Professional Documents
Culture Documents
Rheumatoid arthritis
Scleroderma
Polymyalgia rheumatic
Coordinate her meal schedule with the peak effect of her medication
3. After Billroth II Surgery, the client developed dumping syndrome. Which of the
following should the nurse exclude in the plan of care?
A
4. After the acute phase of congestive heart failure, the nurse should expect the dietary
management of the client to include the restriction of:
A
Potassium
Sodium
Calcium
Magnesium
Notify the MD
Monitor VS
6. The nurse is attending a bridal shower for a friend when another guest, who happens to
be a diabetic, starts to tremble and complains of dizziness. The next best action for the
nurse to take is to:
A
7. Included in the plan of care for the immediate post-gastroscopy period will be:
A
8. A client has Gastroesophageal Reflux Disease (GERD). The nurse should teach the client
that after every meals, the client should
A
9. Mr. Alzawar is in continuous pain from cancer that has metastasized to the bone. Pain
medication provides little relief and he refuses to move. The nurse should plan to:
A
10. After surgery, Gihan returns from the Post-anesthesia Care Unit (Recovery Room) with a
nasogastric tube in place following a gall bladder surgery. She continues to complain of
nausea. Which action would the nurse take?
A
11. Mr. Kalifa a client with CHF, has been receiving a cardiac glycoside, a diuretic, and a
vasodilator drug. His apical pulse rate is 44 and he is on bed rest. The nurse concludes
that his pulse rate is most likely the result of the:
A
Bed-rest regimen
Cardiac glycoside
Diuretic
Vasodilator
12. A client with leukemia is undergoing radiation therapy to the brain and spinal cord. In
planning care for this client, the nurse would include which nursing intervention?
A
B
13. A 60 year old male client comes into the emergency department with complaints of
crushing substernal chest pain that radiates to his shoulder and left arm. The admitting
14. Nurse Jamela is assigned to care for a client who has returned to the nursing unit after
left nephrectomy. Nurse Jamelas highest priority would be
A
Temperature
15. The nurse is teaching the client with right leg fracture regarding the physicians order
for partial weight bearing status. The client understands the health teaching if he
verbalizes:
A
16. Which of the following signs and symptoms would Nurse Maureen include in teaching
plan as an early manifestation of laryngeal cancer?
A
Airway obstruction
Dysphagia
Stomatitis
Hoarseness
17. Noor is ordered laboratory tests after she is admitted to the hospital for angina. The
isoenzyme test that is the most reliable early indicator of myocardial insult is:
A
CK-MB
LDH
AST
SGPT
18. The emergency room nurse admits a child who experienced a seizure at school. The
father comments that this is the first occurrence, and denies any family history of
epilepsy. What is the best response by the nurse?
A
Since this was the first convulsion, it may not happen again.
The seizure may or may not mean your child has epilepsy.
19. A female client is experiencing painful and rigid abdomen and is diagnosed with
perforated peptic ulcer. A surgery has been scheduled and a nasogastric tube is inserted.
The nurse should place the client before surgery in
A
Supine position
Semi-fowlers position
Sims position
20. Amir who has undergone thoracic surgery has chest tube connected to a water-seal
drainage system attached to suction. Presence of excessive bubbling is identified in waterseal chamber, the nurse should
A
21. Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The
nurse understands that this therapy is effective because it:
A
receptors.
B
22. Which of the following statements reflect nursing interventions in the care of the patient
with osteoarthritis?
A
23. A client has suffered from fall and sustained a leg injury. Which appropriate question
would the nurse ask the client to help determine if the injury caused fracture?
A
D
Is the pain sharp and continuous?
24. The laboratory of a male patient with Peptic ulcer revealed an elevated titer of
Helicobacter pylori. Which of the following statements indicate an understanding of this
data?
A
25. A student nurse is assigned to a client who has a diagnosis of thrombophlebitis. Which
action by this team member is most appropriate?
A
Provide active range-of-motion exercises to both legs at least twice every shift.
