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NCLEX Practice Questions RN 2/7

By Omar Arshad / October 27, 2022

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Question 1 of 450
1. Question
1. Question Tag: leukemia
Question Category: Health Promotion and Maintenance
The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:
- ⦁ A. Using oil- or cream-based soaps
- ⦁ B. Flossing between the teeth
- ⦁ C. The intake of salt
- ⦁ D. Using an electric razor
Correct
Incorrect
Question 2 of 450
2. Question
2. Question Tag: tracheostomy
Question Category: Reduction of Risk Potential
The nurse is changing the ties of the client with a tracheostomy. The safest method of changing the tracheostomy ties is to:
- • A. Apply the new tie before removing the old one.
- • B. Have a helper present.
- • C. Hold the tracheostomy with the nondominant hand while removing the old tie.
- • D. Ask the doctor to suture the tracheostomy in place.
Correct
Incorrect
Question 3 of 450
3. Question
3. Question Tag: lung resection
Question Category: Physiological Integrity, Reduction of Risk Potential
The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to:
- • A. Turning the client to the left side
- • B. Milking the tube to ensure patency
- • C. Slowing the intravenous infusion
- • D. Notifying the physician
Correct
Incorrect
Question 4 of 450
4. Question
4. Question Tag: Tetralogy of Fallot
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
The infant is admitted to the unit with tetralogy of fallot. The nurse would anticipate an order for which medication?
- • A. Digoxin
- • B. Epinephrine
- • C. Aminophylline
- • D. Atropine
Correct
Incorrect
Question 5 of 450
5. Question
5. Question Tag: Self-breast exam
Question Category: Health Promotion and Maintenance
The nurse is educating the lady’s club in a self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram below, select where the Tail of Spence is.
- D
- C
- A
- B
Correct
Incorrect
Question 6 of 450
6. Question
6. Question Tag: ventricular septal defect
Question Category: Physiological Integrity, Physiological Adaptation
The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:
- • A. Tire easily
- • B. Grow normally
- • C. Need more calories
- • D. Be more susceptible to viral infections
Correct
Incorrect
Question 7 of 450
7. Question
7. Question Tag: nonstress test
Question Category: Physiological Integrity, Reduction of Risk Potential
The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:
- • A. Determine lung maturity
- • B. Measure the fetal activity
- • C. Show the effect of contractions on fetal heart rate
- • D. Measure the wellbeing of the fetus
Correct
Incorrect
Question 8 of 450
8. Question
8. Question Tag: labor
Question Category: Health Promotion and Maintenance
The nurse is evaluating the client who was admitted 8 hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?
- • A. Instruct the client to push
- • B. Perform a vaginal exam
- • C. Turn off the Pitocin infusion
- • D. Place the client in a semi-Fowler’s position
Correct
Incorrect
Question 9 of 450
9. Question
9. Question Tag: ECG, cardiac arrhythmia
Question Category: Physiological Integrity, Reduction of Risk Potential
The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:
- • A. Atrial flutter
- • B. A sinus rhythm
- • C. Ventricular tachycardia
- • D. Atrial fibrillation
Correct
Incorrect
Question 10 of 450
10. Question
10. Question Tag: lovenox (Enoxaparin)
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A client with clotting disorder has an order to continue lovenox (Enoxaparin) injections after discharge. The nurse should teach the client that lovenox injections should:
- • A. Be injected into the deltoid muscle
- • B. Be injected into the abdomen
- • C. Aspirate after the injection
- • D. Clear the air from the syringe before injections
Correct
Incorrect
Question 11 of 450
11. Question
1. Question Tag: valium (Diazepam), phenergan (Promethazine)
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
The nurse has a preop order to administer valium (Diazepam) 10mg and phenergan (Promethazine) 25mg. The correct method of administering these medications is to:
- • A. Administer the medications together in one syringe
- • B. Administer the medication separately
- • C. Administer the Valium, wait 5 minutes, and then inject the Phenergan
- • D. Question the order because they cannot be given at the same time
Correct
Incorrect
Question 12 of 450
12. Question
12. Question Tag: urinary tract infection
Question Category: Health Promotion and Maintenance
A client with frequent urinary tract infections asks the nurse how she can prevent the recurrence. The nurse should teach the client to:
- • A. Douche after intercourse
- • B. Void every 3 hours
- • C. Obtain a urinalysis monthly
- • D. Wipe from back to front after voiding
Correct
Incorrect
Question 13 of 450
13. Question
13. Question Tag: nursing assistant
Question Category: Safe and Effective Care Environment, Management of Care
Which task should be assigned to the nursing assistant?
- • A. Placing the client in seclusion
- • B. Emptying the Foley catheter of the preeclamptic client
- • C. Feeding the client with dementia
- • D. Ambulating the client with a fractured hip
Correct
Incorrect
Question 14 of 450
14. Question
14. Question Tag: thyroidectomy
Question Category: Physiological Integrity, Reduction of Risk Potential
The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?
- • A. A tracheostomy set
- • B. A padded tongue blade
- • C. An endotracheal tube
- • D. An airway
Correct
Incorrect
Question 15 of 450
15. Question
15. Question Tag: histoplasmosis
Question Category: Physiological Integrity, Physiological Adaptation
The physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by:
- • A. Cats
- • B. Dogs
- • C. Turtles
- • D. Birds
Correct
Incorrect
Question 16 of 450
16. Question
16. Question Tag: chest pain
Question Category: Physiological Integrity, Physiological Adaptation
What’s the first intervention for a patient experiencing chest pain and an p02 of 89%?
- • A. Administer morphine
- • B. Administer oxygen
- • C. Administer sublingual nitroglycerin
- • D. Obtain an electrocardiogram (ECC)
Correct
Incorrect
Question 17 of 450
17. Question
17. Question Tag: abdominal aortic aneurysm
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following signs and symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm?
- • A. Abdominal pain
- • B. Absent pedal pulses
- • C. Chest pain
- • D. Lower back pain
Correct
Incorrect
Question 18 of 450
18. Question
18. Question Tag: cardiomyopathy
Question Category: Physiological Integrity, Physiological Adaptation
In which of the following types of cardiomyopathy does cardiac output remain normal?
- • A. Obliterative
- • B. Restrictive
- • C. Dilated
- • D. Hypertrophic
Correct
Incorrect
Question 19 of 450
19. Question
19. Question Tag: chest pain
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following interventions should be your first priority when treating a patient experiencing chest pain while walking?
- • A. Have the patient sit down.
- • B. Get the patient back to bed.
- • C. Obtain an ECG.
- • D. Administer sublingual nitroglycerin.
Correct
Incorrect
Question 20 of 450
20. Question
20. Question Tag: acute pulmonary edema
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following positions would best aid breathing for a patient with acute pulmonary edema?
- • A. Lying flat in bed
- • B. Left side-lying position
- • C. High Fowler’s position
- • D. Semi-Fowler’s position
Correct
Incorrect
Question 21 of 450
21. Question
21. Question Tag: abruptio placentae
Question Category: Physiological Integrity, Reduction of Risk Potential
A pregnant woman arrives at the emergency department (ED) with abruptio placentae at 34 weeks’ gestation. She’s at risk for which of the following blood dyscrasias?
- • A. Heparin-associated thrombosis and thrombocytopenia (HATT)
- • B. Idiopathic thrombocytopenic purpura (ITP)
- • C. Thrombocytopenia
- • D. Disseminated intravascular coagulation (DIC)
Correct
Incorrect
Question 22 of 450
22. Question
22. Question Tag: vehicle accident, fracture
Question Category: Physiological Integrity, Physiological Adaptation
A 16-year-old patient involved in a motor vehicle accident arrives in the ED unconscious and severely hypotensive. He’s suspected to have several fractures of his pelvis and legs. Which of the following parenteral fluids is the best choice for his current condition?
- • A. Packed red blood cells
- • B. 0.9% sodium chloride solution
- • C. Lactated Ringer’s solution
- • D. Fresh frozen plasma
Correct
Incorrect
Question 23 of 450
23. Question
23. Question Tag: corticosteroids
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
Corticosteroids are potent suppressors of the body’s inflammatory response. Which of the following conditions or actions do they suppress?
- • A. Cushing syndrome
- • B. Pain receptors
- • C. Immune response
- • D. Neural transmission
Correct
Incorrect
Question 24 of 450
24. Question
24. Question Tag: HIV, zidovudine
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A patient infected with human immunodeficiency virus (HIV) begins zidovudine therapy. Which of the following statements best describes this drug’s action?
- • A. It stimulates the immune system.
- • B. It destroys the outer wall of the virus and kills it.
- • C. It interferes with viral replication
- • D. It promotes excretion of viral antibodies.
Correct
Incorrect
Question 25 of 450
25. Question
25. Question Tag: pneumonia
Question Category: Physiological Integrity, Basic Care and Comfort
A 20-year-old patient is being treated for pneumonia. He has a persistent cough and complains of severe pain on coughing. What could you tell him to help him reduce his discomfort?
- • A. “Hold your cough as much as possible.”
- • B. “Place the head of your bed flat to help with coughing.”
- • C. “Restrict fluids to help decrease the amount of sputum.”
- • D. “Splint your chest wall with a pillow for comfort.”
Correct
Incorrect
Question 26 of 450
26. Question
26. Question Tag: asthma, acute respiratory distress
Question Category: Physiological Integrity, Physiological Adaptation
A 19-year-old patient comes to the ED with acute asthma. His respiratory rate is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following actions should you take first?
- • A. Take a full medical history.
- • B. Give a bronchodilator by nebulizer.
- • C. Apply a cardiac monitor to the patient.
- • D. Provide emotional support for the patient.
Correct
Incorrect
Question 27 of 450
27. Question
27. Question Tag: smoke inhalation, hypoxia
Question Category: Physiological Integrity, Physiological Adaptation
A firefighter who was involved in extinguishing a house fire is being treated for smoke inhalation. He developed severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. Which of the following conditions has he most likely developed?
- • A. Atelectasis
- • B. Pneumonia
- • C. Bronchitis
- • D. Acute respiratory distress syndrome (ARDS)
Correct
Incorrect
Question 28 of 450
28. Question
28. Question Tag: pneumothorax
Question Category: Physiological Integrity, Reduction of Risk Potential
Which of the following measures best determines that a patient who had a pneumothorax no longer needs a chest tube?
- • A. You see a lot of drainage from the chest tube.
- • B. Arterial blood gas (ABG) levels are normal.
- • C. The chest X-ray continues to show the lung is 35% deflated.
- • D. The water-seal chamber doesn’t fluctuate when no suction is applied.
Correct
Incorrect
Question 29 of 450
29. Question
29. Question Tag: subdural hematoma
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following nursing interventions should you use to prevent foot drop and contractures in a patient recovering from a subdural hematoma?
- • A. High-top sneakers
- • B. Low-dose heparin therapy
- • C. Physical therapy consultation
- • D. Sequential compressive device
Correct
Incorrect
Question 30 of 450
30. Question
30. Question Tag: increased intracranial pressure
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following signs of increased intracranial pressure (ICP) would appear first after head trauma?
- • A. Bradycardia
- • B. Large amounts of very dilute urine
- • C. Restlessness and confusion
- • D. Widened pulse pressure
Correct
Incorrect
Question 31 of 450
31. Question
31. Question Tag: phenytoin
Question Category: Physiological Integrity, Physiological Adaptation
When giving intravenous (I.V.) phenytoin, which of the following methods should you use?
- • A. Use an in-line filter.
- • B. Withhold other anticonvulsants.
- • C. Mix the drug with saline solution only.
- • D. Flush the I.V. catheter with dextrose solution.
Correct
Incorrect
Question 32 of 450
32. Question
32. Question Tag: hip repair
Question Category: Physiological Integrity, Physiological Adaptation
After surgical repair of a hip, which of the following positions is best for the patient’s legs and hips?
- • A. Abduction
- • B. Adduction
- • C. Prone
- • D. Subluxated
Correct
Incorrect
Question 33 of 450
33. Question
1. Question Tag: acute pancreatitis
Question Category: Physiological Integrity, Physiological Adaptation
Which of the following factors should be the primary focus of nursing management in a patient with acute pancreatitis?
- • A. Nutrition management
- • B. Fluid and electrolyte balance
- • C. Management of hypoglycemia
- • D. Pain control
Correct
Incorrect
Question 34 of 450
34. Question
34. Question Tag: liver biopsy
Question Category: Physiological Integrity, Reduction of Risk Potential
After a liver biopsy, place the patient in which of the following positions?
- • A. Left side-lying, with the bed flat
- • B. Right side-lying, with the bed flat
- • C. Left side-lying, with the bed in semi-Fowler’s position
- • D. Right side-lying, with the bed in semi-Fowler’s position
Correct
Incorrect
Question 35 of 450
35. Question
35. Question Tag: hypothyroidism
Question Category: Physiological Integrity, Reduction of Risk Potential
Which of the following potentially serious complications could occur with therapy for hypothyroidism?
- • A. Acute hemolytic reaction
- • B. Angina or cardiac arrhythmia
- • C. Retinopathy
- • D. Thrombocytopenia
Correct
Incorrect
Question 36 of 450
36. Question
36. Question Tag: diabetes insipidus
Question Category: Physiological Integrity, Physiological Adaptation
Adequate fluid replacement and vasopressin replacement are objectives of therapy for which of the following disease processes?
- • A. Diabetes mellitus
- • B. Diabetes insipidus
- • C. Diabetic ketoacidosis
- • D. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Correct
Incorrect
Question 37 of 450
37. Question
37. Question Tag: type 1 diabetes mellitus
Question Category: Physiological Integrity, Physiological Adaptation
Patients with Type 1 diabetes mellitus may require which of the following changes to their daily routine during periods of infection?
