1. A client as an obsessive-compulsive disorder manifested by d. 1 tablet
the compulsion of handwashing. The nurse knows that
which of the following best describes the client’s need for 9. A client is admitted with suspected pneumonia. The chest
the repetitive acts of handwashing? xray reveals right middle and lower lunch consolidation.
a. Handwashing represents an attempt to During auscultation of the middle and lower lobes, which
manipulate the environment to make it more finding related to the pulmonary system would the nurse
comfortable. anticipate?
b. Handwashing externalizes the anxiety from a a. Inspiratory and expiratory wheezing
source within the bidy to an acceptable b. Decreased breath sounds
substitute outside the body. c. Tympanic hyperresonance
c. Handwashing assists the client to avoid d. Bronchovesicular sounds
undesirable thoughts and maintain some control
over guilt and anxiety. 10. Prior to electroconvulsive therapy (ECT) treatment, the
d. Handwashing helps to maintain the client in an patient receives an injection of a medication that reduces
active state to resist the effects of depression. secretions and protects against vagal bradycardia. Which
medication will you administer?
2. Following the vaginal delivery of an 11-pound baby, the a. Fluoxetine (Prozac)
nurse encourages the mother to breastfeed her newborn. b. Diphenhydramine (Bendaryl)
What is the primary purpose of this action? c. Atropine
a. To initiate the secretion of colostrum d. Epinephrine (Adrenalin)
b. To prevent neonatal hyperglycemia
c. To facilitate maternal-newborn interaction. 11. Patient with Alzheimer’s wandering in the hallway, which
d. To stimulate the uterus to contract. of the following should the nurse do?
a. Place in soft restraints
3. Client is admitted for a series of tests to verify the b. Place in a restraint chair in the nurse station
diagnosis of Cushing’s syndrome. Which of the following c. Place chemical restraints
assessment findings, if observed by the nurse, would d. Ask relative to stay with the patient
support this diagnosis?
a. Buffalo hump, hyperglycemia, and 12. Mrs. Robinson is a 38 year old woman being treated on an
hypernatremia outpatient basis for depression. Three months ago, her
b. Nervousness, tachycardia, and intolerance to husband revealed that he was having an affair with her
heat best friend and planned to file for divorce. Three weeks
c. Lethargy, weight gain and intolerance to cold ago, Mrs. Robinson’s 14 year old son (her only child)
d. Irritability, moon face and dry skin committed suicide on an inpatient psychiatric mental
health unit.in today’s therapy session, Mrs. Robinson
4. The nurse is caring for a child with acute renal failure who reveals to her nurse therapist that she is seriously
is in the intensive care unit. Which assessment finding contemplating suicide herself. What action should the
would indicate a sign of tonsialemia? therapist take?
a. Seizure a. Arrange for voluntary hospitalization, if the
b. ECG changes patient is willing
c. Dyspnea b. None, because people who speak of committing
d. Oliguria suicide seldom do it
c. Arrange for immediate hospitalization
5. In planning care for a 7-year-old client with Grave’s d. Request permission to speak with the husband
disease, what should the nurse do? to suggest marriage counseling
a. Encourage frequent rest periods
b. Encourage strenuous physical activity 13. A young adult client is scheduled for her first debridement
c. Administer thyroid hormone replacement daily of a second-degree burn of the left arm. It is most
d. Encourage a decrease caloric intake important for the nurse to take which of the following
actions?
6. The nurse recognizes which of the following as early sign of a. Assemble all necessary supplies and medications
lithium toxicity? b. Plan adequate time for the dressing change and
a. Restlessness, shuffling gait, involuntary muscle provide emotional support
movements c. Prepare the client and family for the pain the
b. Ataxia, confusion, seizures client will experience during and after the
c. Fine tremors, nausea, vomiting, diarrhea procedure
d. Elevated white blood cell count, orthostatic d. Limit visitation prior to the procedure to reduce
hypotension stress
7. The nurse is preparing to do a shift assessment on a client 14. The nurse is caring for a 67 years old man following a
who was admitted with an upper gastrointestinal bleed. cardiac catheterization. Two hours after the procedure, the
Which signs and symptoms would indicate active bleeding? nurse checks the patient’s insertion site in the antecubital
(Select all that apply) space, and the patient complains that his hand is numb.
