PNLE Exam 1
1. A 10 year old who has sustained a head injury is brought to the emergency department by his mother.
A diagnosis of a mild concussion is made. At the time of discharge, Nurse Ron should instruct the mother
to:
A. Withhold food and fluids for 24 hours.
B. Allow him to play outdoors with his friends.
C. Arrange for a follow up visit with the child’s primary care provider in one week.
D. Check for any change in responsiveness every two hours until the follow-up visit.
2. A male client has suffered a motor accident and is now suffering from hypovolemic shock. Nurse
Helen should frequency assess the client’s vital signs during the compensatory stage of shock, because:
A. Arteriolar constriction occurs
B. The cardiac workload decreases
C. Decreased contractility of the heart occurs
D. The parasympathetic nervous system is triggered
3. A paranoid male client with schizophrenia is losing weight, reluctant to eat, and voicing concerns about
being poisoned. The best intervention by nurse Dina would be to:
A. Allow the client to open canned or pre-packaged food
B. Restrict the client to his room until 2 lbs are gained
C. Have a staff member personally taste all of the client’s food
D. Tell the client the food has been x-rayed by the staff and is safe
4. One day the mother of a young adult confides to nurse Frida that she is very troubled by he child’s
emotional illness. The nurse’s most therapeutic initial response would be:
A. “You may be able to lessen your feelings of guilt by seeking counseling”
B. “It would be helpful if you become involved in volunteer work at this time”
C. “I recognize it’s hard to deal with this, but try to remember that this too shall pass”
D. “Joining a support group of parents who are coping with this problem can be quite helpful.
5. To check for wound hemorrhage after a client has had a surgery for the removal of a tumor in the neck,
nurse grace should:
A. Loosen an edge of the dressing and lift it to see the wound
B. Observe the dressing at the back of the neck for the presence of blood
C. Outline the blood as it appears on the dressing to observe any progression
D. Press gently around the incision to express accumulated blood from the wound
6. A 16-year-old primigravida arrives at the labor and birthing unit in her 38th week of gestation and
states that she is labor. To verify that the client is in true labor nurse Trina should:
A. Obtain sides for a fern test
B. Time any uterine contractions
C. Prepare her for a pelvic examination
D. Apply nitrazine paper to moist vaginal tissue
7. As part of the diagnostic workup for pulmonic stenosis, a child has cardiac catheterization. Nurse Julius
is aware that children with pulmonic stenosis have increased pressure:
A. In the pulmonary vein
B. In the pulmonary artery
C. On the left side of the heart
D. On the right side of the heart
,8. An obese client asks Nurse Julius how to lose weight. Before answering, the nurse should remember
that long-term weight loss occurs best when:
A. Eating patterns are altered
B. Fats are limited in the diet
C. Carbohydrates are regulated
D. Exercise is a major component
9. As a very anxious female client is talking to the nurse May, she starts crying. She appears to be upset
that she cannot control her crying. The most appropriate response by the nurse would be:
A. “Is talking about your problem upsetting you?”
B. “It is Ok to cry; I’ll just stay with you for now”
C. “You look upset; let’s talk about why you are crying.”
D. “Sometimes it helps to get it out of your system.”
10. A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following
I.V. fluids is given first?
