Practice Tests: Practice Exam #9 - 60 questions

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

 

Reduction of Risk Potential


1. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
A) Blanch nail beds for color and refill
B) Assess for post-operative arrhythmias
C) Auscultate for pulmonary congestion
D) Monitor equality of peripheral pulses

Answer: Only for registered users. Please login!

 

2. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Addressing which of the following should take priority in planning care?
A) Esophagitis
B) Leukopenia
C) Fatigue
D) Skin irritation

Answer: Only for registered users. Please login!

 

3. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?
A) Ask client to cough sputum into container
B) Have the client take several deep breaths
C) Provide a appropriate specimen container
D) Assist with oral hygiene

Answer: Only for registered users. Please login!

 

4. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first?
A) Obtain a 12-lead EKG
B) Place client in high Fowler's position
C) Lower the oxygen rate
D) Take baseline vital signs

Answer: Only for registered users. Please login!

 

5. A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?
A) Notify the health care provider
B) Readjust the traction
C) Administer the ordered pm medication
D) Reassess the foot in fifteen minutes

Answer: Only for registered users. Please login!

 

6. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning?
A) Drowsiness
B) Complaint of nausea
C) Pulse rate of 82
D) Restlessness

Answer: Only for registered users. Please login!

 

7. A client has returned from a cardiac catheterization. Which one of the following findings would indicate the client is experiencing a complication from the procedure?
A) Increased blood pressure
B) Increased heart rate
C) Loss of pulse in the extremity
D) Decreased urine output

Answer: Only for registered users. Please login!

 

8. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to
A) wrap the leg with elastic bandages
B) apply pressure at the bleeding site
C) reinforce the dressing and elevate the leg
D) remove the dressings and re-dress the incision

Answer: Only for registered users. Please login!

 

9. The most effective nursing intervention to prevent atelectasis from developing in a post-operative client is to
A) maintain adequate hydration
B) assist client to turn, deep breathe, and cough
C) ambulate client within 12 hours
D) splint incision

Answer: Only for registered users. Please login!

 

10. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?
A) Blood urea nitrogen 50 mg/dl
B) Hemoglobin of 10.3 mg/dl
C) Venous blood pH 7.30
D) Serum potassium 6 mEq/L

Answer: Only for registered users. Please login!

 

11. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse’s immediate attention?
A) Pallor
B) Increased temperature
C) Dyspnea
D) Involuntary muscle spasms

Answer: Only for registered users. Please login!

 

12. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform?
A) Disconnect the client from the ventilator and use a manual resuscitation bag
B) Perform a quick assessment of the client's condition
C) Call the respiratory therapist for help
D) Press the alarm re-set button on the ventilator

Answer: Only for registered users. Please login!

 

13. A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?
A) Have him drink several glasses of water
B) Perform Crede's method on the bladder from the bottom to the top
C) Assist him to stand by the side of the bed to void
D) Wait 2 hours and have him try to void again

Answer: Only for registered users. Please login!

 

14. The provider order reads "Aspirate nasogastric (NG) feeding tube every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take?
A) Hold the tube feeding and notify the provider
B) Administer the tube feeding as scheduled
C) Irrigate the tube with diet cola soda
D) Apply intermittent suction to the feeding tube

Answer: Only for registered users. Please login!

 

15. When caring for a client with a post-right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote
A) relaxation and sleep
B) deep breathing and coughing
C) incisional healing
D) range of motion exercises

Answer: Only for registered users. Please login!

 

16. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
A) "The tube will drain fluid from your chest."
B) "The tube will remove excess air from your chest."
C) "The tube controls the amount of air that enters your chest."
D) "The tube will seal the hole in your lung."

Answer: Only for registered users. Please login!

 

17. To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must
A) apply suction for no more than 10 seconds
B) maintain sterile technique
C) lubricate 3 to 4 inches of the catheter tip
D) withdraw catheter in a circular motion

Answer: Only for registered users. Please login!

