1. A nurse is caring for a client who had a right lower lobectomy and has a closed (water-sealed) chest drainage system in place. Which of these actions should a nurse include in the plan of care?
A. Keep the system below the level of the client’s waist.
B. Change the system every 72 hours.
C. Empty the system every 4 hours.
D. Clamp the system when ambulating the client.
ANS: A
2. An elderly client has a nursing diagnosis of altered tissue perfusion related to chronic occlusive disease of both legs. Which of these actions should a nurse take?
A. Tell the client to avoid crossing their legs.
B. Elevate the client’s legs when in bed.
C. Tell the client to massage the legs for 10 minutes every day.
D. Measure the client’s legs for elastic hose.
ANS: A
3. A nurse is caring for a client who is receiving intravenous therapy. Which of these observations, if present, would indicate to a nurse that the intravenous infusion has infiltrated?
A. Blood backs up in the intravenous tubing.
B. Cutaneous tissue at the intravenous site is swollen.
C. The vein above the intravenous site appears bluish in color.
D. The skin around the intravenous site is cool to the touch.
ANS: B
4. Which of these measures should a nurse include in the plan of care for a client who has hyperthyroidism?
A. Maintaining the client in semi-Fowler’s position.
B. Keeping the client’s environment cool.
C. Restricting the client’s fluid intake.
D. Encouraging the client to eat foods low in calories.
ANS: B
5. A nurse has instructed a client about a sodium-restricted diet. The client should demonstrate understanding of the teaching by selecting which of these foods as LOWEST in sodium content?
A. A fresh fruit salad and iced tea.
B. A cup of canned soup and a glass of milk.
C. A cheese sandwich and french fries.
D. A chicken pot pie and lemonade.
ANS: A
6. Where should a nurse stand when assisting a client who has left-sided paralysis to transfer from the bed to a chair?
At the head of the client’s bed.
On the client’s left side.
On the client’s right side.
At the foot of the client’s bed.
ANS: B
7. A nursing home client has been confined to a geriatric chair for two hours. Which of these measures should a nurse take at this time?
A. Give the client a bed bath.
B. Sit and talk with the client for ten minutes.
C. Walk with the client around the unit.
D. Encourage the client to socialize with the roommate.
ANS: C
8. For which of these reasons should a nurse administer a diuretic to a client early in the morning?
A. Any toxic effects of the drug will be readily recognized.
B. The peak action of the drug will occur while the client is awake.
C. Mobility during the day will increase the volume of urine produced.
D. The client will require additional fluid intake at night.
ANS: B
9. Which of these measures should a nurse include in the care plan of a client who has renal calculi?
A. Restricting fluid intake.
B. Straining all urine.
C. Maintaining bed rest.
D. Limiting potassium intake.
ANS: B
10. A client develops a neurogenic bladder as a result of a spinal cord injury. To initiate a bladder training program for the client a nurse should plan which of these actions?
A. Restrict fluids throughout the day.
B. Compress the abdomen before each voiding.
C. Pour water over the perineum.
D. Observe for patterns of incontinence.
ANS: D
11. A nurse is caring for a client with a self-care deficit related to toileting. Which of these nursing orders would serve as the best guide when providing care to this client?
A. Reposition the client frequently.
B. Offer a bedpan every four hours while the client is awake.
C. Teach coping strategies based on client readiness.
D. Provide emotional support.
ANS: B
12. A nurse removes an indwelling urethral (Foley) catheter from a client. Six hours later, the nurse notes that the client has not voided. Which of these actions should the nurse take?
A. Apply pressure to the client’s suprapubic area.
B. Obtain an order to recatheterize the client.
C. Run the tap water while the client is on the toilet.
D. Tell the client to call whenever there is the urge to void.
ANS: C
13. A nurse who is reinforcing discharge teaching with a client who has active pulmonary tuberculosis should emphasize which of these measures?
