125 application

1. The nurse is planning care for a client who has just returned to the nursing unit following an oral
cholecystogram. The nurse would expect to be able to delete which of the following orders on the
client’s care plan?
a. Monitor hydration status
b. Assess for nausea and vomiting
c. Maintain a clear liquid diet for 72 hours
d. Monitor for abdominal discomfort
2. The nurse is scheduling diagnostic tests for a client. If all of the following diagnostic tests are ordered,
which would be performed last?
a. Gallbladder series
b. Barium enema
c. Barium swallow
d. Oral cholecystogram
3. A client is scheduled for an oral cholecystogram. The nurse would plan to order what type of diet for
the evening meal before the test?
a. Low protein
b. High carbohydrate
c. Fat free
d. liquid
4. a nurse is providing preoperative teaching to a client scheduled for cholecystectomy. Which
intervention would be of highest priority in the preoperative teaching plan?
a. Teaching coughing and deep breathing exercises
b. Teaching leg exercises
c. Providing instructions regarding fluid restrictions
d. Assessing the client’s understanding of the surgical procedure
5. A nurse is giving dietary instruction to a client who has a new colostomy. The nurse encourages the
client to eat foods representing which of the following diets for the first 4 to 6 weeks postoperaively?
a. High protein
b. High carbohydrate
c. Low calorie
d. Low residue
6. A client with ulcerative colitis is diagnosed with a mild case of the disease. The nurse doing dietary
teaching gives the client examples of foods to eat that represent which of the following therapeutic
diets?
a. High fat with milk
b. High protein without milk
c. Low roughage without milk
d. Low roughage with milk
7. A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and sates, “ I’m not
sure I can avoid alcohol.” The most appropriate response is
a. Everything will be all right.
b. I think you should talk more with the doctor about this
c. I don’t believe that
d. I’m not sure that I understand. Would you please explain?
8. Of the following infection control methods, which would you prevent hepatitis B most effectively?
a. Hand washing
b. Hepatitis B vaccine
c. Proper personal hygiene
d. Immune globulin
9. A client with viral hepatitis states, “I am so yellow.” The nurse most appropriately would
a. Assist the client in expressing feelings.
b. Do most of the activities of daily living for the client.
c. Provide information to the client only when the client requests it.
 d. Restrict visitors until the jaundice subsides.
10. A client with viral hepatitis has no appetite, and food makes the client nauseated. Which of the
following nursing interventions would be most appropriate?
a. Explain that high fat diets usually are tolerated better
b. Encourage intake of foods high in protein
c. Explain that the majority of calories need to be consumed in the evening hours
d. Monitor for fluid and electrolyte imbalance
11. The nurse is changing the tracheotomy ties on a client with tracheotomy and is assessing the security of
the ties. What method is used to ensure that the ties are not placed too tightly?
a. The nurse places two fingers between the tie and the neck
b. The tracheotomy can be pulled slightly away from the neck
c. The ties leave no marks on the neck
d. The nurse uses a 12-inch tie that is affixed with Velcro lightly
12. A nurse is preparing fro removal of an endotracheal tube from a client. In preparing to assist the
physician in this procedure, which initial nursing action is most appropriate?
a. Suction the endotracheal tube
b. Deflate the cuff
c. Turn the ventilator off
d. Obtain a code cart and place it at the bedside
13. A client is intubated with an endotracheal tube by the anesthesiologist. What is the responsibility of
the nurse regarding checking for tube placement immediately following tube insertion?
a. The nurse is not responsible for checking for tube placement
b. Arrange for a chest radiograph
c. Auscultate the lungs for presence of bilateral breath sounds
d. Instill air into the endotracheal tube and listen for it being forced into the lungs
14. An older client is diagnosed with a rib fracture and asks the nurse why strapping the ribs is not being
done. Which response by the nurse is the most appropriate?
a. That isn’t done anymore because people often would develop pneumonia from the
constricting effect on the lungs.
b. That might help you to breathe better, but this facility does not carry them in the stockroom.
When you get home, you can purchase one at the medical supply store.
c. Those are only useful if the ribs are fractured in several places at once.
d. That’s a good idea. I’ll ask the physician for an order for one.
