1.
Which of the following
connective tissue disorders is
characterized by insoluble
collagen being formed and
accumulating excessively in the
tissues?
A Rheumatoid arthritis
B Scleroderma
C Systemic lupus
erythematosus
D Polymyalgia rheumatic
2. Helen, a client with myasthenia
gravis, begins to experience
increased difficulty in
swallowing. To prevent aspiration
of food, the nursing action that
would be most effective would
be to:
A Assess her respiratory
status before and after meals
B Change her diet order
from soft foods to clear liquids
C Coordinate her meal
schedule with the peak effect
of her medication
D Place an emergency
tracheostomy set in her room
3. After Billroth II Surgery, the client
developed dumping syndrome.
Which of the following should the
nurse exclude in the plan of
care?
A Reduce the amount of
simple carbohydrate in the diet
B Sit upright for at
least 30 minutes after meals
C Eat small meals every
2-3 hours
D Take only sips of H2O
between bites of solid food
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
B Sodium
C Calcium
D Magnesium
5. A Sengstaken-Blakemore tube is
inserted in the effort to stop the
bleeding esophageal varices in a
patient with complicated liver
cirrhosis. Upon insertion of the
tube, the client complains of
difficulty of breathing. The first
action of the nurse is to:
A Notify the MD
B Monitor VS
C Encourage him to take
deep breaths
D Deflate the
esophageal balloon
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 Encourage the guest to
eat some baked macaroni
B Offer the guest a cup of
coffee
C Give the guest a
glass of orange juice
D Call the guests
personal physician
7. Included in the plan of care for
the immediate post-gastroscopy
period will be:
A Assess for pain and
medicate as ordered
B Assess gag reflex
prior to administration of
fluids
C Maintain NGT to
intermittent suction
D Measure abdominal
girth every 4 hours
8. A client has Gastroesophageal
Reflux Disease (GERD). The
nurse should teach the client
that after every meals, the client
should
A Rest in sitting
position
B Lie down at least 30
minutes
C Drink plenty of water
D Take a short walk
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 Complete A.M. care
quickly as possible when
necessary
B Reassure him that the
nurses will not hurt him
C Let him perform his
own activities of daily living
D Handle him gently when
assisting with required care
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 Change the patients
position.
B Check the patency of
the NGT for any obstruction
C Administer the
prescribed antiemetic.
D Call the physician
immediately
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
B Cardiac glycoside
C Diuretic
D 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 A dandruff shampoo
twice daily
B Not allowing the client
to use a hat or scarf
C Avoiding washing off
the target's marks
D A scalp ointment to
prevent dryness
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 diagnosis is
acute myocardial infarction (MI).
Immediate admission orders
include oxygen by nasal cannula
at 4L/minute, blood work, a chest
radiograph, a 12-lead
electrocardiogram (ECG) and 2
mg of morphine sulfate given
intravenously. The nurse should
first:
A obtain a blood work
B administer the
morphine
C order the chest
radiograph
D obtain a 12 lead ECG
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
B Hourly urine output
C Able to sips clear liquid
D Able to turn side to side
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 I am allowed to put
40% of my weight on my
right leg
B I am allowed to put
10% of my actual weight on my
right leg
C I am not allowed to let
my fractured leg touch the floor
D I should not bear
weight on my fractured leg
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
B Dysphagia
C Stomatitis
D 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
B LDH
C AST
D 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.
B Long term treatment
will prevent future seizures
C The seizure may or
may not mean your child has
epilepsy.
D Do not worry. Epilepsy
can be treated with medications
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
B Semi-fowlers position
C Dorsal recumbent
position
D 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 water-
seal chamber, the nurse
should
A Recognize the system is
functioning correctly
B Check the system for
air leaks
C Strip the chest tube
catheter
D Decrease the amount of
suction pressure
21. Karina a client with myasthenia
gravis is to receive
immunosuppressive therapy. The
nurse understands that this
therapy is effective because it:
A Decreases the
production of auto antibodies
that attack the acetylcholine
receptors.
B Promotes the
removal of antibodies that
impair the transmission of
impulses
C Inhibits the breakdown
of acetylcholine at the
neuromuscular junction.
D Stimulates the
production of acetylcholine at
the neuromuscular junction.
22. Which of the following
statements reflect nursing
 interventions in the care of the
patient with osteoarthritis?
A Provide an analgesic
after exercise.
B Encourage weight
loss and an increase in
aerobic activity.
C Avoid the use of topical
analgesics.
D Assess for the
gastrointestinal complications
associated with COX-2 inhibitors
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 Does the pain feel like
the muscle was stretched?
B Is the pain dull ache?
C Does the discomfort
feel like a cramp?
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 Surgical treatment is
necessary
B No treatment is
necessary at this time
C This result indicates
gastric cancer caused by the
organism
D Treatment will
include Ranitidine and
Antibiotics
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 Apply a heating pad to
the involved site.
B Provide active range-of-
motion exercises to both legs at
least twice every shift.
C Elevate the clients legs
90 degrees.
D Instruct the client
about the need for bed rest.
