WorksheetsGCC Mock Test 8
Total questions: 100
Worksheet time: 2hrs 40mins
Name
Class
Date
1.
A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following?
a)
Hypernatremia
b)
Hypokalemia
c)
Myelosuppression
d)
Leukocytosis
e)
-
2.
A nurse is preparing to reinforce the teaching plan for a patient who has recently been diagnosed with squamous cell carcinoma of the left lung. Which statement by the nurse is correct?
a)
“You have a slow-growing cancer that rarely spreads.”
b)
“In terms of prognosis, you may have only a few months to live.”
c)
“Squamous cell cancer is a very rapidly growing cancer.”
d)
“The cancer has generally metastasized by the time diagnosis is made.”
e)
-
3.
The physician has prescribed Xanax (alprazolam) for a client with acute anxiety. The nurse should teach the client to avoid:
a)
Sun exposure
b)
Drinking beer
c)
Eating cheese
d)
Taking aspirin
e)
-
4.
An elderly client receives instructions regarding the use of warfarin sodium (Coumadin).Which statement indicates the client understands the possible food interactions which may occur with this medication?
a)
I’m going to miss having my evening glass of wine now.
b)
I told my daughter to buy bananas for me. I’ll have to eat more of those now.
c)
I will have to watch my intake of salads, something that I really love.
d)
I am going to begin eating more fish and pork and leave beef alone now.
e)
-
5.
The nurse cares for a client with cervical cancer when the nurse notices the radium implant has been dislodged. Which action should the nurse take first?
a)
Contact the radiology department.
b)
Wrap the implant in a blanket and place it behind a lead shield.
c)
Pick up the implant with long-handled forceps and place it in a lead container.
d)
Contact the physician.
e)
-
6.
Diuretics are ordered for a patient. What would be the best time of day for the nurse to schedule this medication?
a)
. Anytime
b)
Nighttime
c)
Morning
d)
Noon
e)
-
7.
The nurse cares for a client who experienced a cerebral vascular accident. The client’s husband asks why his wife has a splint on her hand. The nurse explains that the splint is needed to prevent:
a)
Skin breakdown.
b)
Deformity of the hand.
c)
Edema.
d)
Muscle wasting.
e)
-
8.
The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis?
a)
Foul breath
b)
Dysphagia
c)
Diarrhea
d)
Chronic hiccups
e)
-
9.
Which condition is caused by arterial bleeding from tears in the distal esophagus or promixal stomach?
a)
Appendicitis.
b)
Gastritis.
c)
Ischemic colitis.
d)
Mallory-Weiss syndrome.
e)
-
10.
The 57-year-old male client has elected to have epidural anesthesia as the anesthetic during a hernia repair. If the client experiences hypotension, the nurse would:
a)
Place him in the Trendelenburg position
b)
Obtain an order for Benedryl
c)
Administer oxygen per nasal cannula
d)
Speed the IV infusion of normal saline
e)
-
11.
The primary nursing consideration when working with a newly admitted adolescent with anorexia nervosa is:
a)
Identifying stressors that contributed to the disorder
b)
Including family members in the client’s care
c)
Establishing a trusting relationship
d)
Restoring the client’s nutritional status
e)
-
12.
The nurse is caring for a patient who was given pain medication before leaving the recovery room. Upon returning to his room, the patient states that he is still experiencing pain and requests more pain medication. Of the following actions, which is the first for the nurse to take?
a)
Tell the patient that he must wait 4 hours for more pain medication.
b)
Give half of the ordered as-needed dose.
c)
Document the patient’s pain.
d)
Notify the practitioner that the patient is still experiencing pain.
e)
-
13.
The practitioner orders I.V. streptokinase for a patient with an evolving MI. During streptokinase therapy, which nursing assessment is most important?
a)
Assess the patient for cardiac arrhythmias.
b)
Assess the patient for signs of bleeding.
c)
Assess the patient for increased chest pain.
d)
Assess the patient for signs of pulmonary edema.
e)
-
14.