15. The nurse is caring for the client with tuberculosis who is fearful of the disease and anxious about
prognosis. In planning nursing care, the nurse would incorporate which of the following as the best
strategy to assist the client in coping with the illness?
a. Encourage the client to visit with the pastoral care department chaplain
b. Ask family members if they wish a psychiatric consult
c. Provide reassurance that continued compliance with medication therapy is the most
proactive way to cope with the disease
d. Allow the client to deal with the disease in an individual fashion
16. The client with active tuberculosis demonstrates less than expected interest in learning about the
prescribed medication therapy. The nurse assesses that this client may ultimately need
a. More medication instructions
b. Involvement of the family in teaching
c. Reinforcement by the physician
d. Directly observed therapy
17. The client is taking brompheniramine maleate (Dimetane). The nurse assesses for which side effect of
this medication?
a. Excitability
b. Drowsiness
c. Excess salivation
d. diarrhea
18. Norfloxacin (Noroxin is prescribed for a client with a Pseudomonas infection of the urinary tract. The
nurse instructs the client to take the medication
a. With meals
b. At bedtime
c. 2 hours after meals
d. With a snack in the late afternoon
19. Aluminum hydroxide (amphojel) is prescribed for the client with chronic renal failure. The nurse would
instruct the client to take this medication
a. On an empty stomach
b. At bedtime
c. With meals
d. In the morning on arising
20. The client with chronic renal failure is receiving ferrous sulfate (feosol). The nurse instructs the client
that which of the following is a common side effect associated with this medication?
a. Fatigue
b. Constipation
c. Headache
d. Weakness
21. The nurse is testing the client for astereognosis. The nurse would ask the client to close the eyes and to
a. Identify three numbers or letters traced in the client’s palm
b. Identify three objects placed in the hand, one at a time
c. State whether one or two skin pricks are felt after pricking the client’s skin bilaterally in the
same place
d. Ask the client to identify the smallest distance where two pricks can be felt, after pricking the
client’s skin with two pins at varying distances
22. The client has an impaired corneal reflex on one side. The client would demonstrate the best
understanding of how to protect the eye by stating to
a. Wear an eye patch
b. Tape the eye shut during the day
c. Use sterile saline drops every few hours to keep the eye moist
d. Wipe inside the lower eyelid with a cotton tipped applicator 3 times a day
23. The nurse is planning care for the client who displays confusion caused by a neurological problem.
Which of the following approaches by the nurse would be least helpful in assisting this client?
a. Giving simple, clear directions
b. Providing a stable environment
c. Providing sensory cues
d. Encouraging multiple visitors at one time
24. The nurse is conducting a neurological assessment including a health history on a client with
neurological disorder. The nurse notes that the client is having difficulty in answering the questions and
should
a. Defer the health history and proceed with the neurological examination
b. Defer the health history and neurological examination
c. Ask a family member to stay during the interview
d. Ask a second nurse to be present during the interview
25. The nurse has formulated a nursing diagnosis of Ineffective Breathing Pattern for a client with a
neurological disorder. The nurse would avoid including which of the following activities in the care plan
for this client?
a. Keep the head and neck in good alignment
b. Elevate the head of the bed 30 degrees
c. Keep the client lying in a supine position
d. Keep suction equipment at the bedside
26. The nurse is trying to help the family of an unconscious client cope with the situation. Which
intervention would the nurse plan to incorporate into the care routine for the client?
a. Discouraging the family from touching the client
 b. Explaining equipment and procedures on an ongoing basis
c. Ensuring adherence to visiting hours to assure the client’s rest
d. Encouraging the family not to “give in” to their feelings of grief
27. The nurse is suctioning secretions from the unconscious client who has a tracheostomy. The nurse
should avoid which of the following actions?
a. Keeping a supply of suction catheters at the bedside
b. Auscultating breath sounds to determine the need for suctioning
c. Hyperoxygenating the client before, during, and after suctioning
d. Making sure not to suction for longer than 30 seconds
28. The nurse has formulated the nursing diagnosis Risk for Impaired Skin Integrity for an unconscious
client. The nurse would avoid including which of the following interventions in the plan of care?
a. Reposition every 2 hours and massage bony prominences
b. Apply protective pads to heels and elbows
c. Add a small amount of alcohol to the daily bath water
d. Provide perineal care every 8 hours and after incontinence
29. A client is suspected of sustaining a probable minor head injury following a motor vehicle accident and
is admitted to the hospital for observation. The nurse leaves the cervical collar applied to the client in
place until
a. The physician makes rounds
b. The family comes to visit
c. The result of spinal x-ray films is known
d. The nurse needs to do physical care
30. The nurse is conducting home visits for a head-injured client with residual cognitive deficits. The client
has problems with memory, has a shortened attention span, is distracted easily, and processes
information slowly. The nurse plans to talk with the primary physician about a referral to a
a. Psychologist
b. Neuropsychologist
c. Social worker
d. Vocational rehabilitation specialist
31. The nurse is caring for a client who has undergone craniotomy and has a supratentorial incision. The
nurse would place the client in which of the following positions postoperatively?