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 better
forliver healing.
B Because of portal
hyperemesis, the blood flows
around the liver and ammonia
made from protein collects in the
brain causing hallucinations.
C The liver heals better
with a high carbohydrates diet
rather than protein.
D The liver cannot rid
the body of ammonia that is
made by the breakdown of
protein in the digestive
system.
27. Nurse Perry is evaluating the
renal function of a male client.
After documenting urine volume
and characteristics, Nurse Perry
assesses which signs as the best
indicator of renal function.
A Pulse rate
B Blood pressure
C Consciousness
D Distension of the
bladder
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 The illness is usually
associated with chronic
respiratory infections
B The disease is easily
transmissible in schools and
camps
C It is not "caught" but
is a response to a previous B-
hemolytic strep infection
D AGN is a streptococcal
infection that involves the kidney
tubules
29. The nurse is planning care for a
client during the acute phase of
a sickle cell vaso-occlusive crisis.
Which of the following actions
would be most appropriate?
A Administer analgesic
therapy as ordered
B Fluid restriction 1000cc
per day
C Encourage increased
caloric intake
D Ambulate in hallway 4
times a day
30. Which description of pain would
be most characteristic of a
duodenal ulcer?
A Sharp pain in the
epigastric area that radiates to
the right shoulder
B Gnawing, dull,
aching, hungerlike pain in
the epigastric area that is
relieved by food intake
C A sensation of painful
pressure in the midsternal area
D RUQ pain that increases
after meal
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 Meat loaf and
strawberries
B Meat loaf and coffee
C Tomato soup and
buttered bread
D Tomato soup and apple
pie
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
B Fatigue
C Hypocalcemia
D advanced breast cancer
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 It inactivates thrombin
that forms and dissolves existing
thrombi.
B It prevents
conversion of factors that
are needed in the formation
of clots.
C It dissolves existing
thrombi.
D It interferes with
vitamin K absorption
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
B Peritonitis
C Chrons disease
D Diverticulitis
35. What instructions should the
client be given before
undergoing a paracentesis?
A Strict bed rest following
procedure
B NPO 12 hours before
procedure
C Empty bladder before
procedure
D Empty bowel before
procedure
36. Which of the drug of choice for
pain controls the patient with
acute pancreatitis?
A Codeine
B NSAIDS
C Morphine
D Meperidine
37. Days after abdominal surgery,
the clients wound dehisces. The
safest nursing intervention when
this occurs is to
A Approximate the wound
edges with tapes
B Cover the wound
with sterile, moist saline
dressing
C Irrigate the wound with
sterile saline
D Hold the abdominal
contents in place with a sterile
gloved hand
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 Risk of the procedure
with his other injuries
B Presence of
abdominal drains for several
days after surgery
C Complete safety of the
procedure
D Expectation of
postoperative bleeding
39. A 3 year-old had a hip spica cast
applied 2 hours ago. In order to
facilitate drying, the nurse
should
A Use a heat lamp to
reduce the drying time
B Expose the cast to air
and turn the child frequently
C Turn the child as little as
possible
D Handle the cast with the
abductor bar
40. What would be the primary goal
of therapy for a client with
pulmonary edema and heart
failure?
A Enhance comfort
B Improve respiratory
status
C Peripheral edema
decreased
D Increase cardiac
output
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
B Let the client raise
his forearm and monitor for
flexion of the biceps
C Have the client spread
all the fingers wide and resist
pressure.
D Have the client grasp
the nurses hand while noting the
clients strength of the first and
second fingers
42. At a senior citizens meeting a
nurse talks with a client who has
diabetes mellitus Type 1. Which
 statement by the client during
the conversation is most
predictive of a potential for
impaired skin integrity?
A "I give my insulin to
myself in my thighs."
B "Here are my up and
down glucose readings that I
wrote on my calendar."
C "Sometimes when I
put my shoes on I don't know
where my toes are."
D "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 Administration of
thyroid hormone will prevent
problems
B Physical
growth/development will be
delayed
C They can expect the
child will be mentally retarded
D This rare problem is
always hereditary
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
B Continue observing for
dyspnea and crepitus
C Encourage frequent
coughing and deep breathing
D Turn him from side to
side at least every 2 hours
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 Irrigate the NGT with 50
cc of sterile
B Discontinue the low-
intermittent suction
C Notify the MD of your
findings
D Reposition the NGT
by advancing it gently NSS
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 Inspiratory stridor
with a brassy cough
B Shallow respirations
C Decreased aeration in
lung fields
D Diffuse expiratory
wheezing
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 abdominal striae and
ankle enlargement
B large thighs and upper
arms
C posterior neck fat
pad and thin extremities
D pendulous abdomen
and large hips
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
B Airway
C Level of consciousness
D 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 Place sterile gauze
between the affected digits
B Wrap the affected
extremity in a blanket and
apply moist heat
C Rewarm the extremity
with controlled and rapid
rewarming until the injured part
flushes
D Elevate the affected
extremity
50. Which type of jaundice in adults
is the result of increased
destruction of red blood cells?
