WorksheetsGCC Mock Test 7
Total questions: 100
Worksheet time: 2hrs 40mins
Name
Class
Date
1.
A client presents a Durable Power of Attorney for Health Care designating the client’s niece as the person to make health care decisions for the client should the client become incapacitated and unable to make informed health care decisions. The Durable Power of Attorney identifies the niece as the:
a)
Legal next of kin.
b)
Health care proxy or surrogate decision-maker for health care issues only.
c)
Health care proxy or surrogate decision-maker for health care and financial issues.
d)
Person responsible for the client’s hospital bill. Your Answer
e)
-
2.
The nurse is caring for a comatose patient who has suffered a closed head injury. Which intervention should the nurse implement to prevent increases in ICP?
a)
Suctioning the airway every hour and as needed
b)
Elevating the head of the bed 30 to 45 degrees
c)
Turning the patient and changing his position every 2 hours
d)
Maintaining a well-lit room Your Answer
e)
-
3.
After reviewing morning laboratory data belonging to a trauma client, the nurse notices that the client’s potassium is 5.6 mEq/L. The nurse should immediately:
a)
Attach the client to a heart monitor and obtain vital signs.
b)
Call the physician.
c)
Call the emergency response team.
d)
Begin chest compressions. Your Answer
e)
-
4.
A hospital coworker states, “I can’t remember my password for the computerized patient information system. May I please log on with your password to get some information that I need to care for one of my clients?” Which response to this request would be most appropriate and in compliance with confidentiality of computerized client health information?
a)
You may log on using my password just this one time, but you need to call the information technology department and have them reset your password for you.
b)
I am uncomfortable with someone using my password to access computerized client health information. I will log in for you and then you can access the information that you need. Look the other way while I log in.
c)
I will log in and access the information for you.Which client are we talking about?
d)
I am uncomfortable with you using my password to access computerized client health information as this is a violation of client confidentiality. You will need to call the information technology department so that they can reset your computer access password for you.
e)
-
5.
A client being treated with sodium warfarin has an INR of 9.0. 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 dosage
c)
Instruct the client regarding the drug therapy
d)
Increase the frequency of neurological assessments Your Answer
e)
-
6.
The nurse on oncology is caring for a client with a white blood count of 800, a platelet count of 150,000, and a red blood cell count of 250,000. During evening visitation, a visitor is noted to be coughing and sneezing. What action should the nurse take?
a)
Ask the visitor to wash his hands
b)
Document the visitor’s condition in the chart
c)
Ask the visitor to leave and not return until the client’s white blood cell count is 1,000
d)
Provide the visitor with a mask and gown
e)
-
7.
A client has just been admitted to the medical unit and the nurse is performing an initial physical assessment. The nurse finds that the client has difficulty hearing questions. The nurse also notices an empty glasses case that was sent up with the client from the emergency department. Based on this information, which action should first be taken by the nurse?
a)
Determine out of which ear the client hears best and if there is a hearing deficit in both ears. Then ask the client about the empty glasses case.
b)
Ask the client about use of any “assistive devices” and document the client’s response.
c)
Look through the client’s belongings to determine if there is a pair of glasses and a hearing aid.
d)
Notify the physician of the client’s difficulty hearing and the empty glasses case. Your Answer
e)
-
8.
Which diet is associated with an increased risk of colorectal cancer?
a)
Low protein, complex carbohydrates
b)
High protein, simple carbohydrates
c)
High fat, refined carbohydrates
d)
Low carbohydrates, complex proteins Your Answer
e)
-
9.
To enhance adaptive language skills in a young client, the nurse educates parents to foster appropriate language in social situations. An example is:
a)
Effective persuasion, such as polite versus impolite language.
b)
Direct versus indirect language when demanding action.
c)
Correction of pronunciation or grammar errors.
d)
Introduction of new topics. Your Answer
e)
-
10.
The nurse is caring for a client who is experiencing pruritis. Which would be the most appropriate nursing intervention?
a)
Suggest the client take warm showers B.I.D.
b)
Add baby oil to the client’s bath water
c)
Apply powder to the client’s skin
d)
Suggest a hot water rinse after bathing Your Answer
e)
-
11.
The nurse is auscultating the lungs of a patient following chest tube insertion. Which of the following results indicates correct chest tube placement?
a)
Bronchial sounds heard at both bases
b)
Vesicular sounds heard over upper lung fields
c)
Bronchovesicular sounds heard over both lung fields
d)
Crackles heard on the affected side Your Answer
e)
-
12.
