TAKE-HOME TEST DRILL FOR THE BREAK
NAME DATE COMPLETED 1. The client client is brought brought to the emergency emergency departme department nt due to drug poisoning poisoning.. hich o! the !ollo"ing nursing inter#entions is most e$ecti#e in the management o! the client%s condition& A. 'ast 'astri ric c la#a la#age ge C. Cathart Cathartic ic admin administ istrat ration ion (. Acti# Acti#ate ated d charc charcoa oall D. Mil) Mil) dilut dilutio ion n E. *. +ealth care pro#iders "ere "ere in!ormed o! the presence presence o! biochemical biochemical terrorism terrorism in the area. area. The nurse in the emergency department is helping in preparing and administering antito,ins. hich o! the !ollo"ing agents o! bioterrorism is treated "ith an antito,in& A. (o ( otulism (. -m -mallpo, C. An Anthra, D. Tularemia E. . A client is gi#en Morphine / mg 0 push a!ter a!ter the surgery surgery.. Moments later2 the client is sleeping 3uietly and the #4s are as !ollo"s5 Pulse5 /6 bpm2 775 8 cpm2 (P5 1994/9 mm+g. hich nursing action is the priority this time& A. Let Let the the clie client nt rest rest.. C. Administ Administer er nalo,o nalo,one ne per per physicia physician%s n%s (. Admin Administ ister er o,ygen. ,ygen. order. D. Place epinephrine epinephrine at the the bedside. bedside. E. :. The nurse is assessing the ;uid status o! a client recei#ing recei#ing 0< a!ter a!ter surgery. surgery. hich symptom indicate <E& A. Temperature5 =.6>C2 =.6>C2 (P 694/92 pulse 6= and thready. thready. (. Cool s)in2 s)in2 respira respiratory tory crac)les2 crac)les2 pulse pulse =: and boundi bounding. ng. C. Abdominal Abdominal pain2 pain2 headache headache and lethar lethargy gy.. D. CP o! ?2 @rinary @rinary output5 output5 899 cc4*: cc4*: hours hours and nystagmus. nystagmus. <. ?. An unconscious client "ith "ith multiple multiple inuries arri#es in the emergency emergency department. department. hich o! the !ollo"ing nursing inter#entions recei#es the highest priority& A. -topping -topping bleeding bleeding !rom open "ounds "ounds C. Establ Establish ishing ing an air" air"ay ay (. Chec)i Chec)ing ng !or !or nec) nec) !ract !racture ure D. 7eplac eplacing ing bloo blood d loss loss E. /. A client is reco#ering reco#ering !rom a total laryngectomy procedure. procedure. hich o! the !ollo"ing !ollo"ing inter#entions should the nurse include in the instructions regarding care !or the stoma& -elect all that apply. A. Clean Clean the stoma using diluted diluted alcohol alcohol.. (. Beep "ater "ater a"ay !rom !rom the the stoma. stoma. C. A#oid using soap near the stoma. stoma. D. ipe ipe secretions secretions draining draining around around the stoma using so!t so!t tissue. E. 7e 7egular gularly ly "ash "ash the stoma using "ashcloth. "ashcloth. <. Apply Apply thin layer layer o! petroleum petroleum elly elly into the the s)in surroundi surrounding ng the stoma. stoma. <. 8. A nurse is assessing assessing a group o! o! clients. clients. The nurse )no"s )no"s that "hich client client is at ris) !or ;uid ;uid #olume decit& A. Client Client diagnos diagnosed ed "ith "ith li#er li#er cirrhosis. cirrhosis. C. Client Client diagnos diagnosed ed "ith "ith conges congesti#e ti#e heart heart (. Client Client "ith "ith diminis diminished hed )idney )idney !unction. !unction. !ailure. D. Client Client attached attached to to a colosto colostomy my bag. bag. E. =. A pediatric client is !or discharge a!ter a!ter a plaster plaster cast is applied applied on the le!t !orearm. !orearm. hich o! the !ollo"ing should the nurse include in the home care instructions to be pro#ided to the client%s parent& -elect all that apply. A. To li!t the cast cast "hile it is drying2 drying2 use the ngertip ngertips. s. (. Beep sharp sharp obects obects and small toys !ar !ar !rom !rom the cast. cast. C. @se padded padded obects obects to scratc scratch h itchy parts parts under the the cast. D. Apply heated pad on the edge o! the the cast and o#er o#er the ngers to alle#iate alle#iate coldness. E. 7e 7eport port numbness numbness and tingling tingling in the e,tremity e,tremity immediat immediately ely.. <. Ele#ate Ele#ate a$ected a$ected side !or *::= *::= hours !ollo" !ollo"ing ing the procedur procedure e to a#oid s"elling s"elling.. <. 6. The school school nurse is conducting conducting a health health teaching teaching to a group o! o! parents parents about poison poison pre#ention at home. A mother as)s the nurse about the initial step in case o! poison ingestion. hich o! the !ollo"ing responses i! made by the nurse n urse is incorrect& A. 'i#e 'i#e a bottle bottle i! 0pecac 0pecac to your your child to induce induce #omiti #omiting.F ng.F (. 0nduce 0nduce #omiting #omiting i! your your child s"allo" s"allo"s s lighter lighter ;uid.F ;uid.F C. 'i#e 'i#e your child child "ater "ater or mil) to dilute dilute the the poison.F poison.F D. -tore -tore harm!ul harm!ul chemicals chemicals in hard to reach reach areas.F areas.F
