1. An infant who was just circumcised is to be discharged with his parents. What should the nurse include in the discharge instructions about postcircumcision care?
Apply diapers loosely.
Withhold feedings for 6 hours.
Cleanse the site with alcohol daily.
Expect some bleeding for 48 hours.
2. A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. What is the primary focus of nursing care during this immediate phase?
Inhibiting urinary tract infections
Preventing contractures and atrophy
Avoiding flexion or hyperextension of the spine
Preparing the client for vocational rehabilitation
3. A client asks for and receives instruction regarding birth control methods. She elects to use a diaphragm with a spermicide. What disadvantage of using a diaphragm should be explained to the client?
It fails half the time when used alone.
It is physically uncomfortable when in place.
Thrombus formation and pulmonary emboli may occur.
Some women find insertion and removal to be objectionable.
4. A nurse is caring for a client in labor. What client response indicates that the transition phase of labor probably has begun?
Assumes the lithotomy position
Perspires and has a flushed face
Indicates back and perineal pain
Exhibits decreases in frequency of contractions
5. A male client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client’s wife indicates that further teaching is required?
“I must touch the shunt several times a day to feel for the bruit.”
“I have to take his blood pressure every day in the arm with the fistula.”
“He will have to be very careful at night not to lie on the arm with the fistula.”
“We really should check the fistula every day for signs of redness and swelling.”
6. An older adult is admitted to a nursing home with the diagnosis of dementia. When the nurse is assessing this client’s mental status, what question best tests the ability for abstract thinking?
“Can you give me today’s complete date?”
“How are a television set and a radio alike?”
“What would you do if you fell and hurt yourself?”
“Can you repeat the following numbers: 8, 3, 7, 1, 5?”
7. A client with multiple sclerosis is in remission. Which diversional activity should the nurse encourage that best meets the client’s needs while in remission?
Hiking
Swimming
Computer classes
Watching television
8. What concept of death should a nurse expect a preschoolage child to have?
Cessation of life
Reversible separation
Happening that affects old people
Someone who takes one away from the family
9. A hospitalized client hurriedly approaches the nurse, saying that it sounds like there is a roaring fire in the bathroom. In reality, the client’s roommate has just turned the shower on full force. What term best describes this experience?
Illusion
Delusion
Dissociation
Hallucination
10. Three days after birth, a breastfeeding newborn becomes jaundiced. The parents bring the infant to the clinic, and blood is drawn for an indirect serum bilirubin level. The test result is 12 mg/dL. The nurse explains that it is physiologic jaundice, a benign condition, which is caused by:
immature liver function.
an inability to synthesize bile.
an increased maternal hemoglobin level.
high hemoglobin with low hematocrit levels.
11. A newborn with acquired herpes simplex virus infection is being discharged. Which developmental pattern is important for the nurse to teach the parents to monitor?
Visual clarity
Renal function
Long bone growth
Responses to sounds
12. A client is admitted to the hospital with a diagnosis of myasthenia gravis. For which common early clinical finding should the nurse assess the client?
Tearing
Blurring
Diplopia
Nystagmus
13. A client with heart failure is on a drug regimen of digoxin (Lanoxin) and furosemide (Lasix). The client dislikes oranges and bananas. Which fruit should the nurse encourage the client to eat?
Apples
Grapes
Apricots
Cranberries
14. A nurse explores with a client who has a history of drug abuse the possibility of joining Narcotics Anonymous (NA). What is a major reason NA is helpful in treating addictive behavior?
More change will take place within the group.
Group members are supportive of each other’s problems.
Group members share a common background and history.
Addiction problems are dealt with more effectively in a group.
15. What is the priority when the nurse is establishing a therapeutic environment for a client?
Providing for the client’s safety
Accepting the client’s individuality
Promoting the client’s independence
Explaining to the client what is being done
16. A blood transfusion is initiated after a client has had emergency surgery. What should the nurse do first when the client develops fever, chills, and low back pain?
Notify a health care provider.
Stop the blood and infuse saline.
Obtain a prescription for an antihistamine.
Slow the rate of the transfusion and inform the blood bank.
17. A client undergoes cardiac catheterization via the femoral artery because of a history of bilateral mastectomies. What is the most important nursing action after the procedure?
Provide a bed cradle.
Check for a pulse deficit.
Elevate the head of the bed.
Assess the groin for bleeding.
18. A client in whom sexual dysfunction is diagnosed comments to the nurse, “Well, I guess my sex life is over.” What is the most appropriate response by the nurse?
“I’m sorry to hear that.”
“Oh, you have a lot of good years left.”
“You are concerned about your sex life?”
“Have you asked your health care provider about that?”
19. A client enters the emergency department, reporting shortness of breath and epigastric distress. What should be the triage nurse’s first intervention?
Assess vital signs.
Insert a saline lock.
