Professional Documents
Culture Documents
1. A client to come to the walk-in clinic with complaints of abdominal pain and diarrhea. The nurse takes the client’s vital
signs. The nurse is implementing which phase of the nursing process?
a. Assessment b. Diagnosis c. Planning d. Implementation
2. The nurse is measuring the client’s urine output and straining the urine to assess for stones. Which of the following should
the nurse record as objective data?
a. The client is complaining of abdominal pain.
b. The client’s urine output was 450 mL.
c. The client stated, “I didn’t see any stones in my urine.”
d. The client stated, “I feel like I have passed a stone.”
3. When evaluating an adult client’s blood pressurereading, the nurse considers the client’s age. This is an example of which
of the following?
a. Comparing data against standards c. Determining gaps in the data
b. Clustering data d. Differentiating cues and inferences
4. Which of the following demonstrates that the nurse Is participating in critical thinking?
a. The nurse admits he/she does not know how to do a procedure and requests help.
b. The nurse makes his/her point with clever and persuasive remarks to win an argument.
c. The nurse accepts without question the values acquired in nursing school.
d. The nurse finds a quick answer, even to complex question.
5. What is missing from the following outcome goal written in a care plan by the nurse? “The client will transfer from bed to
chair with two assists.”
a. Client behavior c. Performance criteria
b. Conditions or modifiers d. Target time
6. The nurse documents the following outcome goal on the care plan: “Anxiety will be relieved within20 to 40 minutes
following administration of lorazepam (Ativan).” The nurse has just performed an activity in which of the following phases
of the nursing process?
a. Assessment c. Implementation
b. Planning d. Evaluation
7. When the client resists taking a liquid medication that is essential to treatment, the nurse demonstrates critical thinking by
doing which of the following first?
a. Omitting this dose of medication and waiting until the client is more cooperative
b. Suggesting the medication can be diluted in a beverage
c. Asking the nurse manager about how to approach the situation
d. Notifying the physician that the nurse was unable to give the client this medication
8. The nurse reassesses a client’s anxiety level 30 minutes after administering lorazepam (Ativan). This is an example of
which type of evaluation?
a. Ongoing b. Intermittent c. Terminal d. Routine
9. Which nurse is demonstrating the assessment relieved phase of the nursing process?
a. The nurse who observes that the client’s pain was with pain medication
b. The nurse who changes the bed linens after the client is incontinent of feces
c. The nurse who asks the client how much lunch was eaten
d. The nurse who works with the client to set desired outcome goals
10. The client states, “My chest hurts and my left arm feels numb.” What is the type and source of this data?
a. Subjective data from a primary source c. Objective data from a primary source
b. Subjective data from a secondary source d. Objective data from a secondary source
11. What is the problem with the following outcome goal, “Client will state pain is less than or equal to a 3 on 0 to 10 pain
scale”?
a. None, goal is written correctly. c. No target time is given.
b. It is not measurable. d. Client behavior is missing.
12. In giving a change-of-shift report, which type of client information given by the nurse is most informative and complete?
a. Vital signs are stable. d. Client voided 250 mL of urine 2 hours after
b. Client is pleasant, alert, and oriented x 3. urinary catheter was removed.
c. The chest x-ray results were negative
13. Twenty minutes after administering a pain medication to the client, the nurse returns to ask if the client’s level of pain has
decreased. The nurse is engaging in which phase of the nursing process?
a. Diagnosing b. Planning c. Implementing d. Evaluating
14. Before palpating the abdomen during an assess ment, the nurse should do which of the following?
a. Put on sterile gloves c. Elevate the client’s head
b. Auscultate bowel sounds d. Personal goals related to health care
15. The nurse would document which of the following in the medical record as objective data obtained during client
assessment?
a. Detailed description of pain in an extremity c. Complaint of numbness of the right hand
b. Loss of hair on bilateral lower legs d. Report of scalp itching each evening
16. The nurse would use which of the following methods of examination to assess for the presence of a bruit in the abdomen?
a. Identify potential or actual health problems c. Assess the client’s response to interventions
b. Perform specialized procedures to maintain d. Intervene to prevent complications
safety
59. The nurse is caring for several clients in the pre- anesthesia room. Of the following client situations, which merits ablative
surgery?
a. Replacing a hip that has degenerative disease c. Removing a diseased party of the kidney
b. Identifying if a tumor is malignant d. Resecting a nerve root
60. A client having surgery has a degree of risk associated with the surgery. Which of the following client-related factors is
responsible for a high degree of risk associated with surgery?
a. Type of institution where surgery is performed c. Average nutritional status
b. Involvement of vital organs d. Little likelihood of complications
61. An infant who is having surgery has a higher risk than an adult. The nurse would interpret that which of the following is
a reason for the increased risk?