'. 19.A patient under"ent surgery "here s)in gra!ting "as done and a drain "as placed temporarily. temporarily. The nurse in charge a!ter the operation should )no" ho" to assess the s)in gra!t. hich o! the !ollo"ing assessments "ould suggest an abnormal s)in gra!t& A. The gra!t gra!t is is "arm "arm to to touch touch D. 'ra!t 'ra!t has a di$erent di$erent color !rom !rom (. (ris) (ris) capil capillar lary y rell rell is noted noted patient%s s)in C. -anguinous -anguinous ;uid ;uid at the the surgica surgicall drain drain E. 11.The client is admitted to a psychiatric unit "ith a diagnosis o! undi$erentiated schiGophrenia. To To cope up "ith an,iety2 an,iety2 the nurse )no"s that the client "ill "ill probably probably use "hich o! the !ollo"ing de!ense mechanism& A. Proection (. 7ationaliGati C. 7egr egressi ession on on D. 7epres epressi sion on E. 1*.The client in the psychiatric unit is copying and imitating the mo#ements o! the nurse. During reco#ery2 the client #erbaliGed thoughts that the nurse is li)e a mirror and !elt connected "ith the nurse. This beha#ior is )no"n by "hich o! the !ollo"ing terms& A. Echopra,ia (. Ego C. Mo Mod delin eling g syntonicity D. 7itu 7itual alis ism m E. 1.The nurse "or)ing in the psychiatric unit noticed that one o! the clients is scheduled !or an ECT the ne,t morning. ho among the !ollo"ing clients "ill most li)ely li)ely undergo ECT& A. A schiGop schiGophreni hrenic c client client hearing hearing #oices #oices (. Client Client "ith Antisocial Antisocial personal personality ity disorder disorder "ith a history history o! bra"ling C. Client Client "ho e,hibit e,hibits s 8 di$erent di$erent personali personalities ties or persona persona D. Client Client "ith maor maor depression depression "ho "ho is in antidepress antidepressants ants !or * months months <. 1:.The nurse is to administer LoraGepam HAti#anI "hich is a benGodiaGepine. The nurse should understand that benGodiaGepines enhance "hich neurotransmitter& A. -erot eroto onin nin C. Dopamine D. Acetylcholin (. 'A(A e E. 1?.(eha#ioral therapy is based on theories regarding learning. The nurse is about to conduct beha#ioral therapy to an adolescent client "ith a psychiatric condition. hich o! the !ollo"ing is not a method or a strategy o! beha#ioral therapy& A. Operan Operantt condi conditio tionin ning g C. -ystem -ystemati atic c desensiti desensitiGat Gation ion (. Mili Milieu eu ther therap apy y D. A#ersio #ersion n therapy therapy E. 1/.A primigra#ida at 1 "ee)s came in "ith the !ollo"ing signs and symptoms5 (P5 1/94119 mm+g2 proteinuria2 and edema. -he is diagnosed "ith preeclampsiaJ Magnesium -ul!ate "as then administered to treat the condition. hich o! the !ollo"ing nursing assessments "ould indicate drug to,icity& A. Patie atient nt is is dro" dro"sy sy C. @rinary @rinary outp output ut o! 1=9 1=9 ml !or !or = hours hours (. E,aggerate E,aggerated d deep deep tendon tendon re;e, re;e,es es D. 7espira espirator tory y rate or 1/4mi 1/4min n E. 18.A '*P* patient ga#e birth to a preterm baby boy. T"el#e hours a!ter deli#ery2 she noted yello"ish discoloration on her baby%s s)in and eyes. -he is "orried and as)ed the nurse about the cause o! her baby%s condition. hat is the most appropriate response !or the nurse to gi#e& A. Early onset onset breast breast mil) aundice aundice is common common in breast!e breast!ed d in!ants. in!ants. (. Don%t "orry2 "orry2 aundice aundice is norma normall a!ter a!ter birth. birth. C. Kour baby "as "as deli#ered deli#ered preterm preterm that that is "hy he has aundice. aundice. D. (reast!eed your baby !re3uently "hile "e !urther assess your baby%s condition. condition. <. 1=.Prior to #aginal e,amination2 the nurse re#ie"s the care o! intrapartum clients. hich one o! the !ollo"ing statements is true about cer#ical changes in a primipara client& A. E$acem E$acement ent prece precedes des dilata dilatatio tion n C. Dilatatio Dilatation n precedes precedes e$acement e$acement (. E$acem E$acement ent and and dilatat dilatation ion occur occur D. E$acem E$acement ent is not not neces necessar sary y simultaneously E. 16.The nurse is ta)ing care o! the client in the acti#e phase o! stage 1 labor. labor. The !etal position is LOA. LOA. hen membranes rupture2 "hich among the !ollo"ing should the nurse e,pects to see5 A. A large large amoun amountt o! bloo bloody dy ;uid ;uid C. A small small amoun amountt o! green greenish ish ;uid ;uid (. A moderat moderate e amount amount o! o! clear clear to to stra" stra" D. A small small segment segment o! the umbilica umbilicall cord cord colored ;uid E.
*9.The client in labor !or the past 19 hrs sho"s no change in cer#ical dilatation and has stayed ? / cm !or the past * hrs. @terine contractions remain regular at *min inter#al2 lasting :9:? seconds. hich is a priority action o! the nurse& A. Assess !or presence o! a !ull bladder. (. -uggest placement o! an internal uterine pressure catheter to determine ade3uacy o! contractions. C. Encourage the "oman to do deep breathing techni3ues. D. -uggest to physician that o,ytocin augmentation be started to stimulate labor. <. *1.The blood count o! the client re#ealed high number o! 7(C. hat is the reason "hy a high number o! 7(C is normal !or clients residing on a higher altitude& A. +igher altitude changes the body%s absorption o! essential nutrients. (. Decrease in atmospheric o,ygen stimulates erythropoiesis. C. 7(C se3uestration o! the spleen is impaired in higher altitudes. D. Limited production o! leu)ocytes and platelets in higher altitudes ma)es the ratio o! 7(C higher. '. **.The nurse is assessing muscle coordination and mobility o! the client "ith musculos)eletal disorder. The nurse noted impulsi#e and brie! muscle t"itching o! the !ace and the limbs. The nding "ould be noted as5 A. Tremor (. Chorea C. Athetosis D. Dystonia E. *.The nurse is assigned to render care to the client "ith altered mobility. hich o! the !ollo"ing statements is true regarding body mechanics "hen mo#ing clients& A. -tand at arm%s length !rom the