- • A. No changes
- • B. Less insulin
- • C. More insulin
- • D. Oral diabetic agents
Correct
Incorrect
Question 38 of 450
38. Question
38. Question Tag:decreased hematocrit
Question Category: Physiological Integrity, Reduction of Risk Potential
On a follow-up visit after having a vaginal hysterectomy, a 32-year-old patient has a decreased hematocrit level. Which of the following complications does this suggest?
- • A. Hematoma
- • B. Hypovolemia
- • C. Infection
- • D. Pulmonary embolus (PE)
Correct
Incorrect
Question 39 of 450
39. Question
39. Question Tag: partial-thickness burn
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following I.V. fluids are given first?
- • A. Albumin
- • B. D5W
- • C. Lactated Ringer’s solution
- • D. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml
Correct
Incorrect
Question 40 of 450
40. Question
40. Question Tag: wound culture
Question Category: Health Promotion and Maintenance
Which of the following techniques is correct for obtaining a wound culture specimen from a surgical site?
- • A. Thoroughly irrigate the wound before collecting the specimen.
- • B. Use a sterile swab and wipe the crusty area around the outside of the wound.
- • C. Gently roll a sterile swab from the center of the wound outward to collect drainage.
- • D. Use a sterile swab to collect drainage from the dressing.
Correct
Incorrect
Question 41 of 450
41. Question
41. Question Tag: furosemide, congestive heart failure
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A nurse is administering IV furosemide to a patient admitted with congestive heart failure. After the infusion, which of the following symptoms is not expected?
- • A. Increased urinary output
- • B. Decreased edema
- • C. Decreased pain
- • D. Decreased blood pressure
Correct
Incorrect
Question 42 of 450
42. Question
42. Question Tag: coronary artery disease
Question Category: Health Promotion and Maintenance
There are a number of risk factors associated with coronary artery disease. Which of the following is a modifiable risk factor?
- • A. Gender
- • B. Age
- • C. Obesity
- • D. Heredity
Correct
Incorrect
Question 43 of 450
43. Question
43. Question Tag: myocardial infarction, tissue plasminogen activator
Question Category: Physiological Integrity, Physiological Adaptation
Tissue plasminogen activator (t-PA) is considered for the treatment of a patient who arrives in the emergency department following the onset of symptoms of myocardial infarction. Which of the following is a contraindication for treatment with t-PA?
- • A. Worsening chest pain that began earlier in the evening
- • B. History of cerebral hemorrhage
- • C. History of prior myocardial infarction
- • D. Hypertension
Correct
Incorrect
Question 44 of 450
44. Question
44. Question Tag: myocardial infarction
Question Category: Health Promotion and Maintenance
Following myocardial infarction, a hospitalized patient is encouraged to practice frequent leg exercises and ambulate in the hallway as directed by his physician. Which of the following choices reflects the purpose of exercise for this patient?
- • A. Increases fitness and prevents future heart attacks
- • B. Prevents bedsores
- • C. Prevents DVT (deep vein thrombosis)
- • D. Prevent constipations
Correct
Incorrect
Question 45 of 450
45. Question
45. Question Tag: cardiogenic shock
Question Category: Physiological Integrity, Physiological Adaptation
A patient arrives in the emergency department with symptoms of myocardial infarction, progressing to cardiogenic shock. Which of the following symptoms should the nurse expect the patient to exhibit with cardiogenic shock?
- • A. Hypertension
- • B. Bradycardia
- • C. Bounding pulse
- • D. Confusion
Correct
Incorrect
Question 46 of 450
46. Question
46. Question Tag: congestive heart failure
Question Category: Physiological Integrity, Physiological Adaptation
A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea. Which of the following actions is the first the nurse should perform?
- • A. Ask the patient to lie down on the exam table.
- • B. Draw blood for chemistry panel and arterial blood gas (ABG).
- • C. Send the patient for a chest x-ray.
- • D. Check blood pressure.
Correct
Incorrect
Question 47 of 450
47. Question
47. Question Tag: nitroglycerin, angina
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A clinic patient has recently been prescribed nitroglycerin for treatment of angina. He calls the nurse complaining of frequent headaches. Which of the following responses to the patient is correct?
- • A. “Stop taking the nitroglycerin and see if the headaches improve.”
- • B. “Go to the emergency department to be checked because nitroglycerin can cause bleeding in the brain.”
- • C. “Headaches are a frequent side effect of nitroglycerine because it causes vasodilation.”
- • D. “The headaches are unlikely to be related to the nitroglycerin, so you should see your doctor for further investigation.”
Correct
Incorrect
Question 48 of 450
48. Question
48. Question Tag: colon cancer, chemotherapy
Question Category: Physiological Integrity, Reduction of Risk Potential
A patient received surgery and chemotherapy for colon cancer, completing therapy three (3) months previously, and she is now in remission. At a follow-up appointment, she complains of fatigue following activity and difficulty with concentration at her weekly bridge games. Which of the following explanations would account for her symptoms?
- • A. The symptoms may be the result of anemia caused by chemotherapy.
- • B. The patient may be immunosuppressed.
- • C. The patient may be depressed.
- • D. The patient may be dehydrated.
Correct
Incorrect
Question 49 of 450
49. Question
49. Question Tag: hemoglobin
Question Category: Basic Care and Comfort
A clinic patient has a hemoglobin concentration of 10.8 g/dL and reports sticking to a strict vegetarian diet. Which of the following nutritional advice is appropriate?
- • A. The diet is providing adequate sources of iron and requires no changes.
- • B. The patient should add meat to her diet; a vegetarian diet is not advised.
- • C. The patient should use iron cookware to prepare foods, such as dark-green, leafy vegetables and legumes, which are high in iron.
- • D. A cup of coffee or tea should be added to every meal
Correct
Incorrect
Question 50 of 450
50. Question
50. Question Tag: anemia
Question Category: Physiological Integrity, Physiological Adaptation
A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment of severe anemia. Which of the following is the most accurate statement?
- • A. Transfusion reaction is most likely immediately after the infusion is completed.
- • B. PRBCs are best infused slowly through a 20g. IV catheter.
- • C. PRBCs should be flushed with a 5% dextrose solution.
- • D. A nurse should remain in the room during the first 15 minutes of infusion.
Correct
Incorrect
Question 51 of 450
51. Question
51. Question Tag: Epoetin
Question Category: Physiological Integrity, Reduction of Risk Potential
A patient who has received chemotherapy for cancer treatment is given an injection of Epoetin. Which of the following should reflect the findings in a complete blood count (CBC) drawn several days later?
- • A. An increase in neutrophil count
- • B. An increase in hematocrit
- • C. An increase in platelet count
- • D. An increase in serum iron
Correct
Incorrect
Question 52 of 450
52. Question
52. Question Tag: polycythemia vera
Question Category: Physiological Integrity, Physiological Adaptation
A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the diagnosis? Select all Select all that apply.
- • A. Weight loss
- • B. Increased clotting time
- • C. Hypertension
- • D. Headaches
- • E. Polyphagia
- • F. Pruritus
Correct
Incorrect
Question 53 of 450
53. Question
53. Question Tag: platelet count
Question Category: Physiological Integrity, Reduction of Risk Potential
A nurse is caring for a patient with a platelet count of 20,000/microliter. Which of the following is an important intervention?
- • A. Observe for evidence of spontaneous bleeding.
- • B. Limit visitors to family only.
- • C. Give aspirin in case of headaches.
- • D. Impose immune precautions.
Correct
Incorrect
Question 54 of 450
54. Question
54. Question Tag: corticosteroid
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A nurse in the emergency department assesses a patient who has been taking long-term corticosteroids to treat renal disease. Which of the following is a typical side effect of corticosteroid treatment? Select all that apply.
- • A. Hypertension
- • B. Cushingoid features
- • C. Hyponatremia
- • D. Low serum albumin
- • E. Mood swings
Correct
Incorrect
Question 55 of 450
55. Question
55. Question Tag: neutropenia
Question Category: Physiological Integrity, Physiological Adaptation
A nurse is caring for patients in the oncology unit. Which of the following is the most important nursing action when caring for a neutropenic patient?
- • A. Change the disposable mask immediately after use.
- • B. Change gloves immediately after use.
- • C. Minimize patient contact.
- • D. Minimize conversation with the patient.
Correct
Incorrect
Question 56 of 450
56. Question
56. Question Tag: leukemia
Question Category: Health Promotion and Maintenance
A patient is undergoing the induction stage of treatment for leukemia. The nurse teaches family members about infectious precautions. Which of the following statements by family members indicates that the family needs more education?
- • A. We will bring in books and magazines for entertainment.
- • B. We will bring in personal care items for comfort.
- • C. We will bring in fresh flowers to brighten the room.
- • D. We will bring in family pictures and get well cards.
Correct
Incorrect
Question 57 of 450
57. Question
57. Question Tag: acute lymphoblastic leukemia
Question Category: Health Promotion and Maintenance
A nurse is caring for a patient with acute lymphoblastic leukemia (ALL). Which of the following is the most likely age range of the patient?
- • A. 3-10 years
- • B. 25-35 years
- • C. 45-55 years
- • D. over 60 years
Correct
Incorrect
Question 58 of 450
58. Question
58. Question Tag: Hodgkin’s disease
Question Category: Physiological Integrity, Physiological Adaptation
A patient is admitted to the oncology unit for diagnosis of suspected Hodgkin’s disease. Which of the following symptoms is typical of Hodgkin’s disease?
- • A. Painful cervical lymph nodes
- • B. Night sweats and fatigue
- • C. Nausea and vomiting
- • D. Weight gain
Correct
Incorrect
Question 59 of 450
59. Question
59. Question Tag: Hodgkin’s disease
Question Category: Physiological Integrity, Physiological Adaptation
The Hodgkin’s disease patient described in the question above undergoes a lymph node biopsy for definitive diagnosis. If the diagnosis of Hodgkin’s disease were correct, which of the following cells would the pathologist expect to find?
- • A. Lymphoblastic cells
- • B. Reed-Sternberg cells
- • C. Gaucher’s cells
- • D. Rieder’s cells
Correct
Incorrect
Question 60 of 450
60. Question
60. Question Tag: bone marrow aspiration
Question Category: Physiological Integrity, Physiological Adaptation
A patient is about to undergo bone marrow aspiration and biopsy and expresses fear and anxiety about the procedure. Which of the following is the most effective nursing response?
- • A. Warn the patient to stay very still because the smallest movement will increase her pain.
- • B. Encourage the family to stay in the room for the procedure.
- • C. Stay with the patient and focus on slow, deep breathing for relaxation.
- • D. Delay the procedure to allow the patient to deal with her feelings.
Correct
Incorrect
Question 61 of 450
61. Question
61. Question Tag: sickle cell anemia
Question Category: Physiological Integrity, Reduction of Risk Potential
A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?
- • A. Body temperature of 99°F or less
- • B. Toes moved in active range of motion
- • C. Sensation reported when soles of feet are touched
- • D. Capillary refill of < 3 seconds
Correct
Incorrect
Question 62 of 450
62. Question
62. Question Tag: sickle cell crisis
Question Category: Physiological Integrity, Physiological Adaptation
A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?
- • A. Side-lying with knees flexed
- • B. Knee-chest
- • C. High Fowler’s with knees flexed
- • D. Semi-Fowler’s with legs extended on the bed
Correct
Incorrect
Question 63 of 450
63. Question
1. Question Tag: sickle cell crisis
Question Category: Physiological Integrity, Physiological Adaptation
A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of the highest priority for this client?
- • A. Taking hourly blood pressures with mechanical cuff
- • B. Encouraging fluid intake of at least 200mL per hour
- • C. Position in high Fowler’s with knee gatch raised
- • D. Administering Tylenol as ordered
Correct
Incorrect
Question 64 of 450
64. Question
64. Question Tag: sickle cell crisis
Question Category: Physiological Integrity, Basic Care and Comfort
Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
- • A. Peaches
- • B. Cottage cheese
- • C. Popsicle
- • D. Lima beans
Correct
Incorrect
Question 65 of 450
65. Question
65. Question Tag: sickle cell crisis
Question Category: Physiological Integrity, Physiological Adaptation
A newly admitted client has a sickle cell crisis. The nurse is planning care based on the assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention.
- • A. Adjust the room temperature
- • B. Give a bolus of IV fluids
- • C. Start O2
- • D. Administer meperidine (Demerol) 75 mg IV push
Correct
Incorrect
Question 66 of 450
66. Question
66. Question Tag: iron-deficiency anemia
Question Category: Physiological Integrity, Basic Care and Comfort
The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?
- • A. Roast beef, gelatin salad, green beans, and peach pie
- • B. Chicken salad sandwich, coleslaw, French fries, ice cream
- • C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
- • D. Pork chop, creamed potatoes, corn, and coconut cake
Correct
Incorrect
Question 67 of 450
67. Question
67. Question Tag: sickle cell anemia
Question Category: Health Promotion and Maintenance
Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
- • A. A family vacation in the Rocky Mountains
- • B. Chaperoning the local boys club on a snow-skiing trip
- • C. Traveling by airplane for business trips
- • D. A bus trip to the Museum of Natural History
Correct
Incorrect
Question 68 of 450
68. Question
68. Question Tag: vitamin B12 deficiency
Question Category: Physiological Integrity, Physiological Adaptation
The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment?
