WorksheetsGCC Mock Test 11
Total questions: 100
Worksheet time: 2hrs 40mins
Name
Class
Date
1.
The physician prescribes an enema for a patient with suspected appendicitis. Which action should the nurse take?
a)
Prepare 750 mL of irrigating solution warmed to 100° F (37.8° C).
b)
Question the physician about the order.
c)
Provide privacy and explain the procedure to the patient.
d)
Assist the patient to the left lateral Sims’ position. Your Answer
e)
-
2.
Which of the following conditions is most likely related to the development of renal calculi?
a)
Gout
b)
Pancreatitis
c)
Fractured femur
d)
Disc disease Your Answer
e)
-
3.
The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?
a)
“I will have blood drawn every month.”
b)
“I will assess my skin for a rash.”
c)
“I take aspirin for a headache.”
d)
“I will use an electric razor to shave.” Your Answer
e)
-
4.
The nurse is preparing a patient for surgery on the lower abdomen. Which position would the nurse most likely place the client in for surgery on this area?
a)
Lithotomy
b)
Sims
c)
Prone
d)
Trendelenburg
e)
-
5.
The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?
a)
A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis
b)
The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm
c)
A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury
d)
The client who arrives with a large puncture wound to the abdomen and the client with chest pain Your Answer
e)
-
6.
A client at 4 weeks postpartum tells the nurse that she can’t cope any longer and is overwhelmed by her newborn. The baby has old formula on her clothes and under her neck. The mother does not remember when she last bathed the baby and states she does not want to care for the infant. The nurse should encourage the client and her husband to call their health care provider because the mother should be evaluated further for?
a)
Postpartum blues.
b)
Postpartum depression.
c)
Poor bonding.
d)
Infant abuse. Your Answer
e)
-
7.
In which client should partial parenteral nutrition (PPN) not be implemented?
a)
Hepatitis C.
b)
Emphysema.
c)
Mesenteric occlusion.
d)
Chronic renal failure.
e)
-
8.
The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
a)
Use the heel of her hand during percussion
b)
Change the child’s position every 20 minutes
c)
Do percussion after the child eats and at bedtime
d)
Use cupped hands during percussion
e)
-
9.
A patient with Hodgkin’s disease has lymph node involvement on both sides of the diaphragm and involvement of the spleen. According to the Ann Harbor classification system, what stage lymphoma does this patient have?
a)
Stage I
b)
Stage II
c)
Stage III
d)
Stage IV Your Answer
e)
-
10.
A patient, age 68, has a primary brain tumor. During the past 18 months, he has been admitted to the neurologic unit several times for surgery, radiation therapy, and chemotherapy. Today, he is admitted to investigate a recent onset of seizures. The nurse notes that the patient has become listless and sleepy. Which action should the nurse take first?
a)
Assess the patient’s verbal and motor responses and ability to open his eyes.
b)
Ask the patient how he is feeling.
c)
Call the practitioner and report the findings.
d)
Continue observing the patient’s behavior, which may be an adverse effect of phenytoin. Your Answer
e)
-
11.
Which of the following conditions is most likely related to the development of renal calculi?
a)
Gout
b)
Pancreatitis
c)
Fractured femur
d)
Disc disease Your Answer
e)
-
12.
A patient develops left ventricular dysfunction secondary to an MI. During the physical assessment, the nurse would expect to find:
a)
bilateral basilar crackles.
b)
elevated central venous pressure.
c)
pitting sacral edema.
d)
hepatojugular reflux. Your Answer
e)
-
13.
A client complains of an urticarial rash, itching, and dyspnea after receiving an intramuscular injection of penicillin G benzathine (Bicillin L-A). Which medication is the most appropriate primary intervention in this circumstance?
a)
Epinephrine (Adrenaline) 1:1000 to 0.3 mL IV.
b)
Diphenhydramine (Benadryl) 50 mg IV.
c)
Methylprednisolone sodium succinate (Solu- Medrol) 125 mg IV.
d)
Atropine sulfate (Atropine) 0.5 mg IV. Your Answer
e)
-
14.
The physician has prescribed a cleansing enema to a client scheduled for colon surgery. The nurse would place the client:
a)
Prone
b)
Supine
c)
Left Sims
d)
Dorsal recumbent Your Answer
e)
-
15.
