comprehensive review of the nclex by saunders 3rd ed. (autosaved)

7/21/2019 Comprehensive Review of the Nclex by Saunders 3rd Ed. (Autosaved)

http://slidepdf.com/reader/full/comprehensive-review-of-the-nclex-by-saunders-3rd-ed-autosaved 1/22

COMPREHENSIVE REVIEW OF THE NCLEX – RN

EXAMINATION THIRD(3rd

) EDITION

QUESTIONS AND ANSWERS with RATIONALE

1. The nurse is assessing the child with a suspecteddiagnosis of appendicitis. In assessing the intensity

child at McBurney’s point. In performing this

assessment, the nurse knows that McBurney’s point

is located midway between the

1. Right anterior inferior iliac crest and the

umbilicus.

2. Left anterior superior iliac crest and the

umbilicus.

3. Right anterior superior iliac crest and the

umbilicus.

4. Left anterior superior iliac crest and theumbilicus.

ANSWER: 3

Rationale: McBurney’s point is midway between the

right anterior superior iliac crest and the umbilicus.

McBurney’s point is usually the location of greatest

pain in the child with appendicitis.

2. The nurse is caring for a client with a burn injury

to the lower legs. Nitrofurazone (furacin) is

prescribed to be applied to the sites of injury. Thenurse documents which of the following in the plan

of care as the appropriate method to apply this

medication?

1. Apply saline soaked dressings over the

medication.

2. Apply 1-inch film directly to the burn sites.

3. Apply 1∕16-inch film directly to the burn sites.

4. Apply 1/2-inch film directly to the burn sites

after cleansing the wounds.

ANSWER: 3

Rationale: Nitrofurazone (Furacin) is applied

topically to the burn and has a broad spectrum of

antibiotic activity. Nitrofurazone is used in burns in

which bacterial resistance to other agents is a real or

potential problems. A film of 1/16 inch is applied

directly to the burn. Saline-soaked dressings are not

used.

3. A client suspected of having an abdominal tumor

is scheduled for a computerized tomography scan

with dye injection. The nurse tells the client that

1. The test may be painful.

2. The dye injected may cause a warm flushing

sensation. 3. Fluids will be restricted following the test.

4. The test takes about 2 hours.

ANSWER: 2

4. The nurse is caring for a client whose magnesium

level is 3.5 mg/dL. Which assessment sign/symptom

would the nurse most likely expect to note in the

client based on this magnesium level?

1. Tetany

2. Twitches

3. Positive trousseau’s sign

4. Loss of deep tendon reflex

5. The nurse is caring for a client with a diagnosis ofhyperthyroidism. Laboratory studies are performed,

and the serum calcium level is 12 mg/dL. Which

medication would the nurse anticipate to be

prescribed for the client?

1. Calcium gluconate

2. Calcium chloride

3. Calcitonin (Calcimar)

4. Large doses of vitamin D

6. The nurse prepares to administer sodiumpolystyrene sulfonate (Kayexalate) to the client.

Before administering the medication, the nurse

reviews the action of the medication and

understands that it releases

1. Bicarbonate in exchange primarily for sodium

ions.



2. Sodium ions in exchange primarily for

bicarbonate ions.

3. Sodium ions in exchange primarily for

potassium ions.

4. Potassium ions in exchange primarily for

sodium ions.

7. Which of the following clients is least likely at risk

for the development of third spacing?

1. The client with cirrhosis

2. The client with diabetes mellitus.

3. The client with liver failure

4. The client with renal failure

8. The nurse is preparing to care for a clientfollowing a gastroscopy procedure. The nurse

includes which most appropriate component in the

nursing care plan?

1. Place the client in supine position to provide

comfort.

2. Monitor the client’s vital signs every hour for 4

hours.

3. Provide saline gargles immediately on return to

the unit to aid in comfort.

4. Check the gag reflex by using a tongue

depressor to stroke the back of client’s throat.

9. Intravenous Ringer’s lactate solution is prescribed

for the postoperative client. The nursing instructor

asks the nursing student who is caring for the client

about the tonicity of the prescribed intravenous

solution. The nursing student responds correctly by

stating that this solution is

1. Isotonic.

2. Normotonic.

3. Hypotonic.4. Hypertonic.

10. The nurse reviews the arterial blood gas results

of a client with Guillain-Barre syndrome. The pH is

7.35 and the PCO2 is 50mmHg. The nurse interprets

that this client is experiencing which acid-base

imbalance?

1. Respiratory acidosis

2. Respiratory alkalosis

3. Metabolic acidosis

4. Metabolic alkalosis

11. The client is admitted 24 hours following an

aspirin overdose. The nurse assesses this client for

which signs and symptoms indicating the acid-base

disturbance that can occur in the client?

1. Bradycardia and Hyperactivity

2. Restlessness, confusion and a positive

trousseau’s sign

3. Headache, nausea, vomiting and diarrhea

4. Bradypnea, dizziness and paresthesias

12. The adult client with hepatic encephalopathy has

a serum ammonia level of 95 mcg/dL and receives

treatment with lactulose (Chronulac). The nurse

would evaluate that the client had the best and most

realistic response, if the serum ammonia level

changed to which of the following after medication

administration?

1. 80mcg/dL

2. 60mcg/dL3. 10mcg/dL

4. 5mcg/Dl

13. The client who suffered a crush injury to the leg

has a highly positive urine myoglobin level. The

nurse assesses this particular client carefully for

signs of

1. Cerebrovascular accident

2. Acute tubular necrosis

3. Respiratory failure4. Myocardial infarction

14. The adult male client admitted to the hospital

with shock has received fluid volume replacement .

The nurse evaluates that the client has had adequate

fluid resuscitation if the client’s repeat hematocrit



level has decreased to which of the following values

in the normal range?

1. 56%

2. 48%

3. 39%

4. 34%

15. The nurse is formulating a plan of care for a

client receiving enteral feedings. Which nursing

diagnosis is of highest priority for this client?

1. Imbalanced Nutrition, Less Than Body

Requirements.

2. Risk for aspiration

3. Risk for Deficient Fluid Volume

4. Diarrhea

16. A Client who has gastrostomy tube for feeding

refuses to participate in the plan of care, will not

make eye contact, and does not speak to the family

or visitors. The nurse assesses that this client is using

which type of coping mechanism?

1. Self-control

2. Problem-solving

3. Accepting responsibility

4. Distancing

17. The nurse conducting a weight loss program

prepares to monitor a client’s weight loss. What

method would assess the effectiveness of weight

loss most accurately?

1. Daily weights

2. Serum protein levels

3. Calorie counts

4. Daily intake and output

18. The clinic nurse is monitoring a client with

anorexia nervosa. Which statement if made by a

client would indicate to the nurse that treatment has

been effective?

1. ”I no longer have a weight problem.”

2. “I don’t want to starve myself anymore.”

3. “I’ll eat until I don’t feel hungry.”

4. “My friends and I went out to lunch today.”

19. The nurse is teaching the postgastrectomy client

about measures to prevent dumping syndrome.

Which statement by the client indicates a need forfurther teaching?

1. “I need to lie down after eating.”

2. “I need to drink liquids with meals.”

3. ”I need to eat small meals six times daily.”