- • A. Palpate the spleen
- • B. Take the blood pressure
- • C. Examine the feet for petechiae
- • D. Examine the tongue
Correct
Incorrect
Question 69 of 450
69. Question
69. Question Tag: vitamin B12 deficiency
Question Category: Health Promotion and Maintenance
An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator?
- • A. Conjunctiva of the eye
- • B. Soles of the feet
- • C. Roof of the mouth
- • D. Shins
Correct
Incorrect
Question 70 of 450
70. Question
70. Question Tag: anemia
Question Category: Physiological Integrity, Physiological Adaptation
The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?
- • A. BP 146/88
- • B. Respirations 28 shallow
- • C. Weight gain of 10 pounds in 6 months
- • D. Pink complexion
Correct
Incorrect
Question 71 of 450
71. Question
71. Question Tag: polycythemia vera
Question Category: Health Promotion and Maintenance
The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?
- • A. “I will drink 500mL of fluid or less each day.”
- • B. “I will wear a support hose when I am up.”
- • C. “I will use an electric razor for shaving.”
- • D. “I will eat foods low in iron.”
Correct
Incorrect
Question 72 of 450
72. Question
72. Question Tag: acute leukemia
Question Category: Health Promotion and Maintenance
A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment?
- • A. The client collects stamps as a hobby.
- • B. The client recently lost his job as a postal worker.
- • C. The client had radiation for treatment of Hodgkin’s disease as a teenager.
- • D. The client’s brother had leukemia as a child.
Correct
Incorrect
Question 73 of 450
73. Question
73. Question Tag: acute leukemia
Question Category: Health Promotion and Maintenance
An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining the presence of petechiae?
- • A. The abdomen
- • B. The thorax
- • C. The earlobes
- • D. The soles of the feet
Correct
Incorrect
Question 74 of 450
74. Question
74. Question Tag: acute leukemia
Question Category: Health Promotion and Maintenance
A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?
- • A. “Have you noticed a change in sleeping habits recently?”
- • B. “Have you had a respiratory infection in the last 6 months?”
- • C. “Have you lost weight recently?”
- • D. “Have you noticed changes in your alertness?”
Correct
Incorrect
Question 75 of 450
75. Question
75. Question Tag: acute leukemia
Question Category: Physiological Integrity, Reduction of Risk Potential
Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
- • A. Oral mucous membrane, altered related to chemotherapy
- • B. Risk for injury related to thrombocytopenia
- • C. Fatigue related to the disease process
- • D. Interrupted family processes related to life-threatening illness of a family member
Correct
Incorrect
Question 76 of 450
76. Question
76. Question Tag: Hodgkin’s lymphoma
Question Category: Physiological Integrity
A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?
- • A. Sexual dysfunction related to radiation therapy
- • B. Anticipatory grieving related to terminal illness
- • C. Tissue integrity related to prolonged bed rest
- • D. Fatigue related to chemotherapy
Correct
Incorrect
Question 77 of 450
77. Question
77. Question Tag: thrombocytopenic purpura
Question Category: Physiological Integrity
A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:
- • A. Platelet count
- • B. White blood cell count
- • C. Potassium levels
- • D. Partial prothrombin time (PTT)
Correct
Incorrect
Question 78 of 450
78. Question
78. Question Tag: thrombocytopenic purpura
Question Category: Physiological Integrity
The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently is 80, it will be most important to teach the client and family about:
- • A. Bleeding precautions
- • B. Prevention of falls
- • C. Oxygen therapy
- • D. Conservation of energy
Correct
Incorrect
Question 79 of 450
79. Question
79. Question Tag: transsphenoidal hypophysectomy
Question Category: Physiological Integrity
A client with a pituitary tumor has had transsphenoidal hypophysectomy. Which of the following interventions would be appropriate for this client?
- • A. Place the client in Trendelenburg position for postural drainage
- • B. Encourage coughing and deep breathing every 2 hours
- • C. Elevate the head of the bed 30°
- • D. Encourage the Valsalva maneuver for bowel movements
Correct
Incorrect
Question 80 of 450
80. Question
80. Question Tag: diabetes
Question Category: Physiological Integrity
The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:
- • A. Measure the urinary output
- • B. Check the vital signs
- • C. Encourage increased fluid intake
- • D. Weigh the client
Correct
Incorrect
Question 81 of 450
81. Question
81. Question Tag: hemophilia
Question Category: Physiological Integrity
A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
- • A. Place the client in a sitting position with the head hyperextended
- • B. Pack the nares tightly with gauze to apply pressure to the source of bleeding
- • C. Pinch the soft lower part of the nose for a minimum of 5 minutes
- • D. Apply ice packs to the forehead and back of the neck
Correct
Incorrect
Question 82 of 450
82. Question
82. Question Tag: unilateral adrenalectomy
Question Category: Physiological Integrity
A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate postoperative period for the nurse to take is:
- • A. Blood pressure
- • B. Temperature
- • C. Output
- • D. Specific gravity
Correct
Incorrect
Question 83 of 450
83. Question
83. Question Tag: Addison’s disease, glucocorticoids
Question Category: Physiological Integrity
A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?
- • A. Daily weights
- • B. Intake/output measurements
- • C. Sodium and potassium levels monitored
- • D. Glucometer readings as ordered
Correct
Incorrect
Question 84 of 450
84. Question
84. Question Tag: total thyroidectomy
Question Category: Physiological Integrity
A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurse’s next action be?
- • A. Obtain a crash cart
- • B. Check the calcium level
- • C. Assess the dressing for drainage
- • D. Assess the blood pressure for hypertension
Correct
Incorrect
Question 85 of 450
85. Question
85. Question Tag: hypothyroidism
Question Category: Physiological Integrity
A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?
- • A. Impaired physical mobility related to decreased endurance
- • B. Hypothermia r/t decreased metabolic rate
- • C. Disturbed thought processes r/t interstitial edema
- • D. Decreased cardiac output r/t bradycardia
Correct
Incorrect
Question 86 of 450
86. Question
86. Question Tag: arteriogram
Question Category: Physiological Integrity
The client is having an arteriogram. During the procedure, the client tells the nurse, “I’m feeling really hot.” Which response would be best?
- • A. “You are having an allergic reaction. I will get an order for Benadryl.”
- • B. “That feeling of warmth is normal when the dye is injected.”
- • C. “That feeling of warmth indicates that the clots in the coronary vessels are dissolving.”
- • D. “I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing.”
Correct
Incorrect
Question 87 of 450
87. Question
87. Question Tag: healthcare workers
Question Category: Physiological Integrity
The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?
- • A. The nursing assistant wears gloves while giving the client a bath.
- • B. The nurse wears goggles while drawing blood from the client.
- • C. The doctor washes his hands before examining the client.
- • D. The nurse wears gloves to take the client’s vital signs.
Correct
Incorrect
Question 88 of 450
88. Question
88. Question Tag: electroconvulsive therapy, depression
Question Category: Physiological Integrity
The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective?
- • A. The client loses consciousness.
- • B. The client vomits.
- • C. The client’s ECG indicates tachycardia.
- • D. The client has a grand mal seizure.
Correct
Incorrect
Question 89 of 450
89. Question
89. Question Tag: enterobiasis
Question Category: Physiologic Integrity
The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:
- • A. Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep
- • B. Scrape the skin with a piece of cardboard and bring it to the clinic the clinic
- • C. Obtain a stool specimen in the afternoon
- • D. Bring a hair sample to the clinic for evaluation
Correct
Incorrect
Question 90 of 450
90. Question
90. Question Tag: enterobiasis
Question Category: Physiological Integrity
The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?
- • A. Treatment is not recommended for children less than 10 years of age.
- • B. The entire family should be treated.
- • C. Medication therapy will continue for 1 year.
- • D. Intravenous antibiotic therapy will be ordered.
Correct
Incorrect
Question 91 of 450
91. Question
91. Question Tag: pregnancy
Question Category: Safe and Effective Care Environment
The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
- • A. The client receiving linear accelerator radiation therapy for lung cancer
- • B. The client with a radium implant for cervical cancer
- • C. The client who has just been administered soluble brachytherapy for thyroid cancer
- • D. The client who returned from placement of iridium seeds for prostate cancer
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Incorrect
Question 92 of 450
92. Question
92. Question Tag: room assignments
Question Category: Safe and Effective Care Environment
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
- • A. The client with Cushing’s disease
- • B. The client with diabetes
- • C. The client with acromegaly
- • D. The client with myxedema
Correct
Incorrect
Question 93 of 450
93. Question
93. Question Tag: Digitalis
Question Category: Safe and Effective Care Environment
The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:
- • A. Negligence
- • B. Tort
- • C. Assault
- • D. Malpractice
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Incorrect
Question 94 of 450
94. Question
94. Question Tag: licensed practical nurse
Question Category: Safe and Effective Care Environment
Which assignment should not be performed by the licensed practical nurse?
- • A. Inserting a Foley catheter
- • B. Discontinuing a nasogastric tube
- • C. Obtaining a sputum specimen
- • D. Starting a blood transfusion
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Incorrect
Question 95 of 450
95. Question
95. Question Tag: surgery
Question Category: Physiological Integrity
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority?
- • A. Continuing to monitor the vital signs
- • B. Contacting the physician
- • C. Asking the client how he feels
- • D. Asking the LPN to continue the post-op care
Correct
Incorrect
Question 96 of 450
96. Question
1. Question Tag: preeclampsia
Question Category: Safe and Effective Care Environment
Which nurse should be assigned to care for the postpartum client with preeclampsia?
- • A. The RN with 2 weeks of experience in postpartum
- • B. The RN with 3 years of experience in labor and delivery
- • C. The RN with 10 years of experience in surgery
- • D. The RN with 1 year of experience in the neonatal intensive care unit
Correct
Incorrect
Question 97 of 450
97. Question
97. Question Tag: Board of Nursing
Question Category: Safe and Effective Care Environment
Which information should be reported to the state Board of Nursing?
- • A. The facility fails to provide literature in both Spanish and English.
- • B. The narcotic count has been incorrect on the unit for the past 3 days.
- • C. The client fails to receive an itemized account of his bills and services received during his hospital stay.
- • D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.
Correct
Incorrect
Question 98 of 450
98. Question
98. Question Tag: medication administration
Question Category: Safe and Effective Care Environment
The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:
- • A. Call the Board of Nursing
- • B. File a formal reprimand
- • C. Terminate the nurse
- • D. Charge the nurse with a tort
Correct
Incorrect
Question 99 of 450
99. Question
99. Question Tag: home health care
Question Category: Safe and Effective Care Environment
The home health nurse is planning for the day’s visits. Which client should be seen first?
- • A. The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube
- • B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension
- • C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line
- • D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
Correct
Incorrect
Question 100 of 450
100. Question
1. Question Tag: emergency department
Question Category: Safe and Effective Care Environment
The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room?
- • A. A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis
- • B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm
- • C. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury
- • D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain
Correct
Incorrect
Question 101 of 450
101. Question
101. Question Tag: conjunctivitis
Question Category: Physiological Integrity
The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eye drops, the nurse should recognize that it is essential to consider which of the following?
- • A. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops.
- • B. The child should be allowed to instill his own eye drops.
- • C. The mother should be allowed to instill the eyedrops.
- • D. If the eye is clear from any redness or edema, the eye drops should be held.
Correct
Incorrect
Question 102 of 450
102. Question
102. Question Tag: meal planning
Question Category: Health Promotion and Maintenance
The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction?
- • A. “It is okay to give my child white grape juice for breakfast.”
- • B. “My child can have a grilled cheese sandwich for lunch.”
- • C. “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.”
- • D. “For a snack, my child can have ice cream.”
Correct
Incorrect
Question 103 of 450
103. Question
103. Question Tag: toddler
Question Category: Physiological Integrity
A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?
- • A. Ask the parent/guardian to leave the room when assessments are being performed.
- • B. Ask the parent/guardian to take the child’s favorite blanket home because anything from the outside should not be brought into the hospital.
- • C. Ask the parent/guardian to room-in with the child.
- • D. If the child is screaming, tell him this is inappropriate behavior.
Correct
Incorrect
Question 104 of 450
104. Question
104. Question Tag: hearing aid
Question Category: Health Promotion and Maintenance
Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?
- • A. Remove the mold and clean every week.
- • B. Store the hearing aid in a warm place.
- • C. Clean the lint from the hearing aid with a toothpick.
- • D. Change the batteries weekly.
Correct
Incorrect
Question 105 of 450
105. Question
105. Question Tag: tonsillectomy
Question Category: Physiological Integrity
A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:
- • A. Body image disturbance
- • B. Impaired verbal communication
- • C. Risk for aspiration
- • D. Pain
Correct
Incorrect
Question 106 of 450
106. Question
106. Question Tag: bacterial pneumonia
Question Category: Physiological Integrity
A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
- • A. High fever
- • B. Nonproductive cough
- • C. Rhinitis
- • D. Vomiting and diarrhea
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Incorrect
Question 107 of 450
107. Question
107. Question Tag: epiglottitis
Question Category: Safe and Effective Care Environment
The nurse is caring for a client admitted with epiglottitis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?
- • A. Intravenous access supplies
- • B. A tracheostomy set
- • C. Intravenous fluid administration pump
- • D. Supplemental oxygen
Correct
Incorrect
Question 108 of 450
108. Question
108. Question Tag: Grave’s disease
Question Category: Physiological Integrity
A 25-year-old client with Grave’s disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal?
- • A. Bradycardia
- • B. Decreased appetite
- • C. Exophthalmos
- • D. Weight gain
Correct
Incorrect
Question 109 of 450
109. Question
109. Question Tag: celiac disease
Question Category: Health Promotion and Maintenance
The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?