a. Decline in functioning c. Increased possibility of hyperthermia
b. Immaturity of vital organs d. Volume of blood fluctuation
62. A preschool child is facing surgery and may have fears related to the surgery. The type of fears the nurse would anticipate
in this child would be which of the following?
a. Being awake during surgery and experiencing c. Not being able to do the things they used to do
pain d. Medical personnel not knowing what they are
b. Looking drastically different after surgery doing
63. A client has just entered the post anesthesia care unit (PACU) from surgery. The postoperative client’s immediate
needs include initial monitoring of which of the following items?
a. Vital signs, level of consciousness, and presence of pain
b. Skin coloring, surgical incision, limb movements
c. Skin temperature, blood pressure, mental status
d. Temperature, emotional status, social support
64. The nurse in the PACU is assessing a postoperative client. Which of the following indicators suggest alteration in tissue
perfusion?
a. Pallor or cyanosis c. Pain in the incision area
b. Difficulty with mobility d. Fluid loss
65. After surgery, the nurse encourages the client to move from side to side at least every two hours. The client questions this
activity. The nurse ex plains this intervention is to do which of thefollowing?
a. Let peristalsis return at a faster rate. d. Let the lungs alternately achieve maximum
b. Lessen muscle weakness. expansion.
c. Increase client’s ability to sleep.
66. The nurse is assessing the client’s surgical wound in the postoperative period. Which finding indicates the first stage of
healing?
a. Inflammation in the wound edges c. Clot binding the wound edges
b. Bleeding around the incision d. Collagen synthesis
67. The nursing team is creating a care plan for a post- operative client. The diagnosis is pain. An appropriate client outcome
for this client would be which of the following?
a. Balanced fluid intake and output c. Absence of nonverbal signs of pain
b. Seeks help as needed d. Performs leg exercises as instructed
68. A client is being admitted to the hospital on the day before a scheduled surgery. Which of the following is the most
appropriate initial question to ask this preoperative client?
a. “Has your doctor talked to you about the type of surgery you are having? What did the doctor say?”
b. “What questions do you have about your surgery?”
c. “What type of surgery are you having and why are you having it done?”
d. “What do you know about what will be done to you?”
69. A pre-surgical client asks the nurse for more information about the advantages of a general anesthetic. The nurse’s
answer would correctly reflect what information?
a. The respiratory and circulatory functions are depressed.
b. The client loses consciousness and does not perceive pain.
c. The anesthetic agent is not rapidly excreted so that the timing of surgery can be adjusted.
d. General anesthesia reduces the chance that the client suffers from amnesia.
70. A benzodiazepine has been administered to a client preoperatively. After the drug has been administered, the nurse
needs to monitor the client for which of the following side effects?
a. Anxiety c. Hypocalcemia
b. Hypotension d. Extrapyramidal reactions
71. A preoperative client has an elevated hemoglobin and hematocrit. What would the nurse suspect regarding the
significance of this increased value?
a. Immune deficiency c. Malignancy
b. Kidney dysfunction d. Dehydration
72. The nurse has completed preoperative teaching to a pregnant woman. During the discussion, the nurse describes the
different types of anesthesia available. Which statement indicates understanding of regional anesthesia?
a. In spinal anesthesia, the anesthetic agent is injected into the subarachnoid space.
b. The anesthetic agent is injected into the dura mater of the spinal cord for epidural anesthesia.
c. The client is sedated and has some awareness of the event.
d. Regional anesthesia produces analgesia and amnesia.
73. The client arrives in the PACU in an unconscious state. In what position is the unconscious client placed in the immediate
postanesthetic stage?
a. Side lying with face slightly down c. Semi-prone position with the head titled to the
b. Side lying with a pillow under the client’s head side
d. Dorsal recumbent with head turned to the side.
74. The client has been in the PACU unit for 1 hour. The client is now groggy but able to respond to voice commands. While
assessing the client, the nurse checks the bedclothes underneath the client. The nurse is assessing:
a. Drainage from the tubes or drains. c. Hemorrhage.
b. Fluid balance. d. Perspiration.
75. A client is in the postoperative stage and the physician has ordered ambulation. The client has shown a difficulty
understanding the necessity for early ambulation. An appropriate nursing diagnosis for this client would be:
a. Self-care deficit. c. Ineffective coping.
b. Knowledge deficit. d. Risk for injury.
76. The nurse is assessing the client on return to thehospital unit from the PACU and notes the pres ence of a drain in the
surgical wound. A family member observes the drain and asks why the tube was left in the wound. The nurse explains
that drains:
a. Allow drainage of excessive serosanguinous fluid and purulent material.
b. Allow healing to occur at a very rapid rate.
c. Have to be shortened to allow healing to occur from the inside out.
d. Have to be connected to suction tubes.