C. -"i#el the body "hen mo#ing the "or)ing area. client. (. Ele#ate adustable beds to hip le#el. D. Mo#e client "ith "ide base and straight )nees. E. *:.The nurse is assisting the client "ith a crutch in "al)ing starting "ith the !ourpoint gait. hich o! the !ollo"ing procedures is used !or a !ourpoint gait& A. Mo#e the le!t crutch and the right !oot !or"ard. (. Mo#e both crutches !or"ard. C. Ad#ance the a$ected leg and crutches together. D. Mo#e the right crutch !or"ard !ollo"ed by the le!t !oot. <. *?.The nurse is assisting the client and noted tenderness and !ocal pain at the tailbone. hich o! the !ollo"ing conditions "ould the nurse suspect& A. Osteoporosis C. Coccydynia D. Muscular (. Arthritis dystrophy E. */.The nurse is caring !or the client "ith Myasthenia 'ra#is. hich o! the !ollo"ing nursing inter#entions is appropriate !or this condition& A. Monitor duration o! sti$ness and not the intensity to determine "hen to per!orm 7OM. (. hen s"allo"ing is dicult2 gi#e semisolid !oods instead o! li3uids to lessen the ris) o! cho)ing. C. +a#e the client sleep "ith a pillo" bet"een the trun) and arm to decrease tension on the supraspinatus tendon and to pre#ent blood ;o" compromise in its "atershed region. D. Position the client in a semi!o"ler%s position to relie#e dyspnea. <. *8.The client arri#ed in the clinic !or a !ollo" up #isit regarding Tendonitis. The client in!ormed the physician that the pain "as not relie#ed "ith rest2 ice2 compression and ele#ation. hich o! the !ollo"ing inter#entions might be the ne,t order o! the physician !or the client& A. -urgery C. Alternati#e N-A0D (. Opioids D. Chiropractic treatment E. *=.The physician is assessing the client "ith symptoms o! 7heumatoid Arthritis. hich o! the !ollo"ing laboratory tests "ould the nurse e,pect that the physician "ould order& A. Albumin (. CPBM( C. 7(D. 7+!actor E. *6.The nurse is caring !or the client "ho has intermittent claudication. 0! the nurse is unable to palpate !or any pedal pulses "hen e,amining the client2 "hich is a priority nursing inter#ention among the !ollo"ing& A. Noti!y the physician immediately. C. 7echec) pedal pulses "ith a Doppler. (. -chedule the client !or emergency D. Assess apical radial pulses !or any surgery. irregularity. E.
9.The client as)s the nurse about 7aynaud%s disease. hich o! the !ollo"ing "ould be a suitable denition o! 7aynaud%s disease& A. 0t is the constriction o! the cutaneous #essels due to the #asospasm o! the arterioles and the arteries o! the upper and lo"er e,tremities. (. 0t is an occlusi#e disease o! the median and small arteries and #eins. C. 0t is the abnormal dilation o! the arterial "all caused by localiGed "ea)ness and stretching in the "all o! the artery. D. 0t is a chronic disorder in "hich partial or total arterial occlusion depri#es the lo"er e,tremity o! o,ygen and nutrients. <. 1.The nurse is assessing the EC' result o! the client. The condition in "hich the electrical conduction in the A node is absent is )no"n as5 A.
E. :1.A post appendectomy patient is assigned to you. Kou ha#e assessed him that he needs more )no"ledge about proper "ound care. hat role should you apply in this situation& A. 7ole Model (. Counselor C. Caregi#er D. Teacher E. :*.hile on your night rounds2 you ha#e noticed t"o nursing aides placing bed sheets that they ha#e ta)en !rom the ;oor. hat is the proper nursing action& A. Con!ront the t"o nursing aides about their and actions and call them !or pri#ate counseling (. Continue your night rounds2 they ha#e their o"n liabilities on their actions. C. 7emind them the principle o! medical asepsis D. Pro#ide a clothes bas)et !or them <. :.0n a burn patient2 in order to promote ade3uate ;uid "ithin *: hours2 "hat intra#enous ;uid is appropriate& A. D? ater (. L7C. 9.6 N-D. D?N-E. ::.(eing assigned in a pedia "ard2 "hat is the characteristic sign o! a normal psychosocial de#elopment o! a toddler& A. Eri)son%s stage o! initiati#e #s. guilt C. Negati#e beha#ior (. 0maginary playmates. D. Demonstrations o! se,ual curiosity. E. :?.Dening stress2 all o! the !ollo"ing describes its characteristics e,cept5 A. -tress response is natural2 producti#e C. -tress al"ays results to a !eeling o! adapti#e distress (. -tress is not al"ays a result o! damage D. -tress in#ol#es the entire body as a to body "hole E. :/.A 1yrold child is admitted. Loo)ing into the physical de#elopment2 "hat "ill be a$ected4may ha#e a delay& A. al)ing (. -itting C. 7unning D. Cra"ling E. :8.A mother is concerned about the diet o! her child that has noncomplicated acute glomerulonephritis. hat is the appropriate diet regimen you must teach as a nurse& A. Lo"protein2 lo"potassium diet. C. Lo"sodium2 lo"protein diet. (. 7egular diet2 no added salt. D. Lo"sodium2 highprotein diet. E. :=.A patient is on 7espiratory 0solation !or Tuberculosis HT(I. hich o! the !ollo"ing "ould be an indicator !or remo#al o! 0solation Precautions& A. -putum Culture is negati#e !or A<(2 !ollo"ing a course o! 0N+ and PA(. Patient has been on AntiTubercular Drug Therapy "ith 0N+ !or one month%s time C. Patient has no inltrates on chest ,ray D. Absence o! ad#entitious breath sounds <. :6.A client is diagnosed to ha#e Congesti#e +eart