The nurse is caring for a patient who was given pain medication before leaving the recovery room. Upon returning to his room, the patient states that he is still experiencing pain and requests more pain medication. Of the following actions, which is the first for the nurse to take?
a)
Tell the patient that he must wait 4 hours for more pain medication.
b)
Give half of the ordered as-needed dose.
c)
Document the patient’s pain.
d)
Notify the practitioner that the patient is still experiencing pain.
e)
-
15.
Which snack selection by a client with osteoporosis indicates that the client understands the dietary management of the disease?
a)
A glass of orange juice
b)
A blueberry muffin
c)
A cup of yogurt
d)
A banana
e)
-
16.
The physician has prescribed Zoloft (sertraline) for a client who has been taking Nardil (phenelzine). The recommended length of time between discontinuing a monoamine oxidase inhibitor and beginning therapy with a selective serotonin reuptake inhibitor is:
a)
2 days
b)
7 days
c)
10 days
d)
14 days
e)
-
17.
After counseling a 35-year-old client about breast self-examination and mammography, the nurse determines that the client has understood the instructions when the client states which of the following?
a)
“I should have a mammogram every year once I’m 40.”
b)
“I should schedule a mammography examination during my menstrual period.”
c)
“Mammography screening is inexpensive.”
d)
“Mammography is an extremely painful procedure.”
e)
-
18.
A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks. Which laboratory finding indicates that the medication is having the desired effect?
a)
Neutrophil count of 60%
b)
Basophil count of 0.5%
c)
Monocyte count of 2%
d)
Reticulocyte count of 1%
e)
-
19.
The nurse is preparing a client for cervical uterine radiation implant insertion. Which will be included in the nurse’s explanations?
a)
TV or telephone use will not be allowed while the implant is in place.
b)
A Foley catheter is usually inserted.
c)
A high-fiber diet is recommended.
d)
Excretions will be considered radioactive.
e)
-
20.
The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates that the client understands his new diet?
a)
Cornflakes, whole milk, banana, and coffee
b)
Scrambled eggs, bacon, toast, and coffee
c)
Oatmeal, apple juice, dry toast, and coffee
d)
Pancakes, ham, tomato juice, and coffee
e)
-
21.
When implementing an evidence-based nursing program to decrease the incidence of pressure ulcers on a medical-surgical unit, which of the following is the most important to ensure its success?
a)
Obtaining support from management, administration, and physicians
b)
Determining and documenting patient outcomes
c)
Identifying a significant problem that needs to be addressed
d)
Evaluating research based on its validity and reliability
e)
-
22.
In young adulthood, the expected developmental tasks include:
a)
Satisfying and supporting the next generation.
b)
Formulating a sense of oneself and feeling fulfilled.
c)
Developing peer relationships.
d)
Giving and sharing with an individual without asking what will be given or shared in return.
e)
-
23.
The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam?
a)
“You will need to lay flat during the exam.”
b)
“You need to empty your bladder before the procedure.”
c)
“You will be asleep during the procedure.”
d)
“The doctor will inject a medication to treat your illness during the procedure.”
e)
-
24.
Which is the most accurate statement regarding pain?
a)
Pain has been extensively studied and is well understood.
b)
Pain is one of the most common symptoms in medicine.
c)
Pain perception is very objective; every client feels pain the exact same way.
d)
Pain is only a result of physical bodily damage.
e)
-
25.
A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:
a)
Serve high-calorie foods that 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
e)
-
26.
The nurse admits a client to the hospital who was involved in a motor vehicle accident. The client sustained a skull fracture. The nurses knows this client is at risk for increased intracranial pressure and therefore avoids placing the client in which position?
a)
Head turned to the side.
b)
Head of bed at 30 to 45 degrees.
c)
Head midline.
d)
Neck in neutral position.
e)
-
27.