The nurse cares for a client with a chest tube. Which symptom would indicate to the nurse the presence of subcutaneous emphysema?
a)
Dyspnea.
b)
Shortness of breath.
c)
Increased heart rate.
d)
A crackling sensation upon palpation of the chest tube insertion site.
e)
-
13.
A client is brought to the emergency department by ambulance in an altered state of consciousness. The client does not answer questions appropriately, is alternately agitated and drowsy, and speaks loudly and incoherently at intervals. The client’s significant other arrives in the emergency department and asks the nurse for the results of the client’s urine drug screen. The client’s significant other states that the client has used illegal drugs in the past. The significant other needs the information for personal safety and the safety of the couple’s children. What is the best response by the nurse to the request for the results of the urine drug screen?
a)
The results of the urine drug screen are positive for illegal substances.
b)
You are wise to ask for the urine drug screen results for your safety and the children’s safety. The drug screen results are positive for the drugs you gave me information about.
c)
Thank you for the information about the client’s history of illegal drug use. Because you live together and have children together, I can give you those results.
d)
Thank you for the information about the client’s history of illegal drug use. A complete health history helps us give better care. The health information of every client is confidential and protected by law and can not be released without the client’s consent. Does the client have a Durable Power of Attorney for Health Care listing you as the surrogate decision-maker?
e)
-
14.
Which instruction should be given regarding the medication used to treat enterobiasis (pinworms)?
a)
Treatment is not recommended for children less than 10 years of age.
b)
The entire family should be treated.
c)
Medication therapy will continue for 1 year.
d)
Intravenous antibiotic therapy will be ordered. Your Answer
e)
-
15.
A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:
a)
8 a.m.
b)
10 a.m.
c)
3 p.m.
d)
5 a.m. Your Answer
e)
-
16.
A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
a)
Will cause dark staining of the surrounding skin
b)
Produces a cooling sensation when applied
c)
Can alter the function of the thyroid
d)
Produces a burning sensation when applied
e)
-
17.
Due to a high census, it has been necessary for a number of clients to be transferred to other units within the hospital. Which client should be transferred to the postpartum unit?
a)
A 66-year-old female with a gastroenteritis
b)
A 40-year-old female with a hysterectomy
c)
A 27-year-old male with severe depression
d)
A 28-year-old male with ulcerative colitis Your Answer
e)
-
18.
A patient with pneumonia in the right lower lobe is prescribed percussion and postural drainage. When performing percussion and postural drainage, the nurse should position him:
a)
in semi-Fowler’s position with his knees bent.
b)
in a right side-lying position with the foot of his bed elevated.
c)
in a prone or supine position with the foot of his bed elevated higher than his head.
d)
bent at the waist leaning slightly forward. Your Answer
e)
-
19.
The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia. Which foods are highest in B12?
a)
Meat, eggs, dairy products
b)
Peanut butter, raisins, molasses
c)
Broccoli, cauliflower, cabbage
d)
Shrimp, legumes, bran cereals Your Answer
e)
-
20.
The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?
a)
A 10-year-old with lacerations of the face
b)
A 15-year-old with sternal bruises
c)
A 34-year-old with a fractured femur
d)
A 50-year-old with dislocation of the elbow Your Answer
e)
-
21.
A client with ulcerative colitis requires an illeostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma?
a)
Perform massage of the stoma three times a day
b)
Include high-fiber foods, especially nuts, in the diet
c)
Limit fluid intake to prevent loose stools
d)
Cleanse the peristomal skin meticulously
e)
-
22.
A hemodialysis client presents to the dialysis clinic for a regularly scheduled dialysis session. The nurse assesses the client’s dialysis access graft before beginning the treatment. The graft site appears reddened and feels abnormally warm to the touch. The client reports a fever and aching joints for the past two days and a headache starting that morning. The client’s temperature is 101.5 degree F.What is the most appropriate immediate action by the nurse to provide the correct treatment for the client?
a)
The nurse should begin the client’s hemodialysis treatment immediately.
b)
The nurse should begin the client’s hemodialysis treatment, but monitor the client carefully for any worsening of the complaints or symptoms, or an increase in the client’s temperature.
c)
The nurse should ask if the client feels well enough for dialysis that day.
d)
The nurse should immediately notify the client’s nephrologist of the assessment findings and vital signs.
e)
-
23.
