medical orders, which action should the nurse delegate to the Licensed Practical/Vocational Nurse (LPN/LVN)?

1. Start an intravenous line and cap it with a saline lock.
2. Monitor vital signs every 15 minutes.
3. Administer morphine sulfate 2 mg IV push immediately.
4. Insert a urinary catheter.

Answer 9

4. Insert a urinary catheter.

In a client whose condition is deteriorating, the RN should delegate the task that is most procedural in nature (in this case the urinary catheter). The LPN is able to collect data to report to the RN, but in a client whose acuity is changing, it is better for the RN to make the assessments (option 2). The RN should also insert the IV line and immediately administer the IV medication.

Question 10

An 86-year-old client will be undergoing a surgical procedure. Which of the following changes would the nurse make in the informed consent process for this elderly client?

1. Providing adequate time for the client to process the information
2. Encouraging the family members to make the decision for the client
3. Encouraging the client to sign immediately before the client forgets the purpose of the surgery
4. Providing the client with reading material about the surgery and the postoperative instructions

Answer 10

1. Providing adequate time for the client to process the information

Question 11

The labor and delivery nurse would make it a priority to assess which of the following two newborn body systems immediately after birth?

1. Gastrointestinal and hepatic
2. Urinary and hematologic
3. Neurologic and temperature control
4. Respiratory and cardiovascular

Answer 11

4. Respiratory and cardiovascular

Question 12

The nurse is caring for the client who is recovering from partial thickness burns. Which of the following breakfast options indicates client understanding of the recommended diet?

1. Two slices of toast with butter, orange juice, skim milk
2. Two poached eggs, hash brown potatoes, whole milk
3. Three pancakes with syrup, two slices of bacon, apple juice
4. One cup of oatmeal with skim milk, 1/2 grapefruit, coffee

Answer 12

2. Two poached eggs, hash brown potatoes, whole milk

The eggs provide 24 grams of protein and the whole milk adds calories. The other options are lower in protein and calories. A client recovering from burns requires a high-protein, high-calorie diet.

Option 1 does not reflect an adequate protein source. Option 3 reflects an increased carbohydrate source and bacon is considered a fat, not protein. Option 4 does not reflect a high-protein, high-calorie meal but rather a low-calorie meal selection with a greater carbohydrate content.

Question 13

An adult client with diabetes insipidus who has been taking desmopressin (DDAVP) intranasally comes to the clinic for a regularly scheduled appointment. The nurse assesses the client’s mental status and notes some disorientation and behavioral changes. Significant pedal edema is also present. What should be the nurse’s next action?

1. Check vital signs and notify the physician.
2. Have the client return in the morning for reevaluation.
3. Instruct the client to limit salt intake for a few days.
4. Suggest that the client change the route of administration to subcutaneous injections.

Answer 13

1. Check vital signs and notify the physician.

Question 14

The nurse is assigned to the care of a client receiving radiation therapy for cancer. Which of the following activities needed in the care of a client receiving external beam radiation therapy could be safely delegated to an unlicensed assistive person (UAP) working on the nursing unit? Select all that apply.

1. Observe the skin site following a treatment session.
2. Document intake from the meal trays.
3. Assess variations in level of fatigue during the shift.
4. Explore how the client is coping with treatment.
5. Assist the client to ambulate in the hall.

Answer 14

2. Document intake from the meal trays.
3. Assist the client to ambulate in the hall.

Question 15

A 76-year-old woman visits the ambulatory clinic with reports of having difficulty reading and doing needlework because of visual distortions with blurring of images directly in the line of vision. The peripheral vision assessment by the nurse yields normal findings. The nurse suspects that this client is experiencing which of the following visual problems?

1. Glaucoma
2. Detached retina
3. Cataracts
4. Macular degeneration

Answer 15

4. Macular degeneration

Visual difficulty caused by distortions and impairment of central vision is common with macular degeneration. Peripheral vision in most cases is normal. The symptoms are not characteristic of glaucoma (loss of peripheral vision), cataracts (gradual deterioration of vision with opacity of lens), or detached retina (sudden change in vision with a sense of a curtain falling over the field of vision).

Question 16

A female client states that she will not undergo any invasive testing for her “stomach pain.” The nurse explains that which of the following tests could be completed to assess the abdomen and still meet the client’s wishes?

1. Abdominal ultrasound
2. Barium swallow
3. Colonoscopy
4. CT scan with contrast

Answer 16

1. Abdominal ultrasound

Question 17

Certain that her stomach pain is a symptom of cancer, a female client with somatization disorder exhibits pressured, rapid speech; elevated pulse and blood pressure; palpitations; and preoccupation with her pain, despite negative results from a gastroscopy. The nurse formulates which of the following as the priority nursing diagnosis?