a. Blood pressure 80/52 mmHg The nurse should:
b. Stool black and tarry a. Change the position of his hand
c. Hemoglobin 18g/dL b. Check his grip strength in both hands
d. Hematocrit 32% c. Notify the physician
e. Heart rate 128 beats/min d. Instruct the patient to exercise his fingers
f. Respirations 32 and shallow
8. Mr. Rollins is a known alcoholic who is brought to the 15. A client is to receive 1000mL of IV fluid over 10 hours. The
Emergency Department by the police. He has severe IV tubing set calibration is 15gtt/mL.how many drops per
ascites from his chronic alcoholism and the physician minute would the nurse give?
prescribes spironolactone 50mg orally now. The pharmacy a. 125gtt/min
dispenses spironolactone 25mg tablets. How many tablets b. 115gtt/min
do you give Mr. Rollins? c. 25gtt/min
a. 2 tablets d. 100gtt/min
b. 0.5 tablet
c. 4 tablets
, 16. Which intervention would the nurse anticipate for a 23. A 47 year old woman comes to the outpatient psychiatric
patient who is diagnosed with osteitisdeformans (Paget’s clinic for treatment of a fear of heights. The nurse knows
disease)? that phobias include:
a. Biphosphate and recommended doses if calcium a. Projection and displacement
and vitamin D b. Sublimation and internalization
b. Calcitonin and vitamin A supplements c. Rationalization and intellectualization
c. Estrogen and physical therapy d. Reaction formation and symbolization
d. A low-phosphorus and aerobic exercise
24. When teaching a client with myasthenia gravis about the
17. The nurse has just received report from the previous shift. management of the disease, what advice should the nurse
Which of the following clients should the nurse see first? give to the patient?
a. A client who is receiving a blood transfusion and a. Prevent structured, active exercises at least twice
complains of a dry mouth a week to prevent muscle atrophy
b. A client who is scheduled to receive heparin and b. Protect extremities from injury due to decreased
PTT is 70 seconds sensory perception
c. A client who is receiving ciprofloxacin (Cipro) and c. Arrange a routine to accommodate frequent
complains of fine macular rash visits to doctor’s office
d. A client who is receiving IV potassium and d. Perform necessary physically demanding
complains of burning at the IV site activities in the morning
18. Refer to the following list of drug indications, actions and 25. Client with paranoid thinks he is the son of the US
side effects. Which statement matches with simvastatin president. During interaction, he began to have
(Zocor)? hallucinations again, which action should be done by the
a. Lowers LDL level, increase HDL level, and slows nurse first?
progression of coronary artery disease. Adverse a. Ignore the hallucinations and proceed with the
effects may include myopathy, and interaction
hepatotoxicity b. Recognize the patient’s anxiety the proceed with
b. Lowers LDL, triglycerides, and apolipoprotein B the interaction
levels by blocking absorption in the c. Let the hallucinations be the center or topic of
gastrointestinal tract. Minimal adverse effects the interaction
have been identified. d. Ask for help
c. Lowers LDL cholesterol and VDL triglyceride
levels; raises HDL. May cause severe flushing 26. Your patient has been admitted in preterm labor and is
d. Reduces VLDL and increases HDL levels. receiving magnesium sulfate as a tocolytic. You prepare her
Gastrointestinal disturbances and an increased for the common side effects of this medication, which
risk of gallstones may occur. include drowsiness, lethargy, feeling warm and
a. Palpitations
19. A client is admitted with irritable bowel syndrome. The b. Muscular weakness
nurse would anticipate the client’s history to reflect which c. Tremulousness
of the following? d. Tachycardia
a. Pattern of alternating diarrhea and constipation
b. Chronic diarrhea stools occurring 10-12 times 27. A client has just been admitted after sustaining a second-
per day degree thermal injury to his right arm. Which of the
c. Diarrhea and vomiting with severe abdominal following nursing observations is most important to report
distention to the doctor?
d. Bloody stools with increased cramping after a. Pain around the periphery of the injury
eating b. Gastric pH less than 6.0
c. Increased edema of the right arm
20. The nurse is preparing to do postoperative assessment on d. An elevated hematocrit
a 5 year old child who has undergone tonsillectomy. During
the assessment, the nurse should be alert for bleeding.