a. Head of bed flat, head and neck midline
b. Head of bed flat, head turned to the non-operative side
c. Head of the bed elevated 30 to 45 degrees, head and neck midline
d. Head of bed elevated 30 to 45 degrees, head turned to the operative side
32. The client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to
administer care. The nurse would
a. Advise the client that rehabilitation progresses more quickly with cooperation
b. Acknowledge the client’s anger and continue to encourage participation in care
c. Leave the client alone until ready to participate
d. Ask the family to deliver the care
33. The nurse is plann9ing to put aneurysm precautions in place for the client with a cerebral aneurysm.
The nurse avoids including which item as part of the precautions?
a. Prevent pushing or straining activities
b. Maintain the head of bed at 15 degrees
c. Limit caffeinated coffee to 1 cup per day
d. Provide physical aspects of care
34. The nurse is administering medications to the client with trigeminal neuralgia. The nurse brings which
of the following prescribed medications to the client for pain relief?
a. Meperidine hydrochloride (demerol) and hydroxyzine (vistaril)
b. Carbamazepine (tegretol) and phenytoin (dilantin
c. Acetaminophen (tylenol) and codeine sulfate
d. Oxycodone and aspirin (percodan)
35. The client with a neurological impairment experiences urinary incontinence. Which nursing action
would be most helpful in assisting the client to adapt to this alteration?
a. Establishing a toileting schedule
b. Inserting a Foley catheter
c. Using adult diapers
d. Padding the bed with an absorbent cotton pad
36. The client with a neurological problem has a nursing diagnosis of Hyperthermia. Which measure would
the nurse avoid while trying to lower the client’s body temperature?
a. Giving tepid sponge baths
b. Administering acetaminophen (Tylenol) per protocol
c. Applying a hypothermia blanket
d. Placing ice packs in the axilla and groin areas
37. The nurse is preparing the client who is scheduled to have a cerebral angiography performed. The
nurse would assess the client for
a. Allergy to salmon
b. Allergy to iodine or shellfish
c. Claustrophobia
d. Excessive weight
38. The client is nervous about having a magnetic resonance imaging (MRI) procedure. Which statement by
the nurse would provide the most reassurance to the client about the procedure?
a. It is necessary to remove any metal or metal-containing objects before having the MRI done to
avoid the metal being drawn into the magnetic field
b. The MRI machine is a long, hollow narrow tube and make you feel claustrophobic
c. Even though you are alone in the scanner, you will be in voice communication with the
technologist at all times during the procedure
d. You will be able to eat before the procedure unless you get nauseous easily. If so, you should
eat lightly
39. The nurse is administering mouth care to an unconscious client. The nurse should avoid doing which of
the following?
a. Positioning the client on the side
b. Using products that contain lemon or alcohol
c. Cleansing the mucous membranes with toothettes
d. Brushing the teeth with a small toothbrush
40. The nurse is planning care for the client with intracranial pressure monitoring. Which of the following
interventions would be contraindicated in the plan of care?
a. Using strict aseptic technique when touching the monitoring system
b. Assessing the insertion site for signs and symptoms of infection
c. Leveling the transducer at the lowest point of the ear
d. Checking all stopcocks and connections for leaks
41. The nurse is providing care to the client with increased ICP. Which of the following approaches is least
beneficial in controlling the client’s ICP from an environmental viewpoint?
a. Maintaining a clam atmosphere
b. Reducing environmental noise
c. Clustering nursing activities to be done all at one time
d. Allowing the client uninterrupted time for sleep
42. The nurse has an order to give “dexamethasone (decadron) 4 mg intravenously (IV) now” to the
postcraniotomy client. The nurse administers the medication
a. IV push over 1 minute
b. IV push over 4 minutes
c. IV piggy back in 50 mL of normal saline over 10 minutes
d. IV piggy back in 50 mL of normal saline over 30 minutes
43. The nurse is teaching the paraplegic client measures to promote skin integrity. Which of the following
instruction will be least helpful to the client?
a. Shifting weight every 2 hours while in a wheelchair
 b. Using a mirror to inspect for redness and breakdown twice a week
c. Checking the bottom sheet for wetness and wrinkles
d. Using a pressure relief pad while in a wheelchair
44. The client with a subarachnoid hemorrhage has surgery delayed until the client becomes stable. The
nurse plans to administer which of the following medications as ordered to prevent clot breakdown and
dissolution?