4. “I need to avoid concentrated sweets.”

20. A client has been diagnosed with pernicious

anemia. In planning care for the client, the nurse

anticipates that the client will be treated with

1. Thiamine2. Iron

3. Vitamin B12

4. Folic acid

21. An older postoperative client has been tolerating

a full liquid diet, and the nurse plans to advance the

diet to solid food as prescribed. Which assessment is

most important for the nurse to make before

advancing the diet to solids?

1. Food preferences2. Cultural preferences

3. Preference of bowel sounds

4. Ability to chew

22. The client with diabetes mellitus has been

instructed in the dietary exchange system. The client

ask the nurse if bacon is allowed in the diet. Which

nursing response is most appropriate?

1. “Bacon is much too high in fat.”

2. “Bacon is not allowed.” 3. “One strip of bacon may be eaten if you

eliminate one teaspoon of butter.”

4. “Bacon may be eaten if you eliminate one

meat item from your diet.”



23. The client with heart disease is provided

instructions regarding a low-fat diet. The nurse

determines that the client understands the diet if

the client states that the food item to avoid is

1. Apples.

2. Oranges.3. Avocado.

4. Cherries.

24. A client with liver cancer who is receiving

chemotherapy tells the nurse that some foods on

the meal tray taste bitter. The nurse would try to

limit which food that is most l ikely to cause this taste

for the client?

1. Beef

2. Potatoes3. Custard

4. Cantaloupe

25. A nursing student is caring for a client who has

been admitted to the hospital with malnutrition. The

student is reviewing the results of the various

laboratory tests performed on the client with the

nursing instructor. Which statement if made by the

nursing student indicates an understanding of the

interpretation of the results?1. “An elevated creatinine level indicates

respiratory problems.”

2. “A normal hemoglobin level indicates that iron

and protein intake is sufficient.”

3. “An elevated albumin level indicates a definite

dehydration.”

4. “A normal red blood cell level indicates

adequate vitamin B6 intake”

26. The nurse notes that the infant with diagnosis ofhydrocephalus has a head that is heavier than the

average infant. The nurse determines that special

safety precautions are needed when moving the

infant. Which statement would the nurse include in

the discharge teaching with the parents to reflect

this safety need?

1. “When picking up your infant, support the

infants neck and head with the open palm of your

hand.”

2. “Feed your infant in a side-lying position.”

3. “Place a helmet on your infant when your in

bed.”4. “Hyperextand your infant’s head with a rolled

blanket under the neck area.”

27. The nurse is performing an admission

assessment on a child with a seizure disorder. The

nurse is interviewing the child’s parents to

determine their adjustment to caring for their child

who has a chronic illness. Which statement if made

by the parents would indicate a need for further

teaching?1. “Our child is involved in a swim program with

neighbors and friends.”

2. “Our child sleeps in our bedroom at night.”

3. “Our babysitter just completed

cardiopulmonary resuscitation training.”

4. “We worry about injuries when our child has a

seizure.”

28. The nurse is reviewing the results of a serum

level drawn from a child who is receivingcarbamazepine(Tegretol) for the control of seizures.

The results indicate a level of 10 mcg/mL. The nurse

analyzes the results and anticipates that the

physician will prescribe.

1. An increase of the dose of the medication.

2. A decrease of the dose of the medication.

3. Discontinuation of the medication.

4. Continuation of the presently prescribed

dosage.

29. The nursing student is asked to describe the

corpus of the uterus. Which of the following

responses, if made by the student, indicates an

understanding of the anatomy of the uterus?

1. “The corpus is the lower portion of the uterus.”

2. “The corpus is the upper part of the uterus.”



3. “The corpus is the area where the cervix meet

the external os.”

4. “The corpus is the area when the vagina meets

the uterus.”

30. The nurse instruct the client with diabetes

mellitus about blood glucose monitoring and

monitoring for signs of hypoglycemia. The nurse

informs the client that hypoglycemia is a blood

glucose level of less than

1. 120 mg/dL.

2. 110 mg/dL.

3. 90 mg/dL.

4. 60 mg/dL.

31. The client newly diagnosed with diabetes

mellitus is instructed by the physician to obtainglucagon for emergency home use. The client asks

the home care nurse about the purpose of the

medication. The nurse instructs the client that the

purpose of the medication is to treat

1. Hypoglycemia from insulin overdose.

2. Hyperglycemia from insufficient insulin.

3. Lipoatrophy from insulin injections.

4. Lipohypertrophy from inadequate insulin

absorption.

32. The nurse is providing care to a Cuban American

client who is terminally ill. Numerous family

members are present most of the time, and many of

the family members are emotional. The most

appropriate action is to

1. Restrict the numbers of family members

visiting at one time.

2. Inform the family that emotional outbursts are

to be avoided.

3. Request permission to move the client to a

private room and allow the family members to visit.4. Contact the physician to speak to the family

regarding their behaviors.

33. The nurse is instructing a postpartum client with

endometritis about preventing the spread of

infection to the newborn infant. The nurse would tell

the client that

1. Hands should be washed thoroughly before

holding the infant.

2. The newborn infant will not be allowed in the

mother’s room at all. 3. There is no danger of the newborn contracting

the disease.

4. Visitors are not allowed to hold the baby.

34. A client presents to the emergency department

with upper gastrointestinal bleeding and is in

moderate distress. In planning care, which nursing

action would be the first priority for this client?

1. Thorough investigation of precipitating events

2. Insertion of a nasogastric tube and hematest of

emesis

3. Complete abdominal examination

4. Assessment of vital signs.

35. The nurse is caring for a client with possible

cholelithiasis who is being prepared for an

intravenous cholangiogram, and the nurse teaches

the client about the procedure. Which client

statement indicates that the client understands thepurpose of this test?

1. “They are going to ‘look at’ my gallbladder and

ducts.”

2. “This procedure will drain my gallbladder.”

3. “My gallbladder will be irrigated.”

4. “They will put medication in my gallbladder.”

36. The nurse provides instructions to a

malnourished client regarding iron supplementation

during pregnancy. Which statement if made by theclient would indicate an understanding of the

instructions?

1. “The iron is best absorbed if taken with orange

juice.”

2. Meat does not provide iron and should be

avoided.”

3. “Iron supplements will give me diarrhea.”



4. “My body has all the iron it needs, and I don’t

need to take supplements.”

37. The nurse has give discharge instructions to the

client who has underwent vein ligation and strippingearly in the day. The nurse evaluates that the client

understands activity and positioning limitations if

the client states that it is most appropriate to

1. Lie down with the legs elevated and avoid

sitting.

2. Cross the legs at the ankle only, but not at the

knee.

3. Sit in the chair 3 times a day for 3 hours at a

time.

4. Walk upright for as much as possible each day.

38. Octreotide acetate (Sandostatin) is prescribed forthe client with acromegaly. The nurse monitors the

client, knowing that which side effect is associated

with the administration of this medication?

1. Constipation

2. Polyuria

3. Abdominal pain

4. Hypotension

39. Levothyroxine (Synthroid) is prescribed for a

client diagnosed with hypothyroidism. The nursereviews the client’s records and notes that the client

presently is taking warfarin (Caumadin). The nurse

contacts the physician, anticipating that the

physician will prescribe which of the following?