26. The husband of a client asks the nurse about the protein-restricted diet ordered because
of advanced liver disease. What statement by the nurse would best explain the purpose of
the diet?
A
Most people have too much protein in their diets. The amount of this diet is
Because of portal hyperemesis, the blood flows around the liver and ammonia
The liver heals better with a high carbohydrates diet rather than protein.
The liver cannot rid the body of ammonia that is made by the breakdown of
Pulse rate
Blood pressure
Consciousness
28. Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the
parents remark: We just dont know how he caught the disease! The nurse's response is
based on an understanding that
A
29. The nurse is planning care for a client during the acute phase of a sickle cell vasoocclusive crisis. Which of the following actions would be most appropriate?
A
Administer analgesic therapy as ordered
B
Sharp pain in the epigastric area that radiates to the right shoulder
Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by
food intake
C
31. Mark has multiple abrasions and a laceration to the trunk and all four extremities says, I
cant eat all this food. The food that the nurse should suggest to be eaten first should be:
A
32. A female client with breast cancer is currently receiving radiation therapy for treatment.
The client is complaining of apathy, hard to concentrate on something, and feeling tired
despite of having time to rest and more sleep. These complains suggest symptoms of
A
radiation pneumonitis
Fatigue
Hypocalcemia
33. A client receiving heparin sodium asks the nurse how the drug works. Which of the
following points would the nurse include in the explanation to the client?
A
34. The client presents with severe rectal bleeding, 16 diarrheal stools a day, severe
abdominal pain, tenesmus and dehydration. Because of these symptoms the nurse should
be alert for other problems associated with what disease?
A
Ulcerative colitis
Peritonitis
Chrons disease
Diverticulitis
35. What instructions should the client be given before undergoing a paracentesis?
A
B
C
36. Which of the drug of choice for pain controls the patient with acute pancreatitis?
A
Codeine
NSAIDS
Morphine
Meperidine
37. Days after abdominal surgery, the clients wound dehisces. The safest nursing
intervention when this occurs is to
A
38. A client with multiple injuries following a vehicular accident is transferred to the critical
care unit. He begins to complain of increased abdominal pain in the left upper quadrant.
A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. In
preparing the client for surgery, the nurse should emphasize in his teaching plan the:
A
39. A 3 year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the
nurse should
A
40. What would be the primary goal of therapy for a client with pulmonary edema and heart
failure?
A
Enhance comfort
41. A nurse wants to assess if the clients brachial plexus was compromised after undergoing
shoulder arthroplasty due to rheumatoid arthritis. To assess the cutaneous nerve status
which of the following would the nurse perform?
A
Ask the client move his thumb toward the palm and back to the neutral position
Let the client raise his forearm and monitor for flexion of the biceps
C
D
Have the client spread all the fingers wide and resist pressure.
Have the client grasp the nurses hand while noting the clients strength of the
"If I bathe more than once a week my skin feels too dry.
43. A newborn has been diagnosed with hypothyroidism. In discussing the condition and
treatment with the family, the nurse should emphasize
A
44. To promote continued improvement in the respiratory status of a client following chest
tube removal after a chest surgery for multiple rib fracture, the nurse should:
A
Encourage bed rest with active and passive range of motion exercises
45. The client underwent Billroth surgery for gastric ulcer. Post-operatively, the drainage
from his NGT is thick and the volume of secretions has dramatically reduced in the last
2 hours and the client feels like vomiting. The most appropriate nursing action is to:
A
46. A child in the Emergency Room is diagnosed with an acute episode of Croup (Acute
laryngotracheo - bronchitis). During the initial assessment, which of the following
finding would the nurse expect to find?
A
Shallow respirations
47. A nurse at the weight loss clinic assesses a client who has a large abdomen and a
rounded face. Which additional assessment finding would lead the nurse to suspect that
the client has Cushings syndrome rather than obesity?
