Practice Examination Two
Part One
You will have two hours and 30 minutes to complete Part One.
1. Shortly after being admitted to the coronary care unit with an
acute myocardial infarction (MI), a client reports midsternal chest
pain radiating down the left arm. The nurse notices that the client
is restless and slightly diaphoretic, and measures a temperature of
99. 6°F (37.6℃), a heart rate of 102 beats/minute; regular,
slightly labored respirations at 26 breaths/minute; and a blood
pressure of 150/90mmHg. Which nursing diagnosis takes highest
priority?
A. Risk for imbalanced body temperature.
B. Decreased cardiac output.
C. Anxiety.
D. Acute pain.
2. A client with hepatitis C develops liver failure and GI
hemorrhage. The blood products that would most likely bring about
hemostasis in the client are
A. whole blood and albumin.
B. platelets and packed red blood cells.
C. fresh frozen plasma and whole blood.
D. cryoprecipitate and fresh frozen plasma.
3. A client hospitalized with pneumonia has thick, tenacious
secretions. To help liquefy these secretions, the nurse should
A. turn the client every 2 hours.
B. elevate the head of the bed 30 degrees.
C. encourage increased fluid intake.
D. maintain a cool room temperature.
4. The client is to receive an IV infusion of 3000 mL of dextrose
and normal saline solution over 24 hours. The nurse observes that the
rate is 150mL/hour. If the solution runs continuously at this rate,
the infusion will be completed in
A. 12 hours.
B. 20 hours.
C. 24 hours.
D. 50 hours.
5. The nurse is teaching a psychiatric client about her
prescribed drugs, chlorpromazine and benztropine. Why is benztropine
administered?
A. To reduce psychotic symptoms.
B. To reduce extrapyramidal symptoms.
C. To control nausea and vomiting.
D. To relieve anxiety.
, 6. A female client has just been diagnosed with condylomata
acuminata (genital warts). What information is appropriate to tell
this client?
A. This condition puts her at a higher risk for cervical cancer;
therefore, she should have a Papanicolaou (Pap) test annually.
B. The most common treatment is metronidazole (Flagyl), which
should eradicate the problem within 7 to 10 days.
C. The potential for transmission to her sexual partner will be
eliminated if condoms are used every time they have sexual
intercourse.
D. The human papillomavirus (HPV), which causes condylomata
aeuminata, can't be transmitted during oral sex.
7. The nurse is caring for an elderly client who exhibits signs
of dementia. The most common cause of dementia in an elderly client
is
A. delirium.
B. depression.
C. excessive drug use.
D. Alzheimer's disease.
8. To assess a client's cranial nerve function, the nurse should
A. assess hand grip.
B. assess orientation to person, time, and place.
C. assess arm drifting.
D. assess gag reflex.
9. A client with hypotonic labor dysfunction is receiving
oxytoein augmentation. Her contractions become more frequent and
intense. Dilation progresses to 8 cm, but the fetal head remains at
station +1. The nurse notes a soft bulge just above the symphysis.
Which of the following actions is best?
A. Re-evaluate the fetal presentation.
B. Change the client's position.
C. Offer a narcotic analgesic.
D. Help the client urinate.
10. The nurse is caring for a neonate with congenital clubfoot.
After the final cast has been removed, which member of the health
care team will most likely help the neonate with leg and ankle
exercises and provide his parents with a home exercise regimen?
A. Occupational therapist.
B. Physical therapist.
C. Recreational therapist.
D. Speech therapist.
11. The nurse is administering total parenteral nutrition (TPN)
to a client who underwent surgery for gastric cancer. What is a major
complication of TPN?
, A. Hyperglycemia.
B. Extreme hunger.
C. Hypotension.
D. Hypoglycemia.
12. Which one of the following clients is at the greatest risk
for aspiration?
A. A stroke client with dysarthria.
B. An ambulatory client with Alzheimer's disease.
C. A 92-year-old client who needs help with activities of daily
living (ADLs).
D. A client with severe, deforming rheumatoid arthritis.
13. Drugs to treat acute anxiety are prescribed to a client
hospitalized for an acute myocardial infarction. The client is
reluctant to take anti-anxiety drugs. The nurse suspects that the
client is holding the drugs under his tongue and disposing of them
after she has left the room. What should the nurse do first?
A. Report her suspicions to the client's physician.
B. Talk to the client about his attitude toward the medications.
C. Search the client's room for evidence of the medications.
D. Tell the client that his behavior must stop for his own well-
being.
14. The nurse is providing care for a postoperative client who
has undergone a small bowel resection. The nurse may use an epidural
catheter for which of the following?