Which of the following are external factors that subject the skin to injury?
a)
Emaciation and infections
b)
Allergens and radiation
c)
Radiation and emaciation
d)
Allergens and infections Your Answer
e)
-
16.
A new graduate nurse identifies an abnormal heart sound while performing a client assessment. The graduate nurse asks the charge nurse to listen to the client’s heart sounds. The charge nurse confirms that the client has a systolic heart murmur. This action by the graduate nurse is an example of:
a)
Continuity of care.
b)
Delegation.
c)
Consultation.
d)
Supervision. Your Answer
e)
-
17.
Which nursing diagnosis is the highest priority for the client taking analgesic agents?
a)
Risk for infection.
b)
Risk for injury.
c)
Risk for impaired gas exchange.
d)
Risk for constipation. Your Answer
e)
-
18.
A male client is admitted with a tentative diagnosis of Hodgkin’s lymphoma. The client with Hodgkin’s lymphoma commonly reports:
a)
Finding enlarged nodes in the neck while shaving
b)
Projectile vomiting upon arising
c)
Petechiae and easy bruising
d)
Frequent, painless hematuria Your Answer
e)
-
19.
The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin?
a)
Cyanocobalamine
b)
Protamine sulfate
c)
Streptokinase
d)
Sodium warfarin Your Answer
e)
-
20.
Health care facilities store a large portion of their clients’ health information on the facility’s health information system. Each health care team member with a need to access health information is given a password or log in code. How closely is access to a facility’s health information system monitored?
a)
Access is not monitored. After receiving a log in code and password, each employee accesses health information on the honor system.
b)
Access is monitored intermittently.
c)
Access of the health information system is monitored closely and constantly for inappropriate use of the system and health information stored on the system. There is a record of every log in, date, time and the information accessed.
d)
Access is monitored only during business office hours when the system usage is the highest. Your Answer
e)
-
21.
The nurse cares for a client diagnosed with metabolic alkalosis.Metabolic alkalosis occurs in:
a)
Head trauma.
b)
Hypoxia.
c)
Steroid therapy.
d)
Uremia. Your Answer
e)
-
22.
A client complains of an urticarial rash, itching, and dyspnea after receiving an intramuscular injection of penicillin G benzathine (Bicillin L-A). Which medication is the most appropriate primary intervention in this circumstance?
a)
Epinephrine (Adrenaline) 1:1000 to 0.3 mL IV.
b)
Diphenhydramine (Benadryl) 50 mg IV.
c)
Methylprednisolone sodium succinate (Solu- Medrol) 125 mg IV.
d)
Atropine sulfate (Atropine) 0.5 mg IV. Your Answer
e)
-
23.
A client with diabetes mellitus has a prescription for Glucotrol XL (glipizide). The client should be instructed to take the medication:
a)
At bedtime
b)
With breakfast
c)
Before lunch
d)
After dinner Your Answer
e)
-
24.
Which of the following conditions is most likely related to the development of renal calculi?
a)
Gout
b)
Pancreatitis
c)
Fractured femur
d)
Disc disease Your Answer
e)
-
25.
The nurse is caring for a client in the intensive care unit with acute cardiopulmonary problems. The client is receiving mechanical ventilation for cardiopulmonary support. How often is a chest x-ray indicated for clients receiving mechanical ventilation?
a)
Hourly.
b)
Once daily.
c)
Twice daily.
d)
Weekly. Your Answer
e)
-
26.
When planning the postoperative care of a patient who underwent surgery for repair of a lacerated spleen after an alcohol-related motor vehicle accident, what intervention should take priority in the immediate postoperative period?
a)
Monitoring the patient for signs and symptoms of alcohol withdrawal
b)
Encouraging early ambulation
c)
Splinting the abdomen for coughing and deep-breathing exercise
d)
Monitoring the patient’s renal function Your Answer
e)
-
27.
A primigravid client at 8 weeks’ gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago, she has noticed flulike symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina. The nurse refers the client to a physician because the nurse suspects which of the following sexually transmitted diseases?
a)
Gonorrhea.
b)
Chlamydia trachomatis infection.
c)
Syphilis.
d)
Herpes genitalis.
e)
-
28.
The nurse who is caring for a client with cancer notes a WBC of 1,000. Which intervention would be most appropriate to include when caring for this client?
a)
Assess temperature every 4 hours, due to risk for hypothermia
b)
Instruct the client to avoid large crowds and people who are sick
c)
Instruct in the use of a soft toothbrush
d)
Assess for hematuria Your Answer
e)
-
29.