1. An increased dosage of warfarin.

2. A decreased dosage of warfarin.

3. An increased dosage of levothyroxine.

4. A decreased dosage of levothyroxine.

40. The nurse is teaching the client with emphysemaabout positions that help breathing during dyspneic

episodes. The nurse instruct the client to avoid

which of the following positions, which will

aggravate breathing?

1. Sitting up with the elbows resting on the knees

2. Standing and leaning against the wall

3. Lying on the back in low Fowler’s position

4. Sitting up and leaning on a table

41. The client is about to undergo a lumbar

puncture. The nurse describes to the client that

which of the following positions will be used duringthe procedure?

1. Side-lying with the legs pulled up and the head

bent down onto the chest

2. Side-lying with a pillow under the hip

3. prone with a pillow under the abdomen

4. Prone in slight trendelenburg’s position

42. The nurse recognizes that which of the following

interventions is unlikely to facilitate effective

communication between the dying client and his orher family?

1. The nurse encourages the client and family to

identify and discuss feelings openly.

2. The nurse makes decisions for the client and

family to relieve them of unnecessary demands.

3. The nurse assists the client and family in

carrying out spiritually meaningful practices.

4. The nurse maintains a calm attitude and one of

acceptance when the family or client expresses

anger.

43. The client with acute pancreatitis is experiencing

severe pain from the disorder. The nurse determines

that the client understood suggestions for

positioning to reduce pain if the client avoided.

1. Leaning forward.

2. Drawing the legs up to the chest.

3. Sitting up.

4. Lying flat.

44. The client has had surgery to repair a fractured

left hip. The nurse obtains which of the following

most important items from the unit storage area to

use when repositioning the client from side in bed?

1. Abductor’s splint

2. Adductor splint

3. Bed pillow



4. Overhead trapeze

45. The nurse is preparing to care for a client who

has undergone a myelogram using a oil-based

contrast agent. The nurse plans to position the clienton bedrest for

1. 6 to 8 hours with the head of bed flat.

2. 6 to 8 hours with the head of bed elevated 15

to degrees.

3. 2 to 4 hours with the head of bed flat.

4. 2 to 4 hours with the head of bed elevated 15

to 30 degrees.

46. The nurse has given activity guidelines to the

client with chronic back pain. The nurse determinesthat the client understood the instructions if the

client states to avoid which of the following

positions?

1. Lying on the side with knees and hips bent

2. Lying prone

3. Standing with one foot on a step or stool

4. Sitting using a lumbar roll or pillow.

47. The nurse has just admitted to the nursing unit a

client with basilar skull fracture who is at risk forincreased intracranial pressure. Pending specific

physician orders, the nurse would avoid placing the

client in which of the following positions?

1. Neck in neutral position

2. Head of bed elevated 30 to 40 degrees

3. Flat with head turned to the side

4. Head midline

48. The nurse reviews the arterial blood gas results

of an assigned client and notes that the laboratoryreport indicates a pH of 7.30, PCO2 of 58 mm Hg, PO2

of 80 mm Hg, and a HCO3 of 27 mEq/L. The nurse

interprets that the client has which acid-base

disturbance?

1. Metabolic Acidosis

2. Metabolic Alkalosis

3. Respiratory Acidosis

4. Respiratory Alkalosis

49. Cortesone acetate (Cortone) is prescribed for a

client with adrenal insufficiency. The nurse provides

instructions to the client regarding the medication.Which statement if made by the client indicates a

need for further instruction?

1. “I will eat a good breakfast every day.”

2. “I will avoid people with colds.”

3. “I will limit my sodium intake.”

4. “I will stop the medication when I feel better.”

50. The hospitalized client with diabetes mellitus

received NPH insulin in the morning. The nurse

monitors the client for hypoglycemia, knowing thatthe peak action occurs.

1. 2 to 4 hours after administration.




51. The nurse has admitted a client to the clinical

nursing unit following modified right radical

mastectomy for the treatment of breast cancer. The

nurse plans to place the right arm in which of thefollowing positions?

1. Elevated above shoulder level

2. Elevated on a pillow

3. Level with the right atrium

4. Dependent to the right atrium.

52. On the second postpartum day, a woman

complains of burning on urination, urgency, and

frequency of urination. A urinalysis is collected, and

the results indicate the presence of a urinary tractinfection. The nurse instruct the new mother

regarding measures to take for the treatment of the

infection. Which of the following statements if made

by the mother would indicate a need for further

instructions?

1. “The prescribed medication must be taken

until it is completed.”



2. “My fluid intake should be increased to at least

three thousand milliliters daily.”

3. “I need to urinate frequently throughout the

day.”

4. “I should consume foods and fluids that will

increase urine alkalinity.”

53. The registered nurse is beginning a new job in a

clinic and is attending an orientation session.

Following the orientation session, another new

employee asks the registered nurse to describe case

management, a component of the discussion in the

orientation session, because the employee did not

understand the concept clearly. The registered nurse

responds that

1. “Case management requires an experiencednurse because it represents a primary health

prevention focus and is managed by a single nurse.”

2. “Case management saves money for the

institution because client’s with similar problems are

treated in the same manner.”

3. “Case management is an important concept,

but it doesn’t promote appropriate use of

personnel.”

4. “Case management will maximize hospital

revenues and at the same time provide optimal

outcome of client care.”

54. The nurse provides dietary instructions to a

client with diabetes mellitus regarding the

prescribed diabetic diet. Which statement if made by

the client indicates a need for further teaching?

1. “I need to drink diet soft drinks.”

2. “I’ll eat a balanced meal plan.”

3. “I need to purchase special dietetic foods.”

4. “I’ll snack on fruit instead of cake.”

55. The client received 20 units of NPH insulin

subcutaneously at 8 AM. The nurse should assess the

client for a hypoglycemic reaction at

1. 10 AM

2. 11 AM

3. 5 PM

4. 11 PM

56. The community health nurse is working with

disaster relief in a local community following a

hurricane that ruined many homes in thecommunity. The nurse is working to find housing for

the survivors and is organizing counseling services.

These actions of the nurse represents which type of

level of prevention?

1. The primary level of prevention

2. The secondary level of prevention

3. The tertiary level of prevention

4. The fourth level of prevention

57. A pregnant women in her second trimester callsthe prenatal clinic nurse to report a recent exposure

to a child with rubella. Which of the following

responses by the nurse would be most appropriate

and supportive to the woman?

1. “There is no need to be concerned if you don’t

have a fever or rash within the next two days.”

2. “Be sure to tell the doctor on your next

prenatal visit, but there is little risk in the second

trimester.”

3. “You should avoid all school-aged children

during pregnancy.” 4. “You were wise to call. I will check your rubella

titer screening results, and we can identify

immediately whether future interventions are

needed.”

58. The breast-feeding mother of an infant with

lactose intolerance asks the nurse about dietary

measures. The nurse tells the mother to avoid

1. Hard cheeses

2. Green, leafy vegetables3. Dried beans

4. Egg yolk

59. A client with diabetes mellitus is told that

amputation of the leg is necessary to sustain life. The

client is upset and states to the nurse, “This is all the



doctor’s fault! I have done everything that the

doctors has asked me to do!” The nurse interprets

the clients statements as

1. An expected coping mechanism.

2. A need to notify the hospital lawyer.

3. An expression of guilt on the part of the client.4. An ineffective coping mechanism.

60. A client brought to the emergency room is dead

on arrival. The family of the client tells the physician

that the client had a terminal cancer. The emergency

room physician examines the client and asks the

nurse to contact the medical examiner regarding an

autopsy. The family of the client tells the nurse that

they do not want an autopsy performed. Which of

the following responses to the family is mostappropriate?