A primigravid client in a Preparation for Parenting class asks how much blood is lost during an uncomplicated delivery. The nurse should tell the woman:
a)
“The maximum blood loss considered within normal limits is 500 mL.”
b)
“The minimum blood loss considered within normal limits is 1,000 mL.”
c)
“Blood loss during a delivery is rarely estimated unless there is a hemorrhage.”
d)
“It would be very unusual if you lost more than 100 mL of blood during the delivery.” Your Answer
e)
-
24.
A patient undergoes cast placement for a fractured left radius. The nurse should suspect compartment syndrome if the patient experiences pain that:
a)
intensifies with the elevation of the left arm.
b)
disappears with the flexion of the left arm.
c)
increases with the arm in a dependent position.
d)
radiates up the arm to the left scapula. Your Answer
e)
-
25.
A client is admitted with benign prostatic hypertrophy. Which clinical manifestation should the nurse expect?
a)
Frequent urge to void
b)
Foul-smelling urine
c)
Copious urine output
d)
Pain on urination Your Answer
e)
-
26.
Which type of burn is very painful and heals without scarring or contractures in approximately 7 to 14 days?
a)
First degree.
b)
Third degree.
c)
Fourth degree.
d)
Deep second degree. Your Answer
e)
-
27.
The nurse is providing dietary teaching regarding low-sodium diets for a client with hypertension. Which food should be avoided by the client on a low-sodium diet?
a)
Dried beans
b)
Swiss cheese
c)
Peanut butter
d)
American cheese
e)
-
28.
Which statement by a client who is taking topiramate (Topamax) indicates that the client has understood the nurse’s instruction?
a)
“I will take the medicine before going to bed.”
b)
“I will drink 8 to 10 ten-ounce glasses of water a day.”
c)
“I will eat plenty of fresh fruits.”
d)
“I must take the medicine with a meal or snack.” Your Answer
e)
-
29.
The physician has ordered a minimal bacteria diet for a client with cancer. Which seasoning is not permitted for this client?
a)
Salt
b)
Lemon juice
c)
Pepper
d)
Ketchup Your Answer
e)
-
30.
A client with Prinzmetal angina is experiencing migraine headaches. The physician has prescribed Sumatriptan succinate (Imitrex). Which nursing action is most appropriate?
a)
Notify the charge nurse to question the prescription order.
b)
Try to obtain samples for the client to take home.
c)
Reinforce teaching regarding this drug.
d)
Consult with social services about financial assistance with obtaining the drug. Your Answer
e)
-
31.
A client with polycythemia vera is admitted for a phlebotomy. Assessment of the client with polycythemia vera reveals:
a)
Red, sore tongue; fatigue; and paresthesia
b)
Ruddy complexion, dyspnea, and pruritis
c)
Pallor; thin, spoon-shape fingernails; and pica
d)
Nocturnal dyspnea, rales, and weight gain Your Answer
e)
-
32.
A pediatric client is admitted with Munchausen’s syndrome by proxy. The nurse would expect the child to have:
a)
Extreme tooth decay
b)
Unexplained illness
c)
Dermatitis of the lips and tongue
d)
Inability to sweat Your Answer
e)
-
33.
The nurse on oncology is caring for a client with a white blood count of 800, a platelet count of 150,000, and a red blood cell count of 250,000. During evening visitation, a visitor is noted to be coughing and sneezing. What action should the nurse take?
a)
Ask the visitor to wash his hands
b)
Document the visitor’s condition in the chart
c)
Ask the visitor to leave and not return until the client’s white blood cell count is 1,000
d)
Provide the visitor with a mask and gown
e)
-
34.
A nurse calls the hospital’s lift team to assist with transferring an overweight client from the bed to a chair for the first time after hip surgery. Prior to the transfer, the nurse reports the client’s recent surgical procedure, surgical site, and any difficulties that the lift team might expect to encounter while assisting the client out of bed to the chair. The nurse then stays in the client’s room and supervises the procedure until the client transfer is complete and the client has the nurse call system within reach.What steps of the nursing process did the nurse use to appropriately delegate the client care in this example?
a)
Assessment, planning, implementation, and evaluation.
b)
Planning, implementation, delegation, and evaluation.
c)
Delegation, assessment, implementation, and evaluation.
d)
Delegation, planning, assessment, and implementation. Your Answer
e)
-
35.