A
B
48. A newly admitted client is diagnosed with Hodgkins disease undergoes an excisional
cervical lymph node biopsy under local anesthesia. What does the nurse assess first after
the procedure?
A
Incision site
Airway
Level of consciousness
Vital sign
49. A homeless individual is brought to the Emergency Room after having been out in
subfreezing temperatures for three to four days. The toes of the patient's right foot
appear hard and cold with mottling, and are unresponsive to touch. Which of the
following would NOT be included in the initial management of this patient by the
Emergency Room nurse?
A
Rewarm the extremity with controlled and rapid rewarming until the injured part
flushes
D
50. Which type of jaundice in adults is the result of increased destruction of red blood cells?
A
Non-obstructive
Hemolytic
Hepatocellular
Obstructive
51. Abu Salem is a 46 year-old radio technician who is admitted because of mild chest pain.
He is 5 feet, 8 inches tall and weighs 190 pounds. He is diagnosed with a myocardial
infarct. Morphine sulfate, Diazepam (Valium) and Lidocaine are prescribed. The
physician orders 8 mg of Morphine Sulfate to be given IV. The vial on hand is labeled 1
ml/ 10 mg. The nurse should administer:
A
12 minims
8 minims
15 minims
10 minims
Initiation stage
B
C
Progression stage
Promotion stage
Regression stage
53. The physician orders non-weight bearing with crutches for Joy, who had surgery for a
fractured hip. The most important activity to facilitate walking with crutches before
ambulation begun is:
Using the trapeze frequently for pull-ups to strengthen the biceps muscles
54. Mrs. Mantesh a 78 year old client is admitted with the diagnosis of mild chronic heart
failure. The nurse expects to hear when listening to clients lungs indicative of chronic
heart failure would be:
A
Friction rubs
Wheezes
Crackles
Stridor
55. 14 year old girl has been hospitalized with Sickle Cell Anemia in vasoocclusive crisis.
Which of these nursing diagnoses should receive priority in the nursing plan of care:
A
Pain
56. Osteoporosis is characterized by change in bone density or mass and fragile bones that
lead to fractures. A nurse is conducting a health screening clinic for osteoporosis. The
nurse determines that this client seen in the clinic is at the greatest risk of developing
the disorder.
A
57. A nurse is caring for a client who had a closed reduction of a fractured right wrist
followed by the application of a fiberglass cast 12 hours ago. Which finding requires the
nurses immediate attention?
A
58. Nurse Trish is aware that temporary heterograft (pig skin) is used to treat burns because
this graft will:
A
Relieve pain and promote rapid epithelialization
B
59. A client with burns on the chest has periodic episodes of dyspnea. The position that
would provide for the greatest respiratory capacity would be the:
A
Orthopneic position
Supine position
Sims position
Semi-fowlers position
60. The observation that indicates a desired response to thoracostomy drainage of a client
with chest injury is:
A
61. Faida with a history of chronic infection of the urinary system complains of urinary
frequency and burning sensation. To figure out whether the current problem is in renal
origin, the nurse should assess whether the client has discomfort or pain in the
A
Urinary meatus
Suprapubic area
62. After gastroscopy, an adaptation that indicates major complication would be:
A
Abdominal distention
Difficulty in swallowing
Increased GI motility
63. A chest tube with water seal drainage is inserted to a client following a multiple chest
injury. A few hours later, the clients chest tube seems to be obstructed. The most
appropriate nursing action would be to
A
64. Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure
recognizes an adequate amount of high-biologic-value protein when the food the client
selected from the menu was:
A
Cottage cheese
B
Raw carrots
Apple juice
65. An early finding in the EKG of a client with an infarcted myocardium would be:
Elevated ST segments
Disappearance of Q waves
Absence of P wave
Flattened T waves
66. A 57 year-old male client has hemoglobin of 10 mg/dl and a hematocrit of 32%. What
would be the most appropriate follow-up by the home care nurse?