A client who has difficulty taking medications requests that the tablet be crushed and mixed with applesauce.Which medication is appropriate for the nurse to crush?
a)
Enteric-coated aspirin.
b)
Diltiazem hydrochloride (Cardizem SR).
c)
Omeprazole (Prilosec).
d)
Levothyroxine sodium (Levothroid).
e)
-
30.
A 27-year-old primigravid client with insulin-dependent diabetes at 34 weeks’ gestation undergoes a nonstress test, the results of which are documented as reactive. The nurse should tell the client that the test results indicate which of the following?
a)
A contraction stress test is necessary.
b)
The nonstress test should be repeated.
c)
Chorionic villus sampling is necessary.
d)
There is evidence of fetal well-being.
e)
-
31.
Aspiration is defined as the passage of regurgitated gastric contents or other foreign materials into the trachea and down to the smaller air units. The most common and severest form of aspiration is the aspiration of gastric contents. If aspiration is suspected, the nurse should:
a)
Contact the physician.
b)
Elevate the foot of the bed.
c)
Initiate oxygen via a nonrebreather mask.
d)
Lower the client’s head of bed.
e)
-
32.
A client with allergic dermatitis has a prescription for a Medrol (methylprenisolone) dose pack. The client asks why the number of pills decreases each day. The nurse’s response is based on the knowledge that a gradual decreasing of the daily dose is necessary to prevent:
a)
Cushing’s syndrome
b)
Thyroid storm
c)
Cholinergic crisis
d)
Addisonian crisis
e)
-
33.
A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for:
a)
Allergies to pineapples and bananas
b)
A history of streptococcal infections
c)
Prior therapy with phenytoin
d)
A history of alcohol abuse Your Answer
e)
-
34.
The nurse is reviewing assessment data for a patient with a diagnosis of stage III Hodgkin’s disease. This diagnosis is most strongly supported by lymphatic involvement on both sides of the:
a)
blood–brain barrier.
b)
diaphragm.
c)
descending aorta.
d)
spinal column. Your Answer
e)
-
35.
The nurse is taking the blood pressure of an obese client. If the blood pressure cuff is too small, the results will be:
a)
A false elevation
b)
A false low reading
c)
A blood pressure reading that is correct
d)
A subnormal finding Your Answer
e)
-
36.
The nurse is reviewing assessment data for a patient with a diagnosis of stage III Hodgkin’s disease. This diagnosis is most strongly supported by lymphatic involvement on both sides of the:
a)
blood–brain barrier.
b)
diaphragm.
c)
descending aorta.
d)
spinal column. Your Answer
e)
-
37.
Ageism is a negative attitude toward older adults. To prevent ageism when working with older adult clients, the nurse should:
a)
Have knowledge about normal aging while maintaining contact with healthy, independent, older clients.
b)
Speak slowly with increased volume while providing educational pamphlets and brochures.
c)
Limit the client’s activities to prevent injury and promote rest.
d)
Involve the family in decision making and financial concerns. Your Answer
e)
-
38.
The nurse cares for a client diagnosed with atelectasis. Which intervention should be included in the client’s plan of care?
a)
Administer oxygen at 2 litre per minute.
b)
Encourage use of incentive spirometry every hour.
c)
Cough and deep breathe every 4 hours.
d)
Have the client ambulate once a day. Your Answer
e)
-
39.
Acetaminophen (Tylenol) 240mg is ordered for an infant who weighs 12 pounds. The usual dose for an infant is 10–15mg per kilogram of body weight. A nurse should take which action?
a)
Give the medication as ordered
b)
Administer two-thirds of the prescribed dose
c)
Weigh the infant without clothes
d)
Discuss the order with the physician
e)
-
40.
The nurse instructs a client with newly diagnosed diabetes mellitus that hypoglycemia occurs when the blood sugar level is less than:
a)
100 mg/dL.
b)
58 mg/dL.
c)
75 mg/dL.
d)
140 mg/dL. Your Answer
e)
-
41.
The nurse is positioning a client with right hemiplegia. To prevent subluxation of the client’s right shoulder, the nurse should:
a)
Use a pillow to support the client’s arm when she is sitting in a chair
b)
Elevate the arm and hand above chest level when she is lying in bed
c)
Place a pillow under the axilla to elevate the elbow when she is lying in bed
d)
Use a pillow to support the client’s hand when she is sitting in a chair Your Answer
e)
-
42.
