For Answers and Rationale, click here.
51. A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the per-ineum. Which initial action is most appropriate?
❍ A. Document the finding.
❍ B. Report the finding to the doctor. ❍ C. Prepare the client for a C-section.
❍ D. Continue primary care as prescribed.
52. A client with a diagnosis of HPV is at risk for which of the following?
❍ A. Hodgkin’s lymphoma ❍ B. Cervical cancer
❍ C. Multiple myeloma ❍ D. Ovarian cancer
53. During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
❍ A. Syphilis ❍ B. Herpes
❍ C. Gonorrhea ❍ D. Condylomata
54. A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:
❍ A. Venereal Disease Research Lab (VDRL) ❍ B. Rapid plasma reagin (RPR)
❍ C. Fluorescent treponemal antibody (FTA) ❍ D. Thayer-Martin culture (TMC)
55. A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
❍ A. Elevated blood glucose ❍ B. Elevated platelet count
❍ C. Elevated creatinine clearance ❍ D. Elevated hepatic enzymes
56. The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
❍ A. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
❍ B. The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow.
❍ C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
❍ D. The nurse instructs the client to place her arms loose-ly at her side as the nurse strikes the muscle insert just above the wrist.
57. A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor’s order should the nurse question?
❍ A. Magnesium sulfate 4gm (25%) IV ❍ B. Brethine 10mcg IV
❍ C. Stadol 1mg IV push every 4 hours as needed prn
for pain
❍ D. Ancef 2gm IVPB every 6 hours
58. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glyc-erol level. The L/S ratio is 1:1 and the presence of phosphatidyl-glycerol is noted. The nurse’s assessment of this data is:
❍ A. The infant is at low risk for congenital anomalies.
❍ B. The infant is at high risk for intrauterine growth retar-dation.
❍ C. The infant is at high risk for respiratory distress syn-drome.
❍ D. The infant is at high risk for birth trauma.
59. Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
❍ A. Crying
❍ B. Wakefulness ❍ C. Jitteriness ❍ D. Yawning
60. The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
❍ A. Decreased urinary output ❍ B. Hypersomnolence
❍ C. Absence of knee jerk reflex ❍ D. Decreased respiratory rate
61. The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:
❍ A. Place her in Trendelenburg position. ❍ B. Decrease the rate of IV infusion.
❍ C. Administer oxygen per nasal cannula. ❍ D. Increase the rate of the IV infusion.
62. A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?
❍ A. Alteration in nutrition
❍ B. Alteration in bowel elimination ❍ C. Alteration in skin integrity
❍ D. Ineffective individual coping
63. The nurse is caring for a client with uremic frost. The nurse is aware that uremic frost is often seen in clients with:
❍ A. Severe anemia ❍ B. Arteriosclerosis ❍ C. Liver failure
❍ D. Parathyroid disorder
64. The client arrives in the emergency department after a motor vehi-cle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropri-ate priority nursing diagnosis?
❍ A. Alteration in cerebral tissue perfusion ❍ B. Fluid volume deficit
❍ C. Ineffective airway clearance
❍ D. Alteration in sensory perception
65. The home health nurse is visiting an 18-year-old with osteogene-sis imperfecta. Which information obtained on the visit would cause the most concern? The client:
❍ A. Likes to play football
❍ B. Drinks carbonated drinks ❍ C. Has two sisters
❍ D. Is taking acetaminophen for pain
66. The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?
❍ A. Allow the client to keep the fruit.
❍ B. Place the fruit next to the bed for easy access by the client.
❍ C. Offer to wash the fruit for the client.
❍ D. Ask the family members to take the fruit home.
67. The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse’s action should be to:
❍ A. Place the client in Trendelenburg position. ❍ B. Increase the infusion of normal saline.
❍ C. Administer atropine intravenously.
❍ D. Move the emergency cart to the bedside.
68. The client admitted two days earlier with a lung resection acciden-tally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?
❍ A. Order a chest x-ray. ❍ B. Reinsert the tube.
❍ C. Cover the insertion site with a Vaseline gauze. ❍ D. Call the doctor.
69. A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?
❍ A. Assess for signs of abnormal bleeding.