- • A. Ham sandwich on whole-wheat toast
- • B. Spaghetti and meatballs
- • C. Hamburger with ketchup
- • D. Cheese omelet
Correct
Incorrect
Question 110 of 450
110. Question
110. Question Tag: chronic bronchitis
Question Category: Physiological Integrity
The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first?
- • A. Notify the physician
- • B. Recheck the O2 saturation level in 15 minutes
- • C. Apply oxygen by mask
- • D. Assess the pulse
Correct
Incorrect
Question 111 of 450
111. Question
111. Question Tag: amniotomy
Question Category: Physiological Integrity
A gravida 3 para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse be expected to make after the amniotomy?
- • A. Fetal heart tones 160bpm
- • B. A moderate amount of straw-colored fluid
- • C. A small amount of greenish fluid
- • D. A small segment of the umbilical cord
Correct
Incorrect
Question 112 of 450
112. Question
112. Question Tag: vaginal exam
Question Category: Physiological Integrity
The client is admitted to the unit. A vaginal exam reveals that she is 2cm dilated. Which of the following statements would the nurse expect her to make?
- • A. “We have a name picked out for the baby.”
- • B. “I need to push when I have a contraction.”
- • C. “I can’t concentrate if anyone is touching me.”
- • D. “When can I get my epidural?”
Correct
Incorrect
Question 113 of 450
113. Question
113. Question Tag: labor
Question Category: Physiological Integrity
The client is having fetal heart rates of 90–110 bpm during the contractions. The first action the nurse should take is:
- • A. Reposition the monitor
- • B. Turn the client to her left side
- • C. Ask the client to ambulate
- • D. Prepare the client for delivery
Correct
Incorrect
Question 114 of 450
114. Question
1. Question Tag: pitocin, dystocia
Question Category: Physiological Integrity
In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect:
- • A. A painless delivery
- • B. Cervical effacement
- • C. Infrequent contractions
- • D. Progressive cervical dilation
Correct
Incorrect
Question 115 of 450
115. Question
115. Question Tag: footling breech presentation
Question Category: Physiological Integrity
A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?
- • A. Anticipate the need for a Caesarean section
- • B. Apply the fetal heart monitor
- • C. Place the client in Genupectoral position
- • D. Perform an ultrasound exam
Correct
Incorrect
Question 116 of 450
116. Question
116. Question Tag: vaginal exam
Question Category: Physiological Integrity
A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160–170 bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:
- • A. The cervix is closed.
- • B. The membranes are still intact.
- • C. The fetal heart tones are within normal limits.
- • D. The contractions are intense enough for insertion of an internal monitor.
Correct
Incorrect
Question 117 of 450
117. Question
117. Question Tag: labor, primigravida
Question Category: Physiological Integrity
The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primigravida as she completes the early phase of labor?
- • A. Impaired gas exchange related to hyperventilation
- • B. Alteration in placental perfusion related to maternal position
- • C. Impaired physical mobility related to fetal-monitoring equipment
- • D. Potential fluid volume deficit related to decreased fluid intake
Correct
Incorrect
Question 118 of 450
118. Question
118. Question Tag: late decelerations
Question Category: Physiological Integrity
As the client reaches 8 cm dilation, the nurse notes late decelerations on the fetal monitor. The FHR baseline is 165–175 bpm with variability of 0–2bpm. What is the most likely explanation of this pattern?
- • A. The baby is asleep.
- • B. The umbilical cord is compressed.
- • C. There is a vagal response.
- • D. There is uteroplacental insufficiency.
Correct
Incorrect
Question 119 of 450
119. Question
119. Question Tag: variable decelerations
Question Category: Physiological Integrity
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
- • A. Notify her doctor
- • B. Start an IV
- • C. Reposition the client
- • D. Readjust the monitor
Correct
Incorrect
Question 120 of 450
120. Question
1. Question Tag: fetal heart rate
Question Category: Physiological Integrity
Which of the following is a characteristic of a reassuring fetal heart rate pattern?
- • A. A fetal heart rate of 170–180 bpm
- • B. A baseline variability of 25–35 bpm
- • C. Ominous periodic changes
- • D. Acceleration of FHR with fetal movements
Correct
Incorrect
Question 121 of 450
121. Question
121. Question Tag: epidural anesthesia
Question Category: Physiologic Integrity
The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:
- • A. The bladder fills more rapidly because of the medication used for the epidural.
- • B. Her level of consciousness is such that she is in a trancelike state.
- • C. The sensation of the bladder filling is diminished or lost.
- • D. She is embarrassed to ask for the bedpan that frequently.
Correct
Incorrect
Question 122 of 450
122. Question
122. Question Tag: conception
Question Category: Health Promotion and Maintenance
A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when:
- • A. Estrogen levels are low.
- • B. Luteinizing hormone is high.
- • C. The endometrial lining is thin.
- • D. The progesterone level is low.
Correct
Incorrect
Question 123 of 450
123. Question
123. Question Tag: rhythm method
Question Category: Health Promotion and Maintenance
A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the:
- • A. Age of the client
- • B. Frequency of intercourse
- • C. Regularity of the menses
- • D. Range of the client’s temperature
Correct
Incorrect
Question 124 of 450
124. Question
124. Question Tag: diabetes, birth control
Question Category: Health Promotion and Maintenance
A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?
- • A. Intrauterine device
- • B. Oral contraceptives
- • C. Diaphragm
- • D. Contraceptive sponge
Correct
Incorrect
Question 125 of 450
125. Question
125. Question Tag: ectopic pregnancy
Question Category: Physiological Integrity
The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy?
- • A. Painless vaginal bleeding
- • B. Abdominal cramping
- • C. Throbbing pain in the upper quadrant
- • D. Sudden, stabbing pain in the lower quadrant
Correct
Incorrect
Question 126 of 450
126. Question
126. Question Tag: nutrition, pregnancy
Question Category: Health Promotion and Maintenance
The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?
- • A. Hamburger patty, green beans, French fries, and iced tea
- • B. Roast beef sandwich, potato chips, baked beans, and cola
- • C. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea
- • D. Fish sandwich, gelatin with fruit, and coffee
Correct
Incorrect
Question 127 of 450
127. Question
127. Question Tag: hyperemesis gravidarum
Question Category: Physiological Integrity
The client with hyperemesis gravidarum is at risk for developing:
- • A. Respiratory alkalosis without dehydration
- • B. Metabolic acidosis with dehydration
- • C. Respiratory acidosis without dehydration
- • D. Metabolic alkalosis with dehydration
Correct
Incorrect
Question 128 of 450
128. Question
128. Question Tag: pregnancy
Question Category: Health Promotion and Maintenance
A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:
- • A. Elevated human chorionic gonadotropin
- • B. The presence of fetal heart tones
- • C. Uterine enlargement
- • D. Breast enlargement and tenderness
Correct
Incorrect
Question 129 of 450
129. Question
129. Question Tag: diabetes, neonate
Question Category: Physiologic Integrity
The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:
- • A. Hypoglycemic, small for gestational age
- • B. Hyperglycemic, large for gestational age
- • C. Hypoglycemic, large for gestational age
- • D. Hyperglycemic, small for gestational age
Correct
Incorrect
Question 130 of 450
130. Question
130. Question Tag: oral contraceptives
Question Category: Health Promotion and Maintenance
Which of the following instructions should be included in the nurse’s teaching regarding oral contraceptives?
- • A. Weight gain should be reported to the physician.
- • B. An alternate method of birth control is needed when taking antibiotics.
- • C. If the client misses one or more pills, two pills should be taken per day for 1 week.
- • D. Changes in the menstrual flow should be reported to the physician.
Correct
Incorrect
Question 131 of 450
131. Question
1. Question Tag: breastfeeding
Question Category: Health Promotion and Maintenance
The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:
- • A. Diabetes
- • B. Positive HIV
- • C. Hypertension
- • D. Thyroid disease
Correct
Incorrect
Question 132 of 450
132. Question
132. Question Tag: vaginal bleeding
Question Category: Physiological Integrity
A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to:
- • A. Assess the fetal heart tones
- • B. Check for cervical dilation
- • C. Check for firmness of the uterus
- • D. Obtain a detailed history
Correct
Incorrect
Question 133 of 450
133. Question
133. Question Tag: labor
Question Category: Physiological Integrity
A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
- • A. Her contractions are 2 minutes apart.
- • B. She has back pain and a bloody discharge.
- • C. She experiences abdominal pain and frequent urination.
- • D. Her contractions are 5 minutes apart.
Correct
Incorrect
Question 134 of 450
134. Question
134. Question Tag: fetal development, smoking
Question Category: Health Promotion and Maintenance
The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?
- • A. Low birth weight
- • B. Large for gestational age
- • C. Preterm birth, but appropriate size for gestation
- • D. Growth retardation in weight and length
Correct
Incorrect
Question 135 of 450
135. Question
135. Question Tag: RhoGam
Question Category: Physiological Integrity
The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:
- • A. Within 72 hours of delivery
- • B. Within 1 week of delivery
- • C. Within 2 weeks of delivery
- • D. Within 1 month of delivery
Correct
Incorrect
Question 136 of 450
136. Question
136. Question Tag: amniotomy
Question Category: Physiological Integrity
After the physician performs an amniotomy, the nurse’s first action should be to assess the:
- • A. Degree of cervical dilation
- • B. Fetal heart tones
- • C. Client’s vital signs
- • D. Client’s level of discomfort
Correct
Incorrect
Question 137 of 450
137. Question
137. Question Tag: effacement, labor and delivery
Question Category: Physiological Integrity
A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5 cm dilated with 75% effacement. Based on the nurse’s assessment the client is in which phase of labor?
- • A. Active
- • B. Latent
- • C. Transition
- • D. Early
Correct
Incorrect
Question 138 of 450
138. Question
138. Question Tag: narcotic abstinence syndrome
Question Category: health
A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:
- • A. Teaching the mother to provide tactile stimulation
- • B. Wrapping the newborn snugly in a blanket
- • C. Placing the newborn in the infant seat
- • D. Initiating an early infant-stimulation program
Correct
Incorrect
Question 139 of 450
139. Question
139. Question Tag: epidural anesthesia
Question Category:
A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:
- • A. Checking for cervical dilation
- • B. Placing the client in a supine position
- • C. Checking the client’s blood pressure
- • D. Obtaining a fetal heart rate
Correct
Incorrect
Question 140 of 450
140. Question
140. Question Tag: postoperative wound infection
Question Category: Safe and Effective Care Environment
The nurse is aware that the best way to prevent postoperative wound infection in the surgical client is to:
- • A. Administer a prescribed antibiotic
- • B. Wash her hands for 2 minutes before care
- • C. Wear a mask when providing care
- • D. Ask the client to cover her mouth when she coughs
Correct
Incorrect
Question 141 of 450
141. Question
141. Question Tag: fractured hip
Question Category: Physiological Integrity
The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?
- • A. Pain
- • B. Misalignment
- • C. Cool extremity
- • D. Absence of pedal pulses
Correct
Incorrect
Question 142 of 450
142. Question
142. Question Tag: osteoporosis
Question Category: Health Promotion and Maintenance
The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to:
- • A. Lack of exercise
- • B. Hormonal disturbances
- • C. Lack of calcium
- • D. Genetic predisposition
Correct
Incorrect
Question 143 of 450
143. Question
143. Question Tag: Bryant’s traction
Question Category: Physiological Integrity
A 2-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly?
- • A. The infant no longer complains of pain.
- • B. The buttocks are 15° off the bed.
- • C. The legs are suspended in the traction.
- • D. The pins are secured within the pulley.
Correct
Incorrect
Question 144 of 450
144. Question
144. Question Tag: Buck’s traction
Question Category: Physiological Integrity
A client with a fractured hip has been placed in Buck’s traction. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
- • A. Utilizes a Steinman pin
- • B. Requires that both legs be secured
- • C. Utilizes Kirschner wires
- • D. Is used primarily to heal the fractured hips
Correct
Incorrect
Question 145 of 450
145. Question
145. Question Tag: open reduction internal fixation
Question Category: Safe and Effective Care Environment
The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:
- • A. Serum collection (Davol) drain
- • B. Client’s pain
- • C. Nutritional status
- • D. Immobilizer
Correct
Incorrect
Question 146 of 450
146. Question
146. Question Tag: percutaneous gastrostomy tube
Question Category: Health Promotion and Maintenance
Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates an understanding of the nurse’s teaching?
- • A. “I must flush the tube with water after feeding and clamp the tube.”
- • B. “I must check placement four times per day.”
- • C. “I will report to the doctor any signs of indigestion.”
- • D. “If my father is unable to swallow, I will discontinue the feeding and call the clinic.”
Correct
Incorrect
Question 147 of 450
147. Question
147. Question Tag: total knee replacement
Question Category: Physiological Integrity
The nurse is assessing the client with a total knee replacement 2 hours postoperative. Which information requires notification of the doctor?
- • A. Bleeding on the dressing is 3cm in diameter.
- • B. The client has a temperature of 100.6°F (38.1°C).
- • C. The client’s hematocrit is 26%.
- • D. The urinary output has been 60 during the last 2 hours.
Correct
Incorrect
Question 148 of 450
148. Question
148. Question Tag: plumbism
Question Category: Health Promotion and Maintenance
The nurse is caring for the client with a 5-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?
- • A. The client has traveled out of the country in the last 6 months.
- • B. The client’s parents are skilled stained-glass artists.
- • C. The client lives in a house built in one.
- • D. The client has several brothers and sisters.