 

18. A client has a chest tube inserted following a left lower lobectomy required by a stab wound to the chest. While repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?
A) Clamp the chest tube
B) Call the surgeon immediately
C) Prepare for blood transfusion
D) Continue to monitor the rate of drainage

Answer: Only for registered users. Please login!

 

19. The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test?
A) "I can't lie in one position for more than thirty minutes."
B) "I am allergic to shrimp."
C) "I suffer from claustrophobia."
D) "I developed a severe headache after a spinal tap."

Answer: Only for registered users. Please login!

 

20. The nurse is performing a physical assessment on a client who just had an endotracheal tube (ET) inserted. Which finding would call for immediate action by the nurse?
A) Breath sounds can be heard bilaterally
B) Mist is visible in the T-Piece
C) Pulse oximetry of 88 BPM
D) Client is unable to speak

Answer: Only for registered users. Please login!

Physiological Adaptation


1. A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time?
A) "What are you taking for pain and does it provide total relief?"
B) "Did your provider recommend that you be tested for Chlamydia?"
C) "Do you have any questions about your care?"
D) "Did you know a consequence of epididymitis is infertility?"

Answer: Only for registered users. Please login!

 

2. A client with heart failure has a prescription for Digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication
A) can predispose to dysrhythmias
B) may lead to oliguria
C) may cause irritability and anxiety
D) sometimes alters consciousness

Answer: Only for registered users. Please login!

 

3. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is
A) difference in the intake and output
B) changes in the mucous membranes
C) skin turgor
D) weekly weight

Answer: Only for registered users. Please login!

 

4. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client’s pulse and respirations, what should be the function of the second nurse?
A) Relieve the nurse performing CPR
B) Go get the code cart
C) Participate with the compressions or breathing
D) Validate the client's advanced directive

Answer: Only for registered users. Please login!

 

5. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant?
A) hemoglobin level of 12 g/dL
B) pale mucosa of the eyelids and lips
C) hypoactivity
D) a heart rate between 80 and 130

Answer: Only for registered users. Please login!

 

6. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next?
A) Stay with client and observe for airway obstruction
B) Collect pillows and pad the side rails of the bed
C) Place an oral airway in the mouth and suction
D) Announce a cardiac arrest, and assist with intubation

Answer: Only for registered users. Please login!

 

7. Which of these statements from clients who call the community health clinic would suggest the need for a same-day appointment to be seen by the health care provider?
A) "I started my period and now my urine has turned bright red"
B) "I am an diabetic and today I have been going to the bathroom every hour"
C) "I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom"
D) "I went to the bathroom and my urine looked very red and it didn’t hurt when I went"

Answer: Only for registered users. Please login!

 

8. A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis?
A) "I knew this would happen. I've been eating too much red meat lately."
B) "I really enjoyed my fishing trip yesterday. I caught two fish."
C) "I have really been working hard practicing with the debate team at school."
D) "I went to get a cold checked out last week, and I have gotten worse."

Answer: Only for registered users. Please login!

 

9. The nurse assesses a 72 year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding?
A) Decreased urinary output
B) Jugular vein distention
C) Pleural effusion
D) Bibasilar crackles

Answer: Only for registered users. Please login!

 

10. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?
A) Diminished bowel sounds
B) Loss of appetite
C) A cold, pale lower leg
D) Tachypnea

Answer: Only for registered users. Please login!

 

11. A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem?
A) Chest pain
B) Pallor
C) Inspiratory crackles
D) Heart murmur

Answer: Only for registered users. Please login!

 

12. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be to
A) cover the areas with dry sterile dressings
B) assess for dyspnea or stridor
C) initiate intravenous therapy
D) administer pain medication

Answer: Only for registered users. Please login!

 

13. A client with pneumococcal pneumonia was started on antibiotics 16 hours ago. During the nurse’s initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which one would alert the nurse to a complication?
A) "I have a sharp pain in my chest when I take a breath."
B) "I have been coughing up foul-tasting, brown, thick sputum."
C) "I have been sweating all day."
D) "I feel hot off and on."