Which signs and symptoms would indicate active bleeding? 28. Which drug would the nurse question?
(select all that apply) a. Prozac for client with bulimia
a. Drowsiness b. Seroquel for patient with undifferentiated
b. Dark red vomitus schizophrenia
c. Mouth breathing c. Olanzapine for OC
d. Frequent swallowing d. Buspar for client with anxiety
e. Frequent clearing of throat
29. A patient with Raynaud’s disease should be taught to avoid
21. The nurseis preparing to administer carvedilol (Coreg) to a which environmental factor?
patient. Which action should the nurse take first? a. High levels of smog
a. Find the results of the patient’s last blood b. Cold temperature
pressure measurement c. Exposure to secondhand smoke
b. Check the patency of the patient’s IV line d. Contact with pesticide
c. Assess the patient’s current pulse and blood
pressure 30. Which statement by a 7-year-old client would indicate an
d. Review the patient’s urine output as recorded by understanding of when to take medication (via inhaler)?
nurses on the previous shift. a. “After one puff, I can immediately give myself
another puff”
22. Who to see first? b. “I need to depress the top of the inhaler as I
a. Post colectomy with abdominal cramping begin to take a breath.”
b. Patient with post bone marrow transplant with c. “When I remove the inhaler, I can exhale through
diarrhea my mouth.”
c. Patient with cast 30 minutes ago with muscle d. “I need to inhale the medicine and then hold my
spasm breath to the count of 10.”
d. Patient chemo with n/v
31. To detect diabetic ketoacidosis (DKA), which of following
would you test for ketones?
the compulsion of handwashing. The nurse knows that
which of the following best describes the client’s need for 9. A client is admitted with suspected pneumonia. The chest
the repetitive acts of handwashing? xray reveals right middle and lower lunch consolidation.
a. Handwashing represents an attempt to During auscultation of the middle and lower lobes, which
manipulate the environment to make it more finding related to the pulmonary system would the nurse
comfortable. anticipate?
b. Handwashing externalizes the anxiety from a a. Inspiratory and expiratory wheezing
source within the bidy to an acceptable b. Decreased breath sounds
substitute outside the body. c. Tympanic hyperresonance
c. Handwashing assists the client to avoid d. Bronchovesicular sounds
undesirable thoughts and maintain some control
over guilt and anxiety. 10. Prior to electroconvulsive therapy (ECT) treatment, the
d. Handwashing helps to maintain the client in an patient receives an injection of a medication that reduces
active state to resist the effects of depression. secretions and protects against vagal bradycardia. Which
medication will you administer?
2. Following the vaginal delivery of an 11-pound baby, the a. Fluoxetine (Prozac)
nurse encourages the mother to breastfeed her newborn. b. Diphenhydramine (Bendaryl)
What is the primary purpose of this action? c. Atropine
a. To initiate the secretion of colostrum d. Epinephrine (Adrenalin)
b. To prevent neonatal hyperglycemia
c. To facilitate maternal-newborn interaction. 11. Patient with Alzheimer’s wandering in the hallway, which
d. To stimulate the uterus to contract. of the following should the nurse do?
a. Place in soft restraints
3. Client is admitted for a series of tests to verify the b. Place in a restraint chair in the nurse station
diagnosis of Cushing’s syndrome. Which of the following c. Place chemical restraints
assessment findings, if observed by the nurse, would d. Ask relative to stay with the patient
support this diagnosis?
a. Buffalo hump, hyperglycemia, and 12. Mrs. Robinson is a 38 year old woman being treated on an
hypernatremia outpatient basis for depression. Three months ago, her
b. Nervousness, tachycardia, and intolerance to husband revealed that he was having an affair with her
heat best friend and planned to file for divorce. Three weeks
c. Lethargy, weight gain and intolerance to cold ago, Mrs. Robinson’s 14 year old son (her only child)
d. Irritability, moon face and dry skin committed suicide on an inpatient psychiatric mental
health unit.in today’s therapy session, Mrs. Robinson
4. The nurse is caring for a child with acute renal failure who reveals to her nurse therapist that she is seriously
is in the intensive care unit. Which assessment finding contemplating suicide herself. What action should the
would indicate a sign of tonsialemia? therapist take?