77. A client is being discharged following outpatient surgery. The nurse is providing the caregiver with instructions for wound
care. The nurse would instruct the caregiver to report which of the following findings to the surgeon?
a. Scar formation c. No odor of the wound drainage
b. Increased redness or drainage d. No unusual color of the drainage
78. A nurse is assessing a bedridden client when a large erythemic area is noted on the client’s buttocks. In addiction, the
center of the injury looks like an abrasion with a shallow crater. The nurse would classify this ulcer as which of the
following stages?
a. Stage I b. Stage II c. Stage III d. Stage IV
79. In planning nursing care to prevent pressure ulcers in a bedridden client, the nurse should include which of the following
interventions?
a. Slide the client when turning b. Turn and position the client bid
c. Vigorously massage bony prominences d. Hang a turning schedule at the client’s bedside
with a sign sheet
80. A group of student nurses are discussing techniques for dressing changes. The students make the following comments.
The student who needs to review the skill would be the one who makes which of the following statements?
a. “I will clean the wound from the center out.”
b. “To remove the used dressing, I should wear sterile gloves.”
c. “After I clean the wound, I should do my assessments.”
d. “While irrigating the wound, I can use a catheter, which is placed close to the open area.”
81. A client uses a cane to assist with ambulation. After teaching the client how to use a cane, the client makes the following
statements. Which one indicates the need for additional teaching?
a. (1) “My elbow should be slightly flexed while using the cane.
b. (2) “I should hold the cane on my affected side.”
c. (3) “A walker would be more difficult to use than a cane.”
d. (4) “While walking here in the hospital, socks alone may cause me to slip.”
82. A client has been on bedrest with cervical traction for 2 weeks. The traction is discontinued and the client is to ambulate.
Prior to getting the client out of bed, it is important for the nurse to do which of
a. Raise the head of the bed slowly the following b. Assess lower leg muscle strength
initially? c. Provide client with a cane
d. Get a neck brace for the client
83. A client has a large pressure ulcer on his lower extremity. The nurse instructs the client about nutrients needed for
healing, especially vitamin C and protein. While evaluating intake, the nurse knows that the client is eating an appropriate
diet when the client eats which of the following breakfasts?
a. Coffee, buttered toast with jelly, and bacon c. Pancakes with butter and syrup and hot tea
b. Milk, scrambled eggs, and cantaloupe d. Oatmeal with butter, diet soda, and bacon
84. Which assessment of the immobilized client would prompt the nurse to take further action?
a. Client complaining of fatigue c. White blood cell count of 9.5
b. Urinary output of 50 mL an hour d. Absence of bowel sounds
85. The client is a known diabetic. The nurse administers 20 units NPH insulin IV stat per the physician’s order. Subsequent
to receiving the insulin dose, the client had an anaphylactic reaction and died as a result of receiving the NPH insulin IV
rather than subcutaneous, which is the only appropriate route. What liability is involved in this case?
a. The nurse is not legally liable because the nurse administered the medication as ordered by the physician.
b. Only the physician is liable because the physician wrote the order.
c. The nurse is legally liable for the medications administered even though the order was written incorrectly.
d. The nurse is not legally liable because the nurse gave the correct medication, regardless of the route.
86. While the nurse is administering a client’s dose of nitroglycerin sublingual, the client asks why it is administered
sublingually rather than orally. Which of the following is the best response by the nurse?
a. “It is absorbed more rapidly sublingually than when swallowed.”
b. “It is absorbed more rapidly when swallowed than sublingually.”
c. “The absorptions are the same so it really doesn’t matter.”
d. “Sublingual provides a sustained release of the medication.”
87. The nurse is to administer 25 mg of promethazine (Phenergan) IM to a 150-pound client. The nurse knows that this
medication should be given into a deep large muscle mass. The preferred site of injection for this client would be which of
the following?
a. Deltoid b. Dorsogluteal c. Vastus lateralis d. Ventrogluteal
88. To administer 1 mL of a flu vaccine intramuscularly (IM) to an obese adult in the deltoid area you would use what size
needle?
a. 5/8 inch b. 1/2 inch c. 1 ½ inch d. 3/8 inch
89. You are preparing an IM injection of hydroxyzine(Vistaril) that is especially irritating to subcutaneous tissue. To prevent
“tracking” of the medication and irritation to the tissues, it is best to take which of the following actions?
a. Use a small-gauge needle c. Apply ice to the injection site
b. Adminster at a 45-degree angle d. Use the Z-track technique
90. A pediatric client has been diagnosed with conjunctivitus. The nurse is to administer eye drops four times a day (QID).
The nurse should administer the medication by gently dropping the medication onto which of the following areas?
a. Center of the cornea c. Sclera by the outer canthus
b. Sclera by the inner canthus d. Lower conjunctival sac
91. A client received a sever burn in a house fire. On the second day of hospitalization, the physician orders the client to
receive albumin. The nurse explains to the client that which of the following is the rationale for albumin administration?