Practice Tests: Practice Exam #1 - 60 questions

All 60 questions are randomized each time you take the test, and do not appear in the same order here.

 

 1 .A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to

A) Promote the client’s comfort
B) Reduce the drying time
C) Decrease irritation to the skin
D) Improve venous return

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2. The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the client?

A) Clean the meatus, begin voiding, then catch urine stream
B) Void a little, clean the meatus, then collect specimen
C) Clean the meatus, then urinate into container
D) Void continuously and catch some of the urine

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3. Following change-of-shift report on an orthopedic unit, which client should the nurse see first?

A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
C) 72 year-old recovering from surgery after a hip replacement 2 hours ago
D) 75 year-old who is in skin traction prior to planned hip pinning surgery.

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4. A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client’s condition?

A) Comatose, breathing unlabored
B) Glascow Coma Scale 8, respirations regular
C) Appears to be sleeping, vital signs stable
D) Glascow Coma Scale 13, no ventilator required

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5. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug?

A) Bleeding time
B) Coagulation time
C) Prothrombin time
D) Partial thromboplastin time

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6.A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first?

A) Notify both the surgeon and provider
B) Administer the prn dose of albuterol
C) Apply oxygen at 2 liters per nasal cannula
D) Repeat the peak flow reading in 30 minutes

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7.A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report?

A) The client lost 2 pounds in 24 hours
B) The client’s potassium level is 4 mEq/liter.
C) The client’s urine output was 1500 cc in 5 hours
D) The client is to receive another dose of Lasix at 10 PM

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8. A client has been tentatively diagnosed with Graves’ disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse?

A) a report of 10 pounds weight loss in the last month
B) a comment by the client "I just can’t sit still.”
C) the appearance of eyeballs that appear to "pop” out of the client's eye sockets
D) a report of the sudden onset of irritability in the past 2 weeks

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9. The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the provider immediately?

A) prolonged inspiration with each breath
B) expiratory wheezes that are suddenly absent in 1 lobe
C) expectoration of large amounts of purulent mucous
D) appearance of the use of abdominal muscles for breathing

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10.During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time?

A) leave a book about relaxation techniques
B) write out a daily exercise routine for them to assist the client to do
C) list actions to improve the client's daily nutritional intake
D) suggest communication strategies

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11 .An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 160/100 to 180/110 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the provider?

A) Slurred speech
B) Incontinence
C) Muscle weakness
D) Rapid pulse

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12. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the parent indicates that teaching has been inadequate?

A) "I will keep the cast uncovered for the next day to prevent burning of the skin."
B) "I can apply an ice pack over the area to relieve itching inside the cast."
C) "The cast should be propped on at least 2 pillows when my child is lying down."
D) "I think I remember that my child should not stand until after 72 hours."

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13. Which blood serum finding in a client with diabetic ketoacidosis alerts the nurse that immediate action is required?

A) pH below 7.3
B) Potassium of 5.0
C) HCT of 60
D) Pa O2 of 79%

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14. The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test?

A) Client should be NPO after midnight
B) Client should receive a sedative medication prior to the test
C) Discontinue anti-coagulant therapy prior to the test
D) No special preparation is necessary

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15. A client is admitted with infective endocarditis (IE). Which finding would alert the nurse to a complication of this condition?

A) dyspnea
B) heart murmur
C) macular rash
D) Hemorrhage

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16. The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, ”1 will receive tissue from

A) a tissue bank.”
B) a pig.”
C) my thigh."
D) synthetic skin."

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17.A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?

A) Diffuse expiratory wheezing
B) Loose, productive cough
C) No relief from inhalant
D) Fever and chills

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18. A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority?

A) Maintaining proper body alignment
B) Frequent neurovascular assessments of the affected leg
C) Inspection of pin sites for evidence of drainage or inflammation
D) Applying an over-bed trapeze to assist the client with movement in bed

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19. The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time?

A) Daily needs and concerns
B) The overview cardiac rehabilitation
C) Medication and diet guideline
D) Activity and rest guidelines

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20. A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would initially assess for which problem?

A) allergies
B) scabies
C) regression
D) pinworms

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21 . The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?

A) Risk for dehydration
B) Ineffective airway clearance
C) Altered nutrition
D) Risk for injury

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22. The nurse is developing a meal plan that would provide the maximum possible amount of iron for a child with anemia. Which dinner menu would be best?

