1. A nurse applies an ice pack to a client’s leg for 20 minutes. What clinical indicator helps the nurse determine the effectiveness of the treatment?
Local anesthesia
Peripheral vasodilation
Depression of vital signs
Decreased viscosity of blood
2. A client is admitted to the emergency department with a contaminated wound. The client is a poor historian, and the nurse realizes that it is impossible to determine whether the client is immunized against tetanus. Which medication does the nurse expect the health care provider to prescribe because it will produce passive immunity for several weeks with minimal danger of an allergic reaction?
Tetanus toxoid
Equine tetanus antitoxin
Human tetanus antitoxin
Diphtheria, tetanus, pertussis vaccine
3. A nurse is caring for a client on bed rest. How can the nurse system is important for the nurse to consider? help prevent a pulmonary embolus?
Limit the clients fluid intake
Teach the client how to exercise the legs
Encourage use of the incentive spirometer
Maintain the knee gatch position at an angle
4. A nurse is caring for a client with ascites. What does the nurse consider to be the cause of the ascites?
Portal hypotension
Kidney malfunction
Diminished plasma protein level
Decreased production of potassium
5. After abdominal surgery a client reports pain. What action should the nurse take first?
Reposition the client.
Obtain the client’s vital signs.
Administer the prescribed analgesic.
Determine the characteristics of the pain.
6. When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action?
Obtain the vital signs.
Notify the health care provider.
Reinsert the protruding organs using aseptic technique.
Cover the wound with a sterile towel moistened with normal saline.
7. A 70-year-old client with the diagnosis of heart failure and chronic obstructive pulmonary disease (COPD) is admitted to a unit in a long-term care facility for a cardiopulmonary rehabilitation program. Pneumococcal and flu vaccines are administered. The client asks the nurse if the pneumococcal vaccine has to be taken every year like the flu vaccine. How should the nurse respond?
“You need to receive the pneumococcal vaccine every other year.”
“The pneumococcal vaccine should be received in early autumn every year.”
“You should get the flu and pneumococcal vaccines at your annual physical examination.”
“It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose.”
8. A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin?
It stimulates plasma cells directly
A high titer of antibodies is generated
It provides immediate active immunity
A long-lasting passive immunity is produced.
9. A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. What medication does the nurse anticipate will be prescribed for this client?
Vitamin A (Aquasol A)
Cyanocobalamin (Cobex)
Phytonadione (Mephyton)
Ascorbic acid (Ascorbicap)
10. Why are sink faucets in a client’s room considered contaminated?
They are not in sterile areas.
They are opened with dirty hands.
Large numbers of people use them.
Water encourages bacterial growth.
11. A client is receiving an IV infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. What nutritional problem prompts the nurse to notify the health care provider?
Excessive carbohydrate intake
Lack of protein supplementation
Insufficient intake of water-soluble vitamins
Increased concentration of electrolytes in cells
12. A nurse is concerned that a client is at risk for developing hyperkalemia. Which disease does the client have that has caused this concern?
Crohn
Cushing
End-stage renal
Gastroesophageal reflux
13. A client reports severe pain 2 days after surgery. Which initial action should the nurse take after assessing the character of the pain?
Encourage rest.
Obtain the vital signs.
Administer the prn analgesic.
Document the client’s pain response.
14. A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client?
Alkalosis
Renal failure
Hypervolemia
Pulmonary edema
15. A client with hypokalemia is placed on a cardiac monitor to evaluate cardiac activity during IV potassium replacement. Before starting the potassium infusion, what cardiac change is the nurse most likely to identify when observing the monitor?
Lowering of the T wave
Elevation of the ST segment
Shortening of the QRS complex
Increased deflection of the Q wave
16. A nurse in the postanesthesia care unit (PACU) observes that after an abdominal cholecystectomy a client has serosanguineous drainage on the abdominal dressing. What is the next nursing action?
Change the dressing.
Reinforce the dressing.
Replace the tape with Montgomery ties.
Support the incision with an abdominal binder.
17. A nurse is working in a busy emergency department on a hot summer day when four near-drowning victims are admitted. Which near-drowning victim should the nurse assess for signs of hypovolemia?
