just do it

Question 1

A depressed client is seen at the mental health center for follow-up after an attempted suicide
1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains
that the drug must accumulate to an effective level before symptoms are totally relieved. Symptom
relief is expected to occur within:

Answer 1

2-4 weeks

Question 2

Cystic fibrosis is transmitted as an autosomal recessive trait. This means that:

Answer 2

Both parents must be carriers for a child to have the disease

Question 3

A 24-year-old client presents to the emergency department protesting “I am God.” The nurse
identifies this as a:

Answer 3

Delusion

Question 4

In acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4 weeks, or
even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during
the first few days or weeks of an acute episode to manage severe behavioral excitement and acute
psychotic symptoms. In addition to the lithium, which one of the following medications might the the physician prescribe?

Answer 4

Haloperidol (Haldol)

Question 5

A violent client remains in restraints for several hours. Which of the following interventions is
most appropriate while he is in restraints?

Answer 5

Release restraints every 2 hours for client to exercise.

Question 6

The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral
griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child?

Answer 6

Observe for headaches, dizziness, and anorexia.

Question 7

A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h
via nasogastric tube. The rationale for this therapy is to:

Answer 7

Decrease ammonia formation

Question 8

A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures
should be included in the postoperative care?

Answer 8

Observe for evidence of bleeding

Question 9

An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his
left leg that started approximately 20 minutes ago. When performing the admission assessment, the
nurse would expect to observe which of the following:

Answer 9

Decreased or absent pedal pulse in the left leg

Question 10

A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing
assessment, which lab value should elicit further assessment and requires notification of physician?

Answer 10

Hematocrit 60%

Question 11

A male client is experiencing extreme distress. He begins to pace up and down the corridor.
What nursing intervention is appropriate when communicating with the pacing client?

Answer 11

Walk with him as he paces.

Question 12

Prior to an amniocentesis, a fetal ultrasound is done in order to:

Answer 12

Locate the position of the placenta and fetus

Question 13

A 25-year-old client believes she may be pregnant with her first child. She schedules an
obstetric examination with the nurse practitioner to determine the status of her possible pregnancy.
Her last menstrual period began May 20, and her estimated date of confinement using Nagele’s rule
is:

Answer 13

February 27

Question 14

A client is now pregnant for the second time. Her first child weighed 4536 g at delivery. The
client’s glucose tolerance test shows elevated blood sugar levels. Because she only shows signs of
diabetes when she is pregnant, she is classified as having:

Answer 14

Gestational diabetes mellitus

Question 15

A 44-year-old female client is receiving external radiation to her scapula for metastasis of
breast cancer.
Teaching related to skin care for the client would include which of the following?

Answer 15

Encourage her to avoid direct sunlight on the area being treated.

Question 16

The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for
tomorrow’s menu. Which vitamin is the most essential in promoting tissue healing?

Answer 16

Vitamin C

Question 17

A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting
behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on
activities, and monotony. Which of the following nursing implementations would be most effective in
helping him cope with immobility?

Answer 17

Allowing him to do as much for himself as he is able, including learning to do pin-site care under
supervision

Question 18

In client teaching, the nurse should emphasize that fetal damage occurs more frequently with
ingestion of drugs during:

Answer 18

First trimester

Question 19

On admission, the client has signs and symptoms of pulmonary edema. The nurse places the
client in the most appropriate position for a client in pulmonary edema, which is:

Answer 19

High Fowler

Question 20

A client has returned to the unit from the recovery room after having a thyroidectomy. The
nurse knows that a major complication after a thyroidectomy is:

Answer 20

Respiratory obstruction

Question 21

The nurse should facilitate bonding during the postpartum period. What should the nurse
expect to observe in the taking-hold phase?

Answer 21

Mother calls infant by name

Question 22

A female client has just died. Her family is requesting that all nursing staff leave the room. The
family’s religious leader has arrived and is ready to conduct a ceremony for the deceased in the
room, requesting that only family members be present. The nurse assigned to the client should
perform the appropriate nursing action, which might include:

Answer 22

Respect the client’s family’s wishes.

Question 23

A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her
to:

Answer 23

Wear a patch over one eye

Question 24

One of the most reliable assessment tools for adequacy of fluid resuscitation in burned
children is:

Answer 24

Level of consciousness

Question 25

Which one of the following is considered a reliable indicator for assessing the adequacy of
fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to 25% of her
body?

Answer 25

Urine output

Question 26

A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because
this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and
report:

Answer 26

Headache and facial flushing

Question 27

A client states to his nurse that “I was told by the doctor not to take one of my drugs because
it seems to have caused decreasing blood cells.” Based on this information, which drug might the
nurse expect to be discontinued?