A) Fish sticks, french fries, banana, cookies, milk
B) Ground beef patty, lima beans, wheat roll, raisins, milk
C) Chicken nuggets, macaroni, peas, cantaloupe, milk
D) Peanut butter and jelly sandwich, apple slices, milk

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23. The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?

A) Metabolic acidosis
B) Metabolic alkalosis
C) Some increase in the serum hemoglobin
D) A little decrease in the serum potassium

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24. A two year-old child is brought to the provider's office with a chief complaint of mild diarrhea for two days. Nutritional counseling by the nurse should include which statement?

A) Place the child on clear liquids and gelatin for 24 hours
B) Continue with the regular diet and include oral rehydration fluids
C) Give bananas, apples, rice and toast as tolerated
D) Place NPO for 24 hours, then rehydrate with milk and water

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25. The nurse is teaching parents about the appropriate diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include

A) formula or breast milk
B) broth and tea
C) rice cereal and apple juice
D) gelatin and ginger ale

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26. A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is

A) call for emergency transport to the hospital
B) immobilize the limb and joints above and below the injury
C) assess the child and the extent of the injury
D) apply cold compresses to the injured area

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27. The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition?

A) Solid foods should be introduced at 3-4 months
B) Whole milk is difficult for a young infant to digest
C) Fluoridated tap water should be used to dilute milk
D) Supplemental apple juice can be used between feedings

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28. The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials?

A) Solid foods are introduced one at a time beginning with cereal
B) Finely ground meat should be started early to provide iron
C) Egg white is added early to increase protein intake
D) Solid foods should be mixed with formula in a bottle

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29. The nurse planning care for a 12 year-old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include which one of the following as a priority?

A) Limit fluids
B) Client controlled analgesia
C) Cold compresses to elbow
D) Passive range of motion exercise

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30. The nurse is performing a physical assessment on a toddler. Which of the following actions should be the first?

A) Perform traumatic procedures
B) Use minimal physical contact
C) Proceed from head to toe
D) Explain the exam in detail

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31. What finding signifies that children have attained the stage of concrete operations (Piaget)?

A) Explores the environment with the use of sight and movement
B) Thinks in mental images or word pictures
C) Makes the moral judgment that "stealing is wrong"
D) Reasons that homework is time-consuming yet necessary

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32. The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse?

A) "Folic acid should be taken before and after conception."
B) "Multivitamin supplements are recommended during pregnancy."
C) "A well balanced diet promotes normal fetal development."
D) "Increased dietary iron improves the health of mother and fetus."

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33. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily?

A) Spaghetti
B) Watermelon
C) Chicken
D) Tomatoes

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34. While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse to teach them about which of the following actions?

A) Maintain good oral hygiene and dental care
B) Omit medication if the child is seizure free
C) Administer acetaminophen to promote sleep
D) Serve a diet that is high in iron

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35. The nurse is offering safety instructions to a parent with a four month-old infant and a four year-old child. Which statement by the parent indicates understanding of appropriate precautions to take with the children?

A) "I strap the infant car seat on the front seat to face backwards.”
B) "I place my infant in the middle of the living room floor on a blanket to play with my four year-old while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the four year-old naps on the sofa."
D) "I have the four year-old hold and help feed the four month-old a bottle in the kitchen while I make supper."

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36. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements?

A) "The injury is expected to heal quickly because of thin periosteum."
B) "In some instances the result is a retarded bone growth."
C) "Bone growth is stimulated in the affected leg."
D) "This type of injury shows more rapid union than that of younger children."

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37. The parents of a 4 year-old hospitalized child tell the nurse, “We are leaving now and will be back at 6 PM.” A few hours later the child asks the nurse when the parents will come again. What is the best response by the nurse?

A) "They will be back right after supper."
B) "In about 2 hours, you will see them."
C) "After you play awhile, they will be here." D) "When the clock hands are on 6 and 12."

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38. The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse would emphasize that pancreatic enzymes should be taken

A) once each day
B) 3 times daily after meals
C) with each meal or snack
D) each time carbohydrates are eaten

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39. A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning?

A) Use ready-to-feed commercial infant formula
B) Boil the tap water for 10 minutes prior to preparing the formula
C) Let tap water run for 2 minutes before adding to concentrate
D) Buy bottled water labeled "lead free" to mix the formula

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40. Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students?

