3. The nurse is working with parents to plan home care for a 2 year-old with a heart problem. A priority nursing intervention would be to
A) encourage the parents to enroll in cardiopulmonary resuscitation (CPR) class
B) assist the parents to plan quiet play activities at home
C) stress to the parents that they will need relief care givers
D) instruct the parents to avoid contact with persons with infection

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4. Which of these clients would the triage nurse request the provider examine immediately?
A) A 5 month-old infant who has audible wheezing and grunting
B) An adolescent who has soot over the face and shirt
C) A middle-aged man with second degree bums over the right hand
D) A toddler with singed ends of long hair that extends to the waist

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5. The nurse is caring for a client with Rheumatoid Arthritis. Which nursing diagnosis should receive priority in the plan of care?
A) Risk for injury
B) Self care deficit
C) Alteration in comfort
D) Alteration in mobility

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6. The nurse is caring for a client with active tuberculosis who has a history of noncompliance. Which of the following actions by the nurse would represent appropriate care for this client?
A) Instruct the client to wear a high efficiency particulate air mask in public places.
B) Ask a family member to supervise daily compliance
C) Schedule weekly clinic visits for the client
D) Ask the health care provider to change the regimen to fewer medications

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7. A client has been taking alprazolam (Xanax) for 3 days. Nursing assessment should reveal which expected effect of the drug?
A) Tranquilization, numbing of emotions
B) Sedation, analgesia
C) Relief of insomnia and phobias
D) Diminished tachycardia and tremors associated with anxiety

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8. A woman who delivered 5 days ago and had been diagnosed with pregnancy induced hypertension (PIH) calls the hospital triage nurse hotline to ask for advice. She states, “I have had the worst headache for the past 2 days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps.” What should the nurse do next?
A) Advise the client that the swings in her hormones may have that effect. However, suggest for her to call her provider within the next day.
B) Advise the client to have someone bring her to the emergency room as soon as possible.
C) Ask the client to stay on the line, get the address and send an ambulance to the home.
D) Ask what the client has taken? How often? Ask about other specific complaints.

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9. A client on warfarin therapy following coronary artery stent placement calls the clinic to ask if he can take Alka-Seltzer for an upset stomach. What is the best response by the nurse?
A) Avoid Alka-Seltzer because it contains aspirin
B) Take Alka-Seltzer at a different time of day than the warfarin
C) Select another antacid that does not inactivate warfarin
D) Use on-half the recommended dose of Alka-Seltzer

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10. The nurse notes an abrupt onset of confusion in an elderly patient. Which of the following recently-ordered medications would most likely contribute to this change?
A) Anticoagulant
B) Liquid antacid
C) Antihistamine
D) Cardiac glycoside

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11. The nurse is teaching a 27 year-old client with asthma about their therapeutic regime. Which statement would indicate the need for additional instruction?
A) "I should monitor my peak flow every day.”
B) "I should contact the clinic if I am using my medication more often.”
C) "I need to limit my exercise, especially activities such as walking and running."
D) "I should learn stress reduction and relaxation techniques.”

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12. In assessing a post partum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings?
A) Uterine atony
B) Genital lacerations
C) Retained placenta
D) Clotting disorder

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13. The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?
A) Extreme fatigue
B) Increased appetite
C) Intense itching
D) Constipation

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14. The nurse is teaching a client with atrial fibrillation about the use of Coumadin (warfarin) at home. The need to avoid which of these should be emphasized to the client?
A) Large indoor gatherings
B) Exposure to sunlight
C) Active physical exercise
D) Foods rich in vitamin K

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15. A nurse who is a native English speaker admits an elderly Mexican-American migrant worker after an accident that occurred during work. To facilitate communication the nurse should initially
A) Request a Spanish interpreter
B) Speak through the family or co-workers
C) Use pictures, letter boards, or monitoring
D) Assess the client’s ability to speak English

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16. To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment to the
A) finger and toenail quicks
B) eyes
C) perianal area
D) external ear canals

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17. The nurse is caring for a 5 year-old child whose left leg is in skeletal traction. Which of the following activities would be an appropriate diversional activity?
A) Kicking balloons with right leg
B) Playing "Simon Says"
C) Playing hand held games
D) Throw bean bags

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18. The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first?
A) Weight reduction
B) Stress management
C) Physical exercise
D) Smoking cessation

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19. The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?
A) Expiratory wheezes
B) Blurred vision
C) Ascites
D) Dilated pupils

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20. The nurse is caring for an acutely ill 10 year-old client. Which of the following assessment findings would require the nurses immediate attention?
A) Rapid bounding pulse
B) Temperature of 101.3 degrees Fahrenheit (38.5 degrees Celsius)
C) Profuse diaphoresis
D) Slow, irregular respirations

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21. A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age?
A) Death is personified as the bogeyman or devil
B) Death is perceived as being irreversible
C) The child feels guilty for the grandmother's death
D) The child is worried that he, too, might die

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22. While caring for a child with Reye's syndrome, the nurse should give which action the highest priority?
A) monitor intake and output
B) provide good skin care
C) assess level of consciousness
D) assist with range of motion