a. Aminocaproic acid (amicar)
b. Heparin sodium
c. Warfarin (coumadin)
d. Alteplase (activase)
45. The nurse is caring for a client who is receiving intermittent feeding via a nasogastric tube. Before
feeding the client via an NGT. Before feeding the client via the NGT, the nurse first would
a. Check the placement of the tube
b. Check the last time medications were given
c. Rinse the asepto syringe with warm water
d. Warm the feeding to 103 degree fahrenheit
46. When administering a subcutaneous injection of heparin sodium, the nurse should
a. Use a 23 to 25 gauge 1 inch needle
b. Aspirate before injection of the medication
c. Apply heat after the injection
d. Use a 5 to 27 gauge 5/8 inch needle
47. The client has a closed head injury with increased ICP. The ICP is being managed effectively by mannitol
(osmitrol) 25 gm intravenously every 2 hours. The nurse is planning to administer this medication via IV
pump and plans to administer this medication
a. By giving it rapidly over 5 minutes by IV bolus
b. Mixed in solution with the IV antibiotics
c. Piggyback into the packed red blood cells
d. By giving it slowly over 30 to 60 minutes
48. A nurse is teaching a client who is to have a gallium scan about the procedure. The nurse would include
which of the following items as part of the instructions?
a. The gallium will be injected IV 2 to 3 hours before the procedure
b. The procedure takes about 15 minutes to perform
c. The client must stand erect during the filming
d. The client should remain on bed rest for the remainder of the day after the scan
49. The nurse witnesses a client sustain a fall and suspects that the leg may be broken. The nurse takes
priority action?
a. Takes a set of vital signs
b. Calls the radiology department
c. Reassures the client that everything will be fine
d. Immobilizes the leg before moving the client
50. The nurse is giving the client with a left leg cast crutch –walking instructions using the three-point gait.
The client is allowed touchdown of the affected leg. The nurse tells the client to advance the
a. Left leg and right crutch and then right leg and left crutch
b. Crutches and then both legs simultaneously
c. Crutches and the right leg and then advance the left leg
d. Crutches and the left leg and then advance the right leg
51. The client has slight weakness in the right leg. Based on this assessment, the nurse determines that the
client would benefit most from the use of a
a. Walker
b. Wooden crutch
c. Lofstrand crutch
d. Straight leg cane
52. The client who is learning to use a cane is afraid that it will slip with ambulation, causing a fall. The
nurse provides the client with the greatest reassurance by telling the client that
 a. Canes prevent falls, not cause them
b. The cane has a flared tip with concentric rings to give stability
c. The physical therapist will determine whether the cane is inadequate
d. The cane would help to break a fall, even if the client does slip
53. The nurse is caring for a client with fresh application of a plaster leg cast. The nurse would plan to
prevent the development of compartment syndrome by instructing the licensed practical nurse
assigned to care for the client to
a. Elevate the limb and apply ice to the affected leg
b. Elevate the limb and cover the limb with bath blankets
c. Place the leg in a slightly dependent position and apply ice to the affected leg
d. Keep the leg horizontal and apply ice to the affected leg
54. The client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse would plan
to provide which type of wound care to the fasciotomy site?
a. Dry sterile dressing
b. Moist sterile saline dressings
c. Hydrocolloid dressings
d. One-half strength povidone-iodine dressings
55. The nurse is caring for an older client who had a hip pinned after it fractured. Which of the following
would the nurse avoid to minimize the change for further injury?
a. Side rails in the up position
b. Use of a night light in the hospital room and bathroom
c. Call bell placed within reach
d. Delays in responding to the call light
56. The client who has had a total knee replacement tells the nurse that extension of the knee causes pain.
The nurse should
a. Put the client’s knee through full passive ROM
b. Immobilize the knee temporarily
c. Administer an analgesic
d. Notify the physician
57. The nurse has an order to place the client with a herniated lumbar intervertebral disk on bed rest in
William’s position to minimize the pain. The nurse plans to put the bed
a. In a high fowler position with the foot of the bed flat
b. In a semi fowler position with the knees slightly raised
c. In a semi fowler position with the foot of the bed flat
d. Flat with the knees raised
58. The client is being transferred to the nursing unit from the postanesthesia care unit following spinal
fusion with Harrington rod insertion. The nurse would prepare to transfer the client from the stretcher
to the bed by using
a. A bath blanket and the assistance of three persons
b. A bath blanket and the assistance of four persons
c. A slider board and the assistance of two persons
d. A slider board and the assistance of four persons
59. The nurse in the emergency room is assessing a client with an open leg fracture. The nurse inquires
about the date of the client’s last
a. Physical examination
b. Chest x-ray examination
c. Tetanus vaccine
d. Tuberculin test
60. The client is fearful about having an arm cast removed. Which of the following actions by the nurse
would be the most helpful?
a. Telling the client that the saw makes a frightening noise
b. Reassuring the client that no one has had an arm lacerated yet
c. Stating that the hot cutting blades cause burns only rarely
d. Showing the client the cast cutter and explaining how it works
61. The client has skeletal traction applied to the right leg and has an overhead trapeze available for use.
The nurse would assess which of the following as a high risk area for pressure and breakdown?
a. Scapulas
b. Back of the head
c. Right heel
d. Left heel
62. The nurse is planning measures to increase bed mobility of the client in skeletal leg traction. Which of
the following items would the nurse consider to be most helpful for this client?