A. Placing used tissue wipes in a paper bag to be burned.
B. Using a bactericidal soap for bathing.
C. Using disposable dishes.
D. Excluding visitors.
ANS: A
14. A nurse teaches a newly admitted client who is confined to bed to operate the bed controls and the call light. To determine whether the goal has been achieved, the nurse should have the client
A. Explain the procedure in detail.
B. Demonstrate the use of the mechanisms.
C. Answer questions about the procedure.
D. Observe the procedure again
ANS: B
15. A nurse is to administer an oral medication to a client who just vomited. Which of these actions should the nurse take?
A. Withhold the medication and inform the physician.
B. Give the client a carbonated beverage 30 minutes prior to administering the medication.
C. Crush the medication and administer with applesauce.
D. Ask the pharmacy for the medication to be administered by another route.
ANS: A
16. A nurse should recognize that which of these measures would provide the greatest relief of pain for a client who has rheumatoid arthritis?
A. Providing a warm bath.
B. Encouraging active range-of-motion exercises for affected joints.
C. Maintaining bed rest.
D. Massaging affected joints.
ANS: A
17. A postoperative client is to be started on a soft diet of foods high in protein to promote tissue healing. Which of these foods is highest in protein?
A. Chicken broth.
B. Applesauce.
C. Orange-flavored gelatin.
D. Eggnog.
ANS: D
18. Prior to a barium enema, a client’s bowel is cleansed thoroughly for which of these purposes?
A. To decrease peristaltic activity during the examination.
B. To prevent absorption of the barium sulfate solution by the fecal material.
C. To remove excessive intestinal mucus.
D. To allow the barium sulfate solution to outline the mucosa of the colon.
ANS: D
19. A nurse is caring for a client who had a transurethral resection of the prostate (TURP) three days ago. The client’s indwelling catheter was removed two hours ago and the client tells the nurse that he is passing blood-tinged urine. Which of these actions should the nurse take?
A. Check the client’s vital signs.
B. Collect a urine specimen from the client.
C. Call the client’s physician.
D. Encourage the client to increase fluid intake.
ANS: D
20. Which of these problems should a nurse monitor for in a client who is diagnosed with Parkinson’s disease and has difficulty swallowing?
A. Gastritis.
B. Gingivitis.
C. Aspiration.
D. Sore throat.
ANS: C
21. Which of these measures is most important for a nurse to include in the plan of care for a client who has Parkinson’s disease?
A. Providing a cool environment for the client.
B. Encouraging the client to breathe deeply and cough.
C. Limiting physical activity for the client.
D. Increasing the amount of fiber in the client’s diet.
ANS: D
22. A nurse is caring for a client who just had a thyroidectomy. Which of these measures is most important for the nurse to include in the plan of care?
A. Monitoring the client’s urinary output.
B. Checking the client for weight gain.
C. Evaluating the client’s ability to extend their neck.
D. Observing the client for twitching muscles.
ANS: D
23. A client is to receive 200 mL of three-quarter-strength tube feeding. Which of these proportions should a nurse administer?
A. 100 mL of feeding and 100 mL of water.
B. 125 mL of feeding and 75 mL of water.
C. 150 mL of feeding and 50 mL of water.
D. 175 mL of feeding and 25 mL of water.
ANS: C
24. A client’s daily urinary output is measured. Two hours after emptying the drainage bag, a nurse observes that there is no urine in the bag. The nurse should take which of these actions first?
A. Check the drainage tubing for kinks.
B. Replace the drainage system.
C. Irrigate the catheter.
D. Check the placement of the catheter.
ANS: A
25. A 92-year-old client has always been alert and oriented. Today, the client does not recognize the primary nurse and says, “I must go milk the cows,” Which of these actions should the nurse take first?