?.Kou are assigned to spea) to a group o! +igh -chool students about +0 and A0D-. 0n discussing transmission the nurse )no"s that the highest concentration o! the +0 #irus in in!ected patients is in the5 A. -ali#a (. C-< C. (lood D. -emen E. ?:.0n teaching +0 in high school students2 "hat is the appropriate health practice that the nurse should emphasiGe& A. ash "ith antibacterial soap immediately a!ter intercourse. (. @se a late, condom and "ater soluble during intercourse C. A!ter oral se,2 use antibacterial mouth "ash to destroy the +0 #irus D. Abstain !rom intercourse i! the !emale partner is ha#ing her menstrual period. <. ??.hich o! the !ollo"ing is appropriate in a depressed patient& A. @sing silence C. @sing openended 3uestions (. Passi#e
D. 0t is present on areas o! persistent2 nonblanchable redness "hen compared "ith the surrounding s)in. <. //.hich o! the !ollo"ing is considered as a maor !actor in determining pressure inuries to patients& A. 7edness (. Abscess C. Edema D. Pain E. /8.hich o! the !ollo"ing strategy is not essential in pre#enting pressure inuries& A. Promote rubbing and massaging the bony prominences. (. Monitor patient%s nutrition and hydration. C. Maintain good s)in hygiene. D. Pre#ent shear and !riction. <. /=.hich o! the !ollo"ing types o! leg ulcer "hich is o!ten painless& A. enous @lcer C. Diabetic leg ulcer (. Arterial leg ulcer D. (oth A and ( E. /6.All o! the !ollo"ing describes the importance o! using critical thin)ing e,cept5 A. Nurses do not in#ol#e themsel#es in ma)ing important decisions. (. Nurses use )no"ledge in a #arious eld o! study and subects. C. Nurses deal "ith change in a #ery demanding and stress!ul en#ironment. D. Nurses should use it to sol#e client problems and ma)e a reasonable solution. <. 89.Nurses use the nursing process systematically in order to plan and pro#ide the appropriate nursing care. hich o! the !ollo"ing step in the nursing process "here a nurse "ill continue2 modi!y2 or terminate the client%s plan based on the outcomes gathered& A. Diagnosing C. Assessing D. 0mplementin (. E#aluating g E. 81.There are #arious types o! assessment use by a nurse "hich depends on the situation. hich o! the !ollo"ing is per!ormed during any physiologic or psychological crisis o! the patient& A. TimeLapsed 7eassessment C. Problem
(. 0t is the stage "here the patient plans to ma)e actions in the immediate !uture He.g. "ithin ne,t t"o "ee)sI C. 0t is the stage "here the person acti#ely participates in the course o! program designed !or him. D. 0t is the stage "here the person stri#es to pre#ent relapse by integrating actions into his li!e. <. 8=.The denition o! health is #ery comple, and may consider a lot o! !actors. hich o! the !ollo"ing models o! health and "ellness describes that a person is considered healthy as long as they can per!orm their roles in the society& A. Adapti#e Model C. 7ole -tatus Model (. 7ole Consistency Model D. 7ole Per!ormance model E. 86.Agenthosten#ironment model by Lea#ell and Clar) is one o! the theories "hich is "idely use in determining illness rather than promoting "ellness. 0t is based on the interaction o! three !actors5 agent2 host and en#ironment. hich o! the !ollo"ing deals "ith the agent !actor& A. Climate C. Lac) o! body nutrients (. Economic le#el D.
<. =8.7e;e,es are normal to ne"bornJ they are unconscious and in#oluntary responses. hich o! the !ollo"ing in!ant re;e,es is also )no"n as the !encing re;e,& A. (abins)i re;e, C. Tonic nec) re;e, (. -tepping re;e, D. Palmar re;e, E. ==.hich o! the !ollo"ing psychosocial de#elopment stages is considered as the crucial crisis according to Eri)son& A. Autonomy #ersus shame and doubt C. 0dentity #ersus role con!usion (. 0nitiati#e #ersus guilt D. Trust #ersus mistrust E. =6.Nurses use di$erent types o! therapeutic communication techni3ues in order to build an e$ecti#e relationship to"ards their patients. hich o! the !ollo"ing techni3ues illustrates ac)no"ledging the patient& A. Kou trimmed your nails today and "ashed your hands.F (. Kour boo) is here in the dra"er. 0t is not stolen.F C. 0%ll stay "ith you until your mother arri#es.F D. Tell me aboutF <. 69.Learning is represented by a change o! beha#ior. hich o! the !ollo"ing learning theories "here a nurse is seen applying a humanistic theory& A. The nurse "ill pro#ide an enough time !or his patient to sol#e problems through trial and error. (. The nurse "ill ac)no"ledge the patient !or correct beha#ior. C. The nurse "ill encourage acti#e learning by being the !acilitator and4or mentor D. The nurse "ill assess a person%s de#elopmental and indi#idual readiness '. 61.Andragogy is dened as the art and science use in teaching adults. hich o! the !ollo"ing concepts can be used as a guide !or client teaching& A. An adult%s pre#ious e,periences can be used as a resource !or learning. (. As people mature2 they mo#e !rom independence to dependence. C. An adult%s readiness to learn is o!ten not related to a de#elopmental tas) or social role. D. An adult is more oriented in learning "hen material is use sometime in the !uture. +. 6*.Nurses as part o! the health care team can contribute largely on the health literacy o! patients. hich o! the !ollo"ing client beha#iors "ill a nurse suspects that a patient has a problem in terms o! health literacy& A. No presence o! pattern o! e,cuses !or not reading the instruction materials. (. The patient "ill read the instructions instead o! !amily members. C. Pattern o! compliance D. Patient "ill insist that they already understand the in!ormation gi#en to them. 0. 6.A leader is someone "ho can in;uence others to accomplish a specic goal. hich o! the !ollo"ing leadership styles that has a minimal leader acti#ity le#el& A. Authoritarian Leadership -tyle C. LaisseG