a. Television
b. Reading materials
c. Overhead trapeze
d. Fracture bedpan
63. The client with Parkinson’s disease has been prescribed benztropine (cogentine). The nurse assesses
for which of the following GI side effects of this medication?
a. Diarrhea
b. Dry mouth
c. Increased appetite
d. Hyperactive bowel sounds
64. The nurse has administered diazepam (valium) 5 mg intravenously to a client. The nurse should plan to
maintain the client on bed rest for at least
a. 30 minutes
b. 1 hour
c. 3 hours
d. 12 hours
65. The nurse is preparing to administer diazepam (valium) 5 mg IV to a client. The nurse administers the
medication over a period of at least
a. 15 seconds
b. 30 seconds
c. 1 minute
d. 5 minutes
66. A client is having the dosage of clonazepam (klonopin) adjusted. The nurse should plan to
a. Monitor blood glucose levels
b. Institute seizure precautions
c. Weigh the client daily
d. Observe for ecchymosis areas
67. The nurse has an order to administer phenytoin (dilantin) 100 mg IV to a client. The nurse administers
the medication after preparing it in
a. 5% dextrose in 0.45 % normal saline
b. Lactated Ringer’s solution
c. 5% dextrose in water with an in-line filter
d. 0.9% normal saline with an in-line filter
68. The client has an order for valproic acid(depakene) 250mg once daily. To maximize the client’s safety,
the nurse should plan to schedule the medication
a. At bedtime
b. Before breakfast
c. After breakfast
d. With lunch
69. The client with vascular headaches is taking ergotamine (ergostat). The home health nurse periodically
would assess the client for
a. Hypotension
b. Dependent edema
c. Constipation
d. Cool, numb fingers and toes
70. The client on the nursing unit has an order for dextroamphetamine (Dexedrine) 25 mg PO daily. The
nurse collaborates with the dietician to limit the amount of which of the following items on the client’s
dietary trays?
a. Starch
b. Caffeine
c. Protein
d. Fat
71. The client with myasthenia gravis has difficulty chewing and has received a prescription for
pyridostigmine (mestinon). The nurse plans to check to see that the client takes the medication
a. Just after meals
b. Between meals
c. With meals
d. 30 minutes before meals
72. The nurse is providing instructions to a client with osteoporosis regarding appropriate food items to
include in the diet. The nurse tells the client that which food item provides the least amount of
calcium?
a. Plain yogurt
b. Seafood
c. Sardines
d. Pork
73. A client is being treated for depression with amitriptyline hydrochloride (elavil). During the initial
phases of treatment, the most important nursing intervention is to
a. Provide the client a tyramine free diet
b. Obtain frequent drug blood levels
c. Obtain postural blood pressures before administering each dose
d. Assess the client for anticholinergic effects
74. A client who is taking lithium carbonate will be discharged at the end of the week. In formulating a
discharge teaching plan, the nurse plans to instruct the client that it is most important to
a. Avoid soy sauce, wine, and aged cheese
b. Take the medication only as prescribed because it can become addicting
c. Check with the psychiatrist before using any OTC medications
d. Have the lithium level checked every 2 weeks
75. A client who is on lithium carbonate complains of drowsiness, muscle weakness, and lack of
coordination. It is time for the client’s 4 pm dose of lithium. The best nursing action is to
a. Give the 4pmm dose as scheduled and reeducate the client that these are normal side effects of
the medication
b. Give the 4pm dose and document the client’s complaints
c. Give the 4pm dose and notify the physician of the client’s complaints
d. Hold the 4 pm dose and notify the physician of the client’s complaints
76. The home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result
of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased
amount of intrinsic factor in this disorder, the client will need
a. Vitamin B12 injections
b. Vitamin B 6 injections
c. An antibiotic
d. An antacid
77. The nurse is developing a plan of care for a client with a diagnosis of Menieres disease who is being
admitted to the hospital. The priority nursing intervention in the plan of care would focus on which of
the following?
a. Safety measures
b. Self care measures
c. Knowledge about medication therapy
d. Food items to avoid
78. The nurse is preparing to assist the physician with the removal of a chest tube. The nurse gathers items
that will be needed for this procedure. Which of the following items would not be required for removal
of the chest tube?
a. Petrolatum gauze dressing
b. Telfa dressing
c. A sterile 4x4 gauze
d. Adhesive tape
79. A nursing student is developing a plan of care for a client with a chest tube that is attached to a Pleur-
evac drainage system. The nurse intervenes if the student writes which incorrect intervention in the
plan?
a. Position the client in the semi fowler position
b. Add water to the suction chamber as it evaporates
c. Tape the connection sites between the chest tube and drainage system
d. Instruct the client to avoid coughing and deep breathing
80. The physician orders a Salem sump tube for gastrointestinal intubation. The nurse prepares for the
insertion and obtains which of the following items from the supply room?
