1. While awaiting the biopsy report before removal of a tumor, the client reports being afraid of a diagnosis of cancer. How should the nurse respond?
“Worrying is not going to help the situation.”
“Let’s wait until we hear what the biopsy report says.”
“It is very upsetting to have to wait for a biopsy report.”
“Operations are not performed unless there are no other options.”
2. A nurse explains to an obese client that the rapid weight loss during the first week after initiating a diet is because of fluid loss. The weight of extracellular body fluid is approximately 20% of the total body weight of an average individual. Which component of the extracel-lular fluid contributes the greatest proportion to this amount?
Plasma
Interstitial
Dense tissue
Body secretions
3. A client with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage?
Accept the client’s crying.
Encourage unrestricted family visits.
Explain details of the care being given.
Stay nearby without initiating conversation.
4. A physically ill client is being verbally aggressive to the nursing staff. What is the most appropriate initial nursing response?
Accept the client’s behavior.
Explore the situation with the client.
Withdraw from contact with the client.
Tell the client the reason for the staffs actions.
5. A client is hospitalized with a tentative diagnosis of pancreatic cancer. On admission the client asks the nurse, “Do you think I have anything serious, like cancer?” What is the nurse’s best reply?
“What makes you think you have cancer?”
“I don’t know if you do; let’s talk about it.”
“Why don’t you discuss this with your health care provider?”
“You needn’t worry now; we won’t know the answer for a few days.”
6. A client asks the nurse, “Should I tell my partner that I just found out I’m HIV positive?” What is the nurse’s most appropriate response?
“This is a decision you alone can make.”
“Do not tell your partner unless asked.”
“You are having difficulty deciding what to say.”
“Tell your partner that you don’t know how you became sick.”
7. After being medicated for anxiety, a client says to a nurse, “I guess you are too busy to stay with me.” How should the nurse respond?
“I’m so sorry, but I have to see other clients.”
“I have to go now, but I will come back in ten minutes.”
“You’ll be able to rest after the medicine starts working.”
“You’ll feel better after I’ve made you more comfortable.”
8. What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess?
Rapid, thready pulse
Distended jugular veins
Elevated hematocrit level
Increased serum sodium level
9. A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse’s best intervention?
Attempt to identify the client’s concerns.
Reassure the client that the surgery is routine.
Report the client’s anxiety to the health care provider.
Provide privacy by pulling the curtain around the client.
10. A client reports vomiting and diarrhea for 3 days. What clinical finding will most accurately indicate that the client has a fluid deficit?
Presence of dry skin
Loss of body weight
Decrease in blood pressur
Altered general appearance
11. A pediatric nurse receives a subpoena in a court case involving a child. Before appearing in court, what should the nurse review in addition to the State Nurse Practice Act and the ANA Code for Nurses?
Nursing’s Social Policy Statement
State law regarding protection of minors
ANA Standards of Clinical Nursing Practice
References regarding a child’s right to consent
12. A client who was admitted to the hospital with metastatic cancer has a temperature of 100.4° F, a distended abdomen, and abdominal pain. The client asks the nurse, “Do you think that I’m going to have surgery?” How should the nurse respond?
“You seem concerned about having surgery.”
“Some people with your problem do have surgery.”
“I’ll find out for you. Your record will show if surgery is scheduled.”
“I don’t know about any surgery. You’ll have to ask your health care provider.”
13. A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbon-ate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes?
Skeletal and nervous
Circulatory and urinary
Respiratory and urinary
Muscular and endocrin
14. What type of interview is most appropriate when a nurse admits a client to a clinic?
Directive
Exploratory
Problem solving
Information giving
15. A client has been told to stop smoking by the health care provider. The nurse discovers a pack of cigarettes in the client’s bathrobe. What is the nurse’s initial action?
Notify the health care provider.
Report this to the nurse manager.
Tell the client that the cigarettes were found.
Discard the cigarettes without commenting to the client.
16. A nurse administers an intravenous solution of 0.45% sodium chloride. In what category of fluids does this solution belong?
Isotonic
Isomeric
Hypotonic
Hypertonic
17. A nurse is responding to the needs of victims at a collapsed building. What principle guides the nurse’s priorities during this disaster?
Hemorrhage necessitates immediate care to save the most lives.
Those requiring minimal care are treated first so they can help others.