Answer: Only for registered users. Please login!

 

14. Which information is a priority for the nurse to reinforce to an older client after intravenous pyelography?
A) Eat a light diet for the rest of the day
B) Rest for the next 24 hours since the preparation and the test is tiring
C) During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days
D) Measure the urine output for the next day and immediately notify the health care provider if it should decrease

Answer: Only for registered users. Please login!

 

15. A nurse is providing care to a 17 year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?
A) Abnormal breath sounds
B) Cyanosis of the lips
C) Increasing pulse rate
D) Pulse oximeter reading of 92%

Answer: Only for registered users. Please login!

 

16. A nurse is observing a client during an excretory urogram. Which of these observations indicate a complication is occurring?
A) "The client complains of a salty taste in the mouth when the dye is injected."
B) "The client’s entire body turns a bright red color.
C) "The client states “I have a feeling of getting warm.”
D) "The client gags and complains “I am getting sick.”

Answer: Only for registered users. Please login!

 

17. The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which statement from the parent supports the presence of this problem?
A) "When I put my finger in the left hand the baby doesn’t respond with a grasp."
B) "My baby doesn’t seem to follow when I shake toys in front of its face."
C) "When it thundered loudly last night the baby didn’t even jump."
D) "When I put the baby in a back lying position that’s how I find it hours later."

Answer: Only for registered users. Please login!

 

18. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and indicates a wish to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture?
A) "Some needles go as deep as 3 inches, depending on where they're placed in the body and what the treatment is for. The needles usually are left in for 15 to 30 minutes."
B) "In traditional Chinese medicine, imbalances in the basic energetic flow of life (known as qi or chi) are thought to cause illness."
C) "The flow of life is believed to flow through major pathways called nerve clusters in your body."
D) "By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations it is believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over."

Answer: Only for registered users. Please login!

 

19. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client’s blood pressure is increasing. Which action should the nurse take first?
A) Check the protein level in urine
B) Have the client turn to the left side
C) Take the temperature
D) Monitor the urine output

Answer: Only for registered users. Please login!

 

20. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission?
A) Side-lying on the left with the head elevated 10 degrees
B) Side-lying on the left with the head elevated 35 degrees
C) Side-lying on the right with the head elevated 10 degrees
D) Side-lying on the right with the head elevated 35 degrees

Answer: Only for registered users. Please login!

 

21. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is
A) heart rate
B) pedal pulses
C) lung sounds
D) pupil responses

Answer: Only for registered users. Please login!

 

22. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal
A) S3 ventricular gallop
B) apical click
C) systolic murmur
D) split S2

Answer: Only for registered users. Please login!

 

23. A 2 year-old child is brought to the emergency department at 2:00 in the afternoon. The mother states: “My child has not had a wet diaper all day.” The nurse finds the child is pale with a heart rate of 132. What assessment data should the nurse obtain next?
A) Status of the eyes and the tongue
B) Description of play activity
C) History of fluid intake
D) Dietary patterns

Answer: Only for registered users. Please login!

 

24. Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump?
A) A young adult with a history of Down syndrome
B) A teenager who reads at a 4th grade level
C) An elderly client with numerous arthritic nodules on the hands
D) A preschooler with intermittent episodes of alertness

Answer: Only for registered users. Please login!

 

25. The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the provider?
A) nausea and vomiting
B) fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
C) diffuse macular rash
D) muscle tenderness

Answer: Only for registered users. Please login!

 

26. The nurse is caring for a client with uncontrolled hypertension. Which findings require immediate nursing action?
A) lower extremity pitting edema
B) rales
C) jugular vein distension
D) weakness in left arm

Answer: Only for registered users. Please login!

 

27. A client has had heart failure. Which intervention is most important for the nurse to implement prior to the initial administration of digoxin to this client?
A) Assess the apical pulse, counting for a full 60 seconds
B) Take a radial pulse, counting for a full 60 seconds
C) Use the pulse reading from the electronic blood pressure device
D) Check for a pulse deficit

Answer: Only for registered users. Please login!