A client is being monitored using a central venous pressure monitor. If the pressure is 2cm of water, the nurse should:
a)
Call the doctor immediately
b)
Slow the intravenous infusion
c)
Listen to the lungs for rales
d)
Administer a diuretic Your Answer
e)
-
43.
The nurse working in a long-term care facility knows that elder abuse most often consists of:
a)
Financial exploitation.
b)
Neglect.
c)
Physical abuse.
d)
Sexual abuse. Your Answer
e)
-
44.
An important intervention in monitoring the dietary compliance of a client with bulimia is:
a)
Allowing the client privacy during mealtimes
b)
Praising her for eating all her meals
c)
Observing her for 1–2 hours after meals
d)
Encouraging her to choose foods she likes and to eat in moderation Your Answer
e)
-
45.
When the nurse is gathering information for the assessment, the patient states, “My stomach hurts about 2 hours after I eat.” Based upon this information, the nurse knows the patient likely has a:
a)
Gastric ulcer
b)
Duodenal ulcer
c)
Peptic ulcer
d)
Curling’s ulcer Your Answer
e)
-
46.
A client with AIDS is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract?
a)
Thoroughly cooking all foods
b)
Offering yogurt and buttermilk between meals
c)
Forcing fluids
d)
Providing small, frequent meals
e)
-
47.
A violently agitated client is brought to the emergency department by police. A Foley catheter is inserted, and the client’s urine is sent for a stat urine drug screen. One of the police officers asks the nurse for a copy of the client’s drug screen results, stating he believes the client operates a mobile methamphetamine lab.Which response by the nurse indicates that the nurse understands the Health Insurance Portability and Accountability Act (HIPAA) as it relates to the officer’s request?
a)
I understand you believe that this client manufactures methamphetamine. I will make a copy of the urine drug screen results for you.
b)
I understand you believe this client manufactures methamphetamine. However, this client is unable to consent to the release of personal medical information right now, and it would be a violation of the client’s right to privacy under HIPAA to release a copy of the urine drug screen results to you.
c)
Yes, the client certainly is behaving like someone high on methamphetamine. Did you find the mobile meth lab? These urine drug screen results will help your case against this client for manufacturing illegal drugs.
d)
Under HIPAA I am not supposed to release the results of the urine drug screen to you, but if you believe this client is manufacturing methamphetamine, you should have the drug screen results. I will not give you a copy, but I will leave the results here on the counter and walk away.You can choose to take them if you want to. Your Answer
e)
-
48.
The nurse cares for a client with a pulmonary embolism. The nurse’s care should focus on which intervention?
a)
Assessing oxygenation status.
b)
Ensuring oxygen delivery devices are functioning.
c)
Monitoring for deep vein thrombosis.
d)
Drawing arterial blood gases (ABGs). Your Answer
e)
-
49.
Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram?
a)
Providing the client with a favorite meal for dinner
b)
Asking if the client has allergies to shellfish
c)
Encouraging fluids the evening before the test
d)
Telling the client what to expect during the test Your Answer
e)
-
50.
The physician has written discharge orders for the client that includes a no-salt-added diet. What is the best education the nurse can provide the client at discharge regarding this type of diet?
a)
When preparing foods, do not add any salt or salt-containing spice preparations to the food. Look for spice preparations that do not contain sodium. Do not add salt to foods after preparation.
b)
Do not use canned or processed foods while cooking. Use salt substitutes to put on food at the table.
c)
Eat a healthy, well-balanced diet at home that is rich in fruits, vegetables, and whole grains.
d)
Eat a healthy, well-balanced diet at home that is rich in fruits, vegetables, and whole grains. When preparing foods, do not add any salt or salt-containing spice preparations to the food. Look for spice preparations that do not contain sodium. Do not add salt to foods after preparation.
e)
-
51.
The nurse is caring for a client following a stroke that left him with apraxia. The nurse knows that the client will:
a)
Be unable to communicate through speech
b)
Have difficulty swallowing
c)
Have difficulty with voluntary movements
d)
Be unable to perform previously learned skills
e)
-
52.