Place client on oxygen.
Draw blood for troponins.
20. A health care provider prescribes transdermal fentanyl (Duragesic) 25 mcg/hr every 72 hours. What is most important for the nurse to do during the first 24 hours after starting the fentanyl?
Titrate the dose until pain is tolerable.
Manage pain with oral pain medication.
Assess the client for anticholinergic side effects.
Take with food to reduce the risk of gastrointestinal upset.
21. Early in the ninth month of pregnancy a client experiences painless vaginal bleeding and is admitted to the hospital. What should the client’s plan of care include?
Giving vitamin K to promote clotting
Performing a rectal examination to assess cervical dilation
Administering an enema to prevent contamination during birth
Placing her in the semi-Fowler position to increase cervical pressure
22. When entering a room, a nurse finds new parents looking at their newborn, who is lying in the bassinet with eyes wide open. What action should the nurse take in response to this infants behavior?
Turn on the lights in the room.
Begin the physical assessment.
Position the infant on the right side.
Encourage the parent to talk to the infant.
23. A client has surgery to repair a fractured right hip. Where should the nurse stand when assisting the client to ambulate?
Behind the client
In front of the client
On the client’s left side
On the client’s right side
24. A client in a mental health facility with the diagnosis of bipolar disorder, manic phase, is argumentative, domineering, and exhibitionistic. A visitor reports that this client is running down the hall scaring people. What should the nurse do first?
Ask the client the reason for running down the hall.
Approach the client along with several staff members.
Assess the client’s behavior in a nonthreatening manner.
Contact the client’s health care provider for an order for seclusion.
25. A nurse is caring for a client with heart failure. The health care provider orders a 2 g sodium diet. What should the nurse include when explaining how a low-salt diet helps achieve a therapeutic outcome?
Allows excess tissue fluid to be excreted.
Helps to control food intake and thus weight.
Aids the weakened heart muscle to contract and improves cardiac output.
Helps reduce potassium accumulation that occurs when sodium intake is high.
26. A nurse is selecting toys for a 5-month-old infant. Which toy should not be given to the infant?
Large snap beads
Soft stuffed animals
Rattles that can be held
Brightly colored mobiles
27. A health care provider prescribes psyllium (Metamucil) 3.5 g twice a day for constipation. What is most important for the nurse to teach this client?
Urine may be discolored.
Each dose should be taken with a full glass of water.
Use only when necessary because it can cause dependence.
Daily use may inhibit the absorption of some fatsoluble vitamins.
28. Which criterion should a nurse use when assessing the gestational age of a preterm infant?
Simian creases
Breast bud size
Reflex stability
Fingernail length
29. A 4-year-old child is brought to the emergency department with a fractured tibia. Which type of fracture should the nurse anticipate will be diagnosed because it is the most frequently encountered fracture in children of this age?
Greenstick
Transverse
Compound
Comminuted
30. A newborn is admitted to the neonatal intensive care unit (NICU) with a myelomeningocele. What is the priority nursing intervention during the first 24 hours?
Use only disposable diapers.
Place the infant prone or in a side-lying position.
Wash the infant’s genital area with an antiinfective.
Perform neurologic checks above or at the site of the lesion.
31. A client’s sputum smears for acid-fast bacillus (AFB) are positive, and transmission-based precautions are instituted. What should the nurse teach family members to do?
Avoid contact with objects in the room.
Limit their contact with nonexposed people.
Put on a gown and gloves before going into the room.
Wear a high-efficiency particulate respirator when visiting.
32. A client is scheduled for a vacuum aspiration abortion to terminate a pregnancy. What should the nurse’s teaching plan include?
It is a lengthy procedure but will cause no pain.
Both she and the father must sign the consent form.
An elevated temperature of 100.4° F or more should be reported immediately.
She will experience a heavy menstrual flow for 1 to 2 weeks after the procedure.
33. A parent whose newborn infant son has a cleft lip and palate asks the nurse, “How should I feed my baby because he has difficulty sucking?” What information should the nurse provide concerning a safe feeding technique for this infant?
“Since he tires easily, it is best to have him lying in bed while he is being fed.”
“He should be held in a horizontal position and fed slowly to avoid aspiration.”
“Try using a soft nipple with an enlarged opening so he can get the milk through a chewing motion.”
“Give him brief rest periods and frequent burpings during feedings so he can get rid of swallowed air.”
34. A nurse is caring for a client with severe gastritis who vomited a large amount of blood. A lavage is ordered by the health care provider. Which response does the nurse expect when using a room temperature irrigating solution?
Coagulation of blood
Neutralization of acids
Constriction of blood vessels
Stimulation of the vagus nerve
35. A health care provider prescribes tolterodine (Detrol) for a client with an overactive bladder. What is most important for the nurse to teach the client to do?