Informed consent must be voluntary and can be given by a client legally competent to make informed decisions only after the client has been fully informed of the proposed procedure, the risks, the benefits, and any alternative treatments, including refusal.Which scenario contains the elements of a legally appropriate informed consent?
a)
The physician writes the order to obtain informed consent for an invasive procedure from a client. The client states,“My doctor did mention that procedure to me, but I don’t understand what is going to be done.”
b)
A client states, “I believe that I am wellinformed about my procedure. I understand the risks and the benefits, and my right to decline the procedure.May I have a clipboard to write on so that I can sign the consent?”
c)
A client diagnosed with Alzheimer’s disease is admitted from an extended-care facility. The client has lucid moments and is oriented to self, but is generally disoriented regarding place and circumstances. There is an order on the chart to obtain informed consent for placement of a central intravenous line.
d)
A 14-year-old client brought to the emergency department states, “I can sign the consent for my procedure.My parents are at work and will not be here for a while. They won’t mind me signing the consent.”
e)
-
28.
When implementing an evidence-based nursing program to decrease the incidence of pressure ulcers on a medical-surgical unit, which of the following is the most important to ensure its success?
a)
Obtaining support from management, administration, and physicians
b)
Determining and documenting patient outcomes
c)
Identifying a significant problem that needs to be addressed
d)
Evaluating research based on its validity and reliability
e)
-
29.
The physician has prescribed Zoloft (sertraline) for a client who has been taking Nardil (phenelzine). The recommended length of time between discontinuing a monoamine oxidase inhibitor and beginning therapy with a selective serotonin reuptake inhibitor is:
a)
2 days
b)
7 days
c)
10 days
d)
14 days
e)
-
30.
Which landmarks are used to obtain an apical pulse?
a)
Left fifth intercostal space, midaxillary line.
b)
Left fifth intercostal space, midclavicular line.
c)
Left second intercostal space, midclavicular line.
d)
Left seventh intercostal space, midclavicular line.
e)
-
31.
The practitioner orders I.V. streptokinase for a patient with an evolving MI. During streptokinase therapy, which nursing assessment is most important?
a)
Assess the patient for cardiac arrhythmias.
b)
Assess the patient for signs of bleeding.
c)
Assess the patient for increased chest pain.
d)
Assess the patient for signs of pulmonary edema.
e)
-
32.
A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following?
a)
Hypernatremia
b)
Hypokalemia
c)
Myelosuppression
d)
Leukocytosis
e)
-
33.
A client awaiting surgery is accidentally given a double dose of morning medication, which includes metformin hydrochloride (Glucophage) 1000 mg and aspirin 81 mg. Which step should the nurse take to ensure no ill effects occur as a result of this incident?
a)
Observe for Kussmaul respirations.
b)
Monitor closely for hypertension.
c)
Test for blood glucose levels.
d)
Document temperature readings.
e)
-
34.
Pain control is an important aspect of client care. Which theory most accurately addresses a client’s pain?
a)
Endorphin-releasing theory.
b)
Nociceptor-reversal theory.
c)
Gate-control theory.
d)
Open-door theory.
e)
-
35.
A primigravid client at 36 weeks’ gestation with premature rupture of the membranes is to be discharged home on bed rest with follow-up by the home health nurse. After instruction about care while at home, which of the following client statements indicates effective teaching?
a)
. “It is permissible to douche if the fluid irritates my vaginal area.”
b)
“I can take either a tub bath or a shower when I feel like it.”
c)
“I should limit my fluid intake to less than 1 quart daily.”
d)
“I should contact the doctor if my temperature is 100.4° F or higher.”
e)
-
36.
Diuretics are ordered for a patient. What would be the best time of day for the nurse to schedule this medication?
a)
. Anytime
b)
Nighttime
c)
Morning
d)
Noon
e)
-
37.
The nurse has just received report from the RN. Which of the following clients should the nurse visit first?
a)
A 50-year-old COPD client with a PCO2 of 50
b)
A 24-year-old admitted after an MVA complaining of shortness of breath
c)
A client with cancer requesting pain medication
d)
A 1-day post-operative cholecystectomy with a temperature of 100°F
e)
-
38.
While caring for a client with hypertension, the nurse notes the following vital signs: BP of 140/20, pulse 120, respirations 36, temperature 100.8°F. The nurse’s initial action should be to:
a)
Call the doctor
b)
Recheck the vital signs
c)
Obtain arterial blood gases
d)
Obtain an ECG
e)
-
39.