C. +emophilia A D. Thalassemia E. 6=.The nurse assesses a client "ith an ileostomy !or possible de#elopment o! "hich o! the !ollo"ing acidbase imbalances& A. 7espiratory acidosis C. Metabolic al)alosis (. Metabolic acidosis D. 7espiratory al)alosis E. 66.The nurse anticipates "hich o! the !ollo"ing responses in a client "ho de#elops metabolic acidosis. A. +eart rate o! 19? bpm C. 7espiratory rate o! 9 cpm (. @rinary output o! 1? ml D. Temperature o! 6 degree Celsius E. 199. A client has a phosphorus le#el o! ?.9mg4dL. The nurse closely monitors the client !or& A. -igns o! tetany C. Cardiac dysrhythmias (. Ele#ated blood glucose D. +ypoglycemia E. 191. A nurse is caring !or a child "ith pyloric stenosis. The nurse "ould "atch out !or symptoms o!& A. omiting large amounts C. Proectile #omiting (. atery stool D. Dar)colored stool E. 19*. The nurse responder nds a patient unresponsi#e in his house. Arrange steps !or adult CP7. A. Assess consciousness D. Chec) !or serious bleeding and shoc) (. 'i#e * breaths E. Open patient%s air"ay C. Per!orm chest compression <. Chec) breathing '. +. QQQ2 QQQ2 QQQ2 QQQ2 QQQ2 QQQ 0. 19. hich o! the !ollo"ing has mostly li)ely occurred "hen there is continuous bubbling in the "ater seal chamber o! the closed chest drainage system& A. The connection has been taped too C. Lung e,pansion tightly D. Air lea) in the system (. The connection tubes are )in)ed E. 19:. hich i! the !ollo"ing young adolescent and adult male clients are at most ris) !or testicular cancer& A. (as)etball player "ho "ears supporti#e gear during bas)etball games (. Teenager "ho s"ims on a #arsity s"im team C. *9yearold "ith undescended testis D. Patient "ith a !amily history o! colon cancer <. 19?. The nurse plans to !re3uently assess a postthyroidectomy patient !or& A. Polyuria (. +ypoacti#e C. +ypertensio D. Laryngospas DT7 n m E. 19/. An 1=monthold baby appears to ha#e a rounded belly2 bo"legs and slightly large head. The nurse concludes& A. The child appears to be a normal C. The child is malnourished toddler D. The child%s large head may ha#e neuro (. The child is de#elopmentally delayed problems. E. 198. A nurse is going to administer ?99mg capsule to a patient. hich is the correct route& A. optic (. intra C. intramuscula D. oral auricular r E. 19=. An appropriate instruction to be included in the discharge teaching o! a patient !ollo"ing a spinal !usion is& A. Don%t use the stairs C. Don%t "al) !or long hours (. Don%t bend at the "aist D. -"imming should be a#oided E. 196. A nurse is preparing to gi#e an 0M inection o! 0ron De,tran that is irritating to the subcutaneous tissue. To pre#ent irritation to the tissue2 "hat is the best action to be ta)en& A. Apply ice o#er the inection site C. @se a *:gaugeneedle (. Administer drug at a :? degree angle D. @se the Gtrac) techni3ue E. 119. hat should a nurse do prior to ta)ing the patient%s history&
A. O$er the patient a glass o! "ater D. As) pertinent in!o !or insurance (. Establish rapport purposes C. As) the patient to disrobe and put on go"n E. 111. A pregnant "oman is admitted !or preeclampsia. The nurse "ould include in the health teaching that magnesium "ill be part o! the medical management to accomplish the !ollo"ing& A. Control seiGures C. To decrease sustained contractions (. promote renal per!usion D. Maintain intrauterine homeostasis E. 11*. A nurse is going to administer ear drops to a :yearold child. hat is the correct "ay o! instilling the medicine a!ter tilting the patient%s head side"ards& A. Pull the pinna bac) then do"n"ards C. Pull the pinna up then bac)"ards (. Pull the pinna bac) then up"ards D. Pull the pinna do"n then bac)"ards E. 11. A nursing student "as inter#ened by the clinical instructor i! "hich o! the !ollo"ing is obser#ed& A. 0nserting a nasogastric tube C. -uctioning rst the mouth2 then the (. Positioning the in!ant in a sning nose position D. -3ueeGing the bulb syringe to suction mouth E. 11:. Choose amongst the options illustrated belo" that best describes the angle !or an intradermal inection&
<. 11?. During a basic li!e support class2 the instructor said that blind nger s"eeping is not ad#isable !or in!ants. hich among the !ollo"ing could be the reason& A. The mouth is still too small C. -harp ngernails might inure the (. Obect may be pushed deeper into the #ictim throat D. The in!ant might bite E. 11/. A nurse enters a room and nds a patient lying on the ;oor. hich action should the nurse per!orm rst& A. Call !or help C. As) the patient "hat happened (. Establish responsi#eness o! patient D. Assess #ital signs E. 118. A patient "ith complaints o! chest pain "as rushed to the E7. hich priority action should the nurse do rst& A. Administer morphine sul!ate intra#enously (. 0nitiate #enous access by per!orming #enipunture C. Administer o,ygen #ia nasal cannula D. Complete physical assessment and patient history <. 11=. A rehab nurse re#ie"s a poststro)e patient%s immuniGation history. hich immuniGation is a priority !or a 8*yearold patient& A. +epatitis A #accine C. 7ota#irus accine (. +epatitis ( #accine D. Pneumococcal accine E. 116. -e#eral patients !rom a reported condominium re incident "ere rushed to the emergency room. hich should the nurse attend to rst& A. A 1?yearold girl2 "ith burns on the !ace and chest2 reports hoarseness o! the #oice (. A *=yearold man "ith burns on all e,tremities C. A :yearold child "ho is crying inconsolably and reports se#ere headache D. A :9yearold "oman "ith complaints o! se#ere pain on the le!t thigh <.