Correct
Incorrect
Question 149 of 450
149. Question
149. Question Tag: total hip replacement
Question Category: Safe and Effective Care Environment
A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with activities of daily living?
- • A. High-seat commode
- • B. Recliner
- • C. TENS unit
- • D. Abduction pillow
Correct
Incorrect
Question 150 of 450
150. Question
150. Question Tag: abdominal surgery
Question Category: Physiologic Integrity
An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:
- • A. Administer oxygen via nasal cannula
- • B. Have narcan (naloxone) available
- • C. Prepare to administer blood products
- • D. Prepare to do cardio resuscitation
Correct
Incorrect
Question 151 of 450
151. Question
151. Question Tag: room assignments
Question Category: Physiological Integrity, Basic Care and Comfort
Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell’s traction?
- • A. 16-year-old female with scoliosis
- • B. 12-year-old male with a fractured femur
- • C. 10-year-old male with sarcoma
- • D. 6-year-old male with osteomyelitis
Correct
Incorrect
Question 152 of 450
152. Question
152. Question Tag: celebrex (Celecoxib)
Question Category: Health Promotion and Maintenance
A client with osteoarthritis has a prescription for celebrex (Celecoxib). Which instruction should be included in the discharge teaching?
- • A. Take the medication with milk.
- • B. Report chest pain.
- • C. Remain upright after taking for 30 minutes.
- • D. Allow 6 weeks for optimal effects.
Correct
Incorrect
Question 153 of 450
153. Question
153. Question Tag: fracture, cast
Question Category: Safe and Effective Care Environment,, Safety and Infection Control
A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse indicates an understanding of a plaster-of-Paris cast? The nurse:
- • A. Handles the cast with the fingertips
- • B. Petals the cast
- • C. Dries the cast with a hair dryer
- • D. Allows 24 hours before bearing weight
Correct
Incorrect
Question 154 of 450
154. Question
154. Question Tag: fiberglass cast
Question Category: Physiological Integrity, Basic Care and Comfort
The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?
- • A. “It will be alright for your friends to autograph the cast.”
- • B. “Because the cast is made of plaster, autographing can weaken the cast.”
- • C. “If they don’t use chalk to autograph, it is okay.”
- • D. “Autographing or writing on the cast in any form will harm the cast.”
Correct
Incorrect
Question 155 of 450
155. Question
155. Question Tag: Steinmann pin
Question Category: Safe and Effective Care Environment, Management of Care
The nurse is assigned to care for the client with a Steinmann pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?
- • A. Assisting the LPN with opening sterile packages and peroxide.
- • B. Telling the LPN that clean gloves are allowed.
- • C. Telling the LPN that the registered nurse should perform pin care.
- • D. Asking the LPN to clean the weights and pulleys with peroxide.
Correct
Incorrect
Question 156 of 450
156. Question
156. Question Tag: scoliosis, spica cast
Question Category: Physiological Integrity, Reduction of Risk Potential
A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?
- • A. Check the bowel sounds
- • B. Assess the blood pressure
- • C. Offer pain medication
- D. Check for swelling
Correct
Incorrect
Question 157 of 450
157. Question
157. Question Tag: fracture, traction
Question Category: Safe and Effective Care Environment,, Safety and Infection Control
The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?
- • A. Russell’s traction
- • B. Buck’s traction
- • C. Halo traction
- • D. Crutchfield tong traction
Correct
Incorrect
Question 158 of 450
158. Question
158. Question Tag: continuous passive motion device
Question Category: Physiological Integrity, Physiological Adaptation
A client with a total knee replacement has a CPM (continuous passive motion device) applied during the postoperative period. Which statement made by the nurse indicates an understanding of the CPM machine?
- • A. “Use of the CPM will permit the client to ambulate during the therapy.”
- • B. “The CPM machine controls should be positioned distal to the site.”
- • C. “If the client complains of pain during the therapy, I will turn off the machine and call the doctor.”
- • D. “Use of the CPM machine will alleviate the need for physical therapy after the client is discharged.”
Correct
Incorrect
Question 159 of 450
159. Question
159. Question Tag: walker, fracture
Question Category: Safe and Effective Care Environment,, Safety and Infection Control
A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:
- • A. Palms rest lightly on the handles
- • B. Elbows are flexed 0°
- • C. Client walks to the front of the walker
- • D. Client carries the walker
Correct
Incorrect
Question 160 of 450
160. Question
160. Question Tag: prolapsed cord
Question Category: Physiological Integrity, Physiological Adaptation
When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:
- • A. Attempt to replace the cord
- • B. Place the client on her left side
- • C. Elevate the client’s hips
- • D. Cover the cord with a dry, sterile gauze
Correct
Incorrect
Question 161 of 450
161. Question
161. Question Tag: rosuvastatin
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
The client presents to the clinic with a serum cholesterol of 275 mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client?
- • A. Report muscle weakness to the physician.
- • B. Allow six months for the drug to take effect.
- • C. Take the medication with fruit juice.
- • D. Ask the doctor to perform a complete blood count before starting the medication.
Correct
Incorrect
Question 162 of 450
162. Question
162. Question Tag: diazoxide, hypertensive crises
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:
- • A. Utilize an infusion pump
- • B. Check the blood glucose level
- • C. Place the client in Trendelenburg position
- • D. Cover the solution with foil
Correct
Incorrect
Question 163 of 450
163. Question
163. Question Tag: ventral septal defect, Digitalis
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?
- • A. Blood pressure of 126/80
- • B. Blood glucose of 110 mg/dL
- • C. Heart rate of 60 bpm
- • D. Respiratory rate of 30 per minute
Correct
Incorrect
Question 164 of 450
164. Question
164. Question Tag: angina, nitroglycerin
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
The client admitted with angina is given a prescription for nitroglycerin. The client should be instructed to:
- • A. Replenish his supply every 3 months
- • B. Take one every 15 minutes if pain occurs
- • C. Leave the medication in the brown bottle
- • D. Crush the medication and take with water
Correct
Incorrect
Question 165 of 450
165. Question
165. Question Tag: cholesterol
Question Category: Physiological Integrity, Basic Care and Comfort
The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
- • A. Macaroni and cheese
- • B. Shrimp with rice
- • C. Turkey breast
- • D. Spaghetti
Correct
Incorrect
Question 166 of 450
166. Question
166. Question Tag: congestive heart failure
Question Category: Physiological Integrity, Reduction of Risk Potential
The client is admitted with right congestive heart failure. In assessing the client for edema, the nurse should check the:
- • A. Feet
- • B. Neck
- • C. Hands
- • D. Sacrum
Correct
Incorrect
Question 167 of 450
167. Question
167. Question Tag: central venous pressure
Question Category: Physiological Integrity, Reduction of Risk Potential
The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the:
- • A. Phlebostatic axis
- • B. PMI
- • C. Erb’s point
- • D. Tail of Spence
Correct
Incorrect
Question 168 of 450
168. Question
168. Question Tag: hypertension
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
- • A. Question the order
- • B. Administer the medications
- • C. Administer separately
- • D. Contact the pharmacy
Correct
Incorrect
Question 169 of 450
169. Question
169. Question Tag: edema
Question Category: Physiological Integrity, Physiological Adaptation
The best method of evaluating the amount of peripheral edema is:
- • A. Weighing the client daily
- • B. Measuring the extremity
- • C. Measuring the intake and output
- • D. Checking for pitting
Correct
Incorrect
Question 170 of 450
170. Question
170. Question Tag: vaginal cancer, radioactive implant
Question Category: Physiological Integrity, Physiological Integrity, Reduction of Risk Potential
A client with vaginal cancer is being treated with a radioactive vaginal implant. The client’s husband asks the nurse if he can spend the night with his wife. The nurse should explain that:
- A. Overnight stays by family members are against hospital policy.
- B. There is no need for him to stay because staffing is adequate.
- C. His wife will rest much better knowing that he is at home.
- D. Visitation is limited to 30 minutes when the implant is in place.
Correct
Incorrect
Question 171 of 450
171. Question
171. Question Tag: facial stroke
Question Category: Physiological Integrity, Basic Care and Comfort
The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?
- • A. Roast beef sandwich, potato chips, pickle spear, iced tea
- • B. Split pea soup, mashed potatoes, pudding, milk
- • C. Tomato soup, cheese toast, Jello, coffee
- • D. Hamburger, baked beans, fruit cup, iced tea
Correct
Incorrect
Question 172 of 450
172. Question
172. Question Tag: diabetes mellitus, insulin
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
The physician has prescribed Novolog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
- • A. “I will make sure I eat breakfast within 10 minutes of taking my insulin.”
- • B. “I will need to carry candy or some form of sugar with me all the time.”
- • C. “I will eat a snack around three o’clock each afternoon.”
- • D. “I can save my dessert from supper for a bedtime snack.”
Correct
Incorrect
Question 173 of 450
173. Question
173. Question Tag: infant care
Question Category: Health Promotion and Maintenance
The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first 2 weeks of life because:
- • A. New parents need time to learn how to hold the baby.
- • B. The umbilical cord needs time to separate.
- • C. Newborn skin is easily traumatized by washing.
- • D. The chance of chilling the baby outweighs the benefits of bathing.
Correct
Incorrect
Question 174 of 450
174. Question
174. Question Tag: leukemia
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A client with leukemia is receiving Trimetrexate. After reviewing the client’s chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:
- • A. Treat iron-deficiency anemia caused by chemotherapeutic agents
- • B. Create a synergistic effect that shortens treatment time
- • C. Increase the number of circulating neutrophils
- • D. Reverse drug toxicity and prevent tissue damage
Correct
Incorrect
Question 175 of 450
175. Question
175. Question Tag: immunization
Question Category: Health Promotion and Maintenance
A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:
- • A. HibTITER
- • B. Mumps vaccine
- • C. Hepatitis B vaccine
- • D. MMR
Correct
Incorrect
Question 176 of 450
176. Question
1. Question Tag: gastritis
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
The physician has prescribed esomeprazole (Nexium) for a client with erosive gastritis. The nurse should administer the medication:
- • A. 30 minutes before meals
- • B. With each meal
- • C. In a single dose at bedtime
- • D. 30 minutes after meals
Correct
Incorrect
Question 177 of 450
177. Question
177. Question Tag: psychiatric unit
Question Category: Psychosocial Integrity
A client in the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?
- • A. Call security for assistance and prepare to sedate the client.
- • B. Tell the client to calm down and ask him if he would like to play cards.
- • C. Tell the client that if he continues his behavior he will be punished.
- • D. Leave the client alone until he calms down.
Correct
Incorrect
Question 178 of 450
178. Question
178. Question Tag: postpartum
Question Category: Health Promotion and Maintenance
When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:
- • A. Check the client for bladder distention
- • B. Assess the blood pressure for hypotension
- • C. Determine whether an oxytocic drug was given
- • D. Check for the expulsion of small clots
Correct
Incorrect
Question 179 of 450
179. Question
179. Question Tag: hemoptysis
Question Category: Physiological Integrity, Physiological Adaptation
A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client’s symptoms are consistent with a diagnosis of:
- • A. Pneumonia
- • B. Reaction to antiviral medication
- • C. Tuberculosis
- • D. Superinfection due to low CD4 count
Correct
Incorrect
Question 180 of 450
180. Question
180. Question Tag: migraine
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client’s history should be reported to the doctor?
- • A. Diabetes
- • B. Prinzmetal’s angina
- • C. Cancer
- • D. Cluster headaches
Correct
Incorrect
Question 181 of 450
181. Question
181. Question Tag: meningitis
Question Category: Physiological Integrity, Physiological Adaptation
The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig’s sign is charted if the nurse notes:
- • A. Pain on flexion of the hip and knee
- • B. Nuchal rigidity on flexion of the neck
- • C. Pain when the head is turned to the left side
- • D. Dizziness when changing positions
Correct
Incorrect
Question 182 of 450
182. Question
182. Question Tag: Alzheimer’s disease
Question Category: Psychosocial Integrity
The client with Alzheimer’s disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:
- • A. Agnosia
- • B. Apraxia
- • C. Anomia
- • D. Aphasia
Correct
Incorrect
Question 183 of 450
183. Question
183. Question Tag: dementia
Question Category: Psychosocial Integrity
The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:
- • A. Chronic fatigue syndrome
- • B. Normal aging
- • C. Sundowning
- • D. Delusions
Correct
Incorrect
Question 184 of 450
184. Question
184. Question Tag: confusion
Question Category: Psychosocial Integrity
The client with confusion says to the nurse, “I haven’t had anything to eat all day long. When are they going to bring breakfast?” The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?
- • A. “You know you had breakfast 30 minutes ago.”
- • B. “I am so sorry that they didn’t get you breakfast. I’ll report it to the charge nurse.”
- • C. “I’ll get you some juice and toast. Would you like something else?”
- • D. “You will have to wait a while; lunch will be here in a little while.”
Correct
Incorrect
Question 185 of 450
185. Question
185. Question Tag: Alzheimer’s disease
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer’s disease. Which side effect is most often associated with this drug?
- • A. Urinary incontinence
- • B. Headaches & Eye pain
- • C. Confusion & Nightmares
- • D. Constipation & abdominal pain
Correct
Incorrect
Question 186 of 450
186. Question
186. Question Tag: labor
Question Category: Physiological Integrity, Reduction of Risk Potential
A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
- • A. Document the finding
- • B. Report the finding to the doctor
- • C. Prepare the client for a C-section
- • D. Continue primary care as prescribed
Correct
Incorrect
Question 187 of 450
187. Question
187. Question Tag: human papillomavirus
Question Category: Physiological Integrity, Physiological Adaptation
A client with a diagnosis of HPV is at risk for which of the following?
