For Answers and Rationale, click here.
151. The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?
❍ A. The tube will allow for equalization of the lung expan-sion.
❍ B. Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs.
❍ C. Chest tubes relieve pain associated with a collapsed lung.
❍ D. Chest tubes assist with cardiac function by stabilizing lung expansion.
152. A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breast-feeding is most dependent on the:
❍ A. Mother’s educational level ❍ B. Infant’s birth weight
❍ C. Size of the mother’s breast ❍ D. Mother’s desire to breastfeed
153. The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?
❍ A. The presence of scant bloody discharge ❍ B. Frequent urination
❍ C. The presence of green-tinged amniotic fluid ❍ D. Moderate uterine contractions
154. The nurse is measuring the duration of the client’s contractions. Which statement is true regarding the measurement of the dura-tion of contractions?
❍ A. Duration is measured by timing from the beginning of one contraction to the beginning of the next contrac-tion.
❍ B. Duration is measured by timing from the end of one contraction to the beginning of the next contraction.
❍ C. Duration is measured by timing from the beginning of one contraction to the end of the same contraction.
❍ D. Duration is measured by timing from the peak of one contraction to the end of the same contraction.
155. The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiv-ing intravenous Pitocin, the nurse should monitor for:
❍ A. Maternal hypoglycemia ❍ B. Fetal bradycardia
❍ C. Maternal hyperreflexia ❍ D. Fetal movement
156. A client with diabetes visits the prenatal clinic at 28 weeks gesta-tion. Which statement is true regarding insulin needs during preg-nancy?
❍ A. Insulin requirements moderate as the pregnancy pro-gresses.
❍ B. A decreased need for insulin occurs during the second trimester.
❍ C. Elevations in human chorionic gonadotrophin decrease the need for insulin.
❍ D. Fetal development depends on adequate insulin regu-lation.
157. A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:
❍ A. Providing a calm environment ❍ B. Obtaining a diet history
❍ C. Administering an analgesic ❍ D. Assessing fetal heart tones
158. A primigravida, age 42, is six weeks pregnant. Based on the client’s age, her infant is at risk for:
❍ A. Down syndrome
❍ B. Respiratory distress syndrome ❍ C. Turner’s syndrome
❍ D. Pathological jaundice
159. A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:
❍ A. Magnesium sulfate ❍ B. Calcium gluconate
❍ C. Dinoprostone (Prostin E.) ❍ D. Bromocrystine (Parlodel)
160. A client with preeclampsia has been receiving an infusion contain-ing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100mL. The nurse should:
❍ A. Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure.
❍ B. Stop the infusion of magnesium sulfate and contact the physician.
❍ C. Slow the infusion rate and turn the client on her left side.
❍ D. Administer calcium gluconate IV push and continue to monitor the blood pressure.
161. Which statement made by the nurse describes the inheritance pat-tern of autosomal recessive disorders?
❍ A. An affected newborn has unaffected parents. ❍ B. An affected newborn has one affected parent.
❍ C. Affected parents have a one in four chance of passing on the defective gene.
❍ D. Affected parents have unaffected children who are car-riers.
162. A pregnant client, age 32, asks the nurse why her doctor has rec-ommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:
❍ A. Because it is a state law
❍ B. To detect cardiovascular defects ❍ C. Because of her age
❍ D. To detect neurological defects
163. A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse’s response is based on the knowledge that:
❍ A. There is no need to take thyroid medication because the fetus’s thyroid produces a thyroid-stimulating hor-mone.
❍ B. Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy.
❍ C. It is more difficult to maintain thyroid regulation dur-ing pregnancy due to a slowing of metabolism.
❍ D. Fetal growth is arrested if thyroid medication is contin-ued during pregnancy.
164. The nurse is responsible for performing a neonatal assessment on | Quick✓Check | |||||
Quick Answer: 224 | ||||||
a full-term infant. At one minute, the nurse could expect to find: | Detailed Answer: 241 | |||||
❍ A. An apical pulse of 100 | ||||||
❍ B. An absence of tonus | ||||||
❍ C. Cyanosis of the feet and hands | ||||||
❍ D. Jaundice of the skin and sclera | ||||||
165. A client with sickle cell anemia is admitted to the labor and deliv- | Quick Answer: 224 | |||||
ery unit during the first phase of labor. The nurse should antici- | Detailed Answer: 241 | |||||