❍ B. Anticipate an increase in the Coumadin dosage. ❍ C. Instruct the client regarding the drug therapy.
❍ D. Increase the frequency of neurological assessments.
70. Which selection would provide the most calcium for the client who is four months pregnant?
❍ A. A granola bar ❍ B. A bran muffin ❍ C. A cup of yogurt
❍ D. A glass of fruit juice
71. The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates the understanding of magnesium toxicity?
❍ A. The nurse performs a vaginal exam every 30 minutes.
❍ B. The nurse places a padded tongue blade at the bed-side.
❍ C. The nurse inserts a Foley catheter. ❍ D. The nurse darkens the room.
72. The best size cathlon for administration of a blood transfusion to a six-year-old is:
❍ A. 18 gauge ❍ B. 19 gauge ❍ C. 22 gauge ❍ D. 20 gauge
73. A client is admitted to the unit two hours after an explosion caus-es burns to the face. The nurse would be most concerned with the client developing which of the following?
❍ A. Hypovolemia
❍ B. Laryngeal edema ❍ C. Hypernatremia ❍ D. Hyperkalemia
74. The client has recently been diagnosed with diabetes. Which of the following indicates understanding of the management of diabetes?
❍ A. The client selects a balanced diet from the menu.
❍ B. The client can tell the nurse the normal blood glucose level.
❍ C. The client asks for brochures on the subject of dia-betes.
❍ D. The client demonstrates correct insulin injection tech-nique.
75. The client is admitted following cast application for a fractured ulna. Which finding should be reported to the doctor?
❍ A. Pain at the site ❍ B. Warm fingers ❍ C. Pulses rapid
❍ D. Paresthesia of the fingers
76. The client with AIDS should be taught to:
❍ A. Avoid warm climates.
❍ B. Refrain from taking herbals. ❍ C. Avoid exercising.
❍ D. Report any changes in skin color.
77. Which action by the healthcare worker indicates a need for further teaching?
❍ A. The nursing assistant ambulates the elderly client using a gait belt.
❍ B. The nurse wears goggles while performing a veno-puncture.
❍ C. The nurse washes his hands after changing a dressing.
❍ D. The nurse wears gloves to monitor the IV infusion rate.
78. The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT, the nurse should:
❍ A. Apply a tourniquet to the client’s arm.
❍ B. Administer an anticonvulsant medication. ❍ C. Ask the client if he is allergic to shellfish. ❍ D. Apply a blood pressure cuff to the arm.
79. The five-year-old is being tested for enterobiasis (pinworms). Which symptom is associated with enterobiasis?
❍ A. Rectal itching ❍ B. Nausea
❍ C. Oral ulcerations ❍ D. Scalp itching
80. The nurse is teaching the mother regarding treatment for pedicalosis capitis. Which instruction should be given regarding the medication?
❍ A. Treatment is not recommended for children less than 10 years of age.
❍ B. Bed linens should be washed in hot water.
❍ C. Medication therapy will continue for one year. ❍ D. Intravenous antibiotic therapy will be ordered.
81. The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
❍ A. The client with HIV
❍ B. The client with a radium implant for cervical cancer ❍ C. The client with RSV (respiratory synctial virus)
❍ D. The client with cytomegalovirus
82. The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
❍ A. The client with methicillin resistant-staphylococcus aureas (MRSA)
❍ B. The client with diabetes
❍ C. The client with pancreatitis
❍ D. The client with Addison’s disease
83. The doctor accidentally cuts the bowel during surgery. As a result of this action, the client develops an infection and suffers brain damage. The doctor can be charged with:
❍ A. Negligence ❍ B. Tort
❍ C. Assault
❍ D. Malpractice
84. Which assignment should not be performed by the nursing assis-tant?
❍ A. Feeding the client ❍ B. Bathing the client ❍ C. Obtaining a stool
❍ D. Administering a fleet enema
85. The mother calls the clinic to report that her newborn has a rash on his forehead and face. Which action is most appropriate?
❍ A. Tell the mother to wash the face with soap and apply powder.
❍ B. Tell her that 30% of newborns have a rash that will go away by one month of life.