A 20-year-old primigravid client tells the nurse that her mother had a friend who died from hemorrhage about 10 years ago during a vaginal delivery. Which of the following responses would be most helpful?
a)
“Today’s modern technology has resulted in a low maternal mortality rate.”
b)
“Don’t concern yourself with things that happened in the past.”
c)
“In the United States, mothers seldom die in childbirth.”
d)
“What is it that concerns you about pregnancy, labor, and delivery?”
e)
-
40.
Which aerobic gram-negative bacillus is the most common pathogen for all manifestations of urinary tract infection in all groups of clients?
a)
Escherichia coli.
b)
Klebsiella.
c)
Pseudomonas aeruginosa.
d)
Staphylococcus aureus.
e)
-
41.
The nurse working in an outpatient clinic cares for a client immediately after a sigmoidoscopy. Which sign and symptom should be most concerning to the nurse?
a)
Abdominal fullness and pressure.
b)
Grogginess and thirst.
c)
Mild abdominal pain and cramping.
d)
Light-headedness and dizziness.
e)
-
42.
Which nurse should be assigned to care for the postpartal client with preeclampsia? The nurse with:
a)
2 weeks of experience in postpartum
b)
3 years of experience in labor and delivery
c)
10 years of experience in surgery
d)
1 year of experience in the neonatal intensive care unit
e)
-
43.
When instructing a client about the proper use of condoms for pregnancy prevention, which of the following instructions would be included to ensure maximum effectiveness? ■ 1. ■ 2. ■ 3. ■ 4.
a)
Place the condom over the erect penis before coitus.
b)
Withdraw the condom after coitus when the penis is flaccid.
c)
Ensure that the condom is pulled tightly over the penis before coitus.
d)
Obtain a prescription for a condom with nonoxynol 9.
e)
-
44.
A client is currently under the care of the palliative care service of home health and has been experiencing nausea. What nursing actions will most likely promote comfort in this client?
a)
Educate the patient and family in the use of prescribed antiemetics; providing oral care every 2 to 4 hours; consuming a diet of clear liquids and ice chips; and avoiding liquids such as coffee, milk, and citrus juices.
b)
Administer additional pain medication.
c)
Provide education to the patient and family regarding oral care and antiemetic medication.
d)
Take a detailed medical history to determine the cause of the nausea.
e)
-
45.
The 57-year-old male client has elected to have epidural anesthesia as the anesthetic during a hernia repair. If the client experiences hypotension, the nurse would:
a)
Place him in the Trendelenburg position
b)
Obtain an order for Benedryl
c)
Administer oxygen per nasal cannula
d)
Speed the IV infusion of normal saline
e)
-
46.
The major risk factors for intracranial bleeding in clients who receive thrombolytic therapy are:
a)
Age greater than 65 years.
b)
Hypotension at presentation.
c)
Obesity.
d)
Race.
e)
-
47.
A client has the following medications ordered: albuterol sulfate (Proventil) inhaler 2 puffs every 4 hours and fluticasone propionate (Flovent) one puff in each nostril twice a day. Which is a true statement regarding the use of these two medications?
a)
They should not be used together.
b)
The fluticasone propionate (Flovent) should be used first.
c)
The albuterol sulfate (Proventil) should be used first.
d)
The nurse should ask the pharmacist to combine them into one medication.
e)
-
48.
A patient, age 18, develops diabetes insipidus after a severe closed head injury. Which assessment findings would indicate that he also has hypernatremia?
a)
Anorexia, muscle cramps, and a serum sodium level greater than 135 mEq/L
b)
Numbness, muscle cramps, and a positive Trousseau’s
c)
Cardiac arrhythmias, muscle weakness, nausea, and vomiting D.
d)
Thirst, dry and swollen tongue, and disorientation
e)
-
49.
Which aerobic gram-negative bacillus is the most common pathogen for all manifestations of urinary tract infection in all groups of clients?
a)
Escherichia coli.
b)
Klebsiella.
c)
Pseudomonas aeruginosa.
d)
Staphylococcus aureus.
e)
-
50.