Answer 27

Phenytoin (Dilantin)

Question 28

A client has been taking lithium 300 mg po bid for the past two weeks. This morning her
lithium level was 1 mEq/L. The nurse should:

Answer 28

Administer the morning lithium dose as scheduled

Question 29

The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed
toward:

Answer 29

Maintaining an adequate level of hydration

Question 30

Three weeks following discharge, a male client is readmitted to the psychiatric unit for
depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse
admits him to the unit, he says, “I wish I were dead because I am worthless to everyone; I guess I am
just no good.” Which response by the nurse is most appropriate at this time?

Answer 30

“You’ve been feeling sad and alone for some time now?”

Question 31

A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction
with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises.
She will teach the client to:

Answer 31

Inhale slowly and deeply through the nose until the lungs are fully expanded, hold the breath a
couple of seconds, and then exhale slowly through the mouth. Repeat 2-3 more times to complete
the series every 1-2 hours while awake

Question 32

The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which
one of the following actions should the nurse take?

Answer 32

Move furniture out of the way and place a blanket under his head.

Question 33

An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the
emergency room approximately 15 minutes after the accident in excruciating pain with charred
clothing to both legs. What is the first nursing action?

Answer 33

Immerse both legs in cool water.

Question 34

The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a
cardiac client. The physician is notified and orders furosemide (Lasix) 80 mg IV push stat. Which of
the following diagnostic studies is monitored to assess for a major complication of this therapy?

Answer 34

Serum electrolytes

Question 35

A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client
insight and behavioral change by which of the following client statements?

Answer 35

“When I get home, I will need to take my medicines and call my therapist if I have any side effects
or begin to hear voices.”

Question 36

A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine
examination and screening. Which of these plans by the nurse would be most successful?

Answer 36

Provide time for play and becoming acquainted.

Question 37

Diagnostic assessment findings for an infant with possible coarctation of the aorta would
include:

Answer 37

Diminished or absent femoral pulses

Question 38

During a client’s first postpartum day, the nurse assessed that the fundus was located laterally
to the umbilicus.
This may be due to:

Answer 38

Urine retention or a distended bladder

Question 39

An 80-year-old widow is living with her son and daughter- in-law. The home health nurse
has been making weekly visits to draw blood for a prothrombin time test. The client is taking 5 mg of
coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is
suspected. Which of the following are signs of persons who are at risk for abusing an elderly person?

Answer 39

A family member who is having marital problems and is regularly abusing alcohol

Question 40

A 32-year-old female client is being treated for Guillain- Barre syndrome. She complains of
gradually increasing muscle weakness over the past several days. She has noticed an increased
difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding
would indicate a need for immediate further evaluation?

Answer 40

Complaints of shortness of breath

Question 41

Plans for the care of a client with an ulcer caused by emotional problems need to take into
consideration that:

Answer 41

The disorder is a threat to his physical well-being

Question 42

A 55-year-old man has recently been diagnosed with hypertension. His physician orders a lowsodium diet for him. When he asks, “What does salt have to do with high blood pressure?’’ the
nurse’s initial response would be:

Answer 42

“Large amounts of salt in your diet can cause you to retain fluid, which increases your blood
pressure.”

Question 43

A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2-
week period. Her husband asks, “Isn’t that a lot?” The nurse’s best response is:

Answer 43

“Six to 10 treatments are common. Are you concerned about permanent effects?”

Question 44

A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening
complications may occur initially, so the nurse will monitor him closely for serum:

Answer 44

Potassium level of 6.3 mEq/L

Question 45

A 27-year-old primigravida at 32 weeks’ gestation has been diagnosed with complete placenta
previa. Conservative management including bed rest is the proper medical management. The goal for
fetal survival is based on fetal lung maturity. The test used to determine fetal lung maturity is:

Answer 45

Lecithin-sphingomyelin ratio

Question 46

One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium
300 mg po qid. A lithium level is ordered. The client’s level is 1.3 mEq/L. The nurse recognizes that
this level is considered to be:

Answer 46

Within therapeutic range

Question 47

When discussing the relationship between exercise and insulin requirements, a 26-year-old
client with IDDM should be instructed that:

Answer 47

When exercise is increased, insulin needs are decreased

Question 48

A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the
incision, a small part of the abdominal viscera is seen protruding through the incision. This
complication of wound healing is known as:

Answer 48

Evisceration

Question 49

A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus.
What is the first symptom that indicates increased intracranial pressure?

Answer 49

Headache

Question 50

Which nursing implication is appropriate for a client undergoing a paracentesis?

Answer 50

Have the client void before the procedure.

Question 51

A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use,
and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he
tells the nurse, "The devil followed me into this room, I see him standing in the corner with a big
knife. When you leave the room, he's going to cut out my heart." The nurse's best response is:

Answer 51

“I know you’re feeling frightened right now, but I want you to know that I don’t see anyone in the
corner.”

Question 52

To facilitate maximum air exchange, the nurse should position the client in:

Answer 52

Orthopneic

Question 53

A 48-year-old client is in the surgical intensive care unit after having had three-vessel
coronary artery bypass surgery yesterday. She is extubated, awake, alert and talking. She is receiving
digitalis for atrial arrhythmias. This morning serum electrolytes were drawn. Which abnormality
would require immediate intervention by the nurse after contacting the physician?