A Non-obstructive
B Hemolytic
C Hepatocellular
D 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
B 8 minims
C 15 minims
D 10 minims
52. Which of the following stage the
carcinogen is irreversible?
A Initiation stage
B Progression stage
C Promotion stage
D 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:
A Using the trapeze
frequently for pull-ups to
strengthen the biceps muscles
B Sitting up at the edge of
the bed to help strengthen back
muscles
C Doing isometric
exercises on the unaffected leg
D Exercising the
triceps, finger flexors, and
elbow extensors
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
B Wheezes
C Crackles
D 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 Alteration in tissue
perfusion
B Impaired social
interaction
C Pain
D Alteration in body
image
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 A sedentary 65 year
old female who smokes
cigarettes
B A 25 year old female
who jogs
C A 36 year old male who
has asthma
D A 70 year old male who
consumes excess alcohol
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 Skin warm to touch and
normally colored
B Slight swelling of fingers
of right hand
C Client reports
prickling sensation in the
right hand
D Capillary refill of fingers
on right hand is 3 seconds
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 Concurrently used with
topical antimicrobials
C Debride necrotic
epithelium
D Be sutured in place for
better adherence
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
B Supine position
C Sims position
D Semi-fowlers position
60. The observation that indicates a
desired response to
thoracostomy drainage of a
client with chest injury is:
A Increased respiratory
rate
B Increased breath
sounds
C Constant bubbling in
the drainage chamber
D Crepitus detected on
palpation of chest
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
B Pain in the Labium
C Suprapubic area
D Right or left
costovertebral angle
62. After gastroscopy, an adaptation
that indicates major complication
would be:
A Abdominal distention
B Nausea and vomiting
C Difficulty in swallowing
D 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 Milk the tube toward
the collection container as
ordered
B Arrange for a stat Chest
x-ray film.
C Prepare for chest tube
removal
D Clamp the tube
immediately
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
C Apple juice
D Whole wheat bread
65. An early finding in the EKG of a
client with an infarcted
myocardium would be:
A Elevated ST
segments
B Disappearance of Q
waves
C Absence of P wave
D 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 Tell the client to
schedule an appointment with a
hematologist
B Tell the client to call an
ambulance and go to the
emergency department
immediately
C Schedule a repeat
Hemoglobin and Hematocrit in 1
month
D Ask the client if he
has noticed any bleeding or
dark stools
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 gradually rises, I will
consult my physician.
B I will weigh everyday
and I will log it in a
notebook. I will call my
physician whenever I gain 2
lbs or more in a day without
changing my eating habits.
C 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
dont get too much of it in my
diet.
68. Which client is at highest risk for
developing a pressure ulcer?
A 23 year-old in traction
for fractured femur
B 72 year-old with
peripheral vascular disease, who
is unable to walk without
assistance
C 30 year-old who is
comatose following a ruptured
aneurysm0
D 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
B Deeply for 3-4
seconds
C 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 it affects both normal
and tumor cells
B it is a local treatment
affecting only tumor cells
C it has been proven as a
complete cure for cancer
D it is often used as a
palliative measure
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 Extensive peripheral
edema
B Crushing chest pain
C Jugular vein distention
D 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
B Symmetrical gluteal
folds
C Unequal leg length
D Diminished femoral
pulses
73. Most skin conditions related to
HIV disease may be helped
primarily by:
A improvement of the
patient's nutritional status.
B highly active
antiretroviral therapy (HAART).
C low potency topical
corticosteroid therapy.
D 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."
B "Lactation should be
delayed until the "real milk" is
secreted."
C "Nursing will help
contract the uterus and
reduce your risk of
bleeding."
D "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.
76. Which of the following is a
characteristic sign of SLE?
A. Rash on the face
across the bridge of
the nose and cheeks
B. Fatigue
C. Fever
D. Elevated rbc count
77. A child is scheduled for
tonsillectomy. Which of the following
presents the highest risk of aspiration
during surgery?
A. Difficulty swallowing
B. Presence of loose teeth
C. Bleeding during surgery
D. Exudate in the throat
area
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?
A. Call the physician
B. Put on lateral side and lower down the
head
C. Stop the IV
D. Take the vital signs and call the
supervisor
A client with cirrhosis of the liver is
scheduled for a liver biopsy. How will the
nurse position the client after the
procedure?
A. Trendelenburg position
B. Right side lying
C. Semi-Fowlers
A 50-year-old client is receiving radiation
therapy in the chest wall for breast
cancer. She calls her health care provider
and report that she has pain while
swallowing and burning and tightness in
her chest. Which of the following
complications of radiation therapy is most
likely responsible for her symptoms?
A. Hiatal hernia
B. Stomatitis
C. Radiation enteritis
D. Esophagitis
A pregnant client has just given birth
following a cesareanm delivery. While the
client was transported to the recovery
room, the nurse assesses the client and
suspects the client of having pulmonary
embolism, if which of the following clinical
manifestation is present?
A. Bradypnea
B. Bradycardia
C. Dyspnea
D. Decreased respirations