1. Pain
2. Anxiety
3. Hopelessness
4. Disturbed body image

Answer 17

2. Anxiety

Question 18

A client is taking an over-the-counter preparation containing bismuth subsalicylate (Pepto-Bismol) for diarrhea. Which of the following side effects would a nurse monitor for that is unique to the bismuth portion of this drug?

1. Darkening of the tongue
2. Dyspepsia
3. Abdominal pain
4. Diarrhea

Answer 18

1. Darkening of the tongue

Question 19

The nurse is taking a nursing history from the mother of a child being admitted with flare-up of celiac disease. What piece of information would the nurse expect the mother to report?

1. Steatorrhea
2. Increased appetite
3. Cheerful behavior
4. Soft, formed stools

Answer 19

1. Steatorrhea

Question 20

A nurse is discussing the home maintenance regimen with a client who has irritable bowel syndrome. Which of the following statements indicates client understanding?

1. “I’ll take a walk after dinner each evening.”
2. “I’ll have a cigarette after meals to relax.”
3. “I’ll chew gum between meals to curb my appetite.”
4. “I’ll eat a lot of fresh vegetables and fruits.”

Answer 20

1. “I’ll take a walk after dinner each evening.”

Question 21

A primigravida client of 16 weeks gestation states that she has not yet felt fetal movement. The nurse’s best response is:

1. “Your fetus will move any day now. Call me in a week if you don’t feel it.”
2. “Your fetus will begin moving at about 20 weeks gestation.”
3. “You should have been feeling the movement already.”
4. “Your fetus has been moving for the past 9 weeks without you feeling it. You will feel it within a month.”

Answer 21

4. “Your fetus has been moving for the past 9 weeks without you feeling it. You will feel it within a month.”

The embryo’s muscles spontaneously contract beginning at 7 weeks. The mother perceives sensations of movement of the fetus from 16 to 20 weeks gestation. A primigravida usually perceives movement closer to 20 weeks.

Question 22

Following the administration of a diphtheria/pertussis/tetanus (DPT) immunization the nurse notes that the infant has inspiratory stridor. The nurse should take which of the following actions?

1. Administer epinephrine as per protocol orders.
2. Evaluate for pulmonary edema.
3. Inspect for periorbital edema.
4. Assess the baby again in 15 minutes.

Answer 22

1. Administer epinephrine as per protocol orders.

Question 23

The nurse is talking with the unlicensed assistive person (UAP) about time management skills and techniques. Which of the following statements would the nurse make if intending to act as a coach?

1. “You must get the vital signs taken on time or you will be disciplined.”
2. “You never report morning blood glucose levels on time.”
3. “Your timely response to clients’ call lights is exemplary.”
4. “It may be helpful if you bring in linens to the client rooms when you restock the gloves.”

Answer 23

4. “It may be helpful if you bring in linens to the client rooms when you restock the gloves.”

Question 24

A nurse is explaining to a woman considering pregnancy how rubella is transmitted. The nurse determines that the teaching session had the desired outcome if the client states that rubella is transmitted by:

1. The airborne route.
2. Contaminated food.
3. The droplet route.
4. Direct contact.

Answer 24

3. The droplet route.

Question 25

A female client has been successfully resuscitated after cardiac arrest. Her arterial blood gas reveals a pH of 7.6. The nurse attributes this result to which of the following?

1. Anaerobic metabolism, which caused lactic acid production
2. Excess sodium bicarbonate, which was administered during the resuscitation
3. Repeat blood gases, which are performed during a code, frequently show acidosis
4. Normal blood gas results

Answer 25

2. Excess sodium bicarbonate, which was administered during the resuscitation

A pH of 7.6 indicates an alkalotic state. The administration of bicarbonate would be the best answer. Anaerobic metabolism and the production of lactic acid lead to an acidotic state, explaining why blood gases drawn during a code usually show acidosis. This pH is not within normal limits.

Question 26

The nurse would anticipate finding which of the following client characteristics when working with a client who has a pain disorder?

1. A preference to handle pain without medication
2. A lack of understanding of the relationship between pain and stress
3. Adequate role performance
4. Structural damage at the site of pain

Answer 26

2. A lack of understanding of the relationship between pain and stress

Characteristics of a client with pain disorder include believing there is a physical cause for distress when there is no organic basis, the need to use analgesics or drugs to reduce pain, and impaired role performance.