As winter approaches, the nurse counsels an elderly client:
a)
To remain indoors as much as possible.
b)
That he needs thermal protection when outdoors.
c)
To consider spending the winter in a milder climate.
d)
That he will likely become ill if he does not remain in an environment with a constant temperature.
e)
-
51.
A client is admitted for minor injuries sustained in a motorcycle accident. The physician order reads: desmopressin acetate (DDAVP) 0.3 mcg/kg IV × 1 dose. The nurse knows this medication is ordered to manage the client’s:
a)
Christmas disease.
b)
Disseminated intravascular coagulation (DIC).
c)
Sickle-cell anemia.
d)
Von Willebrand’s disease.
e)
-
52.
The primary cause of anemia in a client with chronic renal failure is:
a)
Poor iron absorption
b)
Destruction of red blood cells
c)
Lack of intrinsic factor
d)
Insufficient erythropoietin
e)
-
53.
A 2-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?
a)
“Currant jelly” stools
b)
Projectile vomiting
c)
“Ribbonlike” stools
d)
Palpable mass over the flank
e)
-
54.
In every household, members have to decide the ways in which work and responsibilities will be divided and shared. Different roles include:
a)
Bidder.
b)
Gender.
c)
Provider.
d)
Student.
e)
-
55.
The practitioner orders I.V. streptokinase for a patient with an evolving MI. During streptokinase therapy, which nursing assessment is most important?
a)
Assess the patient for cardiac arrhythmias.
b)
Assess the patient for signs of bleeding.
c)
Assess the patient for increased chest pain.
d)
Assess the patient for signs of pulmonary edema.
e)
-
56.
A client expectorates pink-tinged sputum after returning from a bronchoscopy.Which action is most appropriate for the nurse to take?
a)
Notify the physician.
b)
Obtain the client’s vital signs and then call the physician.
c)
Auscultate the client’s lungs for rhonchi.
d)
Continue to monitor the client’s condition.
e)
-
57.
The nurse knows that the 60-year-old female client’s susceptibility to osteoporosis is most likely related to:
a)
Lack of exercise
b)
Hormonal disturbances
c)
Lack of calcium
d)
Genetic predisposition
e)
-
58.
The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:
a)
Diabetes
b)
Positive HIV
c)
Hypertension
d)
Thyroid disease
e)
-
59.
The nurse has just received report from the RN. Which of the following clients should the nurse visit first?
a)
A 50-year-old COPD client with a PCO2 of 50
b)
A 24-year-old admitted after an MVA complaining of shortness of breath
c)
A client with cancer requesting pain medication
d)
A 1-day post-operative cholecystectomy with a temperature of 100°F
e)
-
60.
The Neuman’s Systems Model maintains that each person (or group of persons) constitutes a system of five variables: physiological, psychological, sociocultural, developmental, and spiritual. These variables exist along a developmental continuum. The spiritual continuum can range from lack of awareness or denial of spirituality to a highly developed spiritual consciousness. A nurse who allows Neuman’s Systems Model to guide practice should address the client’s level of spiritual awareness or development and address any identifiable spiritual needs occurring in reaction to the:
a)
Attitude clients choose in response to suffering.
b)
Availability and efficacy of resources for coping with the stressor.
c)
Meaning of this experience for the client.
d)
Stress of surgery.
e)
-
61.
The nurse is caring for a 9-month-old with suspected celiac disease. Which diet is appropriate?
a)
Whole milk and oatmeal
b)
Breast milk and mixed cereal
c)
Formula and barley cereal
d)
Breast milk and rice cereal
e)
-
62.
Which of the following describes a nosocomial infection?
a)
A client develops MRSA while hospitalized for treatment of a fractured hip.
b)
A client develops a kidney infection from an extended bladder infection.
c)
A client develops hepatitis A after eating in a local restaurant.
d)
A client develops pneumonia after attending a sporting event.
e)
-
63.
