1. A nurse in the prenatal clinic is providing nutritional counseling for a pregnant woman with a cardiac problem. What should the nurse advise the client to do?
Limit the intake of fat.
Increase sodium in the diet.
Eat a moderate amount of protein.
Control the number of calories consumed.
2. Which clients health problem motivates the nurse to question a prescription for a beta blocker?
Heart failure
Hypertension
Sinus tachycardia
Coronary artery disease
3. A nurse in the emergency department is assessing a client who was beaten and sexually assaulted. Which is the nurse’s priority assessment?
The family’s feelings about the attack
The client’s feelings of social isolation
Disturbance in the client’s thought processes
The client’s ability to cope with the situation
4. A child with P-Thalassemia is receiving therapy that includes multiple blood transfusions. This child is at risk for developing which complication?
Serum hepatitis
Allergic response
Pulmonary edema
Hemolytic reaction
5. A client exhibits physical symptoms in response to stress. What nursing intervention may assist the client to reduce the use of physical symptoms as a response to stress?
Limit discussions about the problem.
Provide information regarding medical care.
Teach the client how to eliminate stress at home.
Assist the client in developing new coping mechanisms.
6. A client has just had a suprapubic prostatectomy. Which action should the nurse implement to prevent a secondary bladder infection?
Observe for signs of uremia.
Attach the catheter to suction.
Clamp off the connecting tube.
Change the dressings frequently.
7. A health care provider prescribes selegiline (Eldepryl) 5 mg twice a day for a client with a diagnosis of Parkinson disease. What is most important for the nurse to teach the client?
Eat food high in tyramine.
Ensure that an opioid is not taken currently.
Take the medication in the morning and evening.
Monitor for signs of hypoglycemia and hyperglycemia.
8. A client develops kidney damage as a result of a transfusion reaction. What is the most significant clinical response that the nurse should assess when determining kidney damage?
Glycosuria
Blood in the urine
Decreased urinary output
Acute pain over the kidney
9. A nurse is discussing weight loss with an obese individual with Meniere’s disease. Which suggestion by the nurse is most important?
Limit intake to nine hundred calories a day.
Enroll in an exercise class at the local high school.
Get involved in diversionary activities when there is an urge to eat.
Keep a diary of all foods eaten each day, making certain to list everything.
10. When assessing the oral cavity of a newly admitted client with acquired immunodeficiency syndrome (AIDS), the nurse identifies areas of white plaque on the client’s tongue and palate. What is the nurse’s initial response?
Scrape an area of one of the lesions and send the specimen for a biopsy.
Instruct the client to perform meticulous oral hygiene at least once daily.
Document the presence of the lesions, describing their size, location, and color.
Consider that these lesions are universally found in clients with AIDS and require no treatment.
11. Before discharge, a client with a colostomy questions the nurse about resuming prior activities. What is the nurse’s best response?
“Most sports activities, except for swimming, can be resumed based on your overall physical condition.”
“With counseling and medical guidance, a near normal lifestyle, including complete sexual function, is possible.”
“Activities of daily living should be resumed as quickly as possible to avoid depression and further dependency.”
“After surgery, changes in lifestyle must be made to accommodate the physiologic changes caused by the surgery.”
12. A school nurse knows that many children with attention deficit problems may be learning disabled. The nurse should teach the parents that a child with a learning deficit will:
probably not be self-sufficient as an adult.
have intellectual deficits that interfere with learning.
usually perform two grade levels below their age norm.
experience perceptual difficulties that make learning problematic.
13. A client receiving morphine by patient-controlled analgesia has a respiratory rate of 6 breaths/min. What intervention should the nurse anticipate?
Nasotracheal suction
Mechanical ventilation
Naloxone administration
Cardiopulmonary resuscitation
14. A parent of three young children has contracted tuberculosis. Which should the nurse expect the health care provider to prescribe for members of the family who have a positive reaction to the tuberculin skin test and are candidates for treatment?