1. “It is required by federal law. Why don’t we talk

about it, and why don’t you tell me why you don’t

want the autopsy done?”

2. “The decision is made by the medical

examiner.”

3. “I will contact the medical examiner regarding

your request.”

4. “An autopsy is mandatory for any client who is

dead on arrival.”

61. A pregnant women who is positive for human

immunodeficiency virus (HIV) delivers a newborn

infant, and the nurse provides instruction to help the

mother regarding the newborn infant care. Which

statement by the client indicates the need for

further instructions?

1. “I will be sure to wash my hands before and

following bathroom use.”

2. “Support groups are available to assist me with

understanding my diagnosis of HIV.” 3. “I need to breast-feed, especially for the first

six weeks post-partum.”

4. “My newborn infant should be on antiviral

medication for the first six weeks after delivery.”

62. A pregnant women has a positive history of

genital herpes but has not had lesions during this

pregnancy. The nurse should plan to provide which

of the following information to the client?

1. “You will be isolated from your newborn infant

following delivery.” 2. “You will be evaluated at the time of delivery

for herpetic general tract lesions, and if lesions are

present, a cesarean delivery will be needed.”

3. “There is little risk to your newborn infant

during this pregnancy, birth, and following delivery.”

4. “Vaginal deliveries can reduce neonatal

infection risks even if you have an active lesion at

birth.”

63. A 7-year-old child is diagnosed with viralconjunctivitis. Antibiotic eye drops are prescribed for

the child. The mother asks the nurse when the child

can return to school. The most appropriate response

is

1. “The child can return to school immediately.”

2. “The child should be kept home until the

antibiotic eye drops have been administered for

twenty-four hours .”

3. “The child should be kept home until the

antibiotic eye drops have been administered for

seventy-two hours.” 4. “The child cannot return to school until seen by

the physician in one week.”

64. An adolescent is diagnosed with conjunctivitis,

and the nurse provides information to the

adolescent about the use of contact lenses. Which

statement by the client indicates the need for

further information?

1. “My contact lens can be worn if they are

cleaned as directed.” 2. “I should not wear my contact lens.”

3. “New contact lenses should be obtained.”

4. “My old contact lenses should be discarded.”

65. A pregnant client is seen in the health care clinic

and asks the nurse what causes the breasts to



change in size and appearance during pregnancy.

The nurse plans to base the response on which of

the following?

1. The breasts changes are due to the secretion of

estrogen and progesterone.

2. The breasts become stretched because of theweight gain.

3. The increased metabolic rate causes the

breasts to become larger.

4. Cortisol secreted by the adrenal glands play a

factor in increasing the size and appearance of the

breasts.

66. The nurse is caring for a client receiving bolus

feedings via Levin-type nasogastric tube. As the

nurse is finishing the feeding, the client asks the bedto be positioned flat to sleep. The nurse understands

that the most appropriate position for this client at

this time is which of the following?

1. Head of bed flat with the client in the supine

position for at least 30 minutes

2. Head of bed elevated 30 to 45 degrees with the

client in the right lateral position for 60 minutes

3. Head of bed elevated 45 to 60 degrees with the

client in the supine position for 90 minutes

4. Head of bed in semi-fowlers position with the

client in the left lateral position for 60 minutes

67. Before administering an intermittent tube

feeding through a nasogastric tube, the nurse assess

for gastric residual. The nurse understands that this

procedure is important to

1. Confirm proper nasogastric tube placement.

2. Observe gastric content.

3. Assess fluid and electrolyte status.

4. Evaluate absorption of the last feeding.

68. A 4-year old child is diagnosed with otitis media.

The mother asks the nurse about the causes of this

illness. The nurse responds, knowing that which of

the following is an unassociated risk factors related

to otitis media?

1. Household smoking

2. Bottle-feeding

3. Exposure to other illness in other children

4. A history of Urinary Tract infections.

69. The pediatric nurse assists the physician inperforming a lumbar puncture on a 3-year-old child

with leukemia suspected of having central nervous

system metastasis. The nurse places a child in which

position for this procedure?

1. Prone with the knees flexed to the abdomen

and the head bent with the chin resting on the chest

2. Modified Sims’ position.

3. Lateral recumbent with the knees flexed to the

abdomen and the head bent with the chin resting on

the chest

4. Lithotomy position

70. A client with diabetes mellitus is self-

administering NPH insulin from a vial that is kept at

room temperature. The client asks the nurse about

the length of time an unrefrigerated vial of insulin

will maintain its potency. The most appropriate

response to the client is which of the following?

1. 2 weeks

2. 1 month

3. 2 months4. 6 months

71. The nurse is caring for a client scheduled for

transphenoidal hypophysectomy. The preoperative

teaching instructions would include which most

important statement?

1. “Your hair will need to be shaved.”

2. “Deep breathing and coughing will be needed

after surgery.”

3. “Toothbrushing will not be permitted for atleast two weeks following surgery.”

4. “You will receive spinal anesthesia.”

72. The nurse caring for a client with addison’s

disease would expect to note which of the following

on assessment of the client?



1. Obesity

2. Edema

3. Hypotension

4. Hirsutism

73. The nurse is conducting a prepared child birth

class and is instructing a birth class pregnant women

about the method of effleurage. The nurse instructs

the women to perform the procedure by

1. Contracting and the consciously relaxing

different muscle groups.

2. Contracting an area of the body such as an arm

or leg and then concentrating on letting tension go

from the rest of the body.

3. Massaging the abdomen during contractions

using both hands in a circular motion.4. Instructing the significant other to stroke or

massage a tightened muscle by the use of touch.

74. During a routine prenatal visit, the client

complains of gums that bleed easily with brushing.

The nurse performs an assessment and then teaches

the client about proper nutrition to minimize this

problem. Which statement if made by the client

indicates an understanding of the proper nutrition to

minimize this problem?1. “I will eat three savings of cracked wheat bread

each day.”

2. “I will eat fresh fruits and vegetables for snacks

and for dessert each day.”

3. “I will drink eight ounces of water with each

meal.”

4. “I will eat two saltine crackers before I get up

each morning.”

75. A 6-year-old child has just been diagnosed withlocalized Hodgkin’s disease, and chemotherapy is

planned to begin immediately. The mother of the

child asks the nurse why radiation therapy was not

prescribed as a part of the treatment. The most

appropriate and supportive response to the mother

is

1. “I’m not sure. I’ll discuss it with the physician.”

2. “The child is too young to have radiation

therapy.

3. “It’s very costly, and chemotherapy works just

as well.”

4. “The physician would prefer that you discuss

treatment options with the oncologist.”

76. A diagnostic work-up is being performed on a 1-

year-old child suspected of having a diagnosis of

neuroblastoma. The nurse reviews the result of the

diagnostic tests and understands that which finding

is related most specifically to this type of humor?