The nurse cares for a client with end-stage liver disease due to cirrhosis secondary to alcohol abuse. The nurse monitors the client for which potentially life-threatening complication of cirrhosis?
a)
Ascites.
b)
Hepatomegaly.
c)
Ruptured esophageal varices.
d)
Epistaxis Your Answer
e)
-
36.
A 19-year-old patient comes to the clinic with dark red lesions on her hands, wrist, and waistline. She has scratched several of the lesions so that they are open and bleeding. The nurse instructs the patient to try pressing on the itchy lesions. What is the rationale for this intervention?
a)
. Pressing the skin spreads the beneficial microorganisms.
b)
Pressing is suggested before scratching.
c)
Pressing the skin promotes breaks in the skin.
d)
Pressing the skin stimulates nerve endings.
e)
-
37.
The nurse is caring for a 4-year-old with cerebral palsy. Which nursing intervention will help ready the child for rehabilitative services?
a)
Patching one of the eyes to strengthen the muscles
b)
Providing suckers and pinwheels to help strengthen tongue movement
c)
Providing musical tapes to provide auditory training
d)
Encouraging play with a video game to improve muscle coordination Your Answer
e)
-
38.
The nurse caring for a client with Alzheimer’s disease should initiate which of the following when requesting an action by the client?
a)
Provide a detailed explanation
b)
Give one direction at a time
c)
Offer two choices for each activity
d)
Provide all instructions at one time Your Answer
e)
-
39.
A patient admitted with Parkinson’s disease has an expressionless face and monotone speech. Which of the following observations by the nurse is most accurate?
a)
The patient is most likely depressed and should be left alone.
b)
These are common signs of Parkinson’s disease.
c)
The patient’s antipsychotic medication may need adjustment.
d)
The patient probably has dementia. Your Answer
e)
-
40.
An infant’s Apgar score is 9 at 5 minutes. The nurse is aware that the most likely cause for the deduction of one point is:
a)
The baby is cold.
b)
The baby is experiencing bradycardia.
c)
The baby’s hands and feet are blue.
d)
The baby is lethargic. Your Answer
e)
-
41.
A client being treated with sodium warfarin has an INR of 9.0. 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 dosage
c)
Instruct the client regarding the drug therapy
d)
Increase the frequency of neurological assessments Your Answer
e)
-
42.
Clients who have substance use disorders fall into one of five stages. These stages occur along a continuum that provides a useful framework for monitoring progress. A client admits to the nurse that substance use is causing difficulties in the client’s life.Which stage is the client experiencing?
a)
Action.
b)
Contemplation.
c)
Maintenance.
d)
Precontemplation. Your Answer
e)
-
43.
Which nursing order would the nurse anticipate for a client with pancreatitis?
a)
Force fluids to 3,000mL/24 hours
b)
Insert a nasogastric tube and connect it to low intermittent suction
c)
Place the client in reverse Trendelenburg position
d)
Place the client in enteric isolation Your Answer
e)
-
44.
Prevention and early treatment of Lyme’s disease are crucial because late complications of this disease include:
a)
sterility.
b)
renal failure.
c)
lung abscess.
d)
arthritis.
e)
-
45.
Which area in dark-skinned individuals would be the most likely to show a skin cancerous lesion?
a)
Chest
b)
Arms
c)
Face
d)
Palms
e)
-
46.
A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks’ gestation. She has had a prior pregnancy with pregnancyinduced hypertension. The assessments during this visit include BP 140/90, P 80, and + 2 edema of the ankles and feet. Based on the client’s past history and current assessment, what further information should the nurse obtain to determine if this client is becoming preeclamptic?
a)
Headaches.
b)
Blood glucose level.
c)
Proteinuria.
d)
Edema in lower extremities. Your Answer
e)
-
47.
During discharge teaching about corticosteroids, the patient asks the nurse what the drugs suppress. Which of the following responses by the nurse would be the most accurate?
a)
The sympathetic response
b)
Pain receptors
c)
The inflammatory response
d)
Neural transmission Your Answer
e)
-
48.
When planning a class for primigravid clients about the common discomforts of pregnancy, which of the following physiologic changes of pregnancy should the nurse include in the teaching plan?
a)
The temperature decreases slightly early in pregnancy.
b)
Cardiac output increases by 25% to 50% during pregnancy.
c)
The circulating fibrinogen level decreases as much as 50% during pregnancy.
d)
The anterior pituitary gland secretes oxytocin late in pregnancy. Your Answer
e)
-
49.