a. A tube with a single lumen that connects to suction
b. A tube with a large lumen and an air vent
c. A Sengstaken-Blakemore tube
d. A Dobbhoff weighted tube
81. The nurse is assigned to care for a client following a mastoidectomy. Which nursing intervention would
be appropriate in the care of this client?
a. Maintain a supine position
b. Position the client on the affected side to promote drainage
c. Change the ear dressing daily
d. Monitor for signs of facial nerve injury
82. The nurse provides discharge instructions to a client following a prostatectomy. The nurse instructs the
client to
a. Avoid lifting any objects greater that 30 lb
b. Contact the physician if small clots are noticed in the urine
c. Avoid driving a car for at least 1 week
d. Increased fluid intake to at least 2.5 L per day
83. The nurse is performing an assessment on a client with a diagnosis of Menieres disease. Which
assessment finding would the nurse most likely expect the client to complain of during an acute attack?
a. Tinnitus
b. Headache
c. Fatigue
d. Insomnia
84. The nurse has admitted a client with a diagnosis of an acute attack of Meniere’s disease to the hospital.
The nurse reviews the physician’s orders for the client. Which order would the nurse question?
a. Diphenhydramine
b. Diazepam
c. Atropine sulfate
d. Ambulation 4 times daily
85. The nurse in the health care clinic is preparing to perform an otoscopic examination on an adult client.
In performing the examination the nurse would
a. Position the client lying flat on the side of the ear to be examined
b. Pull the ear lobe down and back before inserting the speculum
c. Tilt the client’s head forward before inserting the speculum
d. Pull the pinna up and back before inserting the speculum
86. The nurse in the health care clinic receives a telephone call from the mother of a child who reports that
an insect has flown into the child’s ear. The mother reports that the child is complaining of a buzzing
sound in the ear. Which priority instruction would the nurse provide to the mother?
a. Report to the clinic immediately
 b. Use a flashlight to coax the insect out of the ear
c. Use tweezers to try to remove the insect
d. Irrigate the ear
87. During a therapy session with a client with paranoid disorder, the client says to the nurse, “You look so
nice today. I love how you do your hair, and I love that perfume that you’re wearing.” Which response
by the nurse would be most therapeutic?
a. Thank you for noticing. I just bought this new perfume.
b. My hair has been a mess. I really needed to have it done.
c. Your comment is inappropriate
d. We are not here to discuss how I look or smell. We are here to talk about you
88. A MAOI is prescribed for the client. The nurse instructs the client that which of the following is a sign/
symptom of toxicity related to the use of this medication?
a. Restlessness
b. Feelings of fatigue
c. Lack of energy
d. Lethargy
89. The nurse is reviewing the plan of care for a client with a diagnosis of depression. The nurse notes that
a nursing diagnosis of Imbalanced Nutrition: less than body requirements is documented in the plan of
care. The nurse avoids which intervention in the plan of care?
a. Allow the client to eat alone in the room if the client requests to do so
b. Assist the client in selecting foods form the food menu
c. Offer small, high calorie, high protein snacks during the day and evening
d. Offer high calorie fluids throughout the day and evening
90. The nurse is developing a plan of care for the client with a diagnosis of paranoia. The nurse avoids
including which intervention in the plan of care?
a. Eliminate any physical contact with the client
b. Provide a warm approach to the client
c. Use simple and clear language when communicating with the client
d. Diffuse any anger or verbal attacks with a no defensive stance
91. The nurse in the ambulatory care unit is caring for a child following a tonsillectomy. The mother of the
child tells the nurse that the child is complaining of a dry throat and would like something to relieve the
dryness. Which of the following would the nurse give to the mother for the child?
a. Cool cherry kool aid
b. A glass of milk
c. Cola with ice
d. Yellow noncitrus jello
92. The nurse is providing instructions to a nursing assistant who is assigned to care for a client with
hemiparesis of the right arm and leg. The nurse would instruct the nursing assistant to place personal
articles for morning care
a. Within the client’s reach on the left side
b. Within the client’s reach on the right side
c. Just out of the client’s reach on the right side
d. Just out of the client’s reach on the left side
93. The nurse is developing a plan of care for a client with a cerebrovascular accident who has dysphagia.
The nurse avoids documenting which of the following in the plan of care?
a. Thicken liquids
b. Provide ample time for the client to chew and swallow
c. Assess for the presence of a swallow reflex
d. Place the food on the affected side of the mouth
94. The nurse is developing a plan of care for a client with a CVA. The nurse notes documentation in the
client’s record that the client has right homonymous hemianopsia. Which of the following would the
nurse include in the plan of care for the client?
a. Approach the client form the right field of vision
b. Place personal articles on the client’s right side
 c. Instruct the client to turn the head to scan the right visual field
d. Place an eye patch on the left eye
95. The nurse is performing an assessment on a client suspected of having trigeminal neuralgia (tic
douloureux). Which of the following assessment questions would elicit data specific to this disorder?
a. Have you had any numbness and tingling in your face?
b. Have you noticed that your eyelid has been drooping?
c. Have you had any facial paralysis?
d. Have you had any sharp pain or any twitching in any part of your face?