A client complains of an urticarial rash, itching, and dyspnea after receiving an intramuscular injection of penicillin G benzathine (Bicillin L-A). Which medication is the most appropriate primary intervention in this circumstance?
a)
Epinephrine (Adrenaline) 1:1000 to 0.3 mL IV.
b)
Diphenhydramine (Benadryl) 50 mg IV.
c)
Methylprednisolone sodium succinate (Solu- Medrol) 125 mg IV.
d)
Atropine sulfate (Atropine) 0.5 mg IV. Your Answer
e)
-
53.
Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram?
a)
Providing the client with a favorite meal for dinner
b)
Asking if the client has allergies to shellfish
c)
Encouraging fluids the evening before the test
d)
Telling the client what to expect during the test Your Answer
e)
-
54.
Which of the following would the nurse identify as the priority to achieve when developing the plan of care for a primigravid client at 38 weeks’ gestation who is hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate?
a)
Decreased generalized edema within 8 hours.
b)
Decreased urinary output during the first 24 hours.
c)
Sedation and decreased reflex excitability within 48 hours.
d)
Absence of any seizure activity during the first 48 hours.
e)
-
55.
Which sedation is typically achieved by administering a single, non-IV dose of a long-acting agent?
a)
Conscious sedation.
b)
General anesthesi
c)
Light sedation.
d)
Regional anesthesia. Your Answer
e)
-
56.
The nurse admits a client to the hospital for a carotid endarterectomy. The nurse should expect to find which condition documented in the client’s history?
a)
End-stage liver disease.
b)
Chronic kidney disease.
c)
Cancer.
d)
Atherosclerosis.
e)
-
57.
Ageism is a negative attitude toward older adults. To prevent ageism when working with older adult clients, the nurse should:
a)
Have knowledge about normal aging while maintaining contact with healthy, independent, older clients.
b)
Speak slowly with increased volume while providing educational pamphlets and brochures.
c)
Limit the client’s activities to prevent injury and promote rest.
d)
Involve the family in decision making and financial concerns. Your Answer
e)
-
58.
A client receiving chemotherapy for breast cancer has an order for Zofran (ondansetron) 8mg PO to be given 30 minutes before induction of the chemotherapy. The purpose of the medication is to:
a)
Prevent anemia
b)
Promote relaxation
c)
Prevent nausea
d)
Increase neutrophil counts Your Answer
e)
-
59.
The nurse instructs a client with newly diagnosed diabetes mellitus that hypoglycemia occurs when the blood sugar level is less than:
a)
100 mg/dL.
b)
58 mg/dL.
c)
75 mg/dL.
d)
140 mg/dL. Your Answer
e)
-
60.
A newborn of 32 weeks gestation is diagnosed with respiratory distress syndrome 3 hours after birth. An assessment finding in the newborn with respiratory distress syndrome is:
a)
Feeding difficulties
b)
Nasal flaring
c)
Increased blood pressure
d)
Temperature instability Your Answer
e)
-
61.
The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
a)
Use the heel of her hand during percussion
b)
Change the child’s position every 20 minutes
c)
Do percussion after the child eats and at bedtime
d)
Use cupped hands during percussion
e)
-
62.
A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?
a)
A client with AIDS being treated with Foscarnet
b)
A client with a fractured femur in a long leg cast
c)
A client with laryngeal cancer with a laryngetomy
d)
A client with diabetic ulcers to the left foot Your Answer
e)
-
63.
A child client who has vomiting, high fever, and cough is prescribed acetaminophen (Tylenol) 325 mg by suppository. The medication on hand is acetaminophen (Tylenol) 650 mg suppository. Which action should the nurse take to provide the proper dose?
a)
Give the child the oral elixir instead.
b)
Break the suppository in half and administer.
c)
Wait for the pharmacy to send a 325-mg suppository.
d)
Contact the physician for a change in dosage order. Your Answer
e)
-
64.
When teaching a primigravid client at 24 weeks’ gestation about the diagnostic tests to determine fetal well-being, which of the following should the nurse include?
a)
A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume, and fetal heart rate reactivity.
b)
A reactive nonstress test is an ominous sign and requires further evaluation with fetal echocardiography.
c)
Contraction stress testing, performed on most pregnant women, can be initiated as early as 16 weeks’ gestation.
d)
Percutaneous umbilical blood sampling uses a needle inserted through the vagina to obtain a sample. Your Answer
e)
-
65.