A
immediately
C
67. A nurse prepares discharge instructions for a patient with chronic syndrome of
inappropriate antidiuretic hormone (SIADH). Which statement indicates that the patient
understands these instructions?
A
I will use a refractometer to check the specific gravity of my urine. If the result
I will weigh everyday and I will log it in a notebook. I will call my physician
Ill check my pulse every morning and will contact my doctor if its rapid or
irregular.
D
I have to avoid too much sodium intake. I will read all food labels to make sure I
assistance
C
75 year-old with left sided paresthesia and is incontinent of urine and stool
69. A client is prescribed an inhaler. How should the nurse instruct the client to breathe in
the medication?
A
As quickly as possible
As slowly as possible
D
Until hearing whistling by the spacer
70. A chemotherapeutic agent 5FU is ordered as an adjunct measure to surgery. Which of
the ff. statements about chemotherapy is true?
A
71. Mr. Dibagulun is admitted to the hospital with a diagnosis of Left-sided CHF. In the
assessment, the nurse should expect to find:
A
Dyspnea on exertion
72. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding
would the nurse anticipate?
A
Limited adduction
73. Most skin conditions related to HIV disease may be helped primarily by:
A
symptomatic therapies
74. A client experiences post partum hemorrhage eight hours after the birth of twins.
Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and
hematocrit are within normal limits. She asks the nurse whether she should continue to
breast feed the infants. Which of the following is based on sound rationale?
A
"Breastfeeding twins will take too much energy after the hemorrhage."
"Nursing will help contract the uterus and reduce your risk of bleeding."
"The blood transfusion may increase the risks to you and the babies.
75. A client is for discharge post TURP. What is the most important teaching a nurse should
take:
A.
Instruct the client to massage the bladder with fist in a rolling motion during
urination.
B.
Report signs of foul odor urine, difficulty of starting urination and fever.
C.
Instruct the client to perform perennial exercise by contracting and relaxing the
perineum.
Fatigue
C.
Fever
D.
77. A child is scheduled for tonsillectomy. Which of the following presents the highest risk
of aspiration during surgery?
A.
Difficulty swallowing
B.
C.
D.
78. The chief clinical manifestation that the nurse would expect in the early stages of
cataract formation is:
A.
Eye pain
B.
Floating spots
C.
Blurred vision
D.
Diplopia
80. The nurse is performing an admission assessment on a client with bladder CA. which of
the following would the nurse most likely to expect?
A.
Hematuria
B.
Burning
C.
Urgency
D.
Frequency
81. A client is admitted to the hospital and has a diagnosis of early stage of CRF. Which of
the following does the nurse expect to note on assessment?
A.
Polyuria
B.
Edema
C.
Oliguria
D.
Anuria
82. A client has developed atrial fibrillation with a ventricular rate of 150 per minute. The
nurse assesses the client for
a. Hypotension and dizziness
b. Nausea and vomiting
c. Hypertension and headache
d. Flat neck veins
2. When assessing a client with ulcerative colitis, which of the following findings would the
nurse report to the physician?
a. Bloody diarrhea
b. Hypotension
c. A hemoglobin level of 12 mg/dL
d. Rebound tenderness
3. Which of the following is a characteristic sign of Lyme Disease Stage I?
a. Signs of neurological disorders
b. Enlarged and inflamed joints
c. Arthalgias
d. Flu-like symptoms
4. Which of the following is not a sign of testicular cancer?
a. Painless testicular swelling
b. Heavy sensation in the scrotum
c. Alopecia
d. Back pain
5. Which of the following data is a sign of paralytic ileus in a patient with acute pancreatitis
and a history of alcoholism?
a. Firm, nontender mass palpable at the lower right costa margin
b. Severe constant pain with rapid onset
c. Inability to pass flatus
d. Loss of anal sphincter control
6. A client is receiving external radiation to the neck for cancer of the larynx. The most
likely side effect to be expected is
a. Constipation
b. Dyspnea
c. Sore throat
d. Diarrhea
7. The client has experienced pulmonary embolism. The nurse assesses for which of the
following symptoms most commonly reported?
a. Dyspnea noted when deep breaths are taken
b. Hot, flushed feeling
c. Chest pain that occurs suddenly
d. Sudden chills and fevers
The nurse is caring for an elderly client with a suspected diagnosis of pneumonia who has just been admitted to the hospital. The
client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to
the unlicensed assistant? Select all that apply.