pate the client’s need for: | ||||||
❍ | A. Supplemental oxygen | |||||
❍ | B. Fluid restriction | |||||
❍ | C. | Blood transfusion | ||||
❍ D. Delivery by Caesarean section | ||||||
166. A client with diabetes has an order for ultrasonography. | Quick Answer: 224 | |||||
Preparation for an ultrasound includes: | Detailed Answer: 241 | |||||
❍ A. | Increasing fluid intake | |||||
❍ | B. | Limiting ambulation | ||||
❍ C. Administering an enema | ||||||
❍ D. Withholding food for eight hours | ||||||
167. An infant who weighs 8 pounds at birth would be expected to | Quick Answer: 224 | |||||
weigh how many pounds at one year? | Detailed Answer: 241 | |||||
❍ | A. | 14 pounds | ||||
❍ | B. | 16 pounds | ||||
❍ | C. | 18 pounds | ||||
❍ | D. | 24 pounds | ||||
168. A pregnant client with a history of alcohol addiction is scheduled | Quick Answer: 224 | |||||
for a nonstress test. The nonstress test: | Detailed Answer: 242 | |||||
❍ A. Determines the lung maturity of the fetus | ||||||
❍ B. Measures the activity of the fetus | ||||||
❍ C. Shows the effect of contractions on the fetal heart rate | ||||||
❍ D. Measures the neurological well-being of the fetus | ||||||
169. A full-term male has hypospadias. Which statement describes hypospadias?
❍ A. The urethral opening is absent
❍ B. The urethra opens on the top side of the penis ❍ C. The urethral opening is enlarged
❍ D. The urethra opens on the under side of the penis
170. A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8cm dilated, with complete effacement. The priority nursing diagnosis at this time is:
❍ A. Alteration in coping related to pain
❍ B. Potential for injury related to precipitate delivery ❍ C. Alteration in elimination related to anesthesia
❍ D. Potential for fluid volume deficit related to NPO status
171. The client with varicella will most likely have an order for which category of medication?
❍ A. Antibiotics ❍ B. Antipyretics ❍ C. Antivirals
❍ D. Anticoagulants
172. A client is admitted complaining of chest pain. Which of the fol-lowing drug orders should the nurse question?
❍ A. Nitroglycerin ❍ B. Ampicillin ❍ C. Propranolol ❍ D. Verapamil
173. Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?
❍ A. Avoid exercise because it fatigues the joints.
❍ B. Take prescribed anti-inflammatory medications with meals.
❍ C. Alternate hot and cold packs to affected joints. ❍ D. Avoid weight-bearing activity.
174. A client with acute pancreatitis is experiencing severe abdominal | Quick✓Check | |||
Quick Answer: 224 | ||||
pain. Which of the following orders should be questioned by the | Detailed Answer: 242 | |||
nurse? | ||||
❍ A. Meperidine 100mg IM m 4 hours PRN pain | ||||
❍ B. Mylanta 30 ccs m 4 hours via NG | ||||
❍ C. Cimetadine 300mg PO m.i.d. | ||||
❍ D. Morphine 8mg IM m 4 hours PRN pain | ||||
175. The client is admitted to the chemical dependence unit with an | Quick Answer: 224 | |||
order for continuous observation. The nurse is aware that the doc- | Detailed Answer: 242 | |||
tor has ordered continuous observation because: | ||||
❍ A. Hallucinogenic drugs create both stimulant and | ||||
depressant effects. | ||||
❍ B. Hallucinogenic drugs induce a state of altered percep- | ||||
tion. | ||||
❍ C. Hallucinogenic drugs produce severe respiratory | ||||
depression. | ||||
❍ D. Hallucinogenic drugs induce rapid physical depend- | ||||
ence. | ||||
176. A client with a history of abusing barbiturates abruptly stops tak- | Quick Answer: 224 | |||
ing the medication. The nurse should give priority to assessing the | Detailed Answer: 242 | |||
client for: | ||||
❍ A. Depression and suicidal ideation | ||||
❍ B. Tachycardia and diarrhea | ||||
❍ C. Muscle cramping and abdominal pain | ||||
❍ D. Tachycardia and euphoric mood | ||||
177. During the assessment of a laboring client, the nurse notes that | Quick Answer: 224 | |||
the FHT are loudest in the upper-right quadrant. The infant is most | Detailed Answer: 243 | |||
likely in which position? | ||||
❍ A. Right breech presentation
❍ B. Right occipital anterior presentation ❍ C. Left sacral anterior presentation
❍ D. Left occipital transverse presentation
178. The primary physiological alteration in the development of asthma is: Quick Answer: 224
Detailed Answer: 243
❍ A. Bronchiolar inflammation and dyspnea
❍ B. Hypersecretion of abnormally viscous mucus
❍ C. Infectious processes causing mucosal edema
❍ D. Spasm of bronchiolar smooth muscle
179. A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:
❍ A. Serve high-calorie foods she can carry with her.
❍ B. Encourage her appetite by sending out for her favorite foods.
❍ C. Serve her small, attractively arranged portions.
❍ D. Allow her in the unit kitchen for extra food whenever she pleases.
180. To maintain Bryant’s traction, the nurse must make certain that the child’s:
❍ A. Hips are resting on the bed, with the legs suspended at a right angle to the bed
❍ B. Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed
❍ C. Hips are elevated above the level of the body on a pil-low and the legs are suspended parallel to the bed
❍ D. Hips and legs are flat on the bed, with the traction positioned at the foot of the bed
181. Which action by the nurse indicates understanding of herpes zoster?
❍ A. The nurse covers the lesions with a sterile dressing. ❍ B. The nurse wears gloves when providing care.