The physician has ordered prostaglandin gel to be administered vaginally to a newly admitted primigravid client. Which of the following indicate that the client has had a therapeutic response to the medication?
a)
Resting period of 2 minutes between contractions.
b)
Normal patellar and elbow reflexes for the past 2 hours.
c)
Softening of the cervix and beginning effacement.
d)
Leaking of clear amniotic fluid in small amounts. Your Answer
e)
-
66.
When teaching a primigravid client at 24 weeks’ gestation about the diagnostic tests to determine fetal well-being, which of the following should the nurse include?
a)
A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume, and fetal heart rate reactivity.
b)
A reactive nonstress test is an ominous sign and requires further evaluation with fetal echocardiography.
c)
Contraction stress testing, performed on most pregnant women, can be initiated as early as 16 weeks’ gestation.
d)
Percutaneous umbilical blood sampling uses a needle inserted through the vagina to obtain a sample. Your Answer
e)
-
67.
The nurse working in a long-term care facility knows that elder abuse most often consists of:
a)
Financial exploitation.
b)
Neglect.
c)
Physical abuse.
d)
Sexual abuse. Your Answer
e)
-
68.
During a childbirth preparation class, a primigravid client at 36 weeks’ gestation tells the nurse, “My lower back has really been bothering me lately.” Which of the following exercises suggested by the nurse would be most helpful?
a)
Pelvic rocking.
b)
Deep breathing.
c)
Tailor sitting.
d)
Squatting. Your Answer
e)
-
69.
Which skin condition is characterized by erythematous plaques with an adherent silvery scale usually appearing over the extensor surfaces of the extremities, including lesions on the palms, soles, scalp, umbilicus, and genital areas?
a)
Impetigo.
b)
Molluscum contagiosum.
c)
Pityriasis rosea.
d)
Psoriasis.
e)
-
70.
A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for:
a)
Allergies to pineapples and bananas
b)
A history of streptococcal infections
c)
Prior therapy with phenytoin
d)
A history of alcohol abuse Your Answer
e)
-
71.
The nurse arrives at a four-wheeler accident finding the client nonresponsive, apneic, and pulseless. After calling for a spectator to help, what would be the nurse’s next action?
a)
Ventilate with a mouth-to-mask device
b)
Begin chest compressions
c)
Administer a precordial thump
d)
Open the airway Your Answer
e)
-
72.
After giving instruction about the cause of the vaginal bleeding to a multigravid client at 36 weeks’ gestation diagnosed with placenta previa, the nurse determines that the teaching has been effective when the client says that the bleeding results from which of the following?
a)
Diminished clotting factors.
b)
Exposure of maternal blood sinuses.
c)
Increased platelet levels.
d)
A large-for-gestational-age fetus. Your Answer
e)
-
73.
An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year?
a)
14 pounds
b)
16 pounds
c)
18 pounds
d)
24 pounds
e)
-
74.
A child with beta thalassemia has developed hemosiderosis. To prevent organ damage, the child will receive chelation therapy with:
a)
Chemet (succimer)
b)
Versenate (calcium disodium versenate)
c)
Desferal (deferoxamine)
d)
EDTA (calcium disodium edetate) Your Answer
e)
-
75.
A 28-year-old woman is scheduled for a glucose tolerance test. She asks the nurse what results indicate diabetes mellitus. The nurse should respond that the minimum parameter for indication of diabetes mellitus is a 2-hour blood glucose level greater than:
a)
120 mg/dL.
b)
150 mg/dL.
c)
200 mg/dL.
d)
250 mg/dL. Your Answer
e)
-
76.
A client is admitted to the nursing unit after experiencing a cerebral vascular accident. The client is unconscious.What is the nurse’s priority intervention?
a)
Preventing skin breakdown.
b)
Maintaining a patent airway.
c)
Preventing muscle atrophy.
d)
Promoting fluid intake. Your Answer
e)
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77.
A client is exposed to an organism that causes disease. The physician prescribes an immunoglobulin to prevent illness. This is an example of:
a)
Passive immunity.
b)
Active immunity.
c)
Acquired immunity.
d)
Herd immunity. Your Answer
e)
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78.
Clients unlikely to abstain from alcohol are not appropriate candidates for treatment with disulfiram (Antabuse), nor are clients with:
a)
A sedentary occupation.
b)
Chronic hepatitis.
c)
Latex allergy.
d)
Significant cardiac disease.
e)
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79.