A. Albumin
B. D5W
C. Lactated Ringer’s solution
D. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml
11. During the first 48 hours after a severe burn of 40% of the clients body surface, the nurse’s
assessment should include observations for water intoxication. Associated adaptations include:
A. Sooty-colored sputum
B. Frothy pink-tinged sputum
C. Twitching and disorientation
D. Urine output below 30ml per hour
12. After a muscle biopsy, nurse Willy should teach the client to:
A. Change the dressing as needed
B. Resume the usual diet as soon as desired
C. Bathe or shower according to preference
D. Expect a rise in body temperature for 48 hours
13. Before a client whose left hand has been amputated can be fitted for a prosthesis, nurse Joy is aware
that:
A. Arm and shoulder muscles must be developed
B. Shrinkage of the residual limb must be completed
C. Dexterity in the other extremity must be achieved
D. Full adjustment to the altered body image must have occurred
14. Nurse Cathy applies a fetal monitor to the abdomen of a client in active labor. When the client has
contractions, the nurse notes a 15 beat per minute deceleration of the fetal heart rate below the baseline
lasting 15 seconds. Nurse Cathy should:
A. Change the maternal position
B. Prepare for an immediate birth
C. Call the physician immediately
D. Obtain the client’s blood pressure
,15. A male client receiving prolonged steroid therapy complains of always being thirsty and urinating
frequently. The best initial action by the nurse would be to:
A. Perform a finger stick to test the client’s blood glucose level
B. Have the physician assess the client for an enlarged prostate
C. Obtain a urine specimen from the client for screening purposes
D. Assess the client’s lower extremities for the presence of pitting edema
16. Nurse Bea recognizes that a pacemaker is indicated when a client is experiencing:
A. Angina
B. Chest pain
C. Heart block
D. Tachycardia
17. When administering pancrelipase (Pancreases capsules) to child with cystic fibrosis, nurse Faith
knows they should be given:
A. With meals and snacks
B. Every three hours while awake
C. On awakening, following meals, and at bedtime
D. After each bowel movement and after postural draianage
18. A preterm neonate is receiving oxygen by an overhead hood. During the time the infant is under the
hood, it would be appropriate for nurse Gian to:
A. Hydrate the infant q15 min
B. Put a hat on the infant’s head
C. Keep the oxygen concentration consistent
D. Remove the infant q15 min for stimulation
19. A client’s sputum smears for acid fast bacilli (AFB) are positive, and transmission-based airborne
precautions are ordered. Nurse Kyle should instruct visitors to:
A. Limit contact with non-exposed family members
B. Avoid contact with any objects present in the client’s room
C. Wear an Ultra-Filter mask when they are in the client’s room
D. Put on a gown and gloves before going into the client’s room
20. A client with a head injury has a fixed, dilated right pupil; responds only to painful stimuli; and
exhibits decorticate posturing. Nurse Kate should recognize that these are signs of:
A. Meningeal irritation
B. Subdural hemorrhage
C. Medullary compression
D. Cerebral cortex compression
21. After a lateral crushing chest injury, obvious right-sided paradoxic motion of the client’s chest
demonstrates multiple rib fraactures, resulting in a flail chest. The complication the nurse should carefully
observe for would be:
A. Mediastinal shift
B. Tracheal laceration
C. Open pneumothorax
D. Pericardial tamponade
, 22. When planning care for a client at 30-weeks gestation, admitted to the hospital after vaginal bleeding
secondary to placenta previa, the nurse’s primary objective would be:
A. Provide a calm, quiet environment
B. Prepare the client for an immediate cesarean birth
C. Prevent situations that may stimulate the cervix or uterus
D. Ensure that the client has regular cervical examinations assess for labor
23. When planning discharge teaching for a young female client who has had a pneumothorax, it is
important that the nurse include the signs and symptoms of a pneumothorax and teach the client to seek
medical assistance if she experiences:
A. Substernal chest pain
B. Episodes of palpitation
C. Severe shortness of breath
D. Dizziness when standing up
24. After a laryngectomy, the most important equipment to place at the client’s bedside would be:
A. Suction equipment
B. Humidified oxygen
C. A nonelectric call bell
D. A cold-stream vaporizer
25. Nurse Oliver interviews a young female client with anorexia nervosa to obtain information for the
nursing history. The client’s history is likely to reveal a:
A. Strong desire to improve her body image
B. Close, supportive mother-daughter relationship
C. Satisfaction with and desire to maintain her present weight
D. Low level of achievement in school, with little concerns for grades
26. Nurse Bea should plan to assist a client with an obsessive-compulsive disorder to control the use of
ritualistic behavior by:
A. Providing repetitive activities that require little thought
B. Attempting to reduce or limit situations that increase anxiety
C. Getting the client involved with activities that will provide distraction
D. Suggesting that the client perform menial tasks to expiate feelings of guilt
27. A 2 ½ year old child undergoes a ventriculoperitoneal shunt revision. Before discharge, nurse John,
knowing the expected developmental behaviors for this age group, should tell the parents to call the
physician if the child:
A. Tries to copy all the father’s mannerisms
B. Talks incessantly regardless of the presence of others
C. Becomes fussy when frustrated and displays a shortened attention span
D. Frequently starts arguments with playmates by claiming all toys are “mine”
28. A urinary tract infection is a potential danger with an indwelling catheter. Nurse Gina can best plan to
avoid this complication by:
A. Assessing urine specific gravity
B. Maintaining the ordered hydration
C. Collecting a weekly urine specimen
D. Emptying the drainage bag frequently
1. A 10 year old who has sustained a head injury is brought to the emergency department by his mother.
A diagnosis of a mild concussion is made. At the time of discharge, Nurse Ron should instruct the mother
to:
A. Withhold food and fluids for 24 hours.
B. Allow him to play outdoors with his friends.
C. Arrange for a follow up visit with the child’s primary care provider in one week.
D. Check for any change in responsiveness every two hours until the follow-up visit.
2. A male client has suffered a motor accident and is now suffering from hypovolemic shock. Nurse
Helen should frequency assess the client’s vital signs during the compensatory stage of shock, because:
A. Arteriolar constriction occurs
B. The cardiac workload decreases
C. Decreased contractility of the heart occurs
D. The parasympathetic nervous system is triggered
3. A paranoid male client with schizophrenia is losing weight, reluctant to eat, and voicing concerns about
being poisoned. The best intervention by nurse Dina would be to:
A. Allow the client to open canned or pre-packaged food
B. Restrict the client to his room until 2 lbs are gained
C. Have a staff member personally taste all of the client’s food
D. Tell the client the food has been x-rayed by the staff and is safe
4. One day the mother of a young adult confides to nurse Frida that she is very troubled by he child’s
emotional illness. The nurse’s most therapeutic initial response would be:
A. “You may be able to lessen your feelings of guilt by seeking counseling”
B. “It would be helpful if you become involved in volunteer work at this time”
C. “I recognize it’s hard to deal with this, but try to remember that this too shall pass”
D. “Joining a support group of parents who are coping with this problem can be quite helpful.
5. To check for wound hemorrhage after a client has had a surgery for the removal of a tumor in the neck,
nurse grace should:
A. Loosen an edge of the dressing and lift it to see the wound
B. Observe the dressing at the back of the neck for the presence of blood
C. Outline the blood as it appears on the dressing to observe any progression
D. Press gently around the incision to express accumulated blood from the wound
6. A 16-year-old primigravida arrives at the labor and birthing unit in her 38th week of gestation and
states that she is labor. To verify that the client is in true labor nurse Trina should:
A. Obtain sides for a fern test
B. Time any uterine contractions
C. Prepare her for a pelvic examination
D. Apply nitrazine paper to moist vaginal tissue
7. As part of the diagnostic workup for pulmonic stenosis, a child has cardiac catheterization. Nurse Julius
is aware that children with pulmonic stenosis have increased pressure:
A. In the pulmonary vein
B. In the pulmonary artery
C. On the left side of the heart
D. On the right side of the heart
,8. An obese client asks Nurse Julius how to lose weight. Before answering, the nurse should remember
that long-term weight loss occurs best when:
A. Eating patterns are altered
B. Fats are limited in the diet
C. Carbohydrates are regulated
D. Exercise is a major component
9. As a very anxious female client is talking to the nurse May, she starts crying. She appears to be upset
that she cannot control her crying. The most appropriate response by the nurse would be:
A. “Is talking about your problem upsetting you?”
B. “It is Ok to cry; I’ll just stay with you for now”
C. “You look upset; let’s talk about why you are crying.”
D. “Sometimes it helps to get it out of your system.”
10. A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following
I.V. fluids is given first?