 

28. A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce?
A) It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum)
B) It is critical to report promptly to your health care provider any findings of peptic ulcers
C) Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors
D) With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine

Answer: Only for registered users. Please login!

 

29. As the nurse is speaking with a group of teens, which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion?
A) Mouth sores
B) Fatigue
C) Diarrhea
D) Hairloss

Answer: Only for registered users. Please login!

 

30. The nurse is discussing Kawasaki disease with a group of students. What statement made by a student about Kawasaki disease is incorrect?
A) "It also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes."
B) "In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain."
C) "Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent."
D) "Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks."

Answer: Only for registered users. Please login!

 

31. The nurse is about to assess a 6 month-old child with non-organic failure-to-thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be
A) irritable and "colicky," making no attempts to pull to standing
B) alert, laughing, playing with a rattle, and sitting with support
C) dusky in color with poor skin turgor over abdomen
D) pale, have thin arms and legs, and uninterested in surroundings

Answer: Only for registered users. Please login!

 

32. A client who was medicated with meperidine hydrochloride (Demerol) 100 mg and hydroxyzine hydrochloride (Vistaril Intramuscular) 50 mg IM for pain related to a fractured lower right leg 1 hour ago reports that the pain is getting worse. The nurse should recognize that the client may be developing which complication?
A) acute compartment syndrome
B) thromboembolitic complications
C) fatty embolism
D) osteomyelitis

Answer: Only for registered users. Please login!

 

33. Which statements by the client would indicate to the nurse an understanding of the issues with end stage renal disease?
A) "I have to go at intervals for epoetin (Procrit) injections at the health department."
B) "I know I have a high risk of clot formation since my blood is thick from too many red cells."
C) "I expect to have periods of little water with voiding and then sometimes to have a lot of water."
D) "My bones will be stronger with this disease since I will have higher calcium than normal."

Answer: Only for registered users. Please login!

 

34. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to
A) call the health care provider immediately
B) administer acetaminophen as ordered as this is normal at this time
C) send blood, urine and sputum for culture
D) increase the client's fluid intake

Answer: Only for registered users. Please login!

 

35. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM, the vital signs were T-99.8 degrees Fahrenheit, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings may be an early indication that the client is developing a complication of labor?
A) FHT 168 beats/min
B) Temperature 100 degrees Fahrenheit
C) Cervical dilation of 4 cm
D) BP 138/88

Answer: Only for registered users. Please login!

 

36. A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?
A) "Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception."
B) "This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate."
C) "After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel to it. The stitches generally dissolve in 7-10 days."
D) "The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort."

Answer: Only for registered users. Please login!

 

37. A female client talks to the nurse in the provider’s office about uterine fibroids, also called leiomyomas or myomas. What statement by the woman indicates more education is needed?
A) "I am the one out of every 4 women that get fibroids, and of women my age - between the 30s or 40s, fibroids occur more frequently."
B) "My fibroids are noncancerous tumors that grow slowly."
C) "My associated problems I have had are pelvic pressure and pain, urinary incontinence,and constipation."
D) "Fibroids that cause no problems still need to be taken out."|

Answer: Only for registered users. Please login!

 

38. A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider?
A) light, pink urine
B) occasional suprapubic cramping
C) minimal drainage into the urinary collection bag
D) reports of the feeling of pulling on the urinary catheter

Answer: Only for registered users. Please login!

 

39. Which order can be associated with the prevention of atelectasis and pneumonia in a client with amyotrophic lateral sclerosis (ALS)?
A) Active and passive range of motion exercises twice a day
B) Use incentive spirometer every 4 hours
C) Chest physiotherapy twice a day
D) Repositioning every 2 hours around the clock

Answer: Only for registered users. Please login!

 

40. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern?
A) Flaccid paralysis
B) Pupils fixed and dilated
C) Diminished spinal reflexes
D) Reduced sensory responses

Answer: Only for registered users. Please login!

 

Practice Tests: Practice Exam #9 - 60 questions