72-year-old rescued from a lake
2-year-old rescued from a bathtub
50-year-old rescued from the ocean
17-year-old rescued from a backyard pool
18. During admission a client appears anxious and says to the nurse, “The doctor told me I have lung cancer. My father died from cancer. I wish I had never smoked.” What is the nurse’s best response?
“You are concerned about your diagnosis.”
“You are feeling guilty about your smoking.”
“There have been advances in lung cancer therapy.”
“Trust your doctor, who is very competent in treating cancer.”
19. While caring for a client with a portable wound drainage system, a nurse observes that the collection container is half full and empties it. What is the next nursing intervention?
Encircle the drainage on the dressing.
Irrigate the suction tube with sterile saline.
Clean the drainage port with an alcohol wipe.
Compress the container before closing the port.
20. A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive?
Hepatitis C (HepC)
Influenza type B (HIB)
Measles, mumps, rubella (MMR)
Diphtheria, tetanus, pertussis (TDaP)
21. A client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation?
The dosage is kept at a minimum.
Only a small part of the body is irradiated.
The client’s physical condition is not a risk factor.
Nutritional environment of the affected cells is a risk factor.
22. A client who had abdominal surgery is receiving patient-controlled analgesia (PCA) intravenously to manage pain. The pump is programmed to deliver a basal dose and bolus doses that can be accessed by the client with a lock-out time frame of 10 minutes. The nurse assesses use of the pump during the last hour and identifies that the client attempted to self-administer the analgesic 10 times. Further assessment reveals that the client is still experiencing pain. What should the nurse do first?
Monitor the client’s pain level for another hour.
Determine the integrity of the intravenous delivery system.
Reprogram the pump to deliver a bolus dose every 8 minutes.
Arrange for the client to be evaluated by the health care provider.
23. A client’s IV infusion infiltrates. What does the nurse identify as the most likely cause of the infiltration?
Excessive height of the IV bag
Failure to secure the catheter adequately
Contamination during the catheter insertion
Infusion of a chemically irritating medication
24. A nurse checking the perineum of a client with a radium implant for cervical cancer observes the packing protruding from the vagina. Why must the nurse notify the health care provider to remove it immediately?
The radioactive packing will injure healthy tissue.
Removal of the packing will prevent excessive blood loss.
The exposure of radium to the environment will diminish its effectiveness.
Removal of the packing will minimize life-threatening contact with the radiation.
25. A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing inter-vention may prevent an accumulation of secretions?
Postural drainage
Cupping the chest
Nasotracheal suctioning
Frequent changes of position
26. Radium inserted in the vagina of a client is now being removed. What safety precaution should the nurse employ when assisting with the radium removal?
Clean the radium in ether or alcohol.
Wear foil-lined rubber gloves while handling the radium.
Ensure that long forceps are available for removing the radium.
Document how long the radium was in place and when it was removed.
27. Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus?
Decreased blood supply
Impaired neural functioning
Perforation of the bowel wall
Obstruction of the bowel lumen
28. A client was treated with a radium implant for cancer of the cervix. What information is important for the nurse to teach the client when giving discharge instructions?
Limit daily fluid intake.
Return for follow-up care.
Continue a low-residue diet.
Take daily mineral supplements.
29. An emaciated older adult with dementia develops a large pressure ulcer after refusing to change position for extended periods of time. The family blames the nurses and threatens to sue. What should be considered when deciding who is to blame?
The client should have been turned regularly.
Older clients frequently develop pressure ulcers.
The nurse is not responsible to the client’s family.
Nurses should respect a client’s right not to be moved.
30. A nurse is caring for a client with an impaired immune system. Which blood protein associated with the immune system is important for the nurse to consider?
Albumin
Globulin
Thrombin
Hemoglobin
31. What is the maximum length of time a nurse should allow an IV bag of solution to infuse?
6 hours
12 hours
18 hours
24 hours
32. A client has seeds containing radium implanted in the pharyngeal area. What should the nurse include in the clients plan of care?
Have the client void every 2 hours.
Maintain the client in an isolation room.
Allow time for the client to verbalize feelings.
Wear 2 pairs of gloves when touching the client during care.
33. The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms?
Soap
Time
Water
Friction
34. A nurse is caring for a client who is receiving an IV infusion. What should the nurse do first if the IV infusion infiltrates?