A. Albumin
B. D5W
C. Lactated Ringer’s solution
D. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml
11. During the first 48 hours after a severe burn of 40% of the clients body surface, the nurse’s
assessment should include observations for water intoxication. Associated adaptations include:
A. Sooty-colored sputum
B. Frothy pink-tinged sputum
C. Twitching and disorientation
D. Urine output below 30ml per hour
12. After a muscle biopsy, nurse Willy should teach the client to:
A. Change the dressing as needed
B. Resume the usual diet as soon as desired
C. Bathe or shower according to preference
D. Expect a rise in body temperature for 48 hours
13. Before a client whose left hand has been amputated can be fitted for a prosthesis, nurse Joy is aware
that:
A. Arm and shoulder muscles must be developed
B. Shrinkage of the residual limb must be completed
C. Dexterity in the other extremity must be achieved
D. Full adjustment to the altered body image must have occurred
14. Nurse Cathy applies a fetal monitor to the abdomen of a client in active labor. When the client has
contractions, the nurse notes a 15 beat per minute deceleration of the fetal heart rate below the baseline
lasting 15 seconds. Nurse Cathy should:
A. Change the maternal position
B. Prepare for an immediate birth
C. Call the physician immediately
D. Obtain the client’s blood pressure
,15. A male client receiving prolonged steroid therapy complains of always being thirsty and urinating
frequently. The best initial action by the nurse would be to:
A. Perform a finger stick to test the client’s blood glucose level
B. Have the physician assess the client for an enlarged prostate
C. Obtain a urine specimen from the client for screening purposes
D. Assess the client’s lower extremities for the presence of pitting edema
16. Nurse Bea recognizes that a pacemaker is indicated when a client is experiencing:
A. Angina
B. Chest pain
C. Heart block
D. Tachycardia
17. When administering pancrelipase (Pancreases capsules) to child with cystic fibrosis, nurse Faith
knows they should be given:
A. With meals and snacks
B. Every three hours while awake
C. On awakening, following meals, and at bedtime
D. After each bowel movement and after postural draianage
18. A preterm neonate is receiving oxygen by an overhead hood. During the time the infant is under the
hood, it would be appropriate for nurse Gian to:
A. Hydrate the infant q15 min
B. Put a hat on the infant’s head
C. Keep the oxygen concentration consistent
D. Remove the infant q15 min for stimulation
19. A client’s sputum smears for acid fast bacilli (AFB) are positive, and transmission-based airborne
precautions are ordered. Nurse Kyle should instruct visitors to:
A. Limit contact with non-exposed family members
B. Avoid contact with any objects present in the client’s room
C. Wear an Ultra-Filter mask when they are in the client’s room
D. Put on a gown and gloves before going into the client’s room
20. A client with a head injury has a fixed, dilated right pupil; responds only to painful stimuli; and
exhibits decorticate posturing. Nurse Kate should recognize that these are signs of:
A. Meningeal irritation
B. Subdural hemorrhage
C. Medullary compression
D. Cerebral cortex compression
21. After a lateral crushing chest injury, obvious right-sided paradoxic motion of the client’s chest
demonstrates multiple rib fraactures, resulting in a flail chest. The complication the nurse should carefully
observe for would be:
A. Mediastinal shift
B. Tracheal laceration
C. Open pneumothorax
D. Pericardial tamponade
, 22. When planning care for a client at 30-weeks gestation, admitted to the hospital after vaginal bleeding
secondary to placenta previa, the nurse’s primary objective would be:
A. Provide a calm, quiet environment
B. Prepare the client for an immediate cesarean birth
C. Prevent situations that may stimulate the cervix or uterus
D. Ensure that the client has regular cervical examinations assess for labor
23. When planning discharge teaching for a young female client who has had a pneumothorax, it is
important that the nurse include the signs and symptoms of a pneumothorax and teach the client to seek
medical assistance if she experiences:
A. Substernal chest pain
B. Episodes of palpitation
C. Severe shortness of breath
D. Dizziness when standing up
24. After a laryngectomy, the most important equipment to place at the client’s bedside would be:
A. Suction equipment
B. Humidified oxygen
C. A nonelectric call bell
D. A cold-stream vaporizer
25. Nurse Oliver interviews a young female client with anorexia nervosa to obtain information for the
nursing history. The client’s history is likely to reveal a:
A. Strong desire to improve her body image
B. Close, supportive mother-daughter relationship
C. Satisfaction with and desire to maintain her present weight
D. Low level of achievement in school, with little concerns for grades
26. Nurse Bea should plan to assist a client with an obsessive-compulsive disorder to control the use of
ritualistic behavior by:
A. Providing repetitive activities that require little thought
B. Attempting to reduce or limit situations that increase anxiety
C. Getting the client involved with activities that will provide distraction
D. Suggesting that the client perform menial tasks to expiate feelings of guilt
27. A 2 ½ year old child undergoes a ventriculoperitoneal shunt revision. Before discharge, nurse John,
knowing the expected developmental behaviors for this age group, should tell the parents to call the
physician if the child:
A. Tries to copy all the father’s mannerisms
B. Talks incessantly regardless of the presence of others
C. Becomes fussy when frustrated and displays a shortened attention span
D. Frequently starts arguments with playmates by claiming all toys are “mine”
28. A urinary tract infection is a potential danger with an indwelling catheter. Nurse Gina can best plan to
avoid this complication by:
A. Assessing urine specific gravity
B. Maintaining the ordered hydration
C. Collecting a weekly urine specimen
D. Emptying the drainage bag frequently