1. Elevated vanillylmandelic acid urinary levels

2. The presence of blast cells in the bone marrow

3. Projectile vomiting occurring most often in the

morning4. Positive Babinski’s sign

77. The nurse is developing a post-operative plan of

care for a 40-year-old male Filipino client scheduled

for an appendectomy. The nurse most appropriately

includes in the plan of care to

1. Inform the client the he will need to ask for

pain medication when needed.

2. Offer pain medication when non verbal signs of

discomfort are identified.3. Offer pain medication regularly as prescribed.

4. Allow the client to maintain control and

request pain medication on his own.

78. The nurse provides instructions regarding home

care to the parents of a 3-year-old child hospitalized

with hemophilia. Which statement if made by a

parent indicates a need for further instructions?

1. “We will supervise the child closely.”

2. “We will pad corners of the furniture.” 3. “We will remove household items that can fall

over easily.”

4. “We will avoid having the child receive

immunizations and cancel scheduled dental

appointments."



79. The nurse is planning to instruct the Mexican

American client about nutrition and dietary

restrictions. When developing the plan, the nurse is

aware that this ethnic group

1. Enjoys food that lacks color, flavor, and texture.

2. Primary eat raw fish.3. Enjoys eating red meat.

4. Views food as a primary form of socialization.

80. The registered nurse is planning the client

assignments for the day. Which of the following is

the most appropriate assignment for the nursing

assistant?

1. A client with bladder cancer who will be

receiving chemotherapy.

2. A client on bedrest who requires range ofmotion exercise every 4 hours.

3. A new diabetic mellitus client scheduled for

discharge

4. A client scheduled to receive a blood

transfusion

81. Prophylthiouracil (PTU) is prescribed for the

client with hyperthyroidism. The nurse provides

instructions to the client regarding the medication

and informs the client to notify the physician ifwhich of the following signs occur?

1. Drowsiness

2. Sore throat

3. Increased urination

4. Dry mouth

82. A client who has been taking iodine solution

(Lugol’s solution, potassium iodide solution) is

admitted to the emergency room and iodine

overdose is suspected. Gastric lavage is initiated toremove the iodine from the stomach. In addition to

treatment with gastric lavage, the nurse anticipates

that which of the following will be administered?

1. Calcium gluconate

2. Vitamin K

3. Acetylcysteine (Mucomyst)

4. Sodium thiosulfate

83. The nurse is interviewing a 16-year-old client

during her initial prenatal clinic visit. The client is

beginning week18 of her first pregnancy. Which

statements if made by the client indicates animmediate need for further investigation?

1. “I don’t like my face anymore. I always look like

I have been crying.”

2. “I don’t like my breasts anymore. These silver

lines are ugly.”

3. “I don’t like my stomach anymore. That brown

line is disgusting.”

4. “I don’t like my figure anymore. My clothes are

all too tight.”

84. The client seen in the health care clinic has

tested positive for gonorrhea. The nurse anticipates

that which medication will be prescribed for the

client based on this finding?

1. Ceftriaxone (Rocephin)

2. Penicillin G benzathine (Bicillin)

3. Acyclovir (Zovirax)

4. Azithromycin (Zithromax)

85. The client is brought into the emergency room inventricular fibrillation. The advanced cardiac life

support nurse prepares to defibrillate by placing

conductive gel pads on which part of the chest?

1. To the upper and lower half of the sternum

2. To the right of the sternum just below the

clavicle and to the left of the precordium

3. To the right shoulder and in the back of the left

shoulder

4. Parallel between the umbilicus and the right

nipple

86. A rubella vaccine is prescribed to be

administered to a 2-day postpartum client. The

nurse preparing to administer the vaccine develops a

list of the potential risks associated with this vaccine.

The nurse reviews the list with the client and

cautions the client to avoid



1. Sunlight for 3 days.

2. Scratching the injection site.

3. Pregnancy for 2 to 3 months after the

vaccination.

4. Sexual intercourse for 2 to 3 months after the

vaccination.

87. The client has undergone mastectomy. The nurse

interprets that the client is making the best

adjustment to the loss of the breast if which of the

following behaviors is observed?

1. Participating in the care of the surgical drain

2. Reading postoperative care booklet

3. Refusing to look at the wound

4. Asking for pain medication when needed

88. The client is preparing for discharge from the

hospital after radical vulvectomy. The nurse plan to

teach this client that which of the following activities

is acceptable after discharge because it will not

precipitate complications?

1. Sexual activity

2. Walking

3. Sitting for lengthy periods

4. Driving a car

89. The child with croup is being discharged from the

hospital. The nurse provides instructions to the

mother and advises the mother to bring the child to

the emergency room if the child

1. Appears tired.

2. Takes fluids poorly.

3. Is irritable.

4. Develops stridor.

90. The emergency room nurse is caring for a child

suspected of epiglottitis and has ensured that the

child has a patent airway. The next priority in the

care of this child would be to

1. Prepare the child for a chest radiograph.

2. Assist the physician with intubation.

3. Prepare the child for tracheostomy.

4. Prepare to administer epinephrine.

91. The nurse reviews a plan of care for a client at 37

weeks of gestation who has sickle cell anemia. The

nurse determines that which nursing diagnosis listedon the nursing care plan will received the highest

priority?

1. Activity Intolerance

2. Disturbed Body image

3. At risk for pain

4. Deficient Fluid Volume

92. The mother arrives at the clinic with her 3-year-

old child. The mother tells the nurse that the child

has had a fever and a cough for the past 2 days andthat this morning the child began to wheeze. Viral

pneumonia is diagnosed. Based on the diagnosis, the

nurse anticipates that which of the following will be

a component of the treatment plan?

1. Orally administered antibiotics

2. Hospitalization and intravenously administered

antibiotics

3. Supportive treatment

4. Intravenous fluid administration

93. A mother of a child with cystic fibrosis asks the

clinic nurse about the disease. The nurse tells the

mother that cystic fibrosis is

1. A disease that causes the formation of multiple

cysts in the lungs.

2. A chronic multisystem disorder affecting the

exocrine glands.

3. Transmitted as an autosomal dominant trait

4. A disease that causes dilation of the

passageways of many organs.

94. Minoxidil solution (Rogaine) is prescribed for the

client to treat hair loss. The nurse tell the client that

the usual dosage for this medication is

1. 1 mL applied 6 times daily.

2. 1 mL applied at bedtime.

3. 1 mL applied 2 times a day.



4. 1 mL applied 4 times a day.

95. Collagenase (Santyl) is prescribed for a client

with a severe burn to the hand. The home care nurse

provides instructions to the client regarding the useof the medication. Which client statement indicates

an accurate understanding of the use of this

medication?

1. “I will apply the ointment once a day and leave

it open to the air.”

2. “I will apply the ointment once a day and cover

it with a sterile dressing.”

3. “I will apply the ointment twice a day and leave

it open to the air.”

4. “I will apply the ointment at bedtime and in the

morning and cover it with a sterile dressing.”

96. The mother of an infant diagnosed with

Hirschsprung’s disease asks the nurse about the

disorder. The nurse tells the mother that this disease

is a

1. Congenital agangliosis or megacolon.

2. Complete small intestinal obstruction.

3. Condition that causes the pyloric valve to

remain open.