1*9. The doctor ordered 1 pac) o! red blood cells HP7(CI to be trans!used to a patient. The nurse prepares the proper 0 tubing. The 0 tubing appropriate !or blood trans!usion comes "ith& A. Air #ent C. 0nline lter (. Microdrip chamber D. -oluset E. 1*1. The e,pected yet negati#e Hharm!ul I result !or posthemodialysis is a decrease in& A. Creatinine (. (@N C. Phosphorus D. 7(C count E. 1**. A patient "as brought to the emergency room a!ter she !ell do"n the stairs. hich o! the !ollo"ing is the best indicator !or increased intracranial pressure in head and spinal inury& A. 0nability to mo#e e,tremities C. 0ncrease in pulse and blood pressure (. Decreased respiratory rate D. Decrease le#el o! consciousness E. 1*. A ne" nurse is administering an enema to a patient. The senior nurse should inter#ene i! the ne" nurse& A. +angs the enema bag 1= inches abo#e C. Ad#ances catheter : inches into the the anus anal canal (. Positions the client on the right side D. Lubricates : inches o! the catheter tip E. 1*:. The medication nurse is going to gi#e a patient his morning medications. hat is the primary action a nurse should do be!ore administering the medications& A. Pro#ide pri#acy C. 'i#e distilled "ater (. 7aise head o! the bed D. Chec) client%s identication bracelet E. 1*?. A 9yearold client is admitted "ith in;ammatory bo"el syndrome HCrohn%s diseaseI. hich o! the !ollo"ing instructions should the nurse include in the health teaching& -elect all that apply A. Corticosteroid meds is part o! the C. Aspirin should be administered treatment D. Antidiarrheal medication can help (. 0nclude mil) in the diet E. 1*/. The client presented "ith complaints o! body "ea)ness2 diGGiness and chest pain. @pon care!ul assessment2 the nurse suspects Angina Pectoris. hich o! the !ollo"ing statements made by the client can conrm this& A. 0 suddenly !elt a pain on my chest "hich radiates to my bac) and armsF. (. 0 suddenly !elt a sharp pain on my lo"er abdomenF. C. The pain does not subside e#en i! 0 restF. D. The pain goes all the "ay do"n to my stomachF. <. 1*8. The client !rom the O7 is trans!erred to the postanesthesia care unit a!ter surgical repair o! abdominal aortic aneurysm. hich o! the !ollo"ing assessment ndings "ould indicate that the repair "as success!ul& A. @rine output o! ?9 mL4hr. (. Presence o! nonpitting2 peripheral edema. C. Clear sclera. D. Presence o! carotid bruit. '. 1*=. The client is scheduled !or cardiac catheteriGation because the physician "ants to #ie" the right side o! the heart. hich o! the !ollo"ing "ould the nurse e,pect to see in this procedure& A. A dye is inected to !acilitate the #ie"ing o! the heart (. Thallium is inected to !acilitate the scintillation camera C. A probe "ith a transducer tip is s"allo"ed by the client. D. A tiny ultrasound probe is inserted into the coronary artery +. 1*6. The client is being treated !or hypo#olemia. To assess the e$ecti#eness o! the treatment2 the Central enous Pressure HCPI o! the client is being monitored. hich o! the !ollo"ing is T7@E about CP& A. The CP is measured "ith a central #enous line in the in!erior #ena ca#a. (. The normal CP is 8 to 6 mm+g. C. The Gero point on the transducer needs to be at the le#el o! the le!t atrium. D. The client needs to be supine2 "ith the head o! the bed ele#ated at :? degrees. 0. 19. The client%s EC' tracing sho"s #entricular tachycardia secondary to lo" magnesium le#el. hich o! the !ollo"ing electrocardiogram tracing results is consistent "ith this nding& A. The appearance o! a @ "a#e
(. -hortened -T segment and a "idened D. Tall T "a#es and depressed -T T "a#e. segment C. Tall2 pea)ed T "a#es E. 11. The nurse is teaching the client ho" to use a dry po"der inhaler HDP0I. hich o! the !ollo"ing are correct instructions gi#en by the nurse& -elect All That Apply. A. Load the drug rst by turning to the ne,t dose o! drug2 or inserting the capsule into the de#ice2 or inserting the dis) or compartment into the de#ice. (. Ne#er "ash or place the inhaler in "ater. C. -ha)e your inhaler prior to use. D. The drug is a dry po"der that is "hy you "ill taste the drug as you inhale. E. Ne#er e,hale into the inhaler. <. Do not remo#e the inhaler !rom your mouth as soon as you ha#e breathe in. <. 1*. The nurse is assigned to render care !or a client "ho has a chest tube drainage system. hich o! the !ollo"ing are appropriate nursing actions& -elect All That Apply. A. -trip the chest tube. (. Empty collection chamber "hen the drainage ma)es contact to the bottom o! the tube. C. Beep chest tube as straight as possible. D. Noti!y the physician o! drainage is greater than 89mL4hr. E. Assess bubbling in the "ater seal chamber. <. Beep drainage system at the le#el o! the client%s chest '. 1. The client "ith DBA is recei#ing bicarbonate 0 in!usion !or treatment o! se#ere metabolic acidosis. The nurse notes that the latest A(' sho"s a p+ o! 8.9. hat should the nurse )eep in mind in gi#ing the drug& A. Chec) #ital signs be!ore gi#ing the drug and monitor serum sodium le#el. (. Per!orm a sensiti#ity test prior to drug administration. C. Mi, the drug "ith D19 ?99 ml 0 ;uid and in!use !or o#er : to = hours. D. Administer the drug slo"ly and monitor the potassium le#e +. 1:. The client "ith a gunshot "ound on the abdomen starts to get lethargic2 is breathing hea#ily2 and the "ound dressing is !ully soa)ed "ith blood. The nurse is e,pected to immediately per!orm "hich o! the !ollo"ing actions& A. Loosen tight clothing and administer o,ygen supply. (. Apply "arm blan)et to pre#ent heat loss. C. Apply large gauGe on the bleeding site to put direct pressure or place a tourni3uet on the artery near the bleeding site. D. 0nitiate 0 access. 0. 1?. The nurse is pro#iding home instructions to a client "ith increased adrenocorticotrophic hormone. The nurse is a"are that the client "ith e,cessi#e corticosteroids is su$ering !rom "hat condition& A. Cushing%s (. Addison%s C. +ypothyroidism syndrome disease D. -0AD+ E. 1/. The nurse is assigned to a postthyroidectomy client and is monitoring !or signs o! hypocalcemia. The nurse gently tapped the area belo" the Gygomatic bone ust in !ront o! the ear. This action "ill elicit5 A.