A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:
a)
8 a.m.
b)
10 a.m.
c)
3 p.m.
d)
5 a.m. Your Answer
e)
-
50.
A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
a)
Will cause dark staining of the surrounding skin
b)
Produces a cooling sensation when applied
c)
Can alter the function of the thyroid
d)
Produces a burning sensation when applied
e)
-
51.
A client with COPD is in respiratory failure. Which of the following results would be the most sensitive indicator that the client will probably be placed on a mechanical ventilator?
a)
PCO2 58
b)
SaO2 90
c)
pH 7.23
d)
HCO3 30 Your Answer
e)
-
52.
A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
a)
Will cause dark staining of the surrounding skin
b)
Produces a cooling sensation when applied
c)
Can alter the function of the thyroid
d)
Produces a burning sensation when applied
e)
-
53.
A 33-year-old client complains of fatigue, anorexia, and a low-grade fever. The client also complains of joint pain. Which condition does the nurse suspect?
a)
Osteoarthritis (OA).
b)
Rheumatoid arthritis (RA).
c)
Systemic lupus erythematosus (SLE).
d)
Anemia. Your Answer
e)
-
54.
The physician has ordered a sterile urine specimen from a client with an in-dwelling catheter. The nurse should:
a)
Open the spout on the urine bag and allow urine to flow into a sterile specimen cup
b)
Disconnect the drainage tube from the collection bag and allow urine to drain into a sterile specimen cup
c)
Disconnect the drainage tube from the catheter and allow urine to drain from the bag into a sterile specimen cup
d)
Use a sterile syringe and needle to remove urine from the port nearest the client and place the urine into a sterile specimen cup
e)
-
55.
A patient, age 64, is found on the floor of his bathroom in his apartment after apparently falling and hitting his head on the bathtub. On admission to the neurologic unit, he has a decreased level of consciousness (LOC). The practitioner’s orders are to elevate the head of the bed; keep the patient’s head in neutral alignment, with neck flexion on head rotation; avoid sharp hip flexion; give an acetaminophen suppository, 300 mg, every 6 hours if the patient’s temperature exceeds 99.8° F (37.7° C); and give dextrose 5% in water (D5W) at 20 mL/hour. Which statement best describes the rationale for the positioning order?
a)
It decreases cerebral arterial pressure.
b)
It does not impede venous outflow.
c)
It prevents flexion contractures.
d)
It prevents aspiration of stomach contents. Your Answer
e)
-
56.
The nurse cares for a client who underwent abdominal surgery 2 days ago. Which symptom suggests the client has developed complications?
a)
Muscle soreness.
b)
Incisional pain.
c)
Abdominal distension.
d)
Serous wound drainage. Your Answer
e)
-
57.
A gravida two para one has just delivered a full-term infant. Which finding indicates separation of the placenta?
a)
Wavelike relaxation of the abdomen
b)
Increased length of the cord
c)
Decreased vaginal bleeding
d)
Inability to palpate the uterus Your Answer
e)
-
58.
A client fell at home and sustained a back injury. The client reports back pain and the inability to play golf or go to the store. The client remains at home most of the time due to the pain.Which nurse’s note includes all of the elements of a complete pain assessment?
a)
The client’s back pain began 6 months ago and has been constant since the fall. The pain is located in the mid-lower back area, is rated a 6 out of 10 on the numeric pain scale, and is described as a constant, dull ache. The pain is made worse by ambulating or standing for more than 5 minutes. The client uses a hot water bottle over the back for some relief at night. The client denies other symptoms related to the back pain. The client reports being unable to play golf since the fall, go to the store, and remains at the home most of the time due to the pain.
b)
The pain is rated a 6 out of 10, and is a constant, dull ache. The client uses a hot water bottle over the back for some relief at night. The client reports being unable to play golf since the fall, go to the store and remains at the home most of the time due to the pain.
c)
The client’s back pain began 6 months ago after a minor fall in the kitchen. The pain has been constant since the fall. The pain is located in the mid-lower back area and is rated a 6 out of 10 on the numeric pain scale.
d)
Client reports pain began after a fall and the pain has limited his physical activity and does not seen to be improving. Your Answer
e)
-
59.