A) Scratching the head more than usual
B) Flakes evident on a student's shoulders
C) Oval pattern occipital hair loss
D) Whitish oval specks sticking to the hair

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41. When interviewing the parents of a child with asthma, it is most important to assess the child's environment for what factor?

A) Household pets
B) New furniture
C) Lead based paint
D) Plants such as cactus

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42. The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated with the findings the infant is displaying?

A) DTaP
B) Hepatitis B
C) Polio
D) H. Influenza

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43.The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse?

A) "I think you or your partner needs to stay with the child while in the hospital."
B) "Oh, that behavior will stop in a few days."
C) "Keep in mind that for the age this is a normal response to being in the hospital."
D) "You might want to "sneak out" of the room once the child falls asleep."

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44. A couple experienced the loss of a 7 month-old fetus. In planning for discharge, what should the nurse emphasize?

A) To discuss feelings with each other and use support persons
B) To focus on the other healthy children and move through the loss
C) To seek causes for the fetal death and come to some safe conclusion
D) To plan for another pregnancy within 2 years and maintain physical health

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45. The nurse is performing a pre-kindergarten physical on a 5 year-old. The last series of vaccines will be administered. What is the preferred site for injection by the nurse?

A) vastus intermedius
B) gluteus maximus
C) vastus lateralis
D) dorsogluteal

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46. A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate

A) Non stress test
B) Abdominal ultrasound
C) Pelvic exam
D) X-ray of abdomen

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47. A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states "This is not my baby, and I do not want it." After repositioning the child safely, the nurse's best response is

A) "This is a common occurrence after birth, but you will come to accept the baby."
B) "Many women have postpartum blues and need some time to love the baby."
C) "What a beautiful baby! Her eyes are just like yours."
D) "You seem upset; tell me what the pregnancy and birth were like for you."

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48. The nurse notes that a 2 year-old child recovering from a tonsillectomy has an temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM the child's parent reports that the child "feels very warm" to touch. The first action by the nurse should be to

A) reassure the parent that this is normal
B) offer the child cold oral fluids
C) reassess the child's temperature
D) administer the prescribed acetaminophen

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49. The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is critical for the nurse to include in the plan of care?

A) hourly urine output
B) white blood count
C) blood glucose every 4 hours
D) temperature every 2 hours

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50. A client is admitted to the rehabilitation unit following a cerebral vascular accident (CVA) and mild dysphagia. The most appropriate intervention for this client is to

A) position client in upright position while eating
B) place client on a clear liquid diet
C) tilt head back to facilitate swallowing reflex
D) offer finger foods such as crackers or pretzels

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51. A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse?

A) Investigating the client's insurance coverage for home IV antibiotic therapy
B) Determining if there are adequate hand washing facilities in the home
C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver
D) Selecting the appropriate venous access device

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52. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to

A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered

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53. The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk. The physiological basis for this instruction is that the medication

A) retards pepsin production
B) stimulates hydrochloric acid production
C) slows stomach emptying time
D) decreases production of hydrochloric acid

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54. A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what?

A) Dystonia
B) Akathisia
C) Brady dyskinesia
D) Tardive dyskinesia

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55. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose?

A) Drowsiness, lethargy, and inactivity
B) Dry mouth, nasal congestion, and blurred vision
C) Rash, blood dyscrasias, severe depression
D) Hyperglycemia, weight gain, and edema

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56. The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client?

A) Complete the entire course of the medication for an effective cure
B) Begin treatment with acyclovir at the onset of symptoms of recurrence
C) Stop treatment if she thinks she may be pregnant to prevent birth defects
D) Continue to take prophylactic doses for at least 5 years after the diagnosis

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57. A 14 month-old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see in the child?

A) Hypothermia
B) Edema
C) Dyspnea
D) Epistaxis

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58. An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze first?

A) Potassium levels
B) Blood pH
C) Magnesium levels
D) Blood urea nitrogen

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59. A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement from the assessment data is likely to explain his noncompliance?

A) "I have problems with diarrhea.”
B) "I have difficulty falling asleep."
C) "I have diminished sexual function."
D) "I often feel jittery."

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60. The nurse caring for a 9 year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis is a priority at this time?

A) Risk for fluid volume deficit related to morphine overdose
B) Decreased gastrointestinal mobility related to mucosal irritation
C) Ineffective breathing patterns related to central nervous system depression
D) Altered nutrition related to inability to control nausea and vomiting

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Practice Exam #1 - 60 questions