96. The nurse is providing instructions to the client with trigeminal neuralgia regarding measures to take to
prevent the episodes of pain. The nurse would instruct the client to
a. Prevent stressful situations
b. Avoid contact with persons with an infection
c. Avoid activities that may cause fatigue
d. Avoid activities that may cause pressure near the face
97. The community health nurse is providing an educational session to community members regarding
dietary measures that will assist in reducing the risk of osteoporosis. The nurse instructs the community
members to increase dietary intake of which food that would be most helpful to minimize this risk?
a. Yogurt
b. Turkey
c. Spaghetti
d. Shellfish
98. The nurse is teaching a client with a right arm cast how to prevent stiff or frozen shoulder. The nurse
would instruct the client to
a. Keep a sling on the arm at all times
b. Lift the shoulder of the casted arm over the head periodically throughout the day
c. Avoid ROM exercises to the affected arm
d. Wear the sling at night time
99. The nurse is preparing a client for ECT that is scheduled for the following morning. Which of the
following is unnecessary in the preprocedure period?
a. Withhold food and fluids for 6 hours before treatment
b. Have the client void before the procedure
c. Remove dentures and contact lenses before the procedure
d. Administer tap water enemas on the evening before the procedure
100. The nurse in the preoperative holding unit administers a dose of scopolamine to a client scheduled
for surgery. The nurse tells the client to expect which side effect of the medication?
a. Excessive urination
b. Diaphoresis
c. Dry mouth
d. Papillary constriction
101. The nurse is assisting the client with cystitis with diet selection of an acid-ash diet. The nurse
encourages the client to select which of the following foods?
a. Low fat milk
b. Baked haddock
c. Garden peas
d. Apples
102. The nurse is teaching the client with nephritic syndrome about managing the disorder. The nurse
instructs the client to adjust which of the following upward or downward according to the amount of
edema present?
a. Water
b. Salt intake
c. Use of diuretics
d. Activity level
103. The nurse is administering a dose of fentanyl (sublimaze) to the client via an epidural catheter after
nephrectomy. Before administering the medication, the nurse would plan to
 a. Aspirate to ensure a CSF return
b. Ensure that naloxone (narcan) is readily available
c. Place the head of the bed flat
d. Flush the catheter with 6 mL sterile water
104. The nurse is administering care to the client immediately following nephrectomy. The nurse
administers IVF as ordered considering that the hourly rate should be calculated based on
a. The number f milliliters of urine output the previous hour
b. One half of the urine output of the previous hour
c. A strict hourly rate of 100 mL
d. A strict hourly rate of 150 mL
105. The client receiving intravesical chemotherapy for cancer of the bladder. The nurse would plan to do
which of the following after the completion of each treatment?
a. Provide increased doses of narcotic analgesic
b. Keep the client on NPO status for 6 hours
c. Place the client on contact isolation for 24 hours
d. Encourage increased oral intake of fluids
106. The client is being transferred to the nursing unit for admission after receiving a radium implant for
bladder cancer. The nurse would take which priority action in the care of this client?
a. Encourage the client to take frequent rest periods
b. Admit the client to a private room
c. Encourage the family to visit
d. Place the client on reverse isolation
107. The client is in extreme pain from scrotal swelling that is caused by epididymitis. The nurse
administers an intramuscular narcotic analgesic in the left arm to relieve the pain. The nurse should
plan to do which of the following actions next?
a. Tell the client to do ROM to the left arm to absorb the medication into the bloodstream
b. Check the name bracelet of the client
c. Put the side rails up on the bed
d. Dim the lights in the room
108. The nurse is caring for the client with epididymitis. The nurse would avoid using which of the
following treatment modalities in the care of the client?
a. Bed rest
b. Scrotal elevation
c. Sitz bath
d. Use of heating pad
109. The client has developed acute renal failure as a complication of glomerulonephritis. The nurse
assesses this client or which of the following expected manifestations?
a. Hypertension
b. Bradycardia
c. Decreased cardiac output
d. Decreased central venous pressure
110. The client with renal failure has a medication order for epoetin alfa (Epogen, Procrit). The nurse
would administer this medication
a. Subcutaneously
b. Intramuscularly
c. With a full glass of water
d. Diluted in juice to enhance taste
111. The nurse is preparing to collect a 24-hour urine specimen from the client. Which of the following is
an inaccurate action when collecting the specimen?