A 33-year-old client complains of fatigue, anorexia, and a low-grade fever. The client also complains of joint pain. Which condition does the nurse suspect?
a)
Osteoarthritis (OA).
b)
Rheumatoid arthritis (RA).
c)
Systemic lupus erythematosus (SLE).
d)
Anemia. Your Answer
e)
-
60.
Which of the following are considered signs and symptoms of a fracture?
a)
Tingling, coolness, and loss of pulses
b)
Loss of sensation, redness, and coolness
c)
Coolness, redness, and a new pain site
d)
Discoloration, deformity, and pain at the site of injury
e)
-
61.
A client with schizoaffective disorder is exhibiting Parkinsonian symptoms. Which medication is responsible for the development of Parkinsonian symptoms?
a)
Zyprexa (olanzapine)
b)
Cogentin (benzatropine mesylate)
c)
Benadryl (diphenhydramine)
d)
Depakote (divalproex sodium) Your Answer
e)
-
62.
A client reports to the nurse in a college student health clinic for minor injuries associated with a fall.Upon further questioning, the client states she is a freshman and that he also misses class usually on Monday mornings. The nurse should screen this client for:
a)
Binge drinking.
b)
Sleep disorder.
c)
Unsafe sex practices.
d)
Suicidal tendency. Your Answer
e)
-
63.
A virus exists that has the potential to cause significant morbidity and mortality globally; killing more Americans every year than any other infectious disease, including AIDS. This virus causes acute viral respiratory illness which is usually self-limited.Which virus does this describe?
a)
.Adenovirus.
b)
Enterovirus.
c)
Influenza.
d)
Paramyxoviruses. Your Answer
e)
-
64.
The nurse is caring for a 4-year-old with cerebral palsy. Which nursing intervention will help ready the child for rehabilitative services?
a)
Patching one of the eyes to strengthen the muscles
b)
Providing suckers and pinwheels to help strengthen tongue movement
c)
Providing musical tapes to provide auditory training
d)
Encouraging play with a video game to improve muscle coordination Your Answer
e)
-
65.
A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to:
a)
Prevent the need for dressing changes
b)
Reduce edema at the incision
c)
Provide for wound drainage
d)
Keep the common bile duct open Your Answer
e)
-
66.
A client has received platelet infusions. Which finding would indicate the most therapeutic effect from the transfusions? ❍ A. ❍ B. ❍ C. ❍ D
a)
Hgb level increase from 8.9 to 10.6
b)
Temperature reading of 99.4°F
c)
White blood cell count of 11,000
d)
Decrease in oozing of blood from IV site
e)
-
67.
During a health history, which statement by a patient indicates a risk of renal calculi?
a)
“I’ve been drinking a lot of cola and soft drinks lately.”
b)
“I’ve been jogging more than usual.”
c)
“I’ve had more stress since we adopted a child last year.”
d)
“I’m a vegetarian and eat cheese two or three times each day.”
e)
-
68.
Which technique is correct for administration of ear drops to a 3-year-old?
a)
Hold the child’s head up and extended
b)
Place the head in chin tuck position
c)
Pull the pinna down and back
d)
Irrigate the ear before medication administration Your Answer
e)
-
69.
A 78-year-old patient has a history of osteoarthritis. Which signs and symptoms would the nurse expect to find on physical assessment?
a)
Joint pain, crepitus, Heberden’s nodes
b)
Hot, inflamed joints; crepitus; joint pain
c)
Tophi, enlarged joints, Bouchard’s nodes
d)
Swelling, joint pain, tenderness on palpation Your Answer
e)
-
70.
Which statement best describes instrumental activities of daily living (IADL)?
a)
Activities that are usually performed in the course of a normal day. These activities include ambulating, eating, dressing, bathing, brushing the teeth, and grooming.
b)
Activities that assist the client in recognizing and managing stress. These activities include facilitating interpersonal relationships, allowing adequate time for rest, and providing regular, nutritious meals.
c)
Activities that allow the client to be independent in society. These activities include shopping, preparing meals, paying bills, and taking medications appropriately.
d)
Activities that support the effectiveness of direct care interventions. These activities include checking equipment, directing the maintenance of the client’s room, and managing the supply of materials needed for client care. Your Answer
e)
-
71.
A client is admitted to the emergency room with symptoms of delirium tremens. After admitting the client to a private room, the priority nursing intervention is to:
a)
Obtain a history of his alcohol use
b)
Provide seizure precautions
c)
Keep the room cool and dark
d)
Administer thiamine and zinc Your Answer
e)
-
72.