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23. A 70 year-old post-operative client has elevated serum BUN, HCT, Cl, and Na+. Creatinine and K+ are within normal limits. The nurse should perform additional assessments to confirm that an actual problem is:
A) Impaired gas exchange
B) Metabolic acidosis
C) Renal insufficiency
D) Fluid volume deficit

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24. A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately
if the following findings are present
A) Temperature of 99.5 degrees Fahrenheit with painful urination
B) An open, reddened wound on the heel
C) Insomnia and daytime fatigue
D) Nausea with 2 episodes of vomiting

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25. A confused client has been placed in physical restraints by order of the provider. Which task could be assigned to an unlicensed assistive personnel (UAP)?
A) Assist the client with activities of daily living
B) Monitor the clients physical safety
C) Evaluate for basic comfort needs
D) Document mental status and muscle strength

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26. The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client stated
A) "I can only wear cotton socks."
B) "I cannot go barefoot around my house."
C) "I will trim coms and calluses regularly."
D) "I should ask a family member to inspect my feet daily."

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27. A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the client
A) "Be sure and eat a fat-free diet until the test."
B) "Do not eat or drink anything but water for 12 hours before the blood test."
C) "Have the blood drawn within 2 hours of eating breakfast."
D) "Stay at the laboratory so 2 blood samples can be drawn an hour apart."

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28. A client who is terminally ill has been receiving high doses of an opioid analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli, what orders would the nurse expect from the health care provider?
A) Decrease the analgesic dosage by half
B) Discontinue the analgesic
C) Continue the same analgesic dosage
D) Prescribe a less potent drug

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29. The nurse is caring for a child with cystic fibrosis. The nurse would anticipate that the child would be deficient in which vitamins?
A) B, D, and K
B) A, D, and K
C) A, C, and D
D) A, B, and C

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30. A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure?
A) Playing with toys in a back yard flower garden
B) Eating small amounts of grass while playing "farm"
C) Playing with cars on the pavement near burning leaves
D) Throwing a ball to a neighborhood child who has poison ivy

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31. The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is
A) advising client to restrict sodium intake
B) taking the blood pressure in the left arm
C) elevating her left arm above heart level
D) compressing the drainage device

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32. The nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. The first action the nurse would perform is to
A) begin cardiopulmonary resuscitation
B) prepare for immediate defibrillation
C) notify the "Code" team and provider
D) assess airway breathing and circulation

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33. The primary teaching for a client following an extracorporeal shock-wave lithotripsy (ESWL) procedure is
A) "Drink 3000 to 4000 cc of fluid each day for one month."
B) "Limit fluid intake to 1000 cc each day for one month."
C) "Increase intake of citrus fruits to three servings per day."
D) "Restrict milk and dairy products for one month."

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34. An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for tracheoesophageal fistula. The mother asks: "When can the tube can be used for feeding?” The nurse's best response would be which of these comments?
A) "Feedings can begin in 5 to 7 days."
B) "The feeding tube can be used immediately."
C) "The stomach contents and air must be drained first."
D) "Healing of the incision must be complete before feeding."

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35. The community health nurse has been caring for an adolescent with a history of morbid obesity, asthma, and hypertension, and is 22 weeks pregnant. Which of these lab reports need to be called to the teen’s provider within the next hour?
A) hemoglobin 11 g/L and calcium 6 mg/dl
B) magnesium 0.8 mEq/L and creatinine 3 mg/dl
C) blood urea nitrogen 28 and glucose 225 mg/dl
D) hematocrit 33% and platelets 200,000

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36. A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in this client’s plan of care within the initial 24 hours?
A) Wear masks with shields if there is potential for fluid splash
B) Use disposable utensils and plates for meals
C) Wear gown and gloves during client contact
D) Provide soft easily digested food with frequent snacks

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37. A nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse’s contribution and begins to find objections to the suggestion. The nurse manager’s best response is:
A) "Let’s move on to a new action that deals with the problem."
B) "I think you need to reserve judgment until after all suggestions are offered."
C) "Very well thought out. Your analytic skills and interest are incredible."
D) "Let’s move to the ‘what if...’ as related to these objections and explore spin off ideas."

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38. A pre-term baby develops nasal flaring, cyanosis and diminished breath sounds on one side. The provider’s diagnosis is spontaneous pneumothorax. Which procedure should the nurse prepare for first?
A) Cardiopulmonary resuscitation
B) Insertion of a chest tube
C) Oxygen therapy
D) Assisted ventilation

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39. A newborn presents with a pronounced cephalhematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?
A) Pain related to periosteal injury
B) Impaired mobility related to bleeding
C) Parental anxiety related to knowledge deficit
D) Injury related to intracranial hemorrhage

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40. A nurse caring for premature newborns in an intensive care setting carefully monitors oxygen concentration. What is the most common complication of this therapy?
A) Intraventricular hemorrhage
B) Retinopathy of prematurity
C) Bronchial pulmonary dysplasia
D) Necrotizing enterocolitis

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