❍ C. Report the rash to the doctor immediately.
❍ D. Ask the mother if anyone else in the family has had a rash in the last six months.
86. Which nurse should not be assigned to care for the client with a radium implant for vaginal cancer?
❍ A. The LPN who is six months postpartum ❍ B. The RN who is pregnant
❍ C. The RN who is allergic to iodine
❍ D. The RN with a three-year-old at home
87. Which information should be reported to the state Board of Nursing?
❍ A. The facility fails to provide literature in both Spanish and English.
❍ B. The narcotic count has been incorrect on the unit for the past three days.
❍ C. The client fails to receive an itemized account of his bills and services received during his hospital stay.
❍ D. The nursing assistant assigned to the client with hepa-titis fails to feed the client and give the bath.
88. The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:
❍ A. Call the Board of Nursing. ❍ B. File a formal reprimand. ❍ C. Terminate the nurse.
❍ D. Charge the nurse with a tort.
89. The home health nurse is planning for the day’s visits. Which client should be seen first?
❍ A. The 78-year-old who had a gastrectomy three weeks ago and has a PEG tube
❍ B. The five-month-old discharged one week ago with pneumonia who is being treated with amoxicillin liquid suspension
❍ C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line
❍ D. The 30-year-old with an exacerbation of multiple scle-rosis being treated with cortisone via a centrally placed venous catheter
90. The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?
❍ A. A client having auditory hallucinations and the client with ulcerative colitis
❍ B. The client who is pregnant and the client with a broken arm
❍ C. A child who is cyanotic with severe dypsnea and a client with a frontal head injury
❍ D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain
91. Before administering eardrops to a toddler, the nurse should rec-ognize that it is essential to consider which of the following?
❍ A. The age of the child ❍ B. The child’s weight
❍ C. The developmental level of the child ❍ D. The IQ of the child
92. The nurse is discussing meal planning with the mother of a two-year-old. Which of the following statements, if made by the moth-er, would require a need for further instruction?
❍ A. “It is okay to give my child white grape juice for break-fast.”
❍ B. “My child can have a grilled cheese sandwich for lunch.”
❍ C. “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.”
❍ D. “For a snack, my child can have ice cream.
93. A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as:
❍ A. The client is at risk for opportunistic diseases. ❍ B. The client is no longer communicable.
❍ C. The client’s viral load is extremely low so he is rela-tively free of circulating virus.
❍ D. The client’s T-cell count is extremely low.
94. The client has an order for sliding scale insulin at 1900 hours and Lantus insulin at the same hour. The nurse should:
❍ A. Administer the two medications together.
❍ B. Administer the medications in two injections.
❍ C. Draw up the Lantus insulin and then the regular insulin and administer them together.
❍ D. Contact the doctor because these medications should not be given to the same client.
95. A priority nursing diagnosis for a child being admitted from sur-gery following a tonsillectomy is:
❍ A. Altered nutrition
❍ B. Impaired communication ❍ C. Risk for injury/aspiration ❍ D. Altered urinary elimination
96. What would the nurse expect the admitting assessment to reveal in a client with glomerulonephritis?
❍ A. Hypertension ❍ B. Lassitude
❍ C. Fatigue
❍ D. Vomiting and diarrhea
97. Which action is contraindicated in the client with epiglottis?
❍ A. Ambulation
❍ B. Oral airway assessment using a tongue blade ❍ C. Placing a blood pressure cuff on the arm
❍ D. Checking the deep tendon reflexes.
98. A 25-year-old client with a goiter is admitted to the unit. What would the nurse expect the admitting assessment to reveal?
❍ A. Slow pulse ❍ B. Anorexia
❍ C. Bulging eyes ❍ D. Weight gain
99. Which of the following foods, if selected by the mother with a child with celiac, would indicate her understanding of the dietary instructions?
❍ A. Whole-wheat toast ❍ B. Angel hair pasta ❍ C. Reuben on rye
❍ D. Rice cereal
100. The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:
❍ A. Elevate the head.
❍ B. Recheck the O2 saturation in 30 minutes. ❍ C. Apply oxygen by mask.
❍ D. Assess the heart rate.