A. Pull up the side rails so the client can be safely left alone.
B. Encourage the client to talk about past experiences.
C. Report the symptoms to the physician.
D. Assess the client for symptoms of a physical illness.
ANS: D
26. While administering an enema to an adult client, how far should a nurse hold the enema bag away from the client?
A. Three inches above the client.
B. Six inches above the client.
C. Twelve inches above the client.
D. Thirty inches above the client
ANS: C
27. A client who has been on nothing by mouth may now have fluids. Which of these beverages should be offered first?
A. Skim milk.
B. Eggnog.
C. Cream of chicken soup.
D. Apple juice.
ANS: D
28. A client who has had a cerebrovascular accident (CVA) has left-sided weakness. To help maintain the client’s affected bodily structures in functional position, a nurse should use which of these articles?
A. A bedboard under the client’s mattress.
B. A small pillow under the client’s left knee.
C. A donut under the client’s left heel.
D. A rolled washcloth in the palm of the client’s left hand.
ANS: D
29. Which of these nursing measures should be included in the care plan for a client who has developed a deep vein thrombosis?
A. Encouraging the client to do isometric exercises.
B. Keeping the client’s knees in a flexed position.
C. Restricting the client’s intake of fluids.
D. Maintaining the client on bed rest.
ANS: D
30. Which of these measures by a nurse would be appropriate in the care of a client on the first day following a total hip replacement?
A. Keeping an abduction pillow in place.
B. Maintaining bed rest.
C. Placing the knees in a flexed position.
D. Ambulating with full weight bearing.
ANS: A
31. Which of these assessment findings, if present, would indicate to a nurse that a client has fecal impaction?
A. Flatulence.
B. Lethargy.
C. Liquid stools.
D. Increased thirst.
ANS: C
32. A nurse is hurrying a nursing home client to the shower. The client is becoming increasingly resistant and threatens the nurse with a cane. Which of these actions would be best?
A. Return the client to a chair and postpone the shower.
B. Get assistance in completing the shower.
C. Reprimand the client and take the cane away.
D. Ignore the incident and continue to the shower.
ANS: A
33. A nurse is caring for a client who has right-sided congestive heart failure. Which of these measures should be included in the plan of care?
A. Maintaining a semi-Fowler’s position.
B. Forcing fluids.
C. Increasing physical activity.
D. Providing nutritional supplements.
ANS: A
34. An elderly client fell and sustained head trauma. A nurse is monitoring this client for signs of increased intracranial pressure. Which of these signs would provide the earliest indication that the client’s intracranial pressure has increased?
A. Change in the level of consciousness.
B. Drop in blood pressure.
C. Decrease in temperature.
D. Difficulty breathing.
ANS: A
35. A client who is on prolonged bed rest should have a footboard for which of these purposes?
A. To improve circulation.
B. To allow the client to exercise the toes.
C. To prevent paralysis of anterior leg muscles.
D. To reduce muscle fatigue.
ANS: C
36. A client who has a history of glaucoma has all of the following orders in preparation for abdominal surgery. Which order should a nurse question?
A. Meperidine (Demerol) hydrochloride 75 mg IM on call.
B. Teach deep breathing and coughing exercises.
C. Soap suds enemas until clear.
D. Atropine sulfate 0.4 mg IM on call.
ANS: D
37. When planning care for elderly clients in long-term care facilities a nurse should give highest priority for which of these measures.
A. Ensuring that they consume at least one liter of fluids.
B. Maintaining a safe environment.
C. Securing assistance from family members.
D. Identifying the problem and making appropriate referral.
ANS: B
38. A client who has chronic obstructive pulmonary disease (COPD) has a respiratory rate of 30 breaths/minute and is started on continuous oxygen therapy. A nurse should recognize that the treatment has been effective if the respiratory rate has
A. Decreased to 20 breaths/minute.
B. Increased to 36 breaths/minute.
C. Remained the same.
D. Decreased to 10 breaths/minute.
ANS: A
39. A client is receiving intermittent nasogastric tube feedings. A nurse should aspirate the residual stomach contents prior to administering a scheduled feeding for which of these purposes?