A primigravid client at 8 weeks’ gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago, she has noticed flulike symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina. The nurse refers the client to a physician because the nurse suspects which of the following sexually transmitted diseases?
a)
Gonorrhea.
b)
Chlamydia trachomatis infection.
c)
Syphilis.
d)
Herpes genitalis.
e)
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80.
What does the nurse recognize as the primary reason that food and fluids are withheld from clients with pancreatitis?
a)
Decrease blood flow to the pancreas
b)
Decrease stimulation of the pancreas
c)
Increase secretion of pancreatic enzymes
d)
Increase insulin production by the pancreas Your Answer
e)
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81.
A patient develops left ventricular dysfunction secondary to an MI. During the physical assessment, the nurse would expect to find:
a)
bilateral basilar crackles.
b)
elevated central venous pressure.
c)
pitting sacral edema.
d)
hepatojugular reflux. Your Answer
e)
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82.
Which statement made by a client’s son signifies abnormal grieving by the client?
a)
“Mother still has episodes of crying, and it’s been 6 months since Daddy died.”
b)
“Mother seems to have forgotten the bad things that Daddy did in his lifetime.”
c)
“She really had a hard time after Daddy’s funeral. She said that she had a sense of longing.”
d)
“Mother has not been saddened at all by Daddy’s death. She acts like nothing has happened.”
e)
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83.
The physician has ordered Cephulac (lactulose) for a client with increased serum ammonia. The nurse knows the medication is having its desired effect if the client experiences:
a)
Increased urination
b)
Diarrhea
c)
Increased appetite
d)
Decreased weight Your Answer
e)
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84.
Implied consent differs from informed consent for an invasive procedure. Which scenario describes implied consent?
a)
The nurse enters a client’s room with the consent form for an invasive procedure. The client reads and signs the consent form but does not engage in conversation with the nurse.
b)
A fully alert and oriented patient is intubated and unable to speak, but nods, gestures, and writes notes to communicate. The client reads and signs the consent for a tracheotomy after the physician explains the risks and benefits of the procedure to the client with the family present.
c)
A paraplegic client listens carefully to the physician’s explanation of a proposed invasive procedure, the risks and benefits, and then gives consent verbally. The physician and nurse both document this and cosign the consent form as witnesses.
d)
client arrives at the emergency department severely short of breath, then collapses unconscious on the floor. The ED staff provides emergent treatment to the client for resuscitation and airway protection. The client’s consent to treatment was implied by the client voluntarily coming to the ED for treatment, even though the client is currently unconscious and unable to give informed consent. Your Answer
e)
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85.
A new graduate nurse identifies an abnormal heart sound while performing a client assessment. The graduate nurse asks the charge nurse to listen to the client’s heart sounds. The charge nurse confirms that the client has a systolic heart murmur. This action by the graduate nurse is an example of:
a)
Continuity of care.
b)
Delegation.
c)
Consultation.
d)
Supervision. Your Answer
e)
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86.
A client complains of an urticarial rash, itching, and dyspnea after receiving an intramuscular injection of penicillin G benzathine (Bicillin L-A). Which medication is the most appropriate primary intervention in this circumstance?
a)
Epinephrine (Adrenaline) 1:1000 to 0.3 mL IV.
b)
Diphenhydramine (Benadryl) 50 mg IV.
c)
Methylprednisolone sodium succinate (Solu- Medrol) 125 mg IV.
d)
Atropine sulfate (Atropine) 0.5 mg IV. Your Answer
e)
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87.
A client has a history of drinking 4 cups of coffee a day, does not exercise, and works a stressful job for 16 hours a day.Which nursing intervention will be most helpful to a middle-aged client experiencing insomnia?
a)
Instruct the client to initiate an exercise routine during the day.
b)
Educate the client on ways to adjust the sleep environment.
c)
Instruct the client on progressive relaxation techniques to be used just before bedtime.
d)
Instruct the client to decrease caffeine intake. Your Answer
e)
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88.
Ageism is a negative attitude toward older adults. To prevent ageism when working with older adult clients, the nurse should:
a)
Have knowledge about normal aging while maintaining contact with healthy, independent, older clients.
b)
Speak slowly with increased volume while providing educational pamphlets and brochures.
c)
Limit the client’s activities to prevent injury and promote rest.
d)
Involve the family in decision making and financial concerns. Your Answer
e)
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89.