A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which of the following should be reported to the doctor?
a)
An elevated white blood cell count
b)
An abdominal bruit
c)
A negative Babinski reflex
d)
Pupils that are equal and reactive to light Your Answer
e)
-
73.
Which instruction should be given regarding the medication used to treat enterobiasis (pinworms)?
a)
Treatment is not recommended for children less than 10 years of age.
b)
The entire family should be treated.
c)
Medication therapy will continue for 1 year.
d)
Intravenous antibiotic therapy will be ordered. Your Answer
e)
-
74.
A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?
a)
Checking the bowel sounds
b)
Assessing the blood pressure
c)
Offering pain medication
d)
Checking for swelling Your Answer
e)
-
75.
Which statement should the nurse include when teaching a patient newly diagnosed with testicular cancer?
a)
“Testicular cancer isn’t responsive to chemotherapy, but it’s highly curative with surgery.”
b)
“Radiation therapy is never used so that the unaffected testicle can remain healthy.”
c)
“Testicular self-examination is still important because having testicular cancer increases the risk of developing a second tumor.”
d)
Taking testosterone after orchiectomy prevents changes in appearance and sexual function.” Your Answer
e)
-
76.
Which statement should the nurse include when teaching a patient newly diagnosed with testicular cancer?
a)
“Testicular cancer isn’t responsive to chemotherapy, but it’s highly curative with surgery.”
b)
“Radiation therapy is never used so that the unaffected testicle can remain healthy.”
c)
“Testicular self-examination is still important because having testicular cancer increases the risk of developing a second tumor.”
d)
Taking testosterone after orchiectomy prevents changes in appearance and sexual function.” Your Answer
e)
-
77.
The physician has ordered cultures for cytomegalovirus (CMV). Which statement is true regarding collection of cultures for cytomegalovirus?
a)
Stool cultures are preferred for definitive diagnosis.
b)
Pregnant caregivers may obtain cultures.
c)
Collection of one specimen is sufficient.
d)
Accurate diagnosis depends on fresh specimens.
e)
-
78.
A client is diagnosed with stage III Hodgkin’s lymphoma. The nurse recognizes that the client has involvement:
a)
In a single lymph node or single site
b)
In more than one node or single organ on the same side of the diaphragm
c)
In lymph nodes on both sides of the diaphragm
d)
In disseminated organs and tissues Your Answer
e)
-
79.
The nurse on oncology is caring for a client with a white blood count of 800, a platelet count of 150,000, and a red blood cell count of 250,000. During evening visitation, a visitor is noted to be coughing and sneezing. What action should the nurse take?
a)
Ask the visitor to wash his hands
b)
Document the visitor’s condition in the chart
c)
Ask the visitor to leave and not return until the client’s white blood cell count is 1,000
d)
Provide the visitor with a mask and gown
e)
-
80.
The nurse teaches an alcoholic client the signs and symptoms of alcohol withdrawal. Which statement by the client indicates that he understands the teaching?
a)
My heart rate may slow down during withdrawal.
b)
I will become very sleepy during withdrawal.
c)
My hands may begin to shake once I quit drinking.
d)
My blood pressure will drop once I quit drinking. Your Answer
e)
-
81.
A client complains of crushing chest pain 3 hours prior to arrival in the emergency department. Initial vital signs show hypotension; a weak, thready pulse; cool, clammy skin; and confusion. Which intervention should the nurse perform first?
a)
Airway management.
b)
Intravenous access.
c)
Obtaining an EKG.
d)
Preparing for intra-aortic balloon pump. Your Answer
e)
-
82.
The nurse assesses a client who is in an arm cast for compartment syndrome. Which is a late symptom of compartment syndrome?
a)
Sudden decrease in pain.
b)
Swelling of the fingers.
c)
Inability to move the fingers.
d)
Change in skin color.
e)
-
83.
Which nursing order would the nurse anticipate for a client with pancreatitis?
a)
Force fluids to 3,000mL/24 hours
b)
Insert a nasogastric tube and connect it to low intermittent suction
c)
Place the client in reverse Trendelenburg position
d)
Place the client in enteric isolation Your Answer
e)
-
84.
Shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia rubra with large clots. The nurse should anticipate an order for:
a)
Methergine
b)
Stadol
c)
Magnesium sulfate
d)
Phenergan Your Answer
e)
-
85.
