Test Questions & Answers Guide 2027/2028
1. A nurse is instilling an otic solution into the adult client’s left ear. The nurse avoids doing which of the
following as part of this procedure?
Options:
A) Warming the solution to room temperature
B) Placing the client in a side-lying position with the ear facing up
C) Pulling the auricle backward and upward
D) Placing the tip of the dropper on the edge of the ear canal
Correct Answer is: D
Explanation : The dropper is not allowed to touch any object or any part of the client’s skin. The solution
is warmed before use. The client is placed on the side with the affected ear upward. The nurse pulls the
auricle backward and upward and instills the medication by holding the dropper about 1 cm above the
ear canal.
2. Levothyroxine sodium (Synthroid) is administered to a hospitalized child with congenital
hypothyroidism. The child vomits 10 minutes after administration of the dose. The most appropriate
nursing action is to:
Options:
A) Repeat the prescribed dose
B) Give two doses of the prescribed medicine on the next day
C) Contact the physician immediately
D) Hold the dose for today
Correct Answer is: A
Explanation : Levothyroxine sodium (Synthroid) is the medication of choice for hypothyroidism. The most
,significant factor adversely affecting the eventual intelligence of children born with congenital
hypothyroidism is inadequate treatment. Therefore, compliance with the medication regimen is
essential. If the infant or child vomits within 1 hour of taking medication, the dose should be
administered again.
3 A client diagnosed as having catatonic excitement has been pacing rapidly non-stop for several hours
and is not eating or drinking. The nurse recognizes that in this situation:
Options:
A) There is an urgent need for physical and medical control
B) There is an urgent need for restraint
C) There is a need to encourage verbalization of feelings
D) The client will soon become catatonic stuporous
Correct Answer is: A
Explanation : Catatonic excitement is manifested by a state of extreme psychomotor agitation. Clients
urgently require physical and medical control because they are often destructive and violent to others,
and their excitement can cause them to injure themselves or to collapse from complete exhaustion.
Options 2, 3, and 4 are incorrect.
4A 52-year-old male client is seen in the physician’s office for a physical examination after experiencing
unusual fatigue over the last several weeks. The client’s height is 5 feet, 8 inches, and weight is 220
pounds. Vital signs are temperature 98o F orally, pulse 86 beats per minute, and respirations 18 breaths
per minute. The blood pressure (BP) is 184/100 mmHg. Random blood glucose is 122 mg/dL. Which of
the following questions should the nurse ask the client first?
Options:
A) Do you exercise regularly?
B) Are you considering trying to lose weight?
C) Is there a history of diabetes mellitus in your family?
D) When was the last time you had your blood pressure checked?
,Correct Answer is: D
Explanation : The client is hypertensive, which is a known major modifiable risk factor for coronary artery
disease (CAD). The other major modifiable risk factors not exhibited by this client include smoking and
hypercholesterolemia. The client is over weight, which is a contributing risk factor. The client’s
nonmodifiable risk factors are age and gender. Because the client present with several risk factors, the
nurse places priority of attention on the client’s major modifiable risk factors.
5A client tells the nurse about a pattern of getting a strong urge to void, which of followed by
incontinence before the client can get to the bathroom. The nurse formulates which of the following
nursing diagnoses for this client?
Options:
A) Reflex Urinary Incontinence
B) Stress Urinary Incontinence
C) Urge Urinary Incontinence
D) Total Urinary Incontinence
Correct Answer is: C
Explanation : Urge incontinence occurs when the client has urinary incontinence soon after experiencing
urgency. Reflex incontinence occurs when incontinence occurs at rather predictable rimes that
correspond to when a certain bladder volume is attained. Stress incontinence occurs when the client
voids in increments that are less than 50 mL and has increased abdominal pressure. Total incontinence
occurs when there is an unpredictable and continuous loss of urine.
6A pregnant client is receiving rehabilitative services for alcohol abuse. The nurse would provide
supportive care by:
Options:
A) Encouraging the client to participate in care and identifying supportive strategies that are helpful
B) Avoiding discussion of the alcohol problem and recovery with the client
C) Minimizing communication with supportive family members
D) Encouraging the client to stop counseling once the infant is born
, Correct Answer is: A
Explanation : The nurse provides supportive care by encouraging the client to participate in care. The
nurse should not avoid discussing the client’s problem with the client, and communication with family
members in important. Counselling needs to continue after the infant is born.
7A client in the second trimester of pregnancy is being assessed at the health care clinic. The nurse
performing the assessment notes that the fetal heart rate is 100 beats per minute. Which nursing action
would be most appropriate?
Options:
A) Document the findings
B) Inform the mother that the assessment is normal and everything is fine
C) Notify the physician
D) Instruct the mother to return to the clinic in 1 week for reevaluation of the fetal heart rate
Correct Answer is: C
Explanation : The fetal heart rate should be between 120 to 160 beats per minute during pregnancy. A
fetal heart rate of 100 beats per minute would require that the physician be notified and the client be
further evaluated. Although the nurse would document the findings, the most appropriate nursing
action is to notify the physician. Options 2 and 4 are inaccurate nursing actions.
8A client is admitted to the hospital with a diagnosis of a leaking cerebral aneurysm and is scheduled for
surgery. The nurse implements which of the following during the preoperative period?
Options:
A) Encourages the client to be up at least twice per day
B) Allows the client to ambulate to the bathroom
C) Obtains a bedside commode for the client’s use
D) Places the client on strict bed rest