a. Seizure a. Arrange for voluntary hospitalization, if the
b. ECG changes patient is willing
c. Dyspnea b. None, because people who speak of committing
d. Oliguria suicide seldom do it
c. Arrange for immediate hospitalization
5. In planning care for a 7-year-old client with Grave’s d. Request permission to speak with the husband
disease, what should the nurse do? to suggest marriage counseling
a. Encourage frequent rest periods
b. Encourage strenuous physical activity 13. A young adult client is scheduled for her first debridement
c. Administer thyroid hormone replacement daily of a second-degree burn of the left arm. It is most
d. Encourage a decrease caloric intake important for the nurse to take which of the following
actions?
6. The nurse recognizes which of the following as early sign of a. Assemble all necessary supplies and medications
lithium toxicity? b. Plan adequate time for the dressing change and
a. Restlessness, shuffling gait, involuntary muscle provide emotional support
movements c. Prepare the client and family for the pain the
b. Ataxia, confusion, seizures client will experience during and after the
c. Fine tremors, nausea, vomiting, diarrhea procedure
d. Elevated white blood cell count, orthostatic d. Limit visitation prior to the procedure to reduce
hypotension stress
7. The nurse is preparing to do a shift assessment on a client 14. The nurse is caring for a 67 years old man following a
who was admitted with an upper gastrointestinal bleed. cardiac catheterization. Two hours after the procedure, the
Which signs and symptoms would indicate active bleeding? nurse checks the patient’s insertion site in the antecubital
(Select all that apply) space, and the patient complains that his hand is numb.
a. Blood pressure 80/52 mmHg The nurse should:
b. Stool black and tarry a. Change the position of his hand
c. Hemoglobin 18g/dL b. Check his grip strength in both hands
d. Hematocrit 32% c. Notify the physician
e. Heart rate 128 beats/min d. Instruct the patient to exercise his fingers
f. Respirations 32 and shallow
8. Mr. Rollins is a known alcoholic who is brought to the 15. A client is to receive 1000mL of IV fluid over 10 hours. The
Emergency Department by the police. He has severe IV tubing set calibration is 15gtt/mL.how many drops per
ascites from his chronic alcoholism and the physician minute would the nurse give?
prescribes spironolactone 50mg orally now. The pharmacy a. 125gtt/min
dispenses spironolactone 25mg tablets. How many tablets b. 115gtt/min
do you give Mr. Rollins? c. 25gtt/min
a. 2 tablets d. 100gtt/min
b. 0.5 tablet
c. 4 tablets
, 16. Which intervention would the nurse anticipate for a 23. A 47 year old woman comes to the outpatient psychiatric
patient who is diagnosed with osteitisdeformans (Paget’s clinic for treatment of a fear of heights. The nurse knows
disease)? that phobias include:
a. Biphosphate and recommended doses if calcium a. Projection and displacement
and vitamin D b. Sublimation and internalization
b. Calcitonin and vitamin A supplements c. Rationalization and intellectualization
c. Estrogen and physical therapy d. Reaction formation and symbolization
d. A low-phosphorus and aerobic exercise
24. When teaching a client with myasthenia gravis about the
17. The nurse has just received report from the previous shift. management of the disease, what advice should the nurse
Which of the following clients should the nurse see first? give to the patient?
a. A client who is receiving a blood transfusion and a. Prevent structured, active exercises at least twice
complains of a dry mouth a week to prevent muscle atrophy
b. A client who is scheduled to receive heparin and b. Protect extremities from injury due to decreased
PTT is 70 seconds sensory perception
c. A client who is receiving ciprofloxacin (Cipro) and c. Arrange a routine to accommodate frequent
complains of fine macular rash visits to doctor’s office
d. A client who is receiving IV potassium and d. Perform necessary physically demanding
complains of burning at the IV site activities in the morning
18. Refer to the following list of drug indications, actions and 25. Client with paranoid thinks he is the son of the US
side effects. Which statement matches with simvastatin president. During interaction