The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?
a)
The graduate places the client in a supine position to read the manometer.
b)
The graduate turns the stop-cock to the off position from the IV fluid to the client.
c)
The graduate instructs the client to perform the Valsalva maneuver during the CVP reading.
d)
The graduate notes the level at the top of the meniscus. Your Answer
e)
-
86.
The nurse cares for a client receiving bolus tube feedings through a Dobhoff tube. The bolus has just been completed. Which position is best for the client?
a)
Side-lying with the head of bed flat.
b)
Right lateral position with head of bed elevated 30 degrees.
c)
Semi-fowler position with head of bed at negative 30 degrees.
d)
Supine position with head of bed elevated 90 degrees. Your Answer
e)
-
87.
A patient complains that he sees a green halo around lights. Upon reviewing the patient’s medication list, the nurse determines that this is most likely caused by a high level of which medication?
a)
Digoxin
b)
Furosemide
c)
Metoprolol
d)
Enalapril Your Answer
e)
-
88.
After a patient experiences a brain stem infarction, the nurse should observe for which condition?
a)
Aphasia
b)
Bradypnea
c)
Contralateral hemiplegia
d)
Numbness and tingling to the face or arm Your Answer
e)
-
89.
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 suspended at a right angle to the bed
c)
Hips are elevated above the level of the body on a pillow and the legs suspended parallel to the bed
d)
Hips and legs are flat on the bed, with the traction positioned at the foot of the bed Your Answer
e)
-
90.
Which of the following signs is one of the earliest indications of cardiogenic shock?
a)
Cyanosis
b)
Decreased urine output
c)
Presence of a fourth heart sound (S4)
d)
Altered LOC
e)
-
91.
A client has a history of left-sided heart failure. The nurse knows that one of the complications of this type of heart failure is pulmonary congestion. What should the nurse expect to find upon assessment?
a)
Tenting of the skin.
b)
Pulmonary hypertension.
c)
Increased jugular vein distension.
d)
Hypotension. Your Answer
e)
-
92.
The nurse witnesses the nursing assistant hitting the client in the long-term care facility. The nursing assistant can be charged with:
a)
Negligence
b)
Tort
c)
Assault
d)
Malpractice Your Answer
e)
-
93.
A client with congestive heart failure has been receiving Digoxin (lanoxin). Which finding indicates that the medication is having a desired effect?
a)
Increased urinary output
b)
Stabilized weight
c)
Improved appetite
d)
Increased pedal edema Your Answer
e)
-
94.
A client has a history of left-sided heart failure. The nurse knows that one of the complications of this type of heart failure is pulmonary congestion. What should the nurse expect to find upon assessment?
a)
Tenting of the skin.
b)
Pulmonary hypertension.
c)
Increased jugular vein distension.
d)
Hypotension. Your Answer
e)
-
95.
The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?
a)
The graduate places the client in a supine position to read the manometer.
b)
The graduate turns the stop-cock to the off position from the IV fluid to the client.
c)
The graduate instructs the client to perform the Valsalva maneuver during the CVP reading.
d)
The graduate notes the level at the top of the meniscus. Your Answer
e)
-
96.
The nurse witnesses the nursing assistant hitting the client in the long-term care facility. The nursing assistant can be charged with:
a)
Negligence
b)
Tort
c)
Assault
d)
Malpractice Your Answer
e)
-
97.
A client is admitted with benign prostatic hypertrophy. Which clinical manifestation should the nurse expect?
a)
Frequent urge to void
b)
Foul-smelling urine
c)
Copious urine output
d)
Pain on urination Your Answer
e)
-
98.
A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to:
a)
Prevent the need for dressing changes
b)
Reduce edema at the incision
c)
Provide for wound drainage
d)
Keep the common bile duct open Your Answer
e)
-
99.
The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia. Which foods are highest in B12?
a)
Meat, eggs, dairy products
b)
Peanut butter, raisins, molasses
c)
Broccoli, cauliflower, cabbage
d)
Shrimp, legumes, bran cereals Your Answer
e)
-
100.
A client has returned to the surgical unit after a laryngectomy. When suctioning the tracheostomy, the nurse should not allow the suction pressure to exceed which level?
a)
120mmHg
b)
145mmHg
c)
160mmHg Your Answer
d)
185mmHg
e)
-
100 %