Answer 53

Serum potassium is low. The nurse should administer KCl as ordered.

Question 54

A male client is scheduled to have angiography of his left leg. The nurse needs to include
which of the following when preparing the client for this procedure?

Answer 54

Validate that he is not allergic to iodine or shellfish.

Question 55

A client had a transurethral resection of the prostate yesterday. He is concerned about the
small amount of blood that is still in his urine. The nurse explains that the blood in his urine:

Answer 55

Is normal and he need not be concerned about it

Question 56

The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on
a fullstrength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms
placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed
blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the
following?

Answer 56

The client aspirated tube feeding.

Question 57

A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea,
vomiting, and sore throat for the past several days. In caring for a young child with symptoms of
influenza, the mother must be cautioned about:

Answer 57

Giving aspirin and bismuth subsalicylate (Pepto-Bismol) to treat the symptoms

Question 58

A male client is considering having laser abdominal surgery and asks the nurse if there is any
advantage in having this type of surgery? The nurse will respond based on the knowledge that laser
surgery:

Answer 58

Has a smaller postoperative infection rate than routine surgery

Question 59

Based on your knowledge of genetic inheritance, which of these statements is true for
autosomal recessive genetic disorders?

Answer 59

Two affected parents always have affected children.

Question 60

The pediatric nurse charts that the parents of a 4-yearold child are very anxious. Which
observation would indicate to the nurse unhealthy coping by these parents:

Answer 60

Refusing to participate in the child’s care

Question 61

The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury.
Normal fluid intake for a child of 2 years is:

Answer 61

1600 mL/24 hr

Question 62

A couple is planning the conception of their first child.
The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is
most likely to ovulate if she states that ovulation should occur on day:

Answer 62

20+2 days

Question 63

The nurse is collecting a nutritional history on a 28- year-old female client with iron-deficiency
anemia and learns that the client likes to eat white chalk. When implementing a teaching plan, the
nurse should explain that this practice:

Answer 63

Interferes with iron absorption because the iron precipitates as an insoluble substance

Question 64

A child becomes neutropenic and is placed on protective isolation. The purpose of protective
isolation is to:

Answer 64

Protect the child from infection

Question 65

A schizophrenic client who is experiencing thoughts of having special powers states that “I am
a messenger from another planet and can rule the earth.” The nurse assesses this behavior as:

Answer 65

Delusions of grandeur

Question 66

Following a gastric resection, which of the following actions would the nurse reinforce with
the client in order to alleviate the distress from dumping syndrome?

Answer 66

Eating a low-carbohydrate diet

Question 67

A 6-year-old child is attending a pediatric clinic for a routine examination. What should the
nurse assess for while conducting a vision screening?

Answer 67

Strabismus

Question 68

Which of the following ECG changes would be seen as a positive myocardial stress test
response?

Answer 68

ST-segment depression

Question 69

A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems
associated with his disease. However, he needs to be encouraged to participate in daily physical
exercise. The ultimate aim of exercise is to:

Answer 69

Establish an effective, habitual breathing pattern

Question 70

A common complication of cirrhosis of the liver is prolonged bleeding. The nurse should be
prepared to administer?

Answer 70

Vitamin K

Question 71

The nurse in the mental health center is instructing a depressed client about the dietary
restrictions necessary in taking her medication, which is a monoamine oxidase (MAO) inhibitor.
Which of the following is she restricting from the client’s diet?

Answer 71

Aged cheese

Question 72

A 67-year-old client will be undergoing a coronary arteriography in the morning. Client
teaching about postprocedure nursing care should include that:

Answer 72

The leg used for arterial puncture should be kept straight for 8-12 hours

Question 73

The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:

Answer 73

Inspiration and expiration are equal

Question 74

Parents should be taught not to prop the bottle when feeding their infants. In addition to the
risk of choking, it puts the infant at risk for:

Answer 74

Otitis media

Question 75

A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a
three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder
irrigation is to prevent:

Answer 75

Clot formation

Question 76

Priapism may be a sign of:

Answer 76

Altered neurological function

Question 77

The healthcare team determines that an elderly client has had progressive changes in memory
over the last 2 years that have interfered with her personal, social, or occupational functioning. Her
memory, learning, attention, and judgment have all been affected in some way. These symptoms
describe which of the following conditions?

Answer 77

Dementia

Question 78

After instructing a female client on circumcision care, the nursery nurse asks her to restate
some of the key points covered. Which statement shows that the client will properly care for her
son’s circumcision?

Answer 78

“I’ll make sure I soak the gauze with warm water first, before I take it off each time.”

Question 79

The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would
be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby
will have:

Answer 79

A low birth weight

Question 80

Respiratory function is altered in a 16-year-old asthmatic. Which of the following is the cause
of this alteration?

Answer 80

Increased airway resistance