- • A. Hodgkin’s lymphoma
- • B. Cervical cancer
- • C. Multiple myeloma
- • D. Ovarian cancer
Correct
Incorrect
Question 188 of 450
188. Question
188. Question Tag: lesion, vulva
Question Category: Physiological integrity, Physiological Adaptation
During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
- • A. Syphilis
- • B. Herpes
- • C. Gonorrhea
- • D. Condylomata
Correct
Incorrect
Question 189 of 450
189. Question
189. Question Tag: treponema pallidum
Question Category: Physiological Integrity, Physiological Adaptation
A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:
- • A. Venereal Disease Research Lab (VDRL)
- • B. Rapid plasma reagin (RPR)
- • C. Fluorescent treponemal antibody (FTA)
- • D. Thayer-Martin culture (TMC)
Correct
Incorrect
Question 190 of 450
190. Question
190. Question Tag: HELLP syndrome
Question Category: Physiological Integrity, Reduction of Risk Potential
A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
- • A. Elevated blood glucose
- • B. Elevated platelet count
- • C. Elevated creatinine clearance
- • D. Elevated hepatic enzymes
Correct
Incorrect
Question 191 of 450
191. Question
191. Question Tag: preeclampsia
Question Category: Physiological Integrity, Reduction of Risk Potential
The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
- • A. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
- • B. The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow.
- • C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
- • D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.
Correct
Incorrect
Question 192 of 450
192. Question
192. Question Tag: diabetes, primigravida
Question Category: Safe and Effective Care Environment,, Safety and Infection Control
A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor’s order should the nurse question?
- • A. Magnesium sulfate 4gm (25%) IV
- • B. Brethine 10 mcg IV
- • C. Stadol 1 mg IV push every 4 hours as needed prn for pain
- • D. Ancef 2gm IVPB every 6 hours
Correct
Incorrect
Question 193 of 450
193. Question
193. Question Tag: amniocentesis
Question Category: Physiological Integrity, Reduction of Risk Potential
A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidylglycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse’s assessment of this data is:
- • A. The infant is at low risk for congenital anomalies.
- • B. The infant is at high risk for intrauterine growth retardation.
- • C. The infant is at high risk for respiratory distress syndrome.
- • D. The infant is at high risk for birth trauma.
Correct
Incorrect
Question 194 of 450
194. Question
194. Question Tag: diabetes
Question Category: Health Promotion and Maintenance
Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
- • A. Crying
- • B. Wakefulness
- • C. Jitteriness
- • D. Yawning
Correct
Incorrect
Question 195 of 450
195. Question
195. Question Tag: magnesium sulfate
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
- • A. Decreased urinary output
- • B. Hypersomnolence
- • C. Absence of knee jerk reflex
- • D. Decreased respiratory rate
Correct
Incorrect
Question 196 of 450
196. Question
196. Question Tag: epidural anesthesia
Question Category: Physiological Integrity, Reduction of Risk Potential
The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:
- • A. Place her in Trendelenburg position
- • B. Decrease the rate of IV infusion
- • C. Administer oxygen per nasal cannula
- • D. Increase the rate of the IV infusion
Correct
Incorrect
Question 197 of 450
197. Question
197. Question Tag: cancer of the pancreas
Question Category: Physiologic Integrity, Physiological Adaptation
A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?
- • A. Alteration in nutrition
- • B. Alteration in bowel elimination
- • C. Alteration in skin integrity
- • D. Ineffective individual coping
Correct
Incorrect
Question 198 of 450
198. Question
198. Question Tag: ascites
Question Category: Physiological Integrity, Reduction of Risk Potential
The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?
- • A. Inspection of the abdomen for enlargement
- • B. Bimanual palpation for hepatomegaly
- • C. Daily measurement of abdominal girth
- • D. Assessment for a fluid wave
Correct
Incorrect
Question 199 of 450
199. Question
199. Question Tag: vehicle accident
Question Category: Physiological Integrity, Physiological Adaptation
The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis?
- • A. Alteration in cerebral tissue perfusion
- • B. Fluid volume deficit
- • C. Ineffective airway clearance
- • D. Alteration in sensory perception
Correct
Incorrect
Question 200 of 450
200. Question
200. Question Tag: osteogenesis imperfecta
Question Category: Safe and Effective Care Environment,, Safety and Infection Control
The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
- • A. Likes to play football
- • B. Drinks several carbonated drinks per day
- • C. Has two sisters with sickle cell tract
- • D. Is taking acetaminophen to control pain
Correct
Incorrect
Question 201 of 450
201. Question
201. Question Tag: white blood cell count
Question Category: Physiological Integrity, Reduction of Risk Potential
The nurse working the organ transplant unit is caring for a client with a decreased white blood cell count. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?
- • A. Allow the client to keep the fruit
- • B. Place the fruit next to the bed for easy access by the client
- • C. Offer to wash the fruit for the client
- • D. Tell the family members to take the fruit home
Correct
Incorrect
Question 202 of 450
202. Question
202. Question Tag: laryngectomy
Question Category: Physiological Integrity, Physiological Adaptation
The nurse is caring for the client following a laryngectomy when suddenly the client becomes unresponsive and pale, with a BP of 90/40 systolic. The initial nurse’s action should be to:
- • A. Place the client in Trendelenburg position
- • B. Increase the infusion of Dextrose in normal saline
- • C. Administer atropine intravenously
- • D. Move the emergency cart to the bedside
Correct
Incorrect
Question 203 of 450
203. Question
203. Question Tag: chest tube
Question Category: Physiological Integrity, Reduction of Risk Potential
The client admitted 2 days earlier that a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?
- • A. Order a chest x-ray
- • B. Reinsert the tube
- • C. Cover the insertion site with a Vaseline gauze
- • D. Call the doctor
Correct
Incorrect
Question 204 of 450
204. Question
204. Question Tag: sodium warfarin
Question Category: Physiological Integrity, Reduction of Risk Potential
A client being treated with sodium warfarin has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?
- • A. Assess for signs of abnormal bleeding
- • B. Anticipate an increase in the Coumadin dosage
- • C. Instruct the client regarding the drug therapy
- • D. Increase the frequency of neurological assessments
Correct
Incorrect
Question 205 of 450
205. Question
205. Question Tag: calcium
Question Category: Health Promotion and Maintenance
Which selection would provide the most calcium for the client who is 4 months pregnant?
- • A. A granola bar
- • B. A bran muffin
- • C. A cup of yogurt
- • D. A glass of fruit juice
Correct
Incorrect
Question 206 of 450
206. Question
206. Question Tag: preeclampsia, magnesium sulfate
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of the possible side effects of magnesium sulfate?
- • A. The nurse places a sign over the bed not to check blood pressure in the right arm.
- • B. The nurse places a padded tongue blade at the bedside.
- • C. The nurse inserts a Foley catheter.
- • D. The nurse darkens the room.
Correct
Incorrect
Question 207 of 450
207. Question
207. Question Tag: blood transfusion
Question Category: Safe and Effective Care Environment, Management of Care
A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The physician has written an order to transfuse 2 units of whole blood. When discussing the treatment, the child’s mother tells the nurse that she does not believe in having blood transfusions and that she will not allow her child to have the treatment. What nursing action is most appropriate?
- • A. Ask the mother to leave while the blood transfusion is in progress
- • B. Encourage the mother to reconsider
- • C. Explain the consequences without treatment
- • D. Notify the physician of the mother’s refusal
Correct
Incorrect
Question 208 of 450
208. Question
208. Question Tag: burns
Question Category: Physiological Integrity, Physiological Adaptation
A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?
- • A. Hypovolemia
- • B. Laryngeal edema
- • C. Hypernatremia
- • D. Hyperkalemia
Correct
Incorrect
Question 209 of 450
209. Question
209. Question Tag: anorexia nervosa
Question Category: Health Promotion and Maintenance, Physiological Adaptation
The nurse is evaluating nutritional outcomes for a patient with anorexia nervosa. Which data best indicates that the plan of care is effective?
- • A. The client selects a balanced diet from the menu.
- • B. The client’s hemoglobin and hematocrit improve.
- • C. The client’s tissue turgor improves.
- • D. The client gains weight.
Correct
Incorrect
Question 210 of 450
210. Question
210. Question Tag: fracture, cast application
Question Category: Physiological Integrity, Physiological Adaptation
The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?
- • A. Pain beneath the cast
- • B. Warm toes
- • C. Pedal pulses weak and rapid
- • D. Paresthesia of the toes
Correct
Incorrect
Question 211 of 450
211. Question
211. Question Tag: barbiturates
Question Category: Psychosocial Integrity
A client with a history of abusing barbiturates abruptly stops taking the medication. The nurse should give priority to assessing the client for:
- • A. Depression and suicidal ideation
- • B. Tachycardia and diarrhea
- • C. Muscle cramping and abdominal pain
- • D. Tachycardia and euphoric mood
Correct
Incorrect
Question 212 of 450
212. Question
212. Question Tag: labor, FHT
Question Category: Physiological Integrity, Physiological Adaptation
During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?
- • A. Right breech presentation
- • B. Right occiput anterior presentation
- • C. Left sacral anterior presentation
- • D. Left occiput transverse presentation
Correct
Incorrect
Question 213 of 450
213. Question
213. Question Tag: asthma
Question Category: Physiological Integrity, Physiological Adaptation
The primary physiological alteration in the development of asthma is:
- • A. Bronchial inflammation and dyspnea
- • B. Hypersecretion of abnormally viscous mucus
- • C. Infectious processes causing mucosal edema
- • D. Spasm of bronchial smooth muscle
Correct
Incorrect
Question 214 of 450
214. Question
214. Question Tag: mania
Question Category: Physiological Integrity, Basic Care and Comfort
A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:
- • A. Serve high-calorie foods she can carry with her
- • B. Encourage her appetite by sending out for her favorite foods
- • C. Serve her small, attractively arranged portions
- • D. Allow her in the unit kitchen for extra food whenever she pleases
Correct
Incorrect
Question 215 of 450
215. Question
215. Question Tag: Bryant’s traction
Question Category: Physiological Integrity, Basic Care and CoMFORT
To maintain Bryant’s traction, the nurse must make certain that the child’s:
- • A. Hips are resting on the bed, with the legs suspended at a right angle to the bed
- • B. Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed
- • C. Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed
- • D. Hips and legs are flat on the bed, with the traction positioned at the foot of the bed
Correct
Incorrect
Question 216 of 450
216. Question
216. Question Tag: herpes zoster
Question Category: Physiological Integrity, Reduction of Risk Potential
Which action by the nurse indicates understanding of herpes zoster?
- • A. The nurse covers the lesions with a sterile dressing.
- • B. The nurse wears gloves when providing care.
- • C. The nurse administers a prescribed antibiotic.
- • D. The nurse administers oxygen.
Correct
Incorrect
Question 217 of 450
217. Question
217. Question Tag: Vancomycin
Question Category: Physiological Integrity, Reduction of Risk Potential
The client has an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that the nurse should contact the lab for them to collect the blood:
- • A. 15 minutes after the infusion
- • B. 30 minutes before the infusion
- • C. 1 hour after the infusion
- • D. 2 hours after the infusion
Correct
Incorrect
Question 218 of 450
218. Question
218. Question Tag: diaphragm
Question Category: Health Promotion and Maintenance
The client using a diaphragm should be instructed to:
- • A. Refrain from keeping the diaphragm in longer than 4 hours
- • B. Keep the diaphragm in a cool location
- • C. Have the diaphragm resized if she gains 5 pounds
- • D. Have the diaphragm resized if she has any surgery
Correct
Incorrect
Question 219 of 450
219. Question
219. Question Tag: postpartum, breastfeeding
Question Category: Health Promotion and Maintenance
The nurse is providing postpartum teaching for a mother planning to breastfeed her infant. Which of the client’s statements indicates the need for additional teaching?
- • A. “I’m wearing a support bra.”
- • B. “I’m expressing milk from my breast.”
- • C. “I’m drinking four glasses of fluid during a 24-hour period.”
- • D. “While I’m in the shower, I’ll allow the water to run over my breasts.”
Correct
Incorrect
Question 220 of 450
220. Question
220. Question Tag: cranial nerve VII
Question Category: Physiological Integrity, Physiological Adaptation
Damage to the VII cranial nerve results in:
- • A. Facial pain
- • B. Absence of ability to smell
- • C. Absence of eye movement
- • D. Tinnitus
Correct
Incorrect
Question 221 of 450
221. Question
221. Question Tag: urinary tract infection
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A client is receiving Pyridium (phenazopyridine hydrochloride) for a urinary tract infection. The client should be taught that the medication may:
- • A. Cause diarrhea
- • B. Change the color of her urine
- • C. Cause mental confusion
- • D. Cause changes in taste
Correct
Incorrect
Question 222 of 450
222. Question
222. Question Tag: Accutane
Question Category: Physiological Integrity, Reduction of Risk Potential
Which of the following tests should be performed before beginning a prescription of Accutane?
- • A. Check the calcium level
- • B. Perform a pregnancy test
- • C. Monitor apical pulse
- • D. Obtain a creatinine level
Correct
Incorrect
Question 223 of 450
223. Question
223. Question Tag: AIDS, acyclovir
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?
- • A. Limit the client’s activity
- • B. Encourage a high-carbohydrate diet
- • C. Utilize an incentive spirometer to improve respiratory function
- • D. Encourage fluids
Correct
Incorrect
Question 224 of 450
224. Question
- acyclovir to such higher-risk patients.