A. Obtaining vital signs
B. Initiating oxygen therapy as needed
C. Applying anti-embolic stockings
D. Assessing the clients chief complaint
A nursing assistant is assigned to care for a client with hemiparesis of the right arm and leg. With regards to morning care, the nurse
instructs the nursing assistant to place personal articles
A. Within the clients reach on the left side.
B. Within the clients reach on the right side.
C. Just out of the clients reach on the right side.
D. Just out of the clients reach on the left side.
Glycosylated hemoglobin of a diabetic client is 4%. What is the nurses correct interpretation?
A. Good control
B. Poor control
C. Fair control
D. Needs further test
For a client placed in Bucks traction, the nurse can provide for countertraction to reduce shear and friction by
A. Providing an overhead trapeze
B. Using a foot board
C. Slightly elevating the head of the bed
D. Slightly elevating the foot of the bed
A patient with tuberculosis is scheduled for chest x-ray. What will the nurse do?
A. Request a portable x-ray to be brought to the patients room
B. Wear a particulate mask when transporting the patient to the x-ray room
C. Bring the patient to the x-ray room when there is fewer crowds in the hallway
D. Ask the patient to wear surgical mask when being transported to the x-ray room.
A nurse is conducting a health teaching for a client who is about to have an inguinal hernia repair (herniorraphy) tomorrow. The
nurse includes all of the following teaching except:
A. Doing lifting works at home 3 weeks after the surgery.
B. Applying ice pack to scrotal area to relieve edema.
C. Wearing scrotal support while ambulating
D. Increasing fiber in the diet to prevent constipation
Rationale: A.
A nurse obtains an order form the physician to restrain a client. The nurse instructs the nursing assistant to apply restraints to the
client. Which of the following observations indicate improper understanding of the nursing assistant in the use of restrains? Select
all that apply.
A. Removing restraints fro 10m minutes every 2 hours for range-of-motion exercises.
B. Restrain straps are safely secured in the side rails
C. The nursing assistant uses safety knot in securing the restrain straps in the bed frame.
D. Allowing enough space between the restrains and skin for movement.
Which of the following would alert the nurse to the potential for delirium tremors in a client undergoing alcohol withdrawal?
A. Ataxia, hunger, hypotension
B. Muscular rigidity, stupor, agitation
C. Hallucinations, hypertension, changes in the level of consciousness
D. Coarse hand tremors, hypotension, agitation
. A client with a diagnosis of peptic ulcer disease ask the nurse about what causes the disease to develop. The nurses appropriately
respond, that according to research, many peptic ulcers are result of which of the following?
A. Diets high in cholesterol
B. Family history of the disease
C. Stress
D. Helicobacter pylori infection
The position of the client for colonoscopy is
A. Prone
B. Right lateral
C. lying on the left side with knees drawn to the chest up
D. Left Sims position
Being weaned from TPN, the client is expected to begin taking solid food today. The ongoing solution rate is has been 100 mL/hour.
A nurse anticipates that which of the following orders regarding the TPN solution will accompany the diet order?
A. Discontinue the TPN.
B. Continue current infusion rate orders for TPN.
C. Decrease TPN rate to 50 mL/hr.
D. Hang 1 L 0.9% normal saline.
A client is receiving TPN in the home setting gained 5 lb weight in a week. The nurse next assesses the client to detect the presence
of which of the following?
A. Crackles on auscultation of the lungs
B. Thirst
C. Decreased blood pressure
D. Polyuria
The nurse after changing the IV bottle observes that the patient exhibits dyspnea. What will the nurse do first?