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1. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extrem-ities every two hours. Which of the following outcome criteria would the nurse use?
? A. Body temperature of 99�F or less
? B. Toes moved in active range of motion
? C. Sensation reported when soles of feet are touched ? D. Capillary refill of < 3 seconds
2. A 30-year-old male from Haiti is brought to the emergency depart-ment in sickle cell crisis. What is the best position for this client?
? A. Side-lying with knees flexed ? B. Knee-chest
? C. High Fowler�s with knees flexed
? D. Semi-Fowler�s with legs extended on the bed
3. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
? A. Taking hourly blood pressures with mechanical cuff ? B. Encouraging fluid intake of at least 200mL per hour ? C. Position in high Fowler�s with knee gatch raised
? D. Administering Tylenol as ordered
4. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
? A. Steak
? B. Cottage cheese ? C. Popsicle
? D. Lima beans
5. A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse�s assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first?
? A. Adjust the room temperature
? B. Give a bolus of IV fluids ? C. Start O2
? D. Administer meperidine (Demerol) 75mg IV push
6. The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?
? A. Roast beef, gelatin salad, green beans, and peach pie
? B. Chicken salad sandwich, coleslaw, French fries, ice cream
? C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
? D. Pork chop, creamed potatoes, corn, and coconut cake
7. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
? A. A family vacation in the Rocky Mountains
? B. Chaperoning the local boys club on a snow-skiing trip ? C. Traveling by airplane for business trips
? D. A bus trip to the Museum of Natural History
8. The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which finding reinforces the diagnosis of B12 deficiency?
? A. Enlarged spleen
? B. Elevated blood pressure ? C. Bradycardia
? D. Beefy tongue
9. The body part that would most likely display jaundice in the dark-skinned individual is the:
? A. Conjunctiva of the eye ? B. Soles of the feet
? C. Roof of the mouth ? D. Shins
10. The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?
? A. BP 146/88
? B. Respirations 28 shallow
? C. Weight gain of 10 pounds in six months ? D. Pink complexion
11. The nurse is teaching the client with polycythemia vera about pre-vention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?
? A. �I will drink 500mL of fluid or less each day.� ? B. �I will wear support hose.�
? C. �I will check my blood pressure regularly.� ? D. �I will report ankle edema.�
12. A 33-year-old male is being evaluated for possible acute leukemia. Which of the following findings is most likely related to the diag-nosis of leukemia?
? A. The client collects stamps as a hobby.
? B. The client recently lost his job as a postal worker.
? C. The client had radiation for treatment of Hodgkin�s dis-ease as a teenager.
? D. The client�s brother had leukemia as a child.
13. Where is the best site for examining for the presence of petechiae in an African American client?
? A. The abdomen ? B. The thorax ? C. The earlobes
? D. The soles of the feet
14. The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important?
? A. �Have you noticed a change in sleeping habits recently?�
? B. �Have you had a respiratory infection in the last six months?�
? C. �Have you lost weight recently?�
? D. �Have you noticed changes in your alertness?�
15. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
? A. Oral mucous membrane, altered related to chemo-therapy
? B. Risk for injury related to thrombocytopenia ? C. Fatigue related to the disease process
? D. Interrupted family processes related to life-threatening illness of a family member
16. A 21-year-old male with Hodgkin�s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?
? A. Sexual dysfunction related to radiation therapy ? B. Anticipatory grieving related to terminal illness ? C. Tissue integrity related to prolonged bed rest ? D. Fatigue related to chemotherapy
17. A client has autoimmune thrombocytopenic purpura. To determine the client�s response to treatment, the nurse would monitor:
? A. Platelet count
? B. White blood cell count ? C. Potassium levels
? D. Partial prothrombin time (PTT)
18. The home health nurse is visiting a client with autoimmune thrombo-cytopenic purpura (ATP). The client�s platelet count currently is 80,000. It will be most important to teach the client and family about:
? A. Bleeding precautions ? B. Prevention of falls ? C. Oxygen therapy
? D. Conservation of energy
19. The client has surgery for removal of a Prolactinoma. Which of the following interventions would be appropriate for this client?
? A. Place the client in Trendelenburg position for postural drainage.
? B. Encourage coughing and deep breathing every two hours.
? C. Elevate the head of the bed 30�.
? D. Encourage the Valsalva maneuver for bowel movements.
20. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority interven-tion for this client is:
? A. Measure the urinary output. ? B. Check the vital signs.
? C. Encourage increased fluid intake. ? D. Weigh the client.
21. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
? A. Place the client in a sitting position. ? B. Administer acetaminophen (Tylenol). ? C. Pinch the soft lower part of the nose. ? D. Apply ice packs to the forehead.
22. A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is:
? A. The blood pressure ? B. The temperature ? C. The urinary output
? D. The specific gravity of the urine
23. A client with Addison�s disease has been admitted with a history of nausea and vomiting for the past three days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?
? A. Glucometer readings as ordered ? B. Intake/output measurements
? C. Evaluating the sodium and potassium levels ? D. Daily weights
24. A client had a total thyroidectomy yesterday. The client is com-plaining of tingling around the mouth and in the fingers and toes. What would the nurses� next action be?
? A. Obtain a crash cart.
? B. Check the calcium level.
? C. Assess the dressing for drainage.
? D. Assess the blood pressure for hypertension.
25. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in four months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?
? A. Impaired physical mobility related to decreased endurance
? B. Hypothermia r/t decreased metabolic rate
? C. Disturbed thought processes r/t interstitial edema ? D. Decreased cardiac output r/t bradycardia
26. The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruc-tion should be given to the client taking rosuvastatin (Crestor)?