A. Antibiotic therapy.
B. Pain management.
C. Blood transfusion.
D. Anticoagulation.
15. The nurse is preparing to remove a previously applied topical
medication from a client. The rationale for removing previously
applied topical medications before applying new medications is to
A. decrease the possibility of absorption on the nurse's skin.
B. allow distribution of medication.
C. prevent soiling of the client's clothes.
D. avoid administering more than the prescribed dose.
16. The nurse is providing home care to a client with failing
vision due to macular degeneration. The nurse is concerned about the
client's safety. Which of the following activities would help to
lessen the client's risk of falling?
A. Arranging pieces of furniture close together so the client can
use them for guidance and support.
B. Encouraging the client to wear a medical identification
bracelet that describes the client’s visual deficit.
, C. Installing a flashing light to indicate when the phone or
doorbell is ringing.
D. Installing handrails in hallways, in bathrooms, and on steps.
17. The nurse is caring for a woman with phenylketonuria who
wants to start a family. Which of the following guidelines should the
nurse provide the woman?
A. Follow a low-phenylalanine diet before trying to conceive.
B. A low-phenylalanine diet is necessary only during the first
trimester.
C. Begin a low-phenylalanine diet when pregnancy is confirmed.
D. Dietary restrictions won't be necessary.
18. A high school student is referred to the school nurse for
suspected substance abuse. Following the nurse's assessment and
interventions, what would be the most desirable outcome?
A. The student discusses conflicts over drug use.
B. The student accepts a referral to a substance abuse counselor.
C. The student agrees to inform his parents of the problem.
D. The student reports increased comfort with making choices.
19. A client is taking spironolactone (Aldactone) to control her
hypertension. Her serum potassium level is 6 mEq/L. For this client,
the nurse's priority would be to assess her
A. neuromuscular function.
B. bowel sounds.
C. respiratory rate.
D. electrocardiogram (ECG) results.
20. The nurse is preparing a treatment plan for a client taking
oral corticosteroids to control severe chronic asthma. Which
statement indicates that the client understands his treatment plan?
A. "I should take corticosteroids on an empty stomach. "
B. "I need to take corticosteroids to help build up my immune
system. "
C. "I should stop taking corticosteroids if I haven't had an
asthma attack for 1 week. "
D. "I'll tell my other health care providers that I'm taking a
corticosteroid. "
21. Which finding is considered normal in a neonate during the
first few days after birth?
A. Weight loss of 25%.
B. Birth weight of 2,000 to 2,500 g.
C. Weight loss then return to birth weight.
D. Weight gain of 25%.
22. Which nursing action takes priority when admitting a elient
with right lower lobe pneumonia?
A. Elevating the head of the bed 45 to 90 degrees.
Part One
You will have two hours and 30 minutes to complete Part One.
1. Shortly after being admitted to the coronary care unit with an
acute myocardial infarction (MI), a client reports midsternal chest
pain radiating down the left arm. The nurse notices that the client
is restless and slightly diaphoretic, and measures a temperature of
99. 6°F (37.6℃), a heart rate of 102 beats/minute; regular,
slightly labored respirations at 26 breaths/minute; and a blood
pressure of 150/90mmHg. Which nursing diagnosis takes highest
priority?
A. Risk for imbalanced body temperature.
B. Decreased cardiac output.
C. Anxiety.
D. Acute pain.
2. A client with hepatitis C develops liver failure and GI
hemorrhage. The blood products that would most likely bring about
hemostasis in the client are
A. whole blood and albumin.
B. platelets and packed red blood cells.
C. fresh frozen plasma and whole blood.
D. cryoprecipitate and fresh frozen plasma.
3. A client hospitalized with pneumonia has thick, tenacious
secretions. To help liquefy these secretions, the nurse should
A. turn the client every 2 hours.
B. elevate the head of the bed 30 degrees.
C. encourage increased fluid intake.
D. maintain a cool room temperature.
4. The client is to receive an IV infusion of 3000 mL of dextrose
and normal saline solution over 24 hours. The nurse observes that the
rate is 150mL/hour. If the solution runs continuously at this rate,
the infusion will be completed in
A. 12 hours.
B. 20 hours.
C. 24 hours.
D. 50 hours.
5. The nurse is teaching a psychiatric client about her
prescribed drugs, chlorpromazine and benztropine. Why is benztropine
administered?
A. To reduce psychotic symptoms.
B. To reduce extrapyramidal symptoms.
C. To control nausea and vomiting.
D. To relieve anxiety.
, 6. A female client has just been diagnosed with condylomata
acuminata (genital warts). What information is appropriate to tell
this client?
A. This condition puts her at a higher risk for cervical cancer;
therefore, she should have a Papanicolaou (Pap) test annually.
B. The most common treatment is metronidazole (Flagyl), which
should eradicate the problem within 7 to 10 days.
C. The potential for transmission to her sexual partner will be
eliminated if condoms are used every time they have sexual
intercourse.
D. The human papillomavirus (HPV), which causes condylomata
aeuminata, can't be transmitted during oral sex.