❍ C. The nurse administers a prescribed antibiotic. ❍ D. The nurse administers oxygen.
182. There is an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that he should contact the lab for them to collect the blood:
❍ A. 15 minutes after the infusion
❍ B. 30 minutes before the fourth infusion ❍ C. One hour after the infusion
❍ D. Two hours after the infusion
183. The client using a diaphragm should be instructed to:
❍ A. Refrain from keeping the diaphragm in longer than four hours
❍ B. Keep the diaphragm in a cool location
❍ C. Have the diaphragm resized if she gains five pounds ❍ D. Have the diaphragm resized if she has any surgery
184. The nurse is providing postpartum teaching for a mother planning to breastfeed her infant. Which of the client’s statements indicates the need for additional teaching?
❍ A. “I’m wearing a support bra.”
❍ B. “I’m expressing milk from my breast.”
❍ C. “I’m drinking four glasses of fluid during a 24-hour period.”
❍ D. “While I’m in the shower, I’ll allow the water to run over my breasts.”
185. Damage to the VII cranial nerve results in:
❍ A. Facial pain
❍ B. Absence of ability to smell ❍ C. Absence of eye movement ❍ D. Tinnitus
186. A client is receiving Pyridium (phenazopyridine hydrochloride) for a urinary tract infection. The client should be taught that the med-ication may:
❍ A. Cause diarrhea
❍ B. Change the color of her urine ❍ C. Cause mental confusion
❍ D. Cause changes in taste
187. Which of the following tests should be performed before begin-ning a prescription of Accutane?
❍ A. Check the calcium level. ❍ B. Perform a pregnancy test. ❍ C. Monitor apical pulse.
❍ D. Obtain a creatinine level.
188. A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?
❍ A. Limit the client’s activity.
❍ B. Encourage a high-carbohydrate diet.
❍ C. Use an incentive spirometer to improve respiratory function.
❍ D. Encourage fluids.
189. A client is admitted for an CAT scan. The nurse should question the client regarding:
❍ A. Pregnancy
❍ B. A titanium hip replacement ❍ C. Allergies to antibiotics
❍ D. Inability to move his feet
190. The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug?
❍ A. Changes in vision ❍ B. Nausea
❍ C. Urinary frequency
❍ D. Changes in skin color
191. The nurse should visit which of the following clients first?
❍ A. The client with diabetes with a blood glucose of 95mg/dL
❍ B. The client with hypertension being maintained on Lisinopril
❍ C. The client with chest pain and a history of angina ❍ D. The client with Raynaud’s disease
192. A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication:
❍ A. Once per day in the morning ❍ B. Three times per day with meals ❍ C. Once per day at bedtime
❍ D. Four times per day
193. Cataracts result in opacity of the crystalline lens. Which of the fol-lowing best explains the functions of the lens?
❍ A. The lens controls stimulation of the retina. ❍ B. The lens orchestrates eye movement.
❍ C. The lens focuses light rays on the retina. ❍ D. The lens magnifies small objects.
194. A client who has glaucoma is to have miotic eyedrops instilled in both eyes. The nurse knows that the purpose of the medication is to:
❍ A. Anesthetize the cornea ❍ B. Dilate the pupils
❍ C. Constrict the pupils
❍ D. Paralyze the muscles of accommodation
195. A client with a severe corneal ulcer has an order for Gentamicin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the follow-ing schedules should be used when administering the drops?
❍ A. Allow five minutes between the two medications. ❍ B. The medications may be used together.
❍ C. The medications should be separated by a cycloplegic drug.
❍ D. The medications should not be used in the same client.
196. The client with color blindness will most likely have problems dis-tinguishing which of the following colors?
❍ A. Orange ❍ B. Violet ❍ C. Red
❍ D. White
197. The client with a pacemaker should be taught to:
❍ A. Report ankle edema
❍ B. Check his blood pressure daily
❍ C. Refrain from using a microwave oven ❍ D. Monitor his pulse rate
198. The client with enuresis is being taught regarding bladder retrain-ing. The nurse should advise the client to refrain from drinking after:
❍ A. 1900 ❍ B. 1200 ❍ C. 1000 ❍ D. 0700
199. Which of the following diet instructions should be given to the client with recurring urinary tract infections?
❍ A. Increase intake of meats. ❍ B. Avoid citrus fruits.
❍ C. Perform pericare with hydrogen peroxide. ❍ D. Drink a glass of cranberry juice every day.
200. The physician has prescribed NPH insulin for a client with dia-betes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
❍ A. “I will make sure I eat breakfast within two hours of taking my insulin.”
❍ B. “I will need to carry candy or some form of sugar with me all the time.”
❍ C. “I will eat a snack around three o’clock each after-noon.”
❍ D. “I can save my dessert from supper for a bedtime snack.”