A client is admitted after a motor vehicle accident. The nurse suspects that the client is in the compensatory stage of shock due to which clinical manifestations?
a)
Blood pressure 120/70, confusion, heart rate 120
b)
Crackles on chest auscultation, mottled skin, lethargy
c)
Skin color jaundice, urine output less than 30mL the past hour, heart rate 170
d)
Rapid, shallow respirations; unconscious; petechiae anterior chest
e)
-
64.
Which snack selection by a client with osteoporosis indicates that the client understands the dietary management of the disease?
a)
A glass of orange juice
b)
A blueberry muffin
c)
A cup of yogurt
d)
A banana
e)
-
65.
A heart murmur is heard at the second left intercostal space along the left sternal border. Which heart valve is found in this area?
a)
Aortic.
b)
Mitral.
c)
Pulmonic.
d)
Tricuspid.
e)
-
66.
The nurse knows that the 60-year-old female client’s susceptibility to osteoporosis is most likely related to:
a)
Lack of exercise
b)
Hormonal disturbances
c)
Lack of calcium
d)
Genetic predisposition
e)
-
67.
When teaching a patient about cardiomyopathy, which statement by the patient indicates that further teaching is needed about the causes of cardiomyopathy?
a)
“It’s caused by plaque in the arteries.”
b)
“It’s caused by a virus.”
c)
“It’s caused by bacteria.”
d)
“It’s caused by certain drugs.”
e)
-
68.
The nurse is measuring the duration of the client’s contractions. Which statement is true regarding the measurement of the duration of contractions?
a)
Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction.
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.
e)
-
69.
Lidocaine is a medication frequently ordered for the client experiencing:
a)
Atrial tachycardia
b)
Ventricular tachycardia
c)
Heart block
d)
Ventricular brachycardia
e)
-
70.
A client is admitted for minor injuries sustained in a motorcycle accident. The physician order reads: desmopressin acetate (DDAVP) 0.3 mcg/kg IV × 1 dose. The nurse knows this medication is ordered to manage the client’s:
a)
Christmas disease.
b)
Disseminated intravascular coagulation (DIC).
c)
Sickle-cell anemia.
d)
Von Willebrand’s disease.
e)
-
71.
A client is diagnosed with iron-deficiency anemia. The nurse expects which complaint from the client?
a)
I am short of breath even while I am sitting.
b)
My face is always flushed.
c)
I always feel like eating.
d)
I can’t taste anything.
e)
-
72.
Which instruction should be included in the discharge teaching for the client with cataract surgery?
a)
A. Over-the-counter eyedrops can be used to treat redness and irritation.
b)
The eye shield should be worn at night.
c)
It will be necessary to wear special cataract glasses.
d)
A prescription for medication to control post-operative pain will be needed.
e)
-
73.
The Neuman’s Systems Model maintains that each person (or group of persons) constitutes a system of five variables: physiological, psychological, sociocultural, developmental, and spiritual. These variables exist along a developmental continuum. The spiritual continuum can range from lack of awareness or denial of spirituality to a highly developed spiritual consciousness. A nurse who allows Neuman’s Systems Model to guide practice should address the client’s level of spiritual awareness or development and address any identifiable spiritual needs occurring in reaction to the:
a)
Attitude clients choose in response to suffering.
b)
Availability and efficacy of resources for coping with the stressor.
c)
Meaning of this experience for the client.
d)
Stress of surgery.
e)
-
74.
The major risk factors for intracranial bleeding in clients who receive thrombolytic therapy are:
a)
Age greater than 65 years.
b)
Hypotension at presentation.
c)
Obesity.
d)
Race.
e)
-
75.
Which is the most accurate statement regarding pain?
a)
Pain has been extensively studied and is well understood.
b)
Pain is one of the most common symptoms in medicine.
c)
Pain perception is very objective; every client feels pain the exact same way.
d)
Pain is only a result of physical bodily damage.
e)
-
76.
