MS

Question 1

1. When assessing a client with chest pain, the nurse obtains a thorough history. Which statement of the patient is most suggestive of anginal pectoris?

A. “The pain got worse when I took a deep breath.”
B. “The pain resolved after I ate a sandwich.”
C. “The pain lasted about 45 minutes.”.
D. The pain occurred while I was mowing the loan

Answer 1

D. The pain occurred while I was mowing the loan

Question 2

2. After experiencing a transient ischemic attack (TIA), a client is prescribed aspirin 80 mg p.o daily. The nurse should teach the client that this medication has been prescribed to
   A. Control headache pain
   B. Enhance immune response
   C. Prevent intracranial bleeding
   D. Decrease platelet coagulation

Answer 2

D. Decrease platelet coagulation

Question 3

3. The physician prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question.
   A. Heparin Sodium (heplock)
   B. Dexamethasone (Decadron)
   C. Methyldopa (aldomet)
   D. Phenytoin (Dilantin)

Answer 3

A. Heparin Sodium (heplock)

Question 4

4. A client with peptic ulcer is about to begin a therapeutic regimen that includes a bland diet, antacids, and ranitidine hcl (Zantac). Which instructions should the nurse provide before this client is discharged.

A. Eat a three balanced meal everyday
B. Stop taking the drug when the symptoms subside
C. Avoid aspirin and products that contain aspirin
D. Increase the intake of fluids containing caffeine

Answer 4

C. Avoid aspirin and products that contain aspirin

Question 5

5. A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?

A. Check the presence of the apical pulse
B. Suction the patient’s artificial airway
C. Increase the oxygen percentage
D. Ventilate using a manual resuscitation bag

Answer 5

B. Suction the patient’s artificial airway

Question 6

6. Which of the following takes the highest priority for Parkinson’s crisis?

A. Altered nutrition: less than body requirements
B. Ineffective airway clearance
C. Altered urinary elimination
D. Risk for injury

Answer 6

B. Ineffective airway clearance

Question 7

7. When communicating with a client with (sensory) receptive aphasia, the nurse should?

A. Allow time for the client to respond
B. Speak loudly and articulate clearly
C. Give the client a writing pad
D. Use short, simple sentences

Answer 7

D. Use short, simple sentences

Question 8

8. The nurse should include which instruction when teaching a client about insulin administration?

A. Administer insulin after the first meal of the day
B. Administer insulin at a 45 degree angle into the deltoid muscle
C. Shake the vial of the insulin vigorously before withdrawing the medication
D. Draw up clear insulin when mixing two types of insulin in one syringe

Answer 8

D. Draw up clear insulin when mixing two types of insulin in one syringe

Question 9

9. A client with hypothyroidism is receiving levothyroxine sodium (Synthroid), 50 mcg. P.O daily. Which of these findings should the nurse recognize as an adverse effect?

A. Dysuria
B. Leg cramps
C. Tachycardia
D. Blurred vision

Answer 9

C. Tachycardia

Question 10

10. A client ABG values are pH=7.12, PaCO2= 40 mmHg, and HCO3= 15 mEq/L. which disorder these ABG values suggests?

A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis

Answer 10

D. Metabolic acidosis

Question 11

11. A client is admitted to the ER with suspected overdose of unknown drug. The client ABG values indicates respiratory acidosis, what should the nurse do first?

A. Prepare to assist with ventilation
B. Monitor the client’s heart rhythm
C. Prepare to begin gastric lavage
D. Obtain urine for drug screening

Answer 11

A. Prepare to assist with ventilation

Question 12

12. A client is being returned to the room after subtotal thyroidectomy. Which piece of equipment is important to the nurse to bring to the client’s bedside?

A. Indwelling foley catheter
B. Tracheostomy set
C. Cardiac monitor
D. Humidifier

Answer 12

B. Tracheostomy set

Question 13

13. Which statement from a client who takes Nitroglycerin ( Nitrostat) as needed for angina pain indicates that further teaching is necessary?

A. I store the tablets in a dark bottle
B. I take the tablet in a full glass of water
C. I check for my tongue to tingle when I take a tablet
D. I’ll go to the hospital if 3 tablets, 5 minutes apart don’t relieve the pain

Answer 13

B. I take the tablet in a full glass of water

Question 14

14. A client with gout is receiving Probenecid. The nurse should monitor which laboratory test when caring for this patient?