1. Question Tag: MRI
Question Category : Physiological Integrity, Reduction of Risk Potential
A client is admitted for an MRI. The nurse should question the client regarding:
- • A. Pregnancy
- • B. A titanium hip replacement
- • C. Allergies to antibiotics
- • D. Inability to move his feet
Correct
Incorrect
Question 225 of 450
225. Question
225. Question Tag: Amphotericin B
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug?
- • A. Changes in vision
- • B. Nausea
- • C. Urinary frequency
- • D. Changes in skin color
Correct
Incorrect
Question 226 of 450
226. Question
226. Question Tag: prioritization
Question Category: Safe and Effective Care Environment, Management of Care
The nurse should visit which of the following clients first?
- • A. The client with diabetes with a blood glucose of 95 mg/dL
- • B. The client with hypertension being maintained on Lisinopril
- • C. The client with chest pain and a history of angina
- • D. The client with Raynaud’s disease
Correct
Incorrect
Question 227 of 450
227. Question
227. Question Tag: cystic fibrosis
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication:
- • A. Once per day in the morning
- • B. Three times per day with meals
- • C. Once per day at bedtime
- • D. Four times per day
Correct
Incorrect
Question 228 of 450
228. Question
228. Question Tag: cataract
Question Category: Physiological Integrity, Physiological Adaptation
Cataracts result in opacity of the crystalline lens. Which of the following best explains the functions of the lens?
- • A. The lens controls stimulation of the retina.
- • B. The lens orchestrates eye movement.
- • C. The lens focuses light rays on the retina.
- • D. The lens magnifies small objects.
Correct
Incorrect
Question 229 of 450
229. Question
229. Question Tag: glaucoma, miotic eye drops
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A client who has glaucoma is to have miotic eye drops instilled in both eyes. The nurse knows that the purpose of the medication is to:
- • A. Anesthetize the cornea
- • B. Dilate the pupils
- • C. Constrict the pupils
- • D. Paralyze the muscles of accommodation
Correct
Incorrect
Question 230 of 450
230. Question
230. Question Tag: corneal ulcer
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A client with a severe corneal ulcer has an order for Gentamicin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops?
- • A. Allow 5 minutes between the two medications.
- • B. The medications may be used together.
- • C. The medications should be separated by a cycloplegic drug.
- • D. The medications should not be used in the same client.
Correct
Incorrect
Question 231 of 450
231. Question
231. Question Tag: color blindness
Question Category: Physiological Integrity, Physiological Adaptation
The client with color blindness will most likely have problems distinguishing which of the following colors?
- • A. Orange
- • B. Violet
- • C. Red
- • D. White
Correct
Incorrect
Question 232 of 450
232. Question
232. Question Tag: pacemaker
Question Category: Health Promotion and Maintenance
The client with a pacemaker should be taught to:
- • A. Report ankle edema
- • B. Check his blood pressure daily
- • C. Refrain from using a microwave oven
- • D. Monitor his pulse rate
Correct
Incorrect
Question 233 of 450
233. Question
233. Question Tag: enuresis
Question Category: Health Promotion and Maintenance

The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after:
- • A. 1900
- • B. 1200
- • C. 1000
- • D. 0700
Correct
Incorrect
Question 234 of 450
234. Question
234. Question Tag: urinary tract infection
Question Category: Health Promotion and Maintenance
Which of the following diet instructions should be given to the client with recurring urinary tract infections?
- • A. Increase intake of meat.
- • B. Avoid citrus fruits.
- • C. Perform peri care with hydrogen peroxide.
- • D. Drink a glass of cranberry juice every day.
Correct
Incorrect
Question 235 of 450
235. Question
235. Question Tag: insulin, diabetes mellitus
Question Category: Health Promotion and Maintenance
The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
- • A. “I will make sure I eat breakfast within 2 hours of taking my insulin.”
- • B. “I will need to carry candy or some form of sugar with me all the time.”
- • C. “I will eat a snack around three o’clock each afternoon.”
- • D. “I can save my dessert from supper for a bedtime snack.”
Correct
Incorrect
Question 236 of 450
236. Question
236. Question Tag: chest tube
Question Category: Physiological Integrity, Physiological Adaptation
The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?
- • A. The tube will allow for equalization of the lung expansion.
- • B. Chest tubes serve as a method of draining blood and serous fluid and assist in re-inflating the lungs.
- • C. Chest tubes relieve pain associated with a collapsed lung.
- • D. Chest tubes assist with cardiac function by stabilizing lung expansion.
Correct
Incorrect
Question 237 of 450
237. Question
237. Question Tag: breastfeeding
Question Category: Health Promotion and Maintenance
A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the:
- • A. Mother’s educational level
- • B. Infant’s birth weight
- • C. Size of the mother’s breast
- • D. Mother’s desire to breastfeed
Correct
Incorrect
Question 238 of 450
238. Question
238. Question Tag: labor
Question Category: Health Promotion and Maintenance
The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?
- • A. The presence of scant bloody discharge
- • B. Frequent urination
- • C. The presence of green-tinged amniotic fluid
- • D. Moderate uterine contractions
Correct
Incorrect
Question 239 of 450
239. Question
239. Question Tag: contractions
Question Category: Physiological Adaptation
The nurse is measuring the duration of the client’s contractions. Which statement is true regarding the measurement of the duration of contractions?
- • A. Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction.
- • B. Duration is measured by timing from the end of one contraction to the beginning of the next contraction.
- • C. Duration is measured by timing from the beginning of one contraction to the end of the same contraction.
- • D. Duration is measured by timing from the peak of one contraction to the end of the same contraction.
Correct
Incorrect
Question 240 of 450
240. Question
240. Question Tag: Pitocin, labor
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:
- • A. Maternal hypoglycemia
- • B. Fetal bradycardia
- • C. Maternal hyperreflexia
- • D. Fetal movement
Correct
Incorrect
Question 241 of 450
241. Question
241. Question Tag: pregnancy, insulin
Question Category: Physiological Integrity, Physiological Adaptation
A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?
- • A. Insulin requirements moderate as the pregnancy progresses.
- • B. A decreased need for insulin occurs during the second trimester.
- • C. Elevations in human chorionic gonadotropin decrease the need for insulin.
- • D. Fetal development depends on adequate insulin regulation.
Correct
Incorrect
Question 242 of 450
242. Question
242. Question Tag: prenatal
Question Category: Health Promotion and Maintenance
A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:
- • A. Providing a calm environment
- • B. Obtaining a diet history
- • C. Administering an analgesic
- • D. Assessing fetal heart tones
Correct
Incorrect
Question 243 of 450
243. Question
243. Question Tag: primigravida
Question Category: Physiological Integrity, Physiological Adaptation
A primigravida, age 42, is 6 weeks pregnant. Based on the client’s age, her infant is at risk for:
- • A. Down syndrome
- • B. Respiratory distress syndrome
- • C. Turner’s syndrome
- • D. Pathological jaundice
Correct
Incorrect
Question 244 of 450
244. Question
244. Question Tag: abortion
Question Category: Physiological Integrity, Physiological Adaptation
A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:
- • A. Magnesium sulfate
- • B. Calcium gluconate
- • C. Dinoprostone (Prostin E.)
- • D. Bromocriptine (Parlodel)
Correct
Incorrect
Question 245 of 450
245. Question
245. Question Tag: preeclampsia
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100mL. The nurse should:
- • A. Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure
- • B. Stop the infusion of magnesium sulfate and contact the physician
- • C. Slow the infusion rate and turn the client on her left side
- • D. Administer calcium gluconate IV push and continue to monitor the blood pressure
Correct
Incorrect
Question 246 of 450
246. Question
246. Question Tag: autosomal recessive disorders
Question Category: Physiological Integrity, Physiological Adaptation
Which statement made by the nurse describes the inheritance pattern of autosomal recessive disorders?
- • A. An affected newborn has unaffected parents.
- • B. An affected newborn has one affected parent.
- • C. Affected parents have a one in four chance of passing on the defective gene.
- • D. Affected parents have unaffected children who are carriers.
Correct
Incorrect
Question 247 of 450
247. Question
247. Question Tag: alpha fetoprotein
Question Category: Physiological Integrity, Physiological Adaptation
A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:
- • A. Because it is a state law
- • B. To detect cardiovascular defects
- • C. Because of her age
- • D. To detect neurological defects
Correct
Incorrect
Question 248 of 450
248. Question
248. Question Tag: hypothyroidism
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse’s response is based on the knowledge that:
- • A. There is no need to take thyroid medication because the fetus’s thyroid produces a thyroid-stimulating hormone.
- • B. Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy.
- • C. It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism.
- • D. Fetal growth is arrested if thyroid medication is continued during pregnancy.
Correct
Incorrect
Question 249 of 450
249. Question
249. Question Tag: neonatal assessment
Question Category: Health Promotion and Maintenance
The nurse is responsible for performing a neonatal assessment on a full-term infant. At 1 minute, the nurse would expect to find:
- • A. An apical pulse of 100
- • B. An absence of tonus
- • C. Cyanosis of the feet and hands
- • D. Jaundice of the skin and sclera
Correct
Incorrect
Question 250 of 450
250. Question
250. Question Tag: sickle cell anemia
Question Category: Health Promotion and Maintenance
A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client’s need for:
- • A. Supplemental oxygen
- • B. Fluid restriction
- • C. Blood transfusion
- • D. Delivery by Caesarean section
Correct
Incorrect
Question 251 of 450
251. Question
251. Question Tag: diabetes
Question Category: Physiologic Integrity, Reduction of Risk Potential
A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes:
- • A. Increasing fluid intake
- • B. Limiting ambulation
- • C. Administering an enema
- • D. Withholding food for 8 hours
Correct
Incorrect
Question 252 of 450
252. Question
252. Question Tag: infant
Question Category: Health Promotion and Maintenance
An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year?
- • A. 14 pounds
- • B. 16 pounds
- • C. 18 pounds
- • D. 24 pounds
Correct
Incorrect
Question 253 of 450
253. Question
253. Question Tag: nonstress test
Question Category: Physiological Integrity, Reduction of Risk Potential
A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test:
- • A. Determines the lung maturity of the fetus
- • B. Measures the activity of the fetus
- • C. Shows the effect of contractions on the fetal heart rate
- • D. Measures the neurological well-being of the fetus
Correct
Incorrect
Question 254 of 450
254. Question
254. Question Tag: hypospadias
Question Category: Physiological Integrity, Physiological Adaptation
A full-term male has hypospadias. Which statement describes hypospadias?
- • A. The urethral opening is absent.
- • B. The urethra opens on the dorsal side of the penis.
- • C. The penis is shorter than usual.
- • D. The urethral meatus opens on the underside of the penis.
Correct
Incorrect
Question 255 of 450
255. Question
255. Question Tag: labor
Question Category: Health Promotion and Maintenance
A gravida 3 para 2 is admitted to the labor unit. 45 minutes ago, the patient was 7 cm dilated and 80% effaced. A current vaginal exam reveals that the client’s cervix is 8 cm dilated, with complete effacement. The priority nursing diagnosis at this time is:
- • A. Alteration in coping related to transitional pain
- • B. Potential for injury related to precipitate delivery
- • C. Alteration in elimination related to anesthesia or perineal tears
- • D. Potential for fluid volume deficit related to NPO status and fluid loss
Correct
Incorrect
Question 256 of 450
256. Question
256. Question Tag: varicella
Question Category: Physiological Integrity, Physiological Adaptation
The client with varicella will most likely have an order for which category of medication?
- • A. Antibiotics
- • B. Antipyretics
- • C. Antivirals
- • D. Anticoagulants
Correct
Incorrect
Question 257 of 450
257. Question
257. Question Tag: chest pain
Question Category: Safe and Effective Care Environment, Safety and Infection Control
A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question?
- • A. Nitroglycerin
- • B. Ampicillin
- • C. Propranolol
- • D. Verapamil
Correct
Incorrect
Question 258 of 450
258. Question
258. Question Tag: rheumatoid arthritis
Question Category: Health Promotion and Maintenance
Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?
- • A. Avoid exercise because it fatigues the joints.
- • B. Take prescribed anti-inflammatory medications with meals.
- • C. Alternate hot and cold packs to affected joints.
- • D. Avoid weight-bearing activity.
Correct
Incorrect
Question 259 of 450
259. Question
259. Question Tag: pancreatitis
Question Category: Safe and Effective Care Environment, Safety and Infection Control
A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should be questioned by the nurse?
- • A. Meperidine 100 mg IM q 4 hours PRN pain
- • B. Mylanta 30 ccs q 4 hours via NG
- • C. Cimetidine 300 mg PO q.i.d.
- • D. Morphine 8 mg IM q 4 hours PRN pain
Correct
Incorrect
Question 260 of 450
260. Question
260. Question Tag: chemical dependence
Question Category: Psychosocial Integrity
The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:
- • A. Hallucinogenic drugs create both stimulant and depressant effects.
- • B. Hallucinogenic drugs induce a state of altered perception.
- • C. Hallucinogenic drugs produce severe respiratory depression.
- • D. Hallucinogenic drugs induce rapid physical dependence.
Correct
Incorrect
Question 261 of 450
261. Question
1. Question Tag: chest pain
Question Category: Physiological Integrity, Physiological Adaptation
A patient arrives at the emergency department complaining of midsternal chest pain. Which of the following nursing actions should take priority?
- • A. A complete history with emphasis on preceding events.
- • B. An electrocardiogram.
- • C. Careful assessment of vital signs.
- • D. Chest exam with auscultation.
Correct
Incorrect
Question 262 of 450
262. Question
262. Question Tag: pneumonia
Question Category: Health Promotion and Maintenance
A patient has been hospitalized with pneumonia and is about to be discharged. A nurse provides discharge instructions to a patient and his family. Which misunderstanding by the family indicates the need for more detailed information?