Isoniazid (INH)
Multiple puncture tests (MPTs)
Bacille Calmette-Guerin (BCG)
Purified protein derivative (PPD)
15. A 7-year-old child with juvenile idiopathic arthritis has difficulty getting ready for school in the morning because of joint pain and stiffness. Which recommendation should the nurse make to the family?
Administer acetaminophen before bedtime.
Ice the joints that are painful in the evening.
Encourage a program of active exercise after awakening.
Provide warm, moist heat to the affected joints before arising.
16. A client with acquired immunodeficiency syndrome (AIDS) is receiving a treatment protocol that includes a protease inhibitor. When assessing the client’s response to this drug, which common side effect should the nurse expect?
Diarrhea
Hypoglycemia
Paresthesias of the extremities
Seeing yellow halos around lights
17. A new father tells the nurse that he is anxious about not feeling like a father. What is the priority nursing action to meet this father’s needs?
Encourage the father’s participation in a parenting class.
Provide time for the father to be alone with and get to know the infant.
Offer the father a demonstration on newborn diapering, feeding, and bathing.
Allow time for the father to ask questions after viewing a film about a new infant.
18. A nurse is evaluating the practice of a home health aide who is caring for a client who has paraplegia. Which action by the home health aide indicates understanding about the nursing team’s responsibility in relation to pressure ulcers?
Inspecting the skin daily
Providing a rubber cushion on which to sit
Massaging body lotion over reddened areas
Applying a heating pad to bony prominences
19. A 3-year-old child is to receive a liquid iron preparation. What should the nurse teach the mother in relation to this medication?
Monitor stools for the occurrence of diarrhea.
Administer the iron at least an hour before meals.
Avoid giving the child orange juice with the iron solution.
Have the child drink the diluted iron preparation through a straw.
20. A nurse is caring for a newly admitted client with anorexia nervosa. What is the priority treatment for the client at this time?
Medications to reduce anxiety
Family psychotherapy sessions
Separation from family members
Correction of electrolyte imbalances
21. Medication is prescribed for a 7-year-old child with attention deficit hyperactivity disorder (ADHD). What information should the school nurse emphasize when discussing this child’s treatment with the parents?
Tutor their child in the subjects that are troublesome.
Monitor the effects of the drug on their child’s behavior.
Explain to their child that the behavior can be controlled if desired.
Avoid imposing too many rules because these will frustrate the child.
22. Three weeks after a kidney transplant, a client develops leukopenia. Which factor should the nurse conclude is the most probable cause of the leukopenia?
Bacterial infection
High creatinine levels
Rejection of the kidney
Antirejection medications
23. After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone. For which manifestation of excessive levels of antidiuretic hormone (ADH) should the nurse assess?
Decreased urine output
Decreased urine specific gravity
Increased serum sodium level
Increased blood urea nitrogen
24. A client is receiving epoetin (Epogen) for the treatment of anemia associated with chronic renal failure. Which client statement indicates to the nurse that further teaching about this medication is necessary?
“I realize it is important to take this medication because it will cure my anemia.”
“I know many ways to protect myself from injury because I am at risk for seizures.”
“I recognize that I may still need blood transfusions if my blood values are very low.”
“I understand that I will still have to take supplemental iron therapy with this medication.”
25. A health care provider orders oropharyngeal suctioning as needed for a client in a coma. Which assessment made by the nurse indicates the need for suctioning?
Gurgling sounds with each breath
Fine crackles at the base of the lungs
Cyanosis in the nail beds of the fingers
Dry cough at increasingly frequent intervals
26. After an abdominal cholecystectomy, a client has a T-tube attached to a collection device. On the day of surgery, at 10:30 PM, 300 mL of bile is emptied from the collection bag. At 6:30 AM the next day, the bag contains 60 mL of bile. What should the nurse consider in response to this information?
The T-tube may have to be irrigated.
The bile is now draining into the duodenum.
Mechanical problems may have developed with the T-tube.