4. Severe inflammation of the gastrointestinaltract.

97. The nurse is preparing to care for a newborn

infant who will be returning from surgery with a

colostomy that was created for imperforate anus.

When the newborn infant returns from surgery, the

nurse assesses the stoma and notes that it i s red and

edematous. Which of the following is the most

appropriate nursing intervention?

1. Call the physician. 2. Document the findings.

3. Apply ice immediately.

4. Elevate the buttocks.

98. The nurse is developing a plan of care for a

preterm newborn infant and is addressing measures

to provide skin care. The nurse develops measures

knowing that the preterm newborn infant’s skin

appears

1. Reddened, thin, and gelatinous with decreased

amounts of subcutaneous fat and open posture.

2. Thin and gelatinous with increasedsubcutaneous fat.

3. Thin and gelatinous with increased amounts of

brown fat.

4. With fine downy hair on a thin epidermal and

dermal layer with increased amount of brown fat.

99. The nurse in the labor room is performing an

initial assessment on a newborn infant. On

assessment of the newborn infant’s head, the nurse

notes that the ears are low set. Which of thefollowing nursing actions would be most

appropriate?

1. Cover the ears with gauze pads.

2. Document the findings.

3. Arrange for hearing testing.

4. Notify the physician.

100. The clinic nurse is assessing the status of

jaundice in a child with hepatitis. Which anatomical

area will provide the best data regarding thepresence of jaundice?

1. The nailbeds

2. The skin in the abdominal area

3. The skin in the sacral area

4. The membranes in the ear canal

101. A prenatal client with a history of heart disease

has been instructed on care at home. Which

statement if made by the client would indicate that

the client understands her needs?1. “There is no restriction on people who visit

me.”

2. “I should avoid stressful situations.”

3. “My weight gain is not important.”

4. “I should rest on my right side.”



102. A prenatal client has acquired the sexual

transmitted infection human papilloma virus. When

planning care, Which of the following interventions

would the nurse anticipate would be prescribed

because of its safety during pregnancy?

1. Cryotherapy2. Use of cytotoxic agents

3. Treatment with imiquimod

4. Treatment with podophyllin

103. The home care nurse is assigned to visit a

Mexican American client to perform an admission

assessment. On initial meeting of the client, The

nurse would

1. Greet the client with a handshake.

2. Avoid touching the client.3. Avoid any affirmative nods during the

conversations with the client.

4. Smile and use humor throughout the entire

admission assessment.

104. Russell’s traction is prescribed for a child with a

lower leg fracture. The mother of a child asks the

nurse about the purpose of the traction. The nurse

explains to the mother that this type of traction

primarily provides1. Reduction or realignment of a fracture site.

2. Keeps the child from moving around in bed.

3. Provides a form of restraint for the child.

4. Will relieve the child’s pain.

105. The home care nurse’s assignment is to visit a

new mother at home 24 to 48 hours after discharge.

Which of the following would the nurse expect to

note in a healthy mother who is breast-feeding her

newborn infant?1. A mother breast-feeding with the infant in a

tummy to tummy position without signs of cracked

nipples; the baby demonstrates bursts of sucking

followed by a pause and swallow.

2. A mother breast-feeding the infant with the

infant’s head turned toward her breast, with the

body flat in her arms; mother with sore nipples and

infant with a suck blister.

3. A mother complaining of breast engorgement

with the infant demonstrating difficulty in latching

onto the breast.

4. A mother with cracked nipples feeding theinfant with a supplemental bottle.

106. The nurse is assigned to care for a client who is

in traction. The nurse prepares a plan of care for the

client and includes which nursing action in the plan?

1. Monitor the weights to be sure that they are

resting on a firm surface.

2. Check the weights to be sure that they are off

of the floor.

3. Make sure that the knots are at the pulleys.4. Make sure the head of the bed is kept at a 45-

to 90- degree angle.

107. A nurse is setting up the physical environment

for an interview with a client and plans to obtain

subjective data regarding the client’s health. Select

all interventions that are appropriate.

___ Set the room temperature at a comfortable

level.

___ Provides seating for the client so that the clientfaces a strong light.

___ Ensures that the distance between the client

and nurse is at least 6 feet.

___ Place a chair for the client across from the

nurse’s desk.

___ Remove distracting objects from the

interviewing area.

___ Ensure comfortable seating at eye level for the

client and nurse.

108. The private duty nurse has been caring for a

terminally ill client whose death is imminent. The

nurse has developed a close relationship with the

family of the client. Which of the following nursing

interventions will the nurse avoid in dealing with the

family during this difficult time?

1. Making the decisions for the family



2. Encouraging family discussion of concerns

3. Encouraging family requested clergy visits

4. Accepting the family’s expressions of anger

109. The nurse is reviewing the record of a pregnantclient and notes that the physician has documented

the presence of chadwick’s sign. The nurse

understands that the hormone responsible for the

development of this sign is which of the following?

1. Human chorionic gonadotropin

2. Estrogen

3. Progesterone

4. Prolactin

110. The nurse is caring for an older client who hasbeen placed in Buck’s extension traction following a

hip fracture. On assessment of the client the nurse

notes that the client is disoriented. The most

appropriate nursing intervention is to

1. Ask the family to stay with the client.

2. Apply restraints to the client.

3. Ask the laboratory to perform electrolyte

studies.

4. Reorient the client frequently and place a clock

and a calendar in the client’s room.

111. The nurse is preparing a plan of care for the

client in skin traction. The nurse includes in the plan

that a priority intervention is to assess the client

frequently for

1. The presence of bowel sounds.

2. Signs of infection around the pin sites.

3. Signs of skin breakdown.

4. Urinary incontinence.

112. A contraction stress test is scheduled for the

pregnant client, and the client asks the nurse about

the test. The nurse tells the client that

1. Small amounts of oxytocin (Pitocin) are

administered during internal fetal monitor to

stimulate fetal uterine contractions.

2. An external fetal monitor is attached, and the

women ambulates on a treadmill until contractions

begin.

3. The uterus is stimulated to contract by the use

of small amount of oxytocin (pitocin) or by nipple

stimulation.4. Uterine contractions are stimulated by

Leopold’s maneuvers.

113. The mother arrives at a well-baby clinic with her

1-month-old infant. She expresses concerns because

one of the infant’s eyes appears to be crossed. The

most appropriate and supportive response by the

nurse is which of the following?

1. “The infants will probably need surgery.”

2. “This condition is probably permanent.” 3. “It bears watching because the other eye may

do the same thing.”

4. “This is normal in the young infant but should

not be present after about age four months.”

114. The physician prescribes “patching” for a child

with strabismus of the right eye and the nurse

instructs the mother regarding this procedure.

Which of the following will the nurse include in the

instructions?1. Place the patch on the right eye.

2. Place the patch on both eyes.

3. Place the patch on the left eye.

4. Alternate the patch from the right to the left

eye hourly.