A multigravid client at 34 weeks’ gestation is being treated with indomethacin (Indocin) to halt preterm labor. If the client delivers a preterm infant, the nurse should notify the nursery personnel about this therapy because of the possibility for which of the following?
a)
Pulmonary hypertension.
b)
Respiratory distress syndrome (RDS).
c)
Hyperbilirubinemia.
d)
Cardiomyopathy.
e)
-
77.
A client has a history of positive HIV with onset of acquired immunodeficiency syndrome (AIDS). The client receives 2 units of whole blood.Which transfusion reaction is this client most likely to have?
a)
Acute hemolytic reaction.
b)
Graft versus host disease.
c)
Allergic reaction.
d)
Febrile transfusion reaction.
e)
-
78.
A client has pneumonia. Which assessment finding best indicates that the client’s respiratory efforts are currently adequate?
a)
The client is able to talk.
b)
The client is alert and oriented.
c)
The client’s O2 saturation is 97%.
d)
The client’s chest movements are uninhibited.
e)
-
79.
A client with hypertension has begun an aerobic exercise program. The nurse should tell the client that the recommended exercise regimen should begin slowly and build up to:
a)
20–30 minutes three times a week
b)
45 minutes two times a week
c)
1 hour four times a week
d)
1 hour two times a week
e)
-
80.
A client arrives in the emergency department after a motor vehicle accident. The client has sinus tachycardia, is hypotensive, and has muffled heart sounds. There is no apparent sign of hemorrhage. Which condition does the nurse suspect?
a)
Cor pulmonale.
b)
Pneumothorax.
c)
Cardiac tamponade.
d)
Pulmonary embolism.
e)
-
81.
In young adulthood, the expected developmental tasks include:
a)
Satisfying and supporting the next generation.
b)
Formulating a sense of oneself and feeling fulfilled.
c)
Developing peer relationships.
d)
Giving and sharing with an individual without asking what will be given or shared in return.
e)
-
82.
The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?
a)
Inspection of the abdomen for enlargement
b)
Bimanual palpation for hepatomegaly
c)
Daily measurement of abdominal girth
d)
Assessment for a fluid wave
e)
-
83.
The nurse is caring for an infant who is on strict intake and output. The used diaper weighs 90.5 grams. The diaper’s dry weight was 62 grams. The infant’s urine output was:
a)
10mL
b)
28.5mL
c)
10 grams
d)
152.5 grams
e)
-
84.
The nurse is caring for a client following a pneumonectomy. Which nursing intervention will help prevent an embolus?
a)
Encouraging the client to use an incentive spirometer
b)
Administering thrombolytic medication as ordered
c)
Telling the client to turn, cough, and breathe deeply
d)
Ambulating the client as soon as possible
e)
-
85.
A nurse is preparing to reinforce the teaching plan for a patient who has recently been diagnosed with squamous cell carcinoma of the left lung. Which statement by the nurse is correct?
a)
“You have a slow-growing cancer that rarely spreads.”
b)
“In terms of prognosis, you may have only a few months to live.”
c)
“Squamous cell cancer is a very rapidly growing cancer.”
d)
“The cancer has generally metastasized by the time diagnosis is made.”
e)
-
86.
Which of the following patients would most benefit from parenteral nutrition?
a)
A client with neck cancer.
b)
A client with a CVA.
c)
A client with severe pancreatitis.
d)
An intubated client.
e)
-
87.
The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:
a)
Apply the new tie before removing the old one
b)
Have a helper present
c)
Hold the tracheotomy with the nondominant hand while removing the old tie
d)
Ask the doctor to suture the tracheotomy in place
e)
-
88.
A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:
a)
Be injected into the deltoid muscle
b)
Be injected in the abdomen
c)
Aspirate after the injection
d)
Clear the air from the syringe before injections
e)
-
89.
A client has a history of positive HIV with onset of acquired immunodeficiency syndrome (AIDS). The client receives 2 units of whole blood.Which transfusion reaction is this client most likely to have?
a)
Acute hemolytic reaction.
b)
Graft versus host disease.
c)
Allergic reaction.
d)
Febrile transfusion reaction.
e)
-
90.