Elevate the IV site.
Discontinue the infusion.
Attempt to flush the tubing.
Apply a warm, moist compress.
35. An arterial blood gas report indicates the client’s pH is 7.25, Pco2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
36. A nurse inadvertently allows an IV solution containing potassium to infuse too rapidly. The health care provider prescribes insulin added to a 10% dextrose in water solution. What is the rationale for the order?
Potassium moves into body cells with glucose and insulin.
Increased insulin accelerates excretion of glucose and potassium.
Glucose with insulin increases metabolism, which accelerates potassium excretion.
Increased potassium causes a temporary slowing of pancreatic production of insulin.
37. A nurse is caring for a client with ascites who is receiving albumin. What infusion rate and oral fluid intake should the nurse expect to have the greatest therapeutic effect?
Slow IV rate and liberal fluid intake
Slow IV rate and restricted fluid intake
Rapid IV rate and withheld fluid intake
Rapid IV rate and moderate fluid intake
38. A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate?
Core rewarming with warm fluids
Ambulation to increase metabolism
Frequent oral temperature assessments
Gastric tube feedings to increase fluid volume
39. What is the priority nursing intervention for a client during the immediate postoperative period?
Monitoring vital signs
Observing for hemorrhage
Maintaining a patent airway
Recording the intake and output
40. What clinical indicator is important for the nurse to assess after a client undergoes a submucosal resection (SMR) for a deviated septum?
Occipital headache
Periorbital crepitus
Expectoration of blood
Changes in vocalization
41. A client who is to receive radiation therapy for cancer says to the nurse, “My family said I will get a radiation burn.” What is the nurse’s best response?
“Your skin will look like a sunburn.”
“A localized skin reaction usually occurs.”
“A daily application of an emollient will prevent a burn.”
“Your family must have had experience with radiation therapy.”
42. A plan of care for a client with type 1 diabetes includes teaching how to self-administer insulin, adjust insulin dosage, select appropriate food on the ordered diet, and test the serum for glucose. The client demonstrates achievement of these skills and is discharged 5 days following admission. What is the legal implication in this situation?
The nurse was functioning as a health teacher.
A home health care nurse should have done the health teaching in the client’s home.
Family members also should have been taught how to administer insulin and perform other aspects of care.
Health care providers are responsible for this care, and the nurse should have cleared the teaching plan before its implementation.
43. A nurse is caring for a client who is receiving serum albumin. What therapeutic effect does the nurse anticipate?
Improved clotting of blood
Formation of red blood cells
Activation of white blood cells
Maintenance of oncotic pressure
44. A nurse adds 20 mEq of potassium chloride to the IV solution of a client with diabetic ketoacidosis. What is the primary purpose for administering this drug?
Treat hyperpnea
Prevent flaccid paralysis
Replace excessive losses
Treat cardiac dysrhythmias
45. In what position should the nurse place a client recovering from general anesthesia?
Supine
Side-lying
High-Fowler
Trendelenburg
46. A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have?
7.20
7.35
7.45
7.48
47. During the initial physical assessment of a newly admitted client with a pressure ulcer, a nurse observes that the clients skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse’s actions adequate?
The nurse should have instituted a plan to increase activity.
The nurse provided supportive nursing care for the well-being of the client.
Debridement of the pressure ulcer should have been done before the dressing was applied.
Treatment should not have been instituted until the health care provider’s orders were received.
48. What clinical finding indicates to a nurse that a client may have hypokalemia?
Edema
Muscle spasms
Kussmaul breathing
Abdominal distention
49. For what clinical indicator should a nurse assess a client who is having a gastric lavage?
Decreased serum pH2
Increased serum oxygen level
Increased serum bicarbonate level
Decreased serum osmotic pressure
50. A nurse is caring for a client who has a radium implant for cancer of the cervix. What is the priority nursing action?
Store urine in lead-lined containers.
Restrict visitors to a ten-minute stay.
Wear a lead-lined apron when giving care.
Avoid giving injections in the gluteal muscle.
51. A client has corrective surgery for a bladder laceration. What nursing intervention takes priority during this client’s postoperative period?