115. A nonstress test is performed on a client who is

pregnant, and the result of the test indicate non

reactive findings. The physician prescribed a

contraction stress test. The test is performed, andthe nurse notes that the physician has documented

the results as negative. The nurse interprets this

finding as indicating

1. A high risk for fetal demise.

2. A normal test result.

3. The need for a cesarean delivery.

4. An abnormal test result.



116. The nurse has developed a plan of care for a

client who is in traction and documents a nursing

diagnosis of Self-Care Deficit. The nurse evaluate the

plan of care and determines that which of thefollowing observations indicates a successful

outcome?

1. The client allows the nurse to complete the

care daily.

2. The client allows the family to assist in the care.

3. The client refuses care.

4. The client assist in self-care as much as

possible.

117. The home care nurse is visiting a client who is ina body cast. The nurse is performing an assessment

and is assessing the psychosocial adjustment of the

client to the cast. The nurse most appropriately

would assess

1. The type of transportation available for follow-

up care

2. The ability to perform activities of daily living.

3. The need for sensory stimulation.

4. The amount of home care support available.

118. The maternity nurse is providing an in-service

educational session to nursing students regarding

the process of conception. The nurse instruct the

nursing students that fertilization of a mature ovum

occurs in which of the following areas?

1. Uterus

2. Ovary

3. Distal third of the fallopian tube

4. Wall of the myometrium

119. The nurse is preparing to teach a client how to

use crutches safely. Before initiating the teaching,

the nurse performs an assessment on the client. The

priority nursing assessment should include which of

the following?

1. The client’s fear related to the use of the

crutches

2. The client’s understanding of the need for

increased mobility

3. The client’s vital signs, muscle strength, and

previous activity level of the client

4. The client’s feelings about the restricted

mobility.

120. The nurse is assessing for Kernig’s sign in a child

with a suspected diagnosis of meningitis. The nurse

performs this test by

1. Bending the head towards the knees and hips

and assessing for pain.

2. Tapping the facial nerve and assessing for

spasm.

3. Compressing the upper arm and assessing for

tetany.

4. Raising the leg with the knee flexed and thenextending the leg at the knee and assessing for pain.

121. The physician has written an order to start

progressive ambulation as tolerated on a

hospitalized client who experiences periods of

confusion because of bedrest and prolonged

confinement to the hospital room. Which nursing

intervention would be most appropriate when

planning to implement the physician’s order and in

addressing the needs of the client?1. Help the client to ambulate in the room for

short distances frequently.

2. Help the client to ambulate to the bedroom in

the client’s room 3 times a day.

3. Progressively increase ambulation in the hall 3

times a day.

4. Assist with range of motion exercises 3 times a

day to increased strength.

122. A client is seen in the health care clinic, and avitamin K deficiency is suspected. On assessment of

the client the nurse would expect to note which of

the following if this vitamin deficiency were present?

1. Client complaints of night blindness

2. Signs of clotting problems

3. Scaly skin

4. Client complaints of skeletal pain



123. The nurse is caring for a postterm, small-for-

gestational-age newborn infant immediately after

admission to the nursery. The priority nursing action

would be to monitor1. Urinary output.

2. Total bilirubin levels.

3. Blood glucose levels.

4. Hemoglobin and hematocrit levels.

124. The nurse is performing an initial assessment on

a large-for-gestational-age newborn infant. Which

physical assessment technique would the nurse

perform to assess for the evidence of birth trauma?

1. Palpate the clavicles for a fracture2. Auscultate the heart for a cadiac defect.

3. Blanch the skin for evidence of jaundice.

4. Perform the Ortolani maneuver for hip

dislocation.

125. Somatropin (Humatrope), a growth hormone, is

prescribed for a client. The nurse reviews the

assessment data in the client’s health record,

knowing that the medication is contraindicated in

which of the following conditions?1. A child with growth hormone deficiency

2. A child with pituitary dwarfism

3. A 20-year-old with growth failure

4. A child with growth failure

126. The nurse is caring for a client who is receiving

growth hormone replacement therapy. The nurse

monitors the client for which side effect of this

therapy?

1. Hyperglycemia2. Hyperthyroidism

3. Hypoglycemia

4. Hypocalciuria

127. The nurse is assessing a client with a diagnosis

of goiter. Which of the following would the nurse

expect to note during the assessment of the client?

1. Client complaints of slow wound healing

2. Client complaints of chronic fatigue

3. An enlarged thyroid gland4. The presence of heart damage

128. A fasting blood glucose screening is performed

on a pregnant client. The results indicate that the

blood glucose is 140mg/dL. Which of the following

would the nurse anticipate to be prescribed for the

mother?

1. Administration of an oral hypoglycemic agent

2. Administration of NPH insulin daily

3. A 3-hour glucose tolerance test4. A sliding scale regular insulin dose

129. The pregnant client seen in the health care

clinic has tested positive for human

immunodeficiency virus. Base on this information,

the nurse determines that

1. The client has the herpes simplex virus.

2. Human immunodeficiency virus antibodies are

detected on the enzyme-linked immunosorbent

assay.3. The neonate definitely will develop this disease

after birth.

4. This client has contacted an airborne disease.

130. During a wellness fair, an adult client admits to

a nurse of not eating a well-balanced diet. According

to the Food Guide Pyramid, which of the following

instructions would the nurse provide to the client?

1. “Your diet should consist of six to eleven

servings of bread, cereal, pasta, or rice a day.” 2. “Your diet should consist of two to four

servings of vegetables a day.”

3. “Your diet should consist of four to five servings

of milk, yogurt, or cheese a day.”

4. “Your diet should consist of four to six servings

of meat, poultry, fish, dry beans, or nuts a day.”



131. An 85-year-old client is hospitalized for a right

fractured hip. During the postoperative period, the

client’s appetite is poor and the client refuses to get

out of bed. Which nursing statement would be most

appropriate to make to the client?1. “It is important for you to get out of bed so that

calcium will go back into the bone.”

2. ”We need to increase your calcium intake

because you are spending too much time in bed.”

3. “We need to give you iodine so that it will help

in hemoglobin synthesis.

4. “You need to remember to turn yourself in bed

every two hours to keep from getting so stiff.”

132. Lindane (Kwell) is prescribed for the treatmentof scabies. The nurse reviews the client’s record,

knowing the medication therapy is contraindicated if

the client is

1. A 42-year-old women.

2. An older client.

3. A 6-year-old child.

4. A 52-year-old man with hypertension.

133. A DuoDerm is prescribed for a client with a leg

ulcer. The home health nurse is preparing a plan ofcare for the client and most appropriately

documents to

1. Change the DuoDerm daily.

2. Apply the DuoDerm over a dry sterile dressing.

3. Change the DuoDerm weekly.

4. Apply the DuoDerm over a normal saline-

soaked dressing.

134. A nurse develops a plan of care for a client

being admitted to the hospital with a diagnosis ofcerebral aneurysm who will be placed on aneurysm

precaution. The nurse includes which intervention in

the plan?

1. Provide the client with a low-fiber-diet.

2. Keep the room lights on to ensure client

orientation to the environment.

3. Place the client in a semiprivate room to

provide stimulation.

4. Restrict visitors to close family or significant

others and keep visits short.

135. Glyburide (DiaBeta) 2.5 mg orally daily is

prescribed for a client. The nurse tells the client

1. To take the medication in the morning before

breakfast

2. To expect his skin color to change from pink to

yellow and to expect pale-colored stools.

3. That the medication is used to prevent foot

infections.