a. Asking the client to void, saving the last specimen, and noting the start time
b. Discarding the urine specimen at the start time
c. Placing the specimen on ice or refrigerated
d. Asking the client to void at the end of the collection and adding this to the collection
112. A cystectomy is performed on the client with a diagnosis of bladder cancer and a Kock pouch is
created for a urinary diversion. The nurse is preparing a discharge teaching plan and includes which
of the following in the plan?
a. External pouch and application care
b. Technique of catheterization
c. Proper administration of prophylactic antibiotics
d. Dietary restrictions
113. The nurse is caring for the client with acute glomerulonephritis. The nurse instructs the nursing
assistant to do which of the following in the care of the client?
a. Monitor the client’s temperature every 2 hours
b. Remove the water pitcher from the bedside
c. Assist the client to ambulate frequently
d. Encourage a diet that is high in protein
114. The client is having difficulty coughing and deep breathing because of pain after a nephrectomy.
Which action by the nurse would be least helpful in promoting optimal respiratory function?
a. Administering pain medication only before ambulation
b. Encouraging use of incentive spirometer hourly
c. Assisting the client to splint the incision during respiratory exercise
d. Offering PRN pain medication every 4 hours when due
115. The client with a bladder injury has had a surgical repair of the injured area and placement of a
suprapubic catheter. The nurse plans to do which of the following to prevent complications of this
procedure?
a. Monitor urine output every shift
b. Encourage a high oral intake of fluids
c. Ensure that the catheter tubing is not kinked
d. Measure specific gravity once a shift
116. The client is about to begin hemodialysis. Which of the following measures would the nurse avoid in
the care of the client?
a. Giving he client a mask to wear during connection to the machine
b. Wearing full protective clothing such as goggles, mask, gloves, and apron
c. Covering the connection site with a bath blanket to enhance extremity warmth
d. Using sterile technique for needle insertion
117. The nurse is preparing to suction fluids from a client with a tracheosttomy tube and gathers the
supplies needed for the procedure. Which of the following is the initial nursing action?
a. Set the suction pressure range at 150 mm Hg
b. Hyperoxygenate the client
c. Place the catheter into the tracheostomy tube
d. Apply suction on the catheter and insert it into the tracheostomy tube
118. The nurse is preparing to perform an abdominal examination on a client. The nurse would place the
client in which of the following positions for this examination?
a. Supine with the head raised slightly and the knees slightly flexed
b. Semi fowler with the head raised 45 degrees and the knees flat
c. Sims’ position
d. Supine with the head and feet flat
119. The nurse is explaining an upper gastrointestinal series to a client and provides the client with the
preprocedure and postprocedure instructions. The nurse informs the client that following this
procedure to expect that the stools will remain white for
a. 1 week
b. 6 hours
c. 8 hours
d. 1 to 2 days
120. The nurse in the neurological unit is caring for a client who was in a motor vehicle accident and
sustained a blunt head injury. On assessment of the client the nurse notes the presence of bloody
drainage from the nose. Which nursing action is most appropriate?
 a. Insert nasal packing
b. Document the findings
c. Monitor the client’s blood pressure and monitor for signs of increased intracranial pressure
d. Contact the physician
121. A nurse is administering senna(senokot) to an older client to treat constipation. The client’s spouse
asks the nurse how the medication works. The nurse incorporates which of the following information
in formulating a reply?
a. Senna lines the wall of the bowel
b. Senna adds fiber and bulk to the stool
c. Senna increases peristalsis
d. Senna stimulates the vagus nerve to improve bowel tone
122. The nurse has just given a client dose of an as-needed medication called loperamide (Imodium). The
nurse documents in the client’s record that the client received this medication for complaints of
a. Tarry stools
b. Abdominal pain
c. Constipation
d. Diarrhea
123. The physician has told the client to take psyllium (Metamucil) daily. The nurse teaches the client to
take this medication with
a. Gelatin, applesauce, or pudding
b. Two glasses of liquid
c. A multivitamin and mineral supplement
d. A dose of antacid
124. The client has an order for magnesium citrate to prevent constipation following barium studies of the
gastrointestinal tract. The nurse administers the magnesium citrate
a. With a full glass of water
b. With fruit juice only
c. After it is chilled in the refrigerator
d. At room temperature
125. Timolol (timoptic) ophthalmic drops have been prescribed for a client with primary open-angle
glaucoma. The client asks the nurse how this medication works. The nurse tells the client that the
medication lowers intraocular pressure by
a. Reducing intracranial pressure
b. Increasing contractions of the ciliary muscle
c. Constricting the pupil
d. Reducing the production of aqueous humor