The nurse is caring for a patient who was given pain medication before leaving the recovery room. Upon returning to his room, the patient states that he is still experiencing pain and requests more pain medication. Of the following actions, which is the first for the nurse to take?
a)
Tell the patient that he must wait 4 hours for more pain medication.
b)
Give half of the ordered as-needed dose.
c)
Document the patient’s pain.
d)
Notify the practitioner that the patient is still experiencing pain.
e)
-
91.
The elderly client with hypomagnesemia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of magnesium sulfate?
a)
The nurse places a sign over the bed not to check blood pressures in the left arm.
b)
The nurse places a padded tongue blade at the bedside.
c)
The nurse measures the urinary output hourly.
d)
The nurse darkens the room.
e)
-
92.
A heart murmur is heard at the second left intercostal space along the left sternal border. Which heart valve is found in this area?
a)
Aortic.
b)
Mitral.
c)
Pulmonic.
d)
Tricuspid.
e)
-
93.
The Neuman’s Systems Model maintains that each person (or group of persons) constitutes a system of five variables: physiological, psychological, sociocultural, developmental, and spiritual. These variables exist along a developmental continuum. The spiritual continuum can range from lack of awareness or denial of spirituality to a highly developed spiritual consciousness. A nurse who allows Neuman’s Systems Model to guide practice should address the client’s level of spiritual awareness or development and address any identifiable spiritual needs occurring in reaction to the:
a)
Attitude clients choose in response to suffering.
b)
Availability and efficacy of resources for coping with the stressor.
c)
Meaning of this experience for the client.
d)
Stress of surgery.
e)
-
94.
The nurse has reinforced teaching to a client who is on isoniazid (INH). Which diet selection would let the nurse know that the teaching has been ineffective?
a)
Tuna casserole
b)
Ham salad
c)
Baked potato
d)
Broiled beef roast
e)
-
95.
A client has a history of positive HIV with onset of acquired immunodeficiency syndrome (AIDS). The client receives 2 units of whole blood.Which transfusion reaction is this client most likely to have?
a)
Acute hemolytic reaction.
b)
Graft versus host disease.
c)
Allergic reaction.
d)
Febrile transfusion reaction.
e)
-
96.
When teaching a patient how to prevent the recurrence of acute glomerulonephritis, which instruction should the nurse include?
a)
“Avoid physical activity.”
b)
“Strain all urine.”
c)
“Seek early treatment for respiratory infections.”
d)
“Monitor urine specific gravity daily.”
e)
-
97.
A laboring client at –2 station has a spontaneous rupture of the membranes and a cord immediately protrudes from the vagina. The nurse should first:
a)
Place gentle pressure upward on the fetal head.
b)
Place the cord back into the vagina to keep it moist.
c)
Begin oxygen by face mask at 8 to 10 L/min.
d)
Turn the client on her left side.
e)
-
98.
Which of the following patients would most benefit from parenteral nutrition?
a)
A client with neck cancer.
b)
A client with a CVA.
c)
A client with severe pancreatitis.
d)
An intubated client.
e)
-
99.
Which of the following is incorrect about informed consent?
a)
It can be revoked by the state, especially when the benefits outweigh the risks.
b)
A person has to be mentally competent to sign an informed consent.
c)
Physicians can waive informed consents in emergency situations.
d)
The name of the procedure, its risks and benefits, and other alternative procedures make up all the essential elements of informed consent.
e)
-
100.
A client’s primary physician writes an order to prepare the client for discharge from the hospital the next day. The client expresses concern to the nurse about the ability to provide self-care and perform daily activities of living after arriving home from the hospital. Which member of the health care team should the nurse contact to provide information and assist the client with resources for an effective discharge plan?
a)
The client’s primary care physician, who will coordinate care and resources for an effective discharge plan individualized to the client’s needs.
b)
The client’s case manager, who will coordinate care and provide information and resources for an effective discharge plan individualized to the client’s needs.
c)
The client’s physical therapist, who will instruct the client to safely navigate the home environment after discharge.
d)
The client’s occupational therapist, who will evaluate the client’s ability to perform selfcare and activities of daily living.
e)
-
100 %