Question 27

Which of the following should be the highest priority of the education plan for a client being treated with medication therapy for a generalized seizure disorder?

1. Take medication even if there is no seizure activity.
2. Physical dependency may result from extended use of medications.
3. Urine may turn pink to brown but is not harmful.
4. Therapeutic effects of medications may not be seen for 2 to 3 weeks.

Answer 27

1. Take medication even if there is no seizure activity.

Question 28

The pediatric nurse needs to rearrange room assignments of clients to accommodate three additional clients who will be admitted during the day. Which two of the following clients would be best for the nurse to place together in the same room? Select all that apply.

1. An 8-year-old who has encephalitis
2. A 10-year old who has a white blood cell count of 2,800/mm
3. A 12-year-old who had an appendectomy
4. An 11-year-old with scarlet fever
5. A 9-year-old receiving chemotherapy for cancer

Answer 28

2. A 10-year old who has a white blood cell count of 2,800/mm
3. A 9-year-old receiving chemotherapy for cancer

The child with the low white blood cell count (normal 5,000-10,000/mm) and the child receiving chemotherapy are at risk for infection and could be cohorted together because they should both be on neutropenic precautions. The child who underwent appendectomy should be separated from the children with viral encephalitis and scarlet fever. The children with infections should not be cohorted because one is viral (encephalitis) and one is bacterial (scarlet fever) in origin.

Question 29

A 32-year-old female client who is HIV-positive is receiving treatment at an outpatient clinic. The nurse reviewing the dietary assessment record notes that the client has been skipping meals and progressively losing weight. What dietary interventions would be best for the nurse to suggest to promote weight gain?

1. Have the client keep a food diary and submit it at the next visit so that more information can be obtained regarding food preferences and usual dietary pattern.
2. Tell the client that her weight may fluctuate in response to her menstrual cycle so there is no need to worry for now.
3. Tell the client that additional salt in the diet will help to increase weight.
4. Tell the client that the use of nutrient-dense food and fortified protein shakes will help promote weight gain.

Answer 29

4. Tell the client that the use of nutrient-dense food and fortified protein shakes will help promote weight gain.

A client who is HIV-positive (regardless of sex) is likely to lose weight due to repeated cycle of wasting and malnutrition. The client, who may be unable to merely increase caloric intake, should be instructed in dietary techniques that maximize quality of intake. Option 1 is incorrect—even though a food diary would provide pertinent information, the response allows for a delay in treatment that could result in further weight loss for the client. The priority is to intervene early on to prevent the onset of wasting. Option 2 is incorrect because it provides the client with a false belief that fluid retention changes associated with the menstrual cycle may have an impact on nutritional status. Option 3 is incorrect—even though increased salt in the diet can lead to fluid retention and weight, it does not address the underlying issue of nutritional balance.

Question 30

The nurse would assess a 76-year-old client for which common problems that most increases the risk for major complications of heart and lung disease?

1. Taking over-the-counter meds with prescription meds
2. Sharing medications with family and friends
3. Following directions exactly and taking medications on a regular basis
4. Polypharmacy resulting from visits to multiple doctors

Answer 30

4. Polypharmacy resulting from visits to multiple doctors

Polypharmacy is using multiple doctors and multiple pharmacies to get the health care needed often from a variety of specialists. The overall problem is that different doctors may not know what other doctors had ordered. Some drugs may interact with others and others may be the same drug in a different form. Overdosing and interactions become more common with this problem.

Question 31

A client with acute respiratory distress syndrome (ARDS) shows no improvement despite increases in the concentration of oxygen administered. What intervention should the nurse attempt which may improve ventilation-perfusion matching?

1. Transfusion of packed red blood cells
2. Infusion of albumin
3. Positioning supine with head elevated 30 to 45 degrees
4. Prone positioning

Answer 31

4. Prone positioning

Placing the client with ARDS in a prone position allows for expansion of the posterior chest wall, which may be effective in enhancing oxygenation. Transfusing red blood cells or albumin does not increase oxygenation in ARDS. Option 3 should have been done as an initial measure.

Question 32

The nurse is giving general information about antihypertensive medications to a young female client with a history of hypertension. The nurse includes that which of the following types of antihypertensives should not be used if the client becomes pregnant?

1. Vasodilators
2. Diuretics
3. Angiotensin converting enzyme (ACE) inhibitors
4. Calcium channel blockers

Answer 32

3. Angiotensin converting enzyme (ACE) inhibitors

Because ACE inhibitors can cause fetal harm or death, they should be discontinued as soon as pregnancy is detected. Their effect on breastfeeding infants is unknown. The effect of other medications is unknown during pregnancy.