Maintain a strict record of fluid intake and urinary output.
Chew the extended release capsule thoroughly before swallowing.
Report episodes of diarrhea or any increase in respiratory secretions.
Avoid activities requiring alertness until the response to medication is known.
36. What client behavior indicates to the nurse that a client with schizophrenia, undifferentiated type, is improving and that the client’s plan of care can be updated?
Stays away from other clients.
Expresses negative feelings freely.
Verbalizes better-developed delusions.
Communicates in an organized manner.
37. A client with a history of alcohol abuse says to the nurse, “Drinking is a way out of my depression.” Which strategy probably is most effective for the client at this time?
A self-help group
Psychoanalytic therapy
A visit with a religious advisor
Talking with an alcoholic friend
38. What is the main reason why a nurse raises three of the four side rails on the bed of a 63-year-old client who has had surgery for a fractured hip?
As a safety measure because of the client’s age
Because older adults should use side rails for safety
To be used as handholds to facilitate the client’s ability to move in bed
Because older adults often are disoriented for several days after anesthesia
39. A client who has a diagnosis of paranoid schizophrenia and has been violent in the past is admitted to the psychiatric unit. What should the nurse do before performing an admission interview?
Move to the client’s side and sit down.
Alert the assault response team about the client’s history.
Have two other staff members present when talking with the client.
Enter the room with another staff member, while remaining between the client and the door.
40. An emergency tracheotomy is performed on a child with acute epiglottitis, and the child is receiving humidified air via a tracheotomy collar. When caring for this child, what early clinical manifestations of hypoxia should alert the nurse to suction the tracheotomy?
Dyspnea and cyanosis
Agitation and diaphoresis
Restlessness and increase in pulse
Severe substernal retractions and stridor
41. What should the nurse emphasize when providing discharge instructions for a client with the diagnosis of Addison disease?
Limit physical activity.
Restrict sodium in the diet.
Continue steroid replacement therapy.
Schedule frequent health care appointments.
42. A preschool-age child has been restricted to bed rest since admission to the hospital. As a response to improvement, the child becomes interested in playing. Based on the child’s developmental level and activity restriction, what should the nurse provide?
Television viewing time
Squeaky stuffed animals
Small farm animals and a little barn
Simple three or four-piece wooden puzzles
43. Although a nurse is unable to identify any obvious signs or symptoms of bleeding, a client repeatedly has tested positive for occult blood in the stool. Which laboratory result is a concern considering this client’s history?
Iron level 100 mcg/dL
Uric acid level 6.5 mg/dL
Hemoglobin level 8.5 g/dL
Transferrin level 300 mg/dL
44. A client at 16 weeks’ gestation calls the nurse at the prenatal clinic and states that her partner just told her he has genital herpes. What should the nurse include when teaching the client about sexual activity?
Condoms must be used when having intercourse.
Sexual abstinence should be practiced during the last six weeks.
It will be necessary to refrain from sexual contact during pregnancy.
Meticulous cleaning of the vaginal area after intercourse is essential.
45. While changing a newborn’s diaper, a client expresses concern about a small spot of red vaginal discharge on the diaper. How should the nurse respond to this concern?
Assess for other signs of bleeding.
Obtain an order for vaginal cultures.
Explain that this is an expected finding.
Apply a urine specimen bag to the perineum.
46. A nurse is assessing a client with major depression. Which clinical manifestation reflects a disturbance in affect related to depression?
Echolalia
Delusions
Confusion
Hopelessness
47. A nurse determines that a postpartum client is gravida 1 and para 1. Her blood type is B negative, and her baby’s blood type is O positive. What should the nurse include in the plan of care?
Type and crossmatch blood.
Obtain an order for RhoGAM.
Determine the father’s blood type.
Observe for signs of ABO incompatibility.
48. A client is admitted to the birthing unit in active labor. An amniotomy is performed. What physiologic change does the nurse expect to occur after the procedure?
Diminished vaginal bleeding
Less discomfort with contractions
Progressive dilation and effacement
Increased maternal and fetal heart rates
49. An older adult male with dementia is admitted to a nursing home. His wife appears frail, tired, and angry when she first visits her husband. She remarks to the nurse in a sarcastic tone, “Let’s see what you can do with him.” What is the nurse’s most therapeutic response?
“It has been very difficult to care for him.”
“I don’t understand what you mean by that comment.”
“I know how to care for clients such as your husband.”
“It’s too bad you didn’t get some help to care for him at home.”
50. A newborn is Rh positive, and the mother is Rh negative. The infant is to receive an exchange transfusion. The nurse explains to the parents that their baby will receive Rh-negative blood because:
it is the same as the mother’s blood.
it is neutral and will not react with the baby’s blood.
the possibility of a transfusion reaction is eliminated.
the red blood cells will not be destroyed by maternal anti-Rh antibodies.