? A. Report muscle weakness to the physician. ? B. Allow six months for the drug to take effect. ? C. Take the medication with fruit juice.
? D. Report difficulty sleeping.
27. The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:
? A. Utilize an infusion pump.
? B. Check the blood glucose level.
? C. Place the client in Trendelenburg position. ? D. Cover the solution with foil.
28. The six-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?
? A. Blood pressure of 126/80 ? B. Blood glucose of 110mg/dL ? C. Heart rate of 60bpm
? D. Respiratory rate of 30 per minute
29. The client admitted with angina is given a prescription for nitro-glycerine. The client should be instructed to:
? A. Replenish his supply every three months. ? B. Take one every 15 minutes if pain occurs. ? C. Leave the medication in the brown bottle. ? D. Crush the medication and take with water.
30. The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
? A. Macaroni and cheese ? B. Shrimp with rice
? C. Turkey breast
? D. Spaghetti with meat sauce
31. The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
? A. Feet ? B. Neck ? C. Hands ? D. Sacrum
32. The nurse is checking the client�s central venous pressure. The nurse should place the zero of the manometer at the:
? A. Phlebostatic axis ? B. PMI
? C. Erb�s point
? D. Tail of Spence
33. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
? A. Question the order.
? B. Administer the medications. ? C. Administer separately.
? D. Contact the pharmacy.
34. The best method of evaluating the amount of peripheral edema is:
? A. Weighing the client daily ? B. Measuring the extremity
? C. Measuring the intake and output ? D. Checking for pitting
35. A client with vaginal cancer is being treated with a radioactive vaginal implant. The client�s husband asks the nurse if he can spend the night with his wife. The nurse should explain that:
? A. Overnight stays by family members is against hospital policy.
? B. There is no need for him to stay because staffing is adequate.
? C. His wife will rest much better knowing that he is at home.
? D. Visitation is limited to 30 minutes when the implant is in place.
36. The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?
? A. Roast beef sandwich, potato chips, pickle spear,
iced tea
? B. Split pea soup, mashed potatoes, pudding, milk ? C. Tomato soup, cheese toast, Jello, coffee
? D. Hamburger, baked beans, fruit cup, iced tea
37. The physician has prescribed Novalog 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 10 minutes 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.�
38. The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recom-mended for the first two weeks of life because:
? A. New parents need time to learn how to hold the baby. ? B. The umbilical cord needs time to separate.
? C. Newborn skin is easily traumatized by washing.
? D. The chance of chilling the baby outweighs the benefits of bathing.
39. A client with leukemia is receiving Trimetrexate. After reviewing the client�s chart, the physician orders Wellcovorin (leucovorin cal-cium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:
? A. Treat iron-deficiency anemia caused by chemothera-peutic agents
? B. Create a synergistic effect that shortens treatment time ? C. Increase the number of circulating neutrophils
? D. Reverse drug toxicity and prevent tissue damage
40. A four-month-old is brought to the well-baby clinic for immuniza-tion. In addition to the DPT and polio vaccines, the baby should receive:
? A. Hib titer
? B. Mumps vaccine
? C. Hepatitis B vaccine ? D. MMR
41. The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:
? A. 30 minutes before a meal ? B. With each meal
? C. In a single dose at bedtime ? D. 30 minutes after meals
42. A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?
? A. Call security for assistance and prepare to sedate the client.
? B. Tell the client to calm down and ask him if he would like to play cards.
? C. Tell the client that if he continues his behavior he will be punished.
? D. Leave the client alone until he calms down.
43. When the nurse checks the fundus of a client on the first postpar-tum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:
? A. Check the client for bladder distention.
? B. Assess the blood pressure for hypotension.
? C. Determine whether an oxytocic drug was given. ? D. Check for the expulsion of small clots.
44. A client is admitted to the hospital with a temperature of 99.8�F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client�s symptoms are consistent with a diagnosis of:
? A. Pneumonia
? B. Reaction to antiviral medication ? C. Tuberculosis
? D. Superinfection due to low CD4 count
45. The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client�s history should be reported to the doctor?
? A. Diabetes
? B. Prinzmetal�s angina ? C. Cancer
? D. Cluster headaches
46. The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irrita-tion and spinal nerve root inflammation. A positive Kernig�s sign is charted if the nurse notes:
? A. Pain on flexion of the hip and knee ? B. Nuchal rigidity on flexion of the neck
? C. Pain when the head is turned to the left side ? D. Dizziness when changing positions
47. The client with Alzheimer�s disease is being assisted with activities of daily living when the nurse notes that the client uses her tooth-brush to brush her hair. The nurse is aware that the client is exhibiting:
? A. Agnosia ? B. Apraxia ? C. Anomia ? D. Aphasia
48. The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:
? A. Chronic fatigue syndrome ? B. Normal aging
? C. Sundowning ? D. Delusions
49. The client with confusion says to the nurse, �I haven�t had any-thing to eat all day long. When are they going to bring breakfast?� The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?
? A. �You know you had breakfast 30 minutes ago.�
? B. �I am so sorry that they didn�t get you breakfast. I�ll report it to the charge nurse.�
? C. �I�ll get you some juice and toast. Would you like something else?�
? D. �You will have to wait a while; lunch will be here in a little while.�
50. The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer�s disease. Which side effect is most often associated with this drug?
? A. Urinary incontinence ? B. Headaches
? C. Confusion ? D. Nausea