A nurse with less than one year of experience complains to an experienced nurse,“The charge nurses are always checking up on me and evaluating my client care. I feel as if the charge nurses do not trust me to give good care to my clients.”Which response by the experienced nurse demonstrates an understanding of appropriate staff supervision?
a)
The charge nurses are accountable for supervising client care and client safety after delegating the client care assignments. The management staff may believe that they are being supportive by being available to you for help or advice.
b)
The charge nurses do that to everyone. It can be annoying sometimes, but I believe that they mean well.
c)
Why don’t you speak to the charge nurses about your perception of not being trusted to care for your clients? This is probably not their intention.
d)
You are a new nurse, and the charge nurses know that you do not have the experience and knowledge base yet to handle some of your assignments. Your Answer
e)
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90.
Acetaminophen (Tylenol) 240mg is ordered for an infant who weighs 12 pounds. The usual dose for an infant is 10–15mg per kilogram of body weight. A nurse should take which action?
a)
Give the medication as ordered
b)
Administer two-thirds of the prescribed dose
c)
Weigh the infant without clothes
d)
Discuss the order with the physician
e)
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91.
A client diagnosed with end-stage liver disease notices a decrease in ascites. The nurse should expect which finding to accompany the decrease in ascites?
a)
Increased urine output.
b)
Increased ankle edema.
c)
Shiny abdominal skin.
d)
Shallow respirations. Your Answer
e)
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92.
Which of the following statements best identifies the rationale for why the nurse reinforces the need for continued prenatal care throughout the pregnancy with an adolescent primigravid client?
a)
Pregnant adolescents are at high risk for pregnancy-induced hypertension.
b)
Gestational diabetes during pregnancy commonly develops in adolescents.
c)
Adolescents need additional instruction related to common discomforts.
d)
The father of the baby is rarely involved in the pregnancy. Your Answer
e)
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93.
A patient with an arterial ulcer over the left lateral malleolus complains of pain at the ulcer site. The nurse caring for this patient understands that the pain is caused most commonly by which of the following?
a)
Infection
b)
Exudate
c)
Ischemia
d)
Edema Your Answer
e)
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94.
A client is admitted to the hospital following a gunshot wound to the abdomen. A temporary colostomy is performed, and the physician writes an order to irrigate the proximal end of the colostomy. The nurse is aware that the proximal end of a doublebarrel colostomy is the end that:
a)
Is the opening on the client’s left side
b)
Is the opening on the distal end on the client’s left side
c)
Is the opening on the client’s right side
d)
Is the opening on the distal right side Your Answer
e)
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95.
When assessing a 34-year-old multigravid client at 34 weeks’ gestation experiencing moderate vaginal bleeding, which of the following would most likely alert the nurse that placenta previa is present?
a)
Painless vaginal bleeding.
b)
Uterine tetany.
c)
Intermittent pain with spotting.
d)
Dull lower back pain. Your Answer
e)
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96.
The physician has ordered prostaglandin gel to be administered vaginally to a newly admitted primigravid client. Which of the following indicate that the client has had a therapeutic response to the medication?
a)
Resting period of 2 minutes between contractions.
b)
Normal patellar and elbow reflexes for the past 2 hours.
c)
Softening of the cervix and beginning effacement.
d)
Leaking of clear amniotic fluid in small amounts. Your Answer
e)
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97.
A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?
a)
A client with AIDS being treated with Foscarnet
b)
A client with a fractured femur in a long leg cast
c)
A client with laryngeal cancer with a laryngetomy
d)
A client with diabetic ulcers to the left foot Your Answer
e)
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98.
The nurse is reviewing assessment data for a patient with a diagnosis of stage III Hodgkin’s disease. This diagnosis is most strongly supported by lymphatic involvement on both sides of the:
a)
blood–brain barrier.
b)
diaphragm.
c)
descending aorta.
d)
spinal column. Your Answer
e)
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99.
A 2-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:
a)
Will need to be repeated when the child is 4 years of age
b)
Is given to determine whether the child is susceptible to pertussis
c)
Is one of a series of injections that protects against dpt and Hib
d)
Is a one-time injection that protects against MMR and varicella Your Answer
e)
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100.
When assessing a 34-year-old multigravid client at 34 weeks’ gestation experiencing moderate vaginal bleeding, which of the following would most likely alert the nurse that placenta previa is present?
a)
Painless vaginal bleeding.
b)
Uterine tetany.
c)
Intermittent pain with spotting.
d)
Dull lower back pain. Your Answer
e)
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