A. RBC count
B. Serum uric acid
C. Serum potassium
D. WBC COUNT

Answer 14

A. RBC count

Question 15

15. A client has been diagnosed with type 1 insulin dependentDM. which client’s comment correlates best with this disorder?

A. I was thirsty all the time. I just couldn’t get enough to drink
B. It seemed like I had no appetite. I had to get myself eat
C. I had cough and cold that just didn’t seem to go away
D. I noticed a pain when I went to the bathroom

Answer 15

A. I was thirsty all the time. I just couldn’t get enough to drink

Question 16

17.After chemotherapy, a client develops N/V. for this client, the nurse should give the highest priority to which action in the plan of care?

A. Serve small portions of bland food
B. Encourage rhythmic breathing exercise
C. Administer metoclopromide and dexamethasone as prescribed
D. Withould fluid for the the first 4-6 hrs

Answer 16

C. Administer metoclopromide and dexamethasone as prescribed

Question 17

18. A client is receiving Zidovudine (Retrovir) to treat AIDS for this client, the nurse should monitor the value of which laboratory test?

A. RBC count
B. Fasting Blood Glucose
C. Serum Calcium
D. Platelet count

Answer 17

A. RBC count

Question 18

19. A client seeks care for low back pain of 2 weeks duration. Which assessment finding suggests a herniated intervertebral disk?

A.Pain that radiates down the posterior thigh
B.Back pain when the knees are flexed
C.Atrophy of the lower legs
D.Positive Homan’s Sign

Answer 18

A.Pain that radiates down the posterior thigh

Question 19

20. For a client with Hepa B, the nurse should monitor closely for the onset development of which clinical manifestation?

Answer 19

D. Irritability and drowsiness

Question 20

21. A client is recovering from ileostomy that was performed to treat inflammatory bowel disease. During the the teaching discharge, the nurse should stress:

A. Increasing fluid intake to prevent dehydration.
B. Wearing appliance pouch only at bedtime.
C. Consuming a high protein, high fiber diet.
D. Taking only enteric medication .

Answer 20

A. Increasing fluid intake to prevent dehydration.

Question 21

22. A client reports sharp chest pain in the right side of the chest and difficulty of breathing and has respiratory rate of 40 bpm. Which goal should the nurse consider as the top priority?

A. Maintenance of adequate circulatory volume
B. Maintenance of effective respiration
C. Anxiety reduction
D. Pain reduction

Answer 21

B. Maintenance of effective respiration

Question 22

23. A client develops bright red urine while receiving heparin for pulmonary embolus. what should the nurse do first?

A. Decrease the heparin infusion rate
B. Prepare to administer protamine sulfate
C. monitor the partial thromboplastin time (PTT)
D. Stop the infusion for 2 hrs and start it at a lower dose as prescribed

Answer 22

C. monitor the partial thromboplastin time (PTT)

Question 23

24. In a client is chronic bronchitis, which sign should lead the nurse to suspect right heart failure (cor pulmonale)
    A. Circumoral cyanosis
    B. Bilateral crackles
    C. Productive cough
    D. Leg edema

Answer 23

D. Leg edema

Question 24

25. When caring for a client with endotracheal tube, the nurse should consider which action to be the most important?

A. Auscultate the lungs for bilateral breath sounds
B. Turning the client from side to side every 2 hrs
C. Monitor serial blood gas every 4 hrs
D. Provide frequent oral hygiene

Answer 24

A. Auscultate the lungs for bilateral breath sounds

Question 25

26. The nurse administers Albuterol (proventil) as prescribes to a client with emphysema. Which findings indicate that the drug is producing a therapeutic effect? A. Rr of 22 bpm B. Dilated and reactive pupils C. Urine output of 40 ml/hr D. PR of 200 bpm

Answer 25

A. Rr of 22 bpm

Question 26

27. Which nursing intervention is the most important during the acute oliguric phase of acuter renal failure? A. Encouraging coughing and deep breathing exercises B. Promoting carbohydrate intake C. Limiting fluid intake for D. Controlling pain

Answer 26

C. Limiting fluid intake

Question 27

28. The nurse must total parenteral nutrition (TPN) through a triple lumen catheter line. What can the nurse do to prevent complications? A. Cover the catheter site with an occlusive dressing B. Use clean technique when changing the dressing C. Insert an indwelling urinary catheter D. Keep the client on complete bed rest

Answer 27

A. Cover the catheter site with an occlusive dressing

Question 28

29. The nurse assesses a client shortly after kidney transplant surgery which postoperative finding should the nurse report to the physician immediatley? A. Serum potassium of 4.9mEq/L B. Serum sodium of 135mEq/L D. Urine output of 400mL in 24hr.