A. To check the pH of the gastrointestinal fluids.
B. To evaluate the osmolarity of the stomach contents.
C. To determine absorption of formula in the stomach.
D. To obtain a specimen of gastric secretion.
ANS: C
40. The desired effect of the nasogastric tube for a postoperative client is to
A. Prevent the collection of bile in the small intestine.
B. Remove the contents of the stomach.
C. Allow enzymes to pass through the pyloric sphincter.
D. Inhibit the production of hydrochloric acid in the stomach.
ANS:B
41. After administering a parenteral medication to a client, which of these actions should a nurse take?
A. Recap the needle before discarding.
B. Replace the needle in the original container before discarding.
C. Discard the needle uncapped.
D. Break the needle before discarding.
ANS: C
42. Which of these objectives is most important to include in the care of a client who has multiple sclerosis?
A. Prevention of contractures.
B. Maintenance of a stimulating environment.
C. Restriction of physical activities.
D. Maintenance of memory.
ANS:A
43. A nurse is preparing to administer a soap suds enema to a client who has not had a bowel movement in three days. Which of these actions should the nurse include in the procedure?
A. Raise the solution 36 inches (90 cm) above the rectum to facilitate flow.
B. Give the fluid slowly to prevent rapid distention of the colon.
C. Insert the rectal tube 10 inches (25 cm) to promote evacuation.
D. Instill the fluid at 98.6 F (37 C) to prevent hypothermia.
ANS: B
44. A client who is on bed rest with an indwelling urinary catheter has had no urinary drainage for the past four hours. Which of these actions should a nurse take first?
A. Force fluids.
B. Elevate the client’s legs.
C. Palpate the client’s suprapubic area.
D. Ensure the drainage bag is below the level of the bed.
ANS: D
45. A nurse is counting a client’s radial pulse and notes that the pulse is irregular in rate and rhythm. Which of these actions should the nurse take next?
A. Have the client rest quietly for 10 minutes, and then take the carotid pulse.
B. Monitor the client’s radial pulse while another person takes the pulse at another site.
C. Lower the client’s wrist and then take the radial pulse on both arms.
D. Measure the client’s apical heart rate for one full minute.
ANS: D
46. When assessing the drainage from a post-mastectomy wound, a nurse should take which of these measures?
A. Checking for dampness in the client’s elastic bandage.
B. Removing the dressing to observe the incision.
C. Turning the client to inspect the back.
D. Measuring the contents of the Hemovac every two hours.
ANS: C
47. A client who is jaundiced reports itching. To relieve the itching, which of these measures would be most helpful?
A. Having the client wear clothing made from synthetic fibers.
B. Giving the client sponge baths with tepid water several times a day.
C. Rubbing the client’s skin with diluted alcohol.
D. Exposing the client to the direct rays of the sun.
ANS: B
48. When a nurse is caring for an elderly client who has dyspnea, which of these measures should be given priority in the plan of care?
A. Splinting the client’s chest when the client is coughing.
B. Assisting the client with ambulation.
C. Providing frequent rest periods for the client.
D. Encouraging the client to perform deep breathing exercises.
ANS: C
49. A client who is suspected of having a hiatal hernia is admitted to the hospital. It is important for a nurse to ask the client which of these questions?
A. " Do you experience heartburn after a large meal?"
B. “Do you experience loose stools after eating?”
C. “Do you have gastric pain before meals?”
D. “Do you have difficulty swallowing when eating?”
ANS: A
50. A nurse should recognize which of these statements as the best explanation for why distraction is a helpful measure for relief of pain?
A. Pain can diminish the client’s interest in the outside world.
B. Pain is indicative of malfunction in the client’s system.
C. Pain perception requires the client’s consciousness and attention.
D. Pain can be relieved by altering the interpretation of the stimulus.
ANS: C