Turning frequently
Raising side rails on the bed
Providing range-of-motion exercises
Massaging the back three times a day
52. An unresponsive older adult is admitted to the emergency department on a hot, humid day. The initial nursing assessment reveals hot, dry skin; a respiratory rate of 36 breaths/ min; and a heart rate of 128 beats/min. What is the initial nursing action?
Offer cool fluids.
Suction the airway.
Remove the clothing.
Prepare for intubation.
53. When a disaster occurs, the nurse may have to treat mass hysteria first. Which response indicates that an individual should be cared for first?
Panic
Coma
Euphoria
Depression
54. A client who was exposed to hepatitis A asks why an injec-tion of gamma globulin is needed. Before responding, what should the nurse consider about how it provides passive immunity?
It increases production of short-lived antibodies
It accelerates antigen-antibody union at the hepatic sites
The lymphatic system is stimulated to produce anti-bodies
The antigen is neutralized by the antibodies that it supplies
55. A client’s serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first?
Call the laboratory to repeat the test.
Take vital signs and notify the health care provider.
Inform the cardiac arrest team to place them on alert.
Take an electrocardiogram and have lidocaine available.
56. A spouse spends most of the day with a client who is receiving chemotherapy for inoperable cancer. The spouse asks the nurse, “What can I do to help?” How can the nurse support the client’s spouse?
Assist the couple to maintain open communication.
Offer the couple a description of the disease process.
Instruct the spouse about the action of the medications.
Meet privately with the spouse to explore personal feelings.
57. A nurse is caring for a client who had an insertion of radium for cancer of the cervix. For what radium reaction should the nurse assess the client?
Pain
Nausea
Excoriation
Restlessness
58. Immediately after receiving spinal anesthesia a client devel-ops hypotension. To what physiologic change does the nurse attribute the decreased blood pressure?
Dilation of blood vessels
Decreased response of chemoreceptors
Decreased strength of cardiac contractions
Disruption of cardiac accelerator pathways
59. A peripheral nerve or dorsal column stimulator is implanted to allay a client’s intractable pain. What discharge instructions should the nurse give the client after surgery?
Tub baths should be avoided.
Analgesics will no longer be necessary.
The transmitter must be worn externally.
The transmitter will interfere with electronic devices.
60. A client is hospitalized for treatment of severe hypertension. Captopril (Capoten) and alprazolam (Xanax) are prescribed. The client quickly finds fault with the therapeutic regimen and nursing care. What does the nurse determine as the probable cause of this behavior?
Denial of illness
Fear of the health problem
Response to cerebral anoxia
Reaction to the antihypertensive drug
61. After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation to the operative site. For which most critical reaction to the radiation should the nurse assess the client?
Dry mouth
Skin reactions
Mucosal edema
Bone marrow suppression
62. A client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve pathway. When operating the TENS unit, which nursing action is appropriate?
Maintain the settings programmed by the health care provider.
Turn the machine on several times a day for ten to twenty minutes.
Adjust the dial on the unit until the client states the pain is relieved.
Apply the color-coded electrodes on the client where they are most comfortable.
63. A 2g sodium diet is prescribed for a client with stage 2 hypertension, and the nurse teaches the client the rationale for this diet. The client reports distaste for the food. The primary nurse hears the client request that the family “bring in a ham and cheese sandwich and fries.” What is the mosteffective nursing intervention?
Discuss the diet with the client and family
Tell the client why salty foods should not be eaten
Explain the dietary restriction to the client’s visitors
Ask the dietitian to teach the client and family about sodium restrictions.
64. A nurse is applying a dressing to a client’s surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated?
Dialysis
Osmosis
Diffusion
Capillarity
65. A client’s arterial blood gas report indicates the pH is 7.52, Pco2 is 32 mm Hg, and HCO3 is 24 mEq/L. What does the nurse identify as a possible cause of these results?
Airway obstruction
Inadequate nutrition
Prolonged gastric suction
Excessive mechanical ventilation
66. A nurse is preparing to change a client’s dressing. What is the reason for using surgical asepsis during this procedure?
Keeps the area free of microorganisms
Confines microorganisms to the surgical site
Protects self from microorganisms in the wound
Reduces the risk for growing opportunistic microorganisms