Answer 28

D. Urine output of 400mL in 24hr.

Question 29

30. A client with advanced cirrhosis has a prothrombin time of 15 seconds compared to a control time of 11 seconds. Which drug should the nurse expect to administer?. A. Spironolactone (aldactone) B. Phytonadione (Mephtyon) C. Furosemide (Lasix) D. Warfarin (Coumadin)

Answer 29

B. Phytonadione (Mephtyon)

Question 30

31. The physician prescribes spironolactone (aldactone) 50 mg PO four times daily for a client with fluid retention due to liver cirrhosis, which finding indicates that the drug is producing therapeutic effect A. Serum k level of 3.5 meq/L B. Weight loss pf 2 lbs in 24 hours C. Serum na level of 135 meq/l D. Blood ph of 7.25

Answer 30

B. Weight loss pf 2 lbs in 24 hours

Question 31

32. While preparing a client with for cholecystectomy, the nurse explains that incentive spirometry will be used after surgery. The nurse also should tell the client the primary purpose of incentive spirometry is: A.Increases respiratory effectiveness B.Preclude the need for nasogastric intubation C.Improve nutritional status during the recovery period D. Decrease the amount of respiratory anesthesia

Answer 31

A.Increases respiratory effectiveness

Question 32

33. A client is receiving a IV infusion of mannitol after undergoing intracranial pressure surgery for removal of a brain tumor. to determine if this drug is producing its therapeutic effect, the nurse should consider which as the most significant? A. decrease level of conscious B. Elevated BP C. increased Urine output D. Decreased heart rate

Answer 32

C. increased Urine output

Question 33

34. A client with cirrhosis of the liver is increasingly confused and combative. Which of the following diets would the nurse expect to be ordered for this client? A. Low fat, low sodium B. High carbohydrate, low protein C. Low potassium, low phosphorus D. Gluten and wheat free.

Answer 33

A. Low fat, low sodium

Question 34

35. A client with exacerbation of COPD and pneumonia has the following ABG results: pH 7.30, PaCO₂ 60 mmHg, PaO₂ 75 mmHg, and HCO₃ 24 mEq/L. The nurse anticipates which intervention? A. Inhale oxygen via face mask B. Encourage coughing and deep breathing C. Administer sodium bicarbonate D. No intervention is needed. ABG values are normal

Answer 34

B. Encourage coughing and deep breathing

Question 35

36. A client with cerebrovascular accident has a nursing diagnosis of ineffective airway clearance. The goal for this client is to mobilize pulmonary secretions. Which action should the nurse plan to take to meet this goal? A. Reposition the client every 2 hrs B. Restrict fluids to 1000 ml in 24 hrs C. Administer 02 by nasal canula as ordered D. Keep the head of the bed at a 30 degrees angle

Answer 35

A. Reposition the client every 2 hrs

Question 36

37. A client with heart failure has been receiving an IV infusion at 125ml/hr. Now the client is short of breath and the nurse notes of bilateral crackles, neck vein distention and tachycardia. What should the nurse do first? A. Notify the physician B. DISCONTINUE THE IV ACCESS DEVICE C. Administer the prescribe diuretic

Answer 36

B. DISCONTINUE THE IV ACCESS DEVICE

Question 37

38. After bronchoscopy, the client must receive NPO until the gag reflex returns. What is the best way to assess the gag reflex? A. Instruct the client to cough B. Ask the client to extend the tongue C. TICKLE THE UVULA WITH A TONGUE BLADE. D. Observe while the client swallow’s sips of water.

Answer 37

C. TICKLE THE UVULA WITH A TONGUE BLADE.

Question 38

39. A client with a history of atrial fibrillation presents to the outpatient clinic with nausea, vomiting, HR of 55bpm, and visual disturbances. The nurse would further assess the client for which of the following conditions? A. Digitalis glycoside toxicity B. Angina C. Heart failure D. Depression

Answer 38

A. Digitalis glycoside toxicity

Question 39

40. A clients ABG values are pH of 7.29, PaO2 48 mmHg, PaCO2 76 mmHg, HCO3 of 36meq/L. The plan of care for this client with these values would include close monitoring for which of the following s/sx?