4. That if an altered taste sensation occurs, to

contact the physician immediately.

136. A nurse employed on a medical unit in a

hospital receives a telephone call from the admission

office and is told that a client with a diagnosis of

mycoplasmal pneumonia will be admitted to the

nursing unit. The nurse prepares for the admission

and obtains the necessary supplies to place the

client on which type of transmission-based

precaution?

Answer: DROPLET PRECAUTION

137. A nurse manager is providing an educational

session to nursing staff members about the phases

of viral hepatitis. The nurse manager tells the staff

that which clinical manifestation(s) are primarily

characteristic of the preicteric phase?

1. Right upper quadrant pain

2. Fatigue, anorexia, and nausea

3. Jaundice, dark-colored urine, and clay-colored

stools

4. Pruritus

138. The registered nurse is planning assignments

for the clients on a nursing units. The registered

nurse needs to assign four clients and has a

registered nurse, a licensed practical (vocational)

nurse, and two nursing assistants on a nursing team.



Which of the following clients would the nurse most

appropriately assign the licensed practical

(vocational) nurse?

1. The client who requires a 24-hour urine

collection

2. An older client requiring assistance with a bedbath and frequent ambulation

3. A client on a mechanical ventilator requiring

frequent assessment and suctioning.

4. A client with an abnormal wound requiring

wound irrigations and dressing changes every 3

hours.

139. A nursing instructor asks the nursing student to

describe the definition of a critical path. Which of

the following statements, if made by the student,indicates a need for further understanding regarding

critical paths?

1. “They are developed through the collaborative

efforts of all members of the health care team.”

2. “They provide an effective way to monitor care

and for reducing or controlling the length of hospital

stay for the client.”

3. “They are developed based on appropriate

standards of care.”

4. “They are nursing care plans and use the steps

of the nursing process.”

140. The nurse is caring for an 18-month old child

who has been vomiting. The most appropriate

position for the child during naps and sleep time is

1. Side-lying position.

2. Prone with the face turned to the side.

3. Supine.

4. Prone with the head elevated.

141. The parents of a child with cleft lip are

concerned and ask the nurse when the lip will be

repaired. The nurse supportively tells the parents

that

1. Cleft lip repair usually is performed between 6

months and 2 years of age.

2. Cleft lip repair usually is performed by 6

months of age.

3. Cleft lip repair usually is performed during the

first week of life.

4. Cleft lip cannot be repaired.

142. The nurse is assessing the client for signs of

postpartum depression. Which of the following if

noted in the new mother, would indicate the need

for further assessment related to this form of

depression?

1. The mother is caring for the infant in a loving

manner.

2. The mother constantly complains of tiredness

and fatigue.

3. The mother demonstrates an interest in thesurroundings.

4. The mother looks forward to visits from the

father of the newborn.

143. A postpartum client is attempting to breast-

feed for the first time. The nurse notes that the

client has inverted nipples. What nursing action can

the nurse take to assist the client in breast-feeding

the newborn infant?

1. Provide breast shells and assist the mother withusing a breast pump before each feeding to make

the nipples easier for the newborn infant to grasp.

2. Have the mother grasp the nipples between

the thumb and the forefinger and tug firmly to get

the nipple to protrude.

3. Massage the breast, applying gentle pressure

on the areola.

4. Take a cool shower, allowing the water to run

over the breast because this will discourage the

nipples to protrude.

144. The nurse instructs the client in breast self-

examination. The nurse tells the client to lie down

and to examine the left breast. The nurse instructs

the client that while examining the left breast to

place a pillow.

1. Under the right shoulder.



2. Under the left shoulder.

3. Under the small of the back.

4. Under the right scapula.

145. The nurse is teaching a breast-self examinationto a client who had a hysterectomy. The most

appropriate instruction regarding when the breast

self-examination should be performed is

1. 7 to 10 days after menses.

2. Just before menses begins.

3. At ovulation time.

4. At a specific day of the month and on that same

day every month thereafter.

146. The nursing instructor asks the nursing studentto describe Montgomery’s tubercles of the breast.

The student indicates an understanding of this

anatomical structure if the student states that the

Montgomery’s tubercles are

1. Sebaceous glands that are located in the

2. Lobes of glandular tissue that secrete milk.

3. Small sacs that contain acinar cells to secrete

milk

4. Ducts containing milk from all areas of the

breast.

147. The 32-year-old female client has a history of

fibrocystic disorder of the breasts. The nurse

interviewing the client asks whether the breast

lumps are more noticeable.

1. In the spring months.

2. In the autumn.

3. After menses.

4. Before menses.

148. A 1-year-old child is diagnosed with

intussusceptions, and the mother of the child asks

the nurse to describe the disorder. The nurse tells

the mother that this disorder is

1. An acute bowel obstruction.

2. A condition when a proximal segment of the

bowel prolapses into a distal segment of the bowel.

3. A condition when a distal segment of the bowel

prolapses into a proximal segment of the bowel.

4. A condition that causes an acute inflammatory

process in the bowel.

149. A 3-year-old child is seen in the health care

clinic, and a diagnosis of encopresis is made. The

nurse reviews the assessment findings expecting to

note documentation of which sign of this disorder?

1. Nausea and Vomiting

2. Diarrhea

3. Evidence of soiled clothing

4. Malaise and anorexia

150. The nurse is teaching the client who hadlaryngectomy for laryngeal cancer how to use an

artificial larynx. The nurse tells the client to

1. Insert the device into the tracheostomy.

2. Hold the device alongside the neck.

3. Hold the device over the upper portion of the

sternum.

4. Swallow air into the esophagus to make

speech.

151. A client is scheduled for a papanicolaou’s smearat the next scheduled clinic visit. The nurse provides

instructions to the client regarding preparation for

this test. The nurse tells the client that

1. The test can be performed during

menstruation.

2. Fluids are restricted on the day of the test.

3. The test is painless.

4. Vaginal douching is required 2 hours before the

test.

152. A nurse witnesses an accident on highway and

stops to provide assistance to the victim. The nurse

notes that the client sustained a head injury and a

compound fracture to the left leg. The nurse

provides the appropriate care before transport of

the victim to the hospital by ambulance. The client

develops a severe bone infection at the site of the



fracture that requires amputation of the leg and files

suit against the nurse who provided care at the

scene of the accident. Which of the following is

accurate regarding the nurses immunity from this

suit?

1. The Good Samaritan law will protect the nurse.2. The Good Samaritan law will not protect the

nurse.

3. The Good Samaritan law will provide immunity

from suit even if the nurse accepted compensation

for the care provided.

4. The Good Samaritan law protects laypersons

and not professional healthcare providers.

153. A client is seen in the clinic for complaints of

thirst, frequent urination, and headaches. Followingdiagnostic studies, diabetes insipidus in diagnosed.

Lypressin (Diapid) is prescribed. The nurse instructs

the client that the medication is prescribed to

1. Relieved the headaches.

2. Increase water reabsorption.

3. Decrease the production of the antidiuretic

hormone.

4. Stimulate the production of aldosterone.

154. Somatrem (Protropin) is prescribed for theclient with pituitary dwarfism. The nurse explains

comprehensive review of the nclex by saunders 3rd ed. (autosaved)

Documents