16. Neurologic conditions can be mani!ested by changes in breathing patterns. The client presents "ith symptom o! Cheyne-to)es respirations. The nurse )no"s that this )ind o! breathing pattern sho"s5 A. Completely irregular breathing pattern "ith random deep and shallo" respirations (. Prolonged inspirations "ith inspiratory and 4or e,piratory pauses C. -ustained regular rapid respirations o! increased depth D. 7hythmic "a,ing and "aning o! both rate and depth o! respiration "ith brie! periods o! interspersed apnea 0. 1:9. The physician is assessing the client%s sensorium by using the 'lasgo" Coma -cale. hich o! the !ollo"ing is true about the 'lasgo" Coma -cale& A. 0! the client does not respond to pain!ul stimuli2 the score is 9. (. A score lo"er than 19 indicates that the client is in a coma. C. A score o! = indicates that the client is alert and oriented. D. A score o! : indicates that the client sustained se#ere head trauma. R. 1:1. The nurse is caring !or a client "ith AL- and is concerned "ith the client%s impaired physical mobility. The !ollo"ing nursing inter#entions are geared to"ards maintaining optimal physical mobility ESCEPT5 A. Maintain an e,ercise program. C. 0nstruct client related sa!ety (. Encourage participation in acti#ities. measures. D. -chedule acti#ities in the morning. E. 1:*. An elderly client had a cerebro#ascular accident or stro)e. The le!t brain is a$ected and is at ris) !or impaired #erbal communication. The nurse as)ed a 3uestion and n oted that the client has diculty tal)ing and communicating his thoughts. hich o! the !ollo"ing terms should the nurse use to document the nding& A. 7ecepti#e Aphasia C. 'lobal aphasia (. E,pressi#e Aphasia D. Apra,ia E. 1:. The client diagnosed "ith AlGheimer%s disease is starting to sho" signs and symptoms. The nurse "ants to assess !or graphesthesia. This is per!ormed by5 A. Testing !or the client%s ability to identi!y an obect that is placed on the hand "ith eyes closed. (. Testing !or the client%s ability to recogniGe the "ritten letter4number in client%s s)in "hile the eyes are closed. C. Ma)ing the client stand2 "ith the arms at the side2 !eet together2 "ith the eyes open and then closed. The client is then obser#ed !or any s"aying. D. Testing !or the presence o! pain once the leg is ;e,ed at the hip2 and then e,tended. <. 1::. The pediatric client presents "ith the !ollo"ing signs and symptoms5 high !e#er2 drooling2 diculty o! breathing and leaning !or"ard in a tripod position. 0mmuniGation history sho"s that the client ne#er recei#ed any +ib #accine. hich o! the !ollo"ing is the priority o! the healthcare pro#ider& A. Continuous o,ygen therapy and constant monitoring o! o,ygen saturation rate. (. A "ell regulated 0 in!usion and timely administration o! antibiotics. C. accination o! +ib and other remaining #accines to complete re3uired immuniGations. D. A#oiding any throat e,amination or agitation o! the child. '. 1:?. The physician prescribed Clarithromycin H(ia,inI *?9mg (0D , 8 days !or the client%s in!ection. 0ncorrect drug !re3uency and duration "ould cause inaccurate trans!er time o! the drug to specic tissues in the body. The nurse e,plains to the client that accumulation o! the drug in specic tissues is the concept o!5 A. Absorption (. Distribution C. Metabolism D. E,cretion E. 1:/. The nurse is to administer Meperidine HDemerolI ? mg through the intramuscular route. A#ailable meperedine is ?9mg4mL. hich o! the !ollo"ing is the least !a#orable inection site !or intramuscular medication& A. entroglutea (. astus C. Deltoid D. Dorsogluteal l lateralis muscle E. 1:8. The client presented "ith complaint o! leg cramps. @pon chec)ing the client%s chart2 the nurse noted that the client is hypertensi#e and is prescribed "ith a ThiaGide diuretic. The appropriate nursing inter#ention !or him is5 A. -top the ThiaGide diuretic (. 7e!er to the physician !or e#aluation o! electrolyte le#el o! the client C. -"itch the client to a loop diuretic
D. 'i#e the client an N-A0D <. 1:=. The client is "heeled into the deli#ery room and is ready !or childbirth. hile cro"ning occurs2 the labor nurse applies gentle pressure o#er the perineum and !etal head. The maneu#er per!ormed is called5 A. (randtAndre"%s maneu#er C. -chultG mechanism (. Mc7obert%s maneu#er D. 7itgen%s maneu#er E. 1:6. The nurse is monitoring the condition o! the postpartum client. As a part o! the postpartum adaptations2 the nurse monitors !or descent o! the uterus and e,pects the !undus to be5 A. On the same le#el a!ter deli#ery C. Decreased by 1.? cm4day (. Decreased by 1 cm4day D. Decreased by * cm4day E. 1?9. The granddaughter o! the client as)ed the nurse i! it is normal !or elderly people to !eel sleepy despite sleeping !or long hours. hich o! the !ollo"ing conditions "ould the nurse suspect& A. -omato!orm (. Malingering D. Amnesia DisO C. An,iety E. 1?1. Chemotherapy is one o! the treatments !or uterine cancer. The client as)ed the nurse ho" chemotherapeutic drugs "or). hich o! the !ollo"ing statements "ill be the best e,planation& A. Chemotherapeutic agents alter molecular structure o! DNA. (. Chemotherapeutic agents hasten cell di#ision. C. Cancer cells are sensiti#e only to chemotherapeutic agents. D. Chemotherapeutic agents act on all rapidly di#iding cells. <. 1?*. omiting is one o! the most common side e$ects o! chemotherapy. The nurse should be a"are o! "hich acidbase imbalance& A. Betoacidosis (. Metab. C. Metab. D. 7espi. acidosis al)alosis al)alosis E. 1?. The client de#elops a *nd degree s)in reaction !rom radiation therapy. The nurse should e,pect the !ollo"ing symptoms ESCEPT5 A. The s)in is scaly. C. There is dry des3uamation present. (. There is an itchy !eeling. D. The s)in is reddened. E. 1?:. The nurse is assessing the muscle coordination and mobility o! the client "ith musculos)eletal disorder. The nurse noted impulsi#e and brie! muscle t"itching o! the !ace and the limbs. This nding is called5 A. Tremor (. Chorea C. Athetosis D. Dystonia E. 1??. The nurse is assigned to render care to a client "ith altered mobility. hich o! the !ollo"ing statements is true regarding body mechanics "hen mo#ing clients& A. -tand at arm%s length !rom the C. -"i#el the body "hen mo#ing the "or)ing area. client. (. Ele#ate adustable beds to hip le#el. D. Mo#e client "ith "ide base and straight )nees. E. 1?/. A client is brought to the reco#ery room a!ter a supratentorial craniotomy to remo#e a large tumor in the le!t side o! the brain. hich o! the !ollo"ing is a sa!e position !or the client& -elect all that apply. A. Lying on the le!t side E. ith e,treme hip ;e,ion (. -emi!o"ler%s position <. Lying "ith the head in a midline C. ith the nec) ;e,ed position D. -upine on the le!t side '. 1?8. The nurse is caring !or a client "ho has Autonomic Dysre;e,ia. hich order !or e,treme hypertension "ould the nurse 3uestion& A. Ni!edipine C. TeraGosin (. Dobutamine D. Nitroglycerine paste E. 1?=. The client "ith acute ischemic stro)e had undergone carotid endarterectomy to remo#e !atty pla3ue !rom the carotid artery. The client returned to the medical ;oor "ithout problems. hich o! the !ollo"ing should the nurse e,pect a!ter a carotid endarterectomy& A. Client is gi#en pain medication as pain is initially common a!ter surgery. (. The client "ill recei#e ;uid and nutrients through a small thin tube.