Answer 39

B.flushed skin and letharygy

Question 40

41.While caring for a client who has sustained an MI, the nurse notes eight premature ventricular contractions in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water and 2L/minute of oxygen the nurse's right course of action would be? A. Increase the IV infusion rate B Notify the physician C. Increase the oxygen concentration D. Administer a prescribed analgesic

Answer 40

B Notify the physician

Question 41

42. Which of the following findings is indicative of MI? A. Elevated serum cholesterol level B. Elevated creatinine phosphokinase (cpk) value C. Agrees to participating in cardiac rehabilitation program D. Can perform self-care activities without pain

Answer 41

B. Elevated creatinine phosphokinase (cpk) value

Question 42

43. Nursing measures for the client who has had an Mi include helping the client to avoid activity that results in Valsalva maneuver. Which of the following actions would help prevent Valsalva maneuver? A. Take fewer deep breaths B. Clench teeth while moving in bed C.Drinks fluids through a straw D.Avoid holding breath during activity

Answer 42

D. Avoid holding breath during activity

Question 43

44. The client has a history of heart failure and the nurse is preparing the client to go home. The nurse should instruct the client to: A. Monitor urine output daily. B. Maintain bed rest for at least one week. C. Monitor daily potassium intake. D. Weight daily.

Answer 43

D. Weight daily.

Question 44

45. Sildenafil (Viagra) is prescribed to treat a child with erectile dysfunction. A nurse reviews the client’s medical record and would question the prescription if which of the following is noted in the client’s history? A. Neuralgia B. Insomnia C. Use of Nitroglycerin D. Use of multivitamin

Answer 44

C. Use of Nitroglycerin

Question 45

46. Digoxin is administered IV to clients with CF primarily because the drugs act to: A. Dilate coronary artery B. Increase myocardial contractility C. Decrease cardiac dysrhythmias D. Decrease electrical conductivity in the heart

Answer 45

B. Increase myocardial contractility

Question 46

47. The client ask the nurse about the reason for taking enalapril maleate. The nurse based her respoyon the fact that enalapril id prescribed for people with heart failure to: A. Lower blood pressure by increasing peripheral resistance B. Lower the heart rate by slowing the conduction system C. Block the conversion of angiotensin I to angiotensin II D. Increase cardiac contractility thereby improving cardiac output

Answer 46

C. Block the conversion of angiotensin I to angiotensin II

Question 47

48. Metropolol tartrate a beta adrenergic antagonist may be administered to a client with heart failure because it acts to: A. Reduce Peripheral vascular vascular resistance B. Increase peripheral vascular resistance C. reduce fluid volume D. Improve myocardial contractility

Answer 47

A. Reduce Peripheral vascular vascular resistance

Question 48

49. Hazel Muray, 32 y/o complains of abrupt onset of chest and back and loss of radial pulses. the nurse suspects that mrs.murray may have: A. Acute MI B. CVA C. Dissecting Abdominal Aorta D. Dissecting thoracic aneurysm

Answer 48

D. Dissecting thoracic aneurysm

Question 49

50. Felicia Gomez is 1 day postoperative from coronary artery bypass surgery. The nurse understands that a postoperative patient who's maintained on bed rest is at high risk for developing: A. Angina B. Arterial bleeding C. Deep vein thrombosis (DVT) D. Dehiscence of the wound

Answer 49

C. Deep vein thrombosis (DVT)

Question 50

51. A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? A. Encourage family members to remain at the bedside. B. Apply soft restraints to protect the patient from injury. C. Keep the room well-lighted to improve patient orientation. D. Minimize contact with the patient to decrease sensory input.

Answer 50

A. Encourage family members to remain at the bedside.

Question 51

52. When administering a mental status examination to a patient with delirium, the nurse should: A. Wait until the patient is well-rested B. Administer an anxiolytic medication. C. Choose a place without distracting stimuli. D. Reorient the patient during the examination.

Answer 51

C. Choose a place without distracting stimuli.

Question 52

(No number). A client is receiving chemotherapy for breast cancer. Which assessment finding indicates chemotherapy induced fluid and electrolyte imbalance? A. Urine output of 400 ml in 8 hours B. Serum potassium level of 3.6 meq/L C. BP of 120/64 to 130/72 mmHg D. Dry oral mucous membrane and cracked lips

Answer 52

D. Dry oral mucous membrane and cracked lips

Question 53

#?. Which is the best control measure for aids?

Answer 53

A. Being faithful to your partner