Victims with head injuries are treated first because the care is most complex.
Children receive the highest priority because they have the greatest life expectancy.
18. A nurse is analyzing how a hyperglycemic client’s blood glucose can be lowered. The nurse considers that the chemical that buffers the client’s excessive acetoacetic acid is:
potassium
bicarbonate
carbon dioxide
sodium chloride
19. A nurse considers that communication links people with their surroundings. What should the nurse identify as the most important communication link?
Social
Physical
Materialistic
Environmental
20. While receiving a preoperative enema, a client starts to cry and says, “I’m sorry you have to do this messy thing for me.” What is the nurse’s best response?
“I don’t mind it.”
“You seem upset.”
“This is part of my job.”
“Nurses get used to this.”
21. A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse’s first consideration when planning care?
Exploring the client’s emotional conflict
Identifying personal feelings toward this client
Planning to discuss this with the client’s family
Developing a rapport with the client’s health care provider
22. A client who has reached the stage of acceptance in the grieving process appears peaceful, but demonstrates a lack of involvement with the environment. How should the nurse address this behavior?
Ignore the client’s behavior when possible.
Accept the behavior the client is exhibiting.
Explore the reality of the situation with the client.
Encourage participation within the client’s environment.
23. A recent immigrant from mainland China is critically ill and dying. What question should the nurse ask when collecting information to meet the emotional needs of this client?
“Do you like living in this country?”
“When did you come to this country?”
“Is there a family member who can translate for you?”
“Which family member do you prefer to receive information?”
24. A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse’s best action?
Orient the client to the unit environment.
Have a copy of hospital regulations available.
Explain that that there is no reason to be concerned.
Reassure the client that the staff is available to answer questions.
25. A nurse is reviewing the health care provider’s orders for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which order should the nurse question?
Oral psyllium (Metamucil)
Oral potassium supplement
Parenteral half normal saline
Parenteral albumin (Albuminar)
26. A nurse is caring for a client with albuminuria resulting in edema. What pressure change does the nurse determine as the cause of the edema?
Decrease in tissue hydrostatic pressure
Increase in plasma hydrostatic pressure
Increase in tissue colloid osmotic pressure
Decrease in plasma colloid oncotic pressure
27. A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client’s outburst, what is the best indication that the nurse-client interaction has been therapeutic?
Increased physical activity
Absence of further outbursts
Relaxation of tensed muscles
Denial of the need for further discussion
28. A nurse is teaching a client about a restricted diet. What is the nurse’s best initial comment?
“What type of foods do you usually eat?”
“You should follow this diet exactly as written.”
“You must limit the intake of foods on this special list.”
“What do you know about this diet that was ordered for you?
29. In today’s health care delivery system, a nurse as a teacher is confronted with multiple stressors. What is the major stressor that detracts from the effectiveness of the teaching effort?
Extent of informed consumerism
Limited time to engage in teaching
Variety of cultural beliefs that exist
Deficient motivation of adult learners
30. A nurse assesses a clients serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important?
Sodium
Calcium
Chloride
Potassium
31. A client is brought to the emergency department after a bee sting. The client has a history of allergies to bees and is having difficulty breathing. What client reaction should cause a nurse the most concern?
Ischemia
Asphyxia
Lactic acidosis
Increased blood pressure
32. A client had extensive, prolonged surgery. Which electrolyte level should the nurse monitor most closely?
Sodium
Calcium
Chloride
Potassium
33. A nurse in a long-term health care setting is assigned to introduce a client who has a Ph.D. to the other clients. The client tells the nurse, “I wish to be called Doctor.” How should the nurse respond?
“Your wish will be respected.”
“Why do you want to be called Doctor?”
“Residents here call one another by their first names.”
“Wouldn’t it be better if the others do not know you are a doctor?”
34. A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful?
Clear breath sounds
Positive pedal pulses
Normal potassium level
Increased urine specific gravity
35. An older adult is treated in the emergency department for soft-tissue injuries that the medical team suspects might be caused by physical abuse. An adult child states that the parent is forgetful and confused and falls all the time. A mini—mental examination indicates that the client is oriented to person, place, and time, and the client does not comment when asked directly how the bruises and abrasions occurred. What is the next nursing action?
Interview the client without the presence of family members.
Report the abuse to the appropriate state agency for investigation.
Accept the adult child’s explanation until more data can be collected.