C. The client may resume physical acti#ities immediately a!ter surgery. D. The client may return home on the same day o! the operation. <. 1?6. 0n e#aluating the client%s postoperati#e condition a!ter carotid endarterectomy2 the nurse should be alert !or possible ner#e inury as e#idenced by5 A. Permanent change in #oice. C. Numbness in the !ace or tongue. (. -leep apnea or nose breathing. D. (leeding. E. 1/9. The client is to recei#e discharge instruction a!ter being admitted to the unit !or seiGures. hich o! the !ollo"ing items should be included in the teaching plan& -elect all that apply. A. A#oid stress!ul situations. E. Beep bathroom and bedroom doors (. Ta)e a bath instead o! sho"ers. unloc)ed. C. ear a medical alert or 0D bracelet. <. 'oing to the gym is generally o)ay. D. Beep seiGure meds "ithin reach. '. 1/1. A client is admitted and diagnosed "ith possible chronic bronchitis. hich o! the !ollo"ing signs and symptoms should the nurse e,pect the client to present& -elect all that apply. A. -carce mucus C. Distincti#e "eight E. Mild attac)s o! production loss dyspnea (. Premature onset o! D. Purulent mucus <. (arrel chest cough production '. 1/*. The nurse in the intensi#e care nursery unit is e#aluating the condition o! the ne"born. The nurse )no"s that the symptoms o! respiratory distress syndrome H7D-I are a result o!5 A. 0ncreased amount o! #asodilation in the lungs (. -mall sur!ace area o! the premature lungs C. Decrease amount o! sur!actant in the in!ant%s lungs D. 0ncrease in the amount o! sur!actant in the in!ant%s lungs +. 1/. The geriatric client "ith a history o! heart attac) and hypertension presented "ith complaints o! unusual "ea)ness and !atigue. @pon e,amination2 the nur se noted diminished breath sounds throughout the lung elds and crac)les on both the lo"er lobes. hich o! the !ollo"ing should be the ne,t action o! the nurse& A. Noti!y the physician and document initial ndings. (.
administered i! the re3uired dose is 199 mg4)g4day gi#en through 0 and the drug comes prediluted in a concentration o! :9 mg4ml& A. 1? ml (. *9 ml C. *? ml D. 9 ml E. 1/6. The nurse and the client are no" on the "or)ing phase o! the helping relationship. The !ollo"ing are client goals during this phase ESCEPT one5 A. Client "ill de#elop a trusting relationship "ith the nurse (. Client "ill acti#ely participate in the helping relationship C. Client "ill participate in acti#ities geared to"ards attaining the goal D. Client "ill e,press !eelings and concerns to the nurse <. 189. The nurse in the intensi#e care unit should be a"are o! the hemodynamic terminologies "hich are a part o! client monitoring. The !orce opposing #entricular eection is termed as5 A. Cardiac output C. A!terload D. ascular (. Preload resistance E. 181. The 0C@ nurse is preparing the instruments needed !or endotracheal intubation. The nurse is )no"ledgeable that clients in the 0C@ o!ten need mechanical assistance to maintain a patent air"ay. hich o! the !ollo"ing is NOT an indication !or endotracheal intubation& A. 7espiratory distress C. +igh ris) o! aspiration (. Prolonged mechanical #entilation D. 0ne$ecti#e clearance o! secretions E. 18*. The client "ith se#ere sensory alteration is trans!erred to the intensi#e care unit. Moments later2 the client became restless and agitated "ith complaints o! hallucinations. The nurse noted the change in the le#el o! consciousness as5 A. Delirium (. Dementia C. -tupor D. Con!usion E. 18. The client complained o! abdominal discom!ort on the rst postoperati#e day. @pon percussion o! the lo"er abdomen2 the nurse e,pects to hear5 A. Dull (.
C. Numbness in hands and !eet D. Positi#e Ch#oste)%s sign E. 1=1. The nurse is caring !or the client "ho had undergone lens remo#al due to cataract. hich nursing inter#ention is most appropriate !or this client& A. Ele#ate the head o! the bed 69 degrees. (. -uggest client to sleep on the nonoperati#e side. C. Assist the client in a sitting position to promote blood circulation e#ery 1? minutes. D. Educate the client about the importance o! aerobic and "eight li!ting e,ercises !or a more rapid reco#ery. <. 1=*. The client "ith (enign Prostatic +ypertrophy is unresponsi#e "ith home treatment and medications. The urologist suggests transurethral resection o! the prostate. hich o! the !ollo"ing sho"s ho" the procedure is per!ormed& A. A lubricated scope "ith a electrocautery loop and irrigation system "ill be inserted in the penis passing through the prostate. A piece o! prostate tissue "ill be cut a"ay and then irrigate the bladder. A urinary catheter "ill be le!t in place a!ter the surgery. (. A scope is passed through the urethra to the bladder and then e,amines prostate2 bladder nec) and area containing the eaculatory duct. C. An incision "ill be made on the lo"er belly to reach the prostate gland and remo#e it as "ell as the adacent lymph node. D. -e#eral hollo" probes are inserted through s)in bet"een the anus and scrotum and into the prostate. ery cold gases are lled through the probes and create ice balls that destroy the prostate. '. 1=. The client scheduled !or total hip replacement recei#ed education on ho" the surgery "ill be per!ormed. hich o! the !ollo"ing statements by the client sho"s complete understanding o! "hat to e,pect a!ter the procedure& A. 0 "ill be asleep during the entire procedure2 and upon a"a)ening2 0 "ill get to see mysel! "ith 0 ;uids2
E. 1=6. The nurse is instructing the client about early detection o! cancer. The nurse should instruct the client to per!orm breast sel!e,amination during5 A. The rst day o! e#ery month C. (e!ore menstruation (. The rst day o! menstruation D. A!ter menstruation E. 169. The geriatric client presented "ith complaints o! diculty in s"allo"ing2 !atigue2 alternating constipation and diarrhea2 abdominal pain2 and blood in the stools. hich o! the !ollo"ing symptoms is NOT included in the "arning signs o! cancer& A. 0rregular pattern o! constipation and C. Diculty in s"allo"ing diarrhea D.
E.