7. The nurse is caring for an elderly client who exhibits signs
of dementia. The most common cause of dementia in an elderly client
is
A. delirium.
B. depression.
C. excessive drug use.
D. Alzheimer's disease.
8. To assess a client's cranial nerve function, the nurse should
A. assess hand grip.
B. assess orientation to person, time, and place.
C. assess arm drifting.
D. assess gag reflex.
9. A client with hypotonic labor dysfunction is receiving
oxytoein augmentation. Her contractions become more frequent and
intense. Dilation progresses to 8 cm, but the fetal head remains at
station +1. The nurse notes a soft bulge just above the symphysis.
Which of the following actions is best?
A. Re-evaluate the fetal presentation.
B. Change the client's position.
C. Offer a narcotic analgesic.
D. Help the client urinate.
10. The nurse is caring for a neonate with congenital clubfoot.
After the final cast has been removed, which member of the health
care team will most likely help the neonate with leg and ankle
exercises and provide his parents with a home exercise regimen?
A. Occupational therapist.
B. Physical therapist.
C. Recreational therapist.
D. Speech therapist.
11. The nurse is administering total parenteral nutrition (TPN)
to a client who underwent surgery for gastric cancer. What is a major
complication of TPN?
, A. Hyperglycemia.
B. Extreme hunger.
C. Hypotension.
D. Hypoglycemia.
12. Which one of the following clients is at the greatest risk
for aspiration?
A. A stroke client with dysarthria.
B. An ambulatory client with Alzheimer's disease.
C. A 92-year-old client who needs help with activities of daily
living (ADLs).
D. A client with severe, deforming rheumatoid arthritis.
13. Drugs to treat acute anxiety are prescribed to a client
hospitalized for an acute myocardial infarction. The client is
reluctant to take anti-anxiety drugs. The nurse suspects that the
client is holding the drugs under his tongue and disposing of them
after she has left the room. What should the nurse do first?
A. Report her suspicions to the client's physician.
B. Talk to the client about his attitude toward the medications.
C. Search the client's room for evidence of the medications.
D. Tell the client that his behavior must stop for his own well-
being.
14. The nurse is providing care for a postoperative client who
has undergone a small bowel resection. The nurse may use an epidural
catheter for which of the following?
A. Antibiotic therapy.
B. Pain management.
C. Blood transfusion.
D. Anticoagulation.
15. The nurse is preparing to remove a previously applied topical
medication from a client. The rationale for removing previously
applied topical medications before applying new medications is to
A. decrease the possibility of absorption on the nurse's skin.
B. allow distribution of medication.
C. prevent soiling of the client's clothes.
D. avoid administering more than the prescribed dose.
16. The nurse is providing home care to a client with failing
vision due to macular degeneration. The nurse is concerned about the
client's safety. Which of the following activities would help to
lessen the client's risk of falling?
A. Arranging pieces of furniture close together so the client can
use them for guidance and support.
B. Encouraging the client to wear a medical identification
bracelet that describes the client’s visual deficit.
, C. Installing a flashing light to indicate when the phone or
doorbell is ringing.
D. Installing handrails in hallways, in bathrooms, and on steps.
17. The nurse is caring for a woman with phenylketonuria who
wants to start a family. Which of the following guidelines should the
nurse provide the woman?
A. Follow a low-phenylalanine diet before trying to conceive.
B. A low-phenylalanine diet is necessary only during the first
trimester.
C. Begin a low-phenylalanine diet when pregnancy is confirmed.
D. Dietary restrictions won't be necessary.
18. A high school student is referred to the school nurse for
suspected substance abuse. Following the nurse's assessment and
interventions, what would be the most desirable outcome?
A. The student discusses conflicts over drug use.
B. The student accepts a referral to a substance abuse counselor.
C. The student agrees to inform his parents of the problem.
D. The student reports increased comfort with making choices.
19. A client is taking spironolactone (Aldactone) to control her
hypertension. Her serum potassium level is 6 mEq/L. For this client,
the nurse's priority would be to assess her
A. neuromuscular function.
B. bowel sounds.
C. respiratory rate.
D. electrocardiogram (ECG) results.
20. The nurse is preparing a treatment plan for a client taking
oral corticosteroids to control severe chronic asthma. Which
statement indicates that the client understands his treatment plan?
A. "I should take corticosteroids on an empty stomach. "
B. "I need to take corticosteroids to help build up my immune
system. "
C. "I should stop taking corticosteroids if I haven't had an
asthma attack for 1 week. "
D. "I'll tell my other health care providers that I'm taking a
corticosteroid. "
21. Which finding is considered normal in a neonate during the
first few days after birth?
A. Weight loss of 25%.
B. Birth weight of 2,000 to 2,500 g.
C. Weight loss then return to birth weight.
D. Weight gain of 25%.
22. Which nursing action takes priority when admitting a elient
with right lower lobe pneumonia?
A. Elevating the head of the bed 45 to 90 degrees.