Refer the client’s clinical record to the hospital ethics committee for review.
36. A client becomes anxious after being scheduled for a colostomy. What is the most effective way for the nurse to help the client?
Administer the prescribed prn sedative.
Encourage the client to express feelings.
Explain the postprocedure course of treatment.
Reassure the client that there are others with this problem.
37. A nurse on the medical-surgical unit tells other staff members, “That client can just wait for the lorazepam (Ativan); I get so annoyed when people drink too much.” What does this nurse’s comment reflect?
Demonstration of a personal bias
Problem solving based on assessment
Development of client acuity to set priorities
Consideration of the complexity of client care
38. A client with hemiplegia is staring blankly at the wall and reports feeling like half a person. What is the initial nursing action?
Use techniques to distract the client.
Include the client in decision making.
Offer to spend more time with the client.
Help the client to problem-solve personal issues.
39. A client has a right above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the client states, “What happened to me? I don’t remember a thing.” What is the nurse’s initial response?
“Tell me what you think happened.”
“You will remember more as you get better.”
“You were in a work-related accident this morning.”
“It was necessary to amputate your leg after the accident.”
40. A nurse is reviewing the laboratory report of a client with a tentative diagnosis of kidney failure. What mechanism does the nurse expect to be maintained when ammonia is excreted by healthy kidneys?
Osmotic pressure of the blood
Acid-base balance of the body
Low bacterial levels in the urine
Normal red blood cell production
41. A nurse is caring for a client with diarrhea. In which clinical indicator does the nurse anticipate a decrease?
Pulse rate
Tissue turgo
Specific gravity
Body temperature
42. A client with cancer of the lung says to the nurse, “If I could just be free of pain for a few days, I might be able to eat more and regain strength.” Which stage of grieving does the nurse conclude the client is in?
Bargaining
Frustration
Depression
Rationalization
43. A nurse is reviewing a client’s serum electrolyte laboratory report. What is a comparison between blood plasma and interstitial fluid?
They both contain the same kinds of ions.
Plasma exerts lower osmotic pressure than does interstitial fluid
Plasma contains more of each kind of ion than does interstitial fluid
Sodium is higher in plasma, whereas potassium is higher in interstitial fluid.
44. A nurse is assigned to change a central line dressing. The agency policy is to clean the site with Betadine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede Betadine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and Betadine. The nurse has a sample of the new product. How should the nurse proceed?
Use the new product sample when changing the dressing.
Cleanse the site with alcohol first and then with Betadine.
Cleanse the site with the new product first and then follow the agency’s protocol.
Follow the agency’s policy unless it is contradicted by a health care provider’s order.
45. What principle must a nurse consider when caring for a client with a closed wound drainage system?
Gravity causes fluids to flow down a pressure gradient.
Fluid flow rate is determined by the diameter of the lumen.
Siphoning causes fluids to flow from one level to a lower level.
Fluids flow from an area of higher pressure to one of lower pressure.
46. A client with internal bleeding is in the intensive care unit (ICU) for observation. At the change of shift an alarm sounds, indicating a decrease in blood pressure. What is the initial nursing action?
Perform an assessment of the client before resuming the change-of-shift report.
Continue the change-of-shift report and include the decrease in blood pressure.
Lower the diastolic pressure limits on the monitor during the change-of-shift report.
Turn off the alarm temporarily and alert the oncoming nurse to the decrease in blood pressure.
47. “But you don’t understand” is a common statement associated with adolescents. What is the nurse’s best response when hearing this?
“I don’t understand what you mean.”
“I do understand; I was a teenager once too.”
“It would be helpful to understand; let’s talk.”
“It’s you who should try to understand others.”
48. How can a nurse best evaluate the effectiveness of communication with a client?
Client feedback
Medical assessments
Health care team conferences
Client’s physiologic responses
49. A nurse is assessing the needs of a client who just learned that a tumor is malignant, has metastasized to several organs, and that the illness is terminal. What behavior does the nurse expect the client to exhibit during the initial stage of grieving?
Crying uncontrollably
Criticizing medical care
Refusing to receive visitors
Asking for a second opinion
50. A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. What is the most therapeutic nursing intervention?
Sitting quietly with the client
Telling the client that crying is not helpful
Suggesting that the client play a board game
Recommending how the client can change this situation