- • A. The patient may resume normal home activities as tolerated but should avoid physical exertion and get adequate rest.
- • B. The patient should resume a normal diet with emphasis on nutritious, healthy foods.
- • C. The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved.
- • D. The patient should continue use of the incentive spirometer to keep airways open and free of secretions.
Correct
Incorrect
Question 263 of 450
263. Question
263. Question Tag: lung cancer
Question Category: Safe and Effective Care Environment, Management of Care
A nurse is caring for an elderly Vietnamese patient in the terminal stages of lung cancer. Many family members are in the room around the clock performing unusual rituals and bringing ethnic foods. Which of the following actions should the nurse take?
- • A. Restrict visiting hours and ask the family to limit visitors to two at a time.
- • B. Notify visitors with a sign on the door that the patient is limited to clear fluids only with no solid food allowed.
- • C. If possible, keep the other bed in the room unassigned to provide privacy and comfort to the family.
- • D. Contact the physician to report the unusual rituals and activities.
Correct
Incorrect
Question 264 of 450
264. Question
264. Question Tag: delegation
Question Category: Safe and Effective Care Environment, Management of Care
The charge nurse on the cardiac unit is planning assignments for the day. Which of the following is the most appropriate assignment for the float nurse that has been reassigned from labor and delivery?
- • A. A one-week postoperative coronary bypass patient, who is being evaluated for placement of a pacemaker prior to discharge.
- • B. A suspected myocardial infarction patient on telemetry, just admitted from the Emergency Department and scheduled for an angiogram.
- • C. A patient with unstable angina being closely monitored for pain and medication titration.
- • D. A postoperative valve replacement patient who was recently admitted to the unit because all surgical beds were filled.
Correct
Incorrect
Question 265 of 450
265. Question
265. Question Tag: type 1 diabetes mellitus
Question Category: Health Promotion and Maintenance
A newly diagnosed 8-year-old child with type I diabetes mellitus and his mother are receiving diabetes education prior to discharge. The physician has prescribed Glucagon for emergency use. The mother asks the purpose of this medication. Which of the following statements by the nurse is correct?
- • A. Glucagon enhances the effect of insulin in case the blood sugar remains high one hour after injection.
- • B. Glucagon treats hypoglycemia resulting from insulin overdose.
- • C. Glucagon treats lipoatrophy from insulin injections.
- • D. Glucagon prolongs the effect of insulin, allowing fewer injections.
Correct
Incorrect
Question 266 of 450
266. Question
266. Question Tag: congestive heart failure
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
An infant with congestive heart failure is receiving diuretic therapy at home. Which of the following symptoms would indicate that the dosage may need to be increased?
- • A. Sudden weight gain
- • B. Decreased blood pressure
- • C. Slow, shallow breathing
- • D. Bradycardia
Correct
Incorrect
Question 267 of 450
267. Question
267. Question Tag: dilantin, seizure disorder
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A patient taking dilantin (Phenytoin) for a seizure disorder is experiencing breakthrough seizures. A blood sample is taken to determine the serum drug level. Which of the following would indicate a sub-therapeutic level?
- • A. 15 mcg/mL
- • B. 4 mcg/mL
- • C. 10 mcg/dL
- • D. 5 mcg/dL
Correct
Incorrect
Question 268 of 450
268. Question
268. Question Tag: acetaminophen toxicity
Question Category: Physiological Integrity, Physiological Adaptation
A patient arrives at the emergency department complaining of back pain. He reports taking at least 3 acetaminophen tablets every three hours for the past week without relief. Which of the following symptoms suggests acetaminophen toxicity?
- • A. Tinnitus
- • B. Diarrhea
- • C. Hypertension
- • D. Hepatic damage
Correct
Incorrect
Question 269 of 450
269. Question
269. Question Tag: morphine sulfate
Question Category: Pharmacological and Parenteral Therapies
A nurse is caring for a cancer patient receiving subcutaneous morphine sulfate for pain. Which of the following nursing actions is most important in the care of this patient?
- • A. Monitor urine output
- • B. Monitor respiratory rate
- • C. Monitor heart rate
- • D. Monitor temperature
Correct
Incorrect
Question 270 of 450
270. Question
270. Question Tag: leg pain
Question Category: Physiological Integrity, Physiological Adaptation
A patient arrives at the emergency department with severe lower leg pain after a fall in a touch football game. Following routine triage, which of the following is the appropriate next step in assessment and treatment?
- • A. Apply heat to the painful area.
- • B. Apply an elastic bandage to the leg.
- • C. X-ray the leg.
- • D. Give pain medication.
Correct
Incorrect
Question 271 of 450
271. Question
271. Question Tag: cardioverter-defibrillator
Question Category: Physiological Integrity, Physiological Adaptation
A nurse caring for several patients in the cardiac unit is told that one is scheduled for implantation of an automatic internal cardioverter-defibrillator. Which of the following patients is most likely to have this procedure?
- • A. A patient admitted for myocardial infarction without cardiac muscle damage.
- • B. A postoperative coronary bypass patient, recovering on schedule.
- • C. A patient with a history of ventricular tachycardia and syncopal episodes.
- • D. A patient with a history of atrial tachycardia and fatigue.
Correct
Incorrect
Question 272 of 450
272. Question
Which patient would be the most appropriate candidate for an ICD?
- A: A patient with myocardial infarction that resolved with no permanent cardiac damage
- B: A patient recovering well from coronary bypass
- C. A patient with a history of ventricular tachycardia and syncopal episodes.
- D: a patient with Atrial tachycardia
Correct
Incorrect
Question 273 of 450
273. Question
273. Question Tag: pulmonary embolism
Question Category: Physiological Integrity, Physiological Adaptation
A nurse calls a physician with the concern that a patient has developed a pulmonary embolism. Which of the following symptoms has the nurse most likely observed?
- • A. The patient is somnolent with decreased response to the family.
- • B. The patient suddenly complains of chest pain and shortness of breath.
- • C. The patient has developed a wet cough and the nurse hears crackles on auscultation of the lungs.
- • D. The patient has a fever, chills, and loss of appetite.
Correct
Incorrect
Question 274 of 450
274. Question
274. Question Tag: abdominal aortic aneurysm
Question Category: Physiological Integrity, Reduction of Risk Potential
A patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect?
- • A. The patient will be admitted to the medicine unit for observation and medication.
- • B. The patient will be admitted to the day surgery unit for sclerotherapy.
- • C. The patient will be admitted to the surgical unit and resection will be scheduled.
- • D. The patient will be discharged home to follow-up with his cardiologist in 24 hours.
Correct
Incorrect
Question 275 of 450
275. Question
275. Question Tag: chemotherapy
Question Category: Physiological Integrity, Reduction of Risk Potential
A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included on the nursing care plan?
- • A. Monitor for fever every 4 hours.
- • B. Require visitors to wear respiratory masks and protective clothing.
- • C. Consider transfusion of packed red blood cells.
- • D. Check for signs of bleeding, including examination of urine and stool for blood.
Correct
Incorrect
Question 276 of 450
276. Question
276. Question Tag: leukemia
Question Category: Health Promotion and Maintenance
A patient is undergoing the induction stage of treatment for leukemia. The nurse teaches family members about infectious precautions. Which of the following statements by family members indicates that the family needs more education?
- • A. We will bring in books and magazines for entertainment.
- • B. We will bring in personal care items for comfort.
- • C. We will bring in fresh flowers to brighten the room.
- • D. We will bring in family pictures and get well cards.
Correct
Incorrect
Question 277 of 450
277. Question
277. Question Tag: acute lymphoblastic leukemia
Question Category: Physiological Integrity, Physiological Adaptation
A nurse is caring for a patient with acute lymphoblastic leukemia (ALL). Which of the following is the most likely age range of the patient?
- • A. 3-10 years
- • B. 25-35 years
- • C. 45-55 years
- • D. over 60 years
Correct
Incorrect
Question 278 of 450
278. Question
278. Question Tag: Hodgkin’s disease
Question Category: Physiological Integrity, Physiological Adaptation
A patient is admitted to the oncology unit for diagnosis of suspected Hodgkin’s disease. Which of the following symptoms is typical of Hodgkin’s disease?
- • A. Painful cervical lymph nodes
- • B. Night sweats and fatigue
- • C. Nausea and vomiting
- • D. Weight gain
Correct
Incorrect
Question 279 of 450
279. Question
279. Question Tag: Hodgkin’s disease
Question Category: Physiological Integrity, Physiological Adaptation
The Hodgkin’s disease patient described in the question above undergoes a lymph node biopsy for definitive diagnosis. If the diagnosis of Hodgkin’s disease were correct, which of the following cells would the pathologist expect to find?
- • A. Reed-Sternberg cells
- • B. Lymphoblastic cells
- • C. Gaucher’s cells
- • D. Rieder’s cells
Correct
Incorrect
Question 280 of 450
280. Question
280. Question Tag: bone marrow aspiration and biopsy
Question Category: Physiological Integrity, Basic Care and Comfort
A patient is about to undergo bone marrow aspiration and biopsy and expresses fear and anxiety about the procedure. Which of the following is the most effective nursing response?
- • A. Warn the patient to stay very still because the smallest movement will increase her pain.
- • B. Encourage the family to stay in the room for the procedure.
- • C. Stay with the patient and focus on slow, deep breathing for relaxation.
- • D. Delay the procedure to allow the patient to deal with her feelings.
Correct
Incorrect
Question 281 of 450
281. Question
281. Question Tag: toilet training
Question Category: Health Promotion and Maintenance
A mother complains to the clinic nurse that her 2 ½-year-old son is not yet toilet trained. She is particularly concerned that, although he reliably uses the potty seat for bowel movements, he isn’t able to hold his urine for long periods. Which of the following statements by the nurse is correct?
- • A. The child should have been trained by age 2 and may have a psychological problem that is responsible for his “accidents.”
- • B. Bladder control is usually achieved before bowel control, and the child should be required to sit on the potty seat until he passes urine.
- • C. Bowel control is usually achieved before bladder control, and the average age for completion of toilet training varies widely from 24 to 36 months.
- • D. The child should be told “no” each time he wets so that he learns the behavior is unacceptable.
Correct
Incorrect
Question 282 of 450
282. Question
282. Question Tag: infant
Question Category: Health Promotion and Maintenance
The mother of a 14-month-old child reports to the nurse that her child will not fall asleep at night without a bottle of milk in the crib and often wakes during the night asking for another. Which of the following instructions by the nurse is correct?
- • A. Allow the child to have the bottle at bedtime, but withhold the one later in the night.
- • B. Put juice in the bottle instead of milk.
- • C. Give only a bottle of water at bedtime.
- • D. Do not allow bottles in the crib.
Correct
Incorrect
Question 283 of 450
283. Question
283. Question Tag: infant
Question Category: Health Promotion and Maintenance
Which of the following actions is not appropriate in the care of a 2-month-old infant?
- • A. Place the infant on her back for naps and bedtime.
- • B. Allow the infant to cry for 5 minutes before responding if she wakes during the night as she may fall back asleep.
- • C. Talk to the infant frequently and make eye contact to encourage language development.
- • D. Wait until at least 4 months to add infant cereals and strained fruits to the diet.
Correct
Incorrect
Question 284 of 450
284. Question
284. Question Tag: constipation
Question Category: Health Promotion and Maintenance
An older patient asks a nurse to recommend strategies to prevent constipation. Which of the following suggestions would be helpful? Note: More than one answer may be correct. Select all that apply.
- • A. Get moderate exercise for at least 30 minutes each day.
- • B. Drink 6-8 glasses of water each day.
- • C. Eat a diet high in fiber.
- • D. Take a mild laxative if you don’t have a bowel movement every day.
- • E. Eat a protein-rich diet.
Correct
Incorrect
Question 285 of 450
285. Question
285. Question Tag: rheumatic fever
Question Category: Physiological Integrity, Physiological Adaptation
A child is admitted to the hospital with suspected rheumatic fever. Which of the following observations is not confirming the diagnosis?
- • A. A reddened rash visible over the trunk and extremities.
- • B. A history of sore throat that was self-limited in the past month.
- • C. A negative antistreptolysin O titer.
- • D. An unexplained fever.
Correct
Incorrect
Question 286 of 450
286. Question
286. Question Tag: congestive heart failure
Question Category: Physiological Integrity, Reduction of Risk Potential
A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea. Which of the following actions is the first the nurse should perform?
- • A. Ask the patient to lie down on the exam table.
- • B. Draw blood for chemistry panel and arterial blood gas (ABG).
- • C. Send the patient for a chest x-ray.
- • D. Check blood pressure.
Correct
Incorrect
Question 287 of 450
287. Question
287. Question Tag: nitroglycerin
Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies
A clinic patient has recently been prescribed nitroglycerin for treatment of angina. He calls the nurse complaining of frequent headaches. Which of the following responses to the patient is correct?
- • A. “Stop taking the nitroglycerin and see if the headaches improve.”
- • B. “Go to the emergency department to be checked because nitroglycerin can cause bleeding in the brain.”
- • C. “Headaches are a frequent side effect of nitroglycerine because it causes vasodilation.”
- • D. “The headaches are unlikely to be related to the nitroglycerin, so you should see your doctor for further investigation.”
Correct
Incorrect
Question 288 of 450
288. Question
288. Question Tag: colon cancer
Question Category: Physiological Integrity, Reduction of Risk Potential
A patient received surgery and chemotherapy for colon cancer, completing therapy 3 months previously, and she is now in remission. At a follow-u