Suction must be reestablished in the portable drainage system.
27. Three days after surgery for cancer of the colon, a nurse introduces the client to colostomy care. Which should the nurse teach the client about skin care around the stoma?
Apply liberal amounts of an oil-based ointment around the stoma.
Rinse the area with peroxide before applying fresh gauze bandages.
Pour saline over the stoma and rub the area to remove hard fecal matter.
Wash the area with soap and water and then apply a protective ointment.
28. A nurse is supervising a recently hired nursing assistant who is caring for a debilitated, bedbound client. What intervention being implemented necessitates the nurse to intervene?
Draining the client’s urinary collection bag into a measuring container
Taking the client’s blood pressure with an electronic sphygmomanometer
Removing boots that kept the client’s feet in dorsiflexion before giving a bath
Replacing a dressing on the client’s buttocks that was contaminated with fecal material
29. Children with special needs have the same needs as those without special needs, although their means of satisfying these needs may be limited. What effect should the nurse expect that these limitations will frequently cause in the child?
Frustration
Overcompensation
Feelings of rejection
Emotional dysfunction
30. A nurse performs preoperative teaching for a client who is to have cataract surgery. Which is most important for the nurse to include concerning what the client should do after surgery?
Remain flat for 3 hours.
Eat a soft diet for 2 days.
Breathe and cough deeply.
Avoid bending from the waist.
31. 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
32. A 5-week-old infant is admitted to the hospital with a tentative diagnosis of a congenital heart defect. The infant tires easily and has difficulty breathing and feeding. In what position should the nurse place this infant?
Supine with the knees flexed
Orthopneic with pillows for support
Side-lying with the upper body elevated
Prone with the head supported by pillows
33. What should the nurse do when caring for a client who is receiving peritoneal dialysis?
Maintain the client in the supine position during the procedure.
Position the client from side to side if fluid is not draining adequately.
Remove the cannula at the end of the procedure and apply a dry, sterile dressing.
Notify the health care provider if there is a deficit of 200 mL in the drainage return.
34. A health care provider orders oxygen therapy via nasal cannula at 2 L/min for an older, confused client with heart failure. Which nursing action is the priority?
Maintaining the client on bed rest
Determining whether the client is agitated
Obtaining a cannula of appropriate size for the client
Investigating whether the client has chronic obstructive pulmonary disease
35. A nurse is caring for a client with chronic kidney failure. What should the nurse teach the client to limit the intake of to help control uremia associated with end-stage renal disease (ESRD)?
Fluid
Protein
Sodium
Potassium
36. A client is diagnosed with varicose veins, and the nurse teaches the client about the pathophysiology associated with this disorder. The client asks, “What can I do to help myself?” What should the nurse respond?
“Limit walking to as little as possible.”
“Reduce fluid intake to one liter of liquid a day.”
“Apply moisturizing lotion on your legs several times a day.”
“Put on compression hose before getting out of bed in the morning.”
37. A nurse assesses a client recently admitted to an alcohol-detoxification unit. What common clinical manifestation should the nurse expect during the initial stage of alcohol detoxification?
Nausea
Euphoria
Bradycardia
Hypotension
38. A nurse is reviewing the laboratory report of a child with tetralogy of Fallot that indicates an elevated RBC count. What does the nurse identify as the cause of the polycythemia?
Low blood pressure
Tissue oxygen needs
Diminished iron level
Hypertrophic cardiac muscle
39. On a 6-week postpartum visit, a new mother tells a nurse she wants to feed her baby whole milk after 2 months because she will be returning to work and can no longer breastfeed. The nurse plans to teach her that she should switch to formula feeding because whole milk does not meet the infant’s nutritional requirements for which constituents?
Fat and calcium
Vitamin C and iron
Thiamine and sodium
Protein and carbohydrates
40. A nurse teaches a client about warfarin (Coumadin). Which juice to avoid identified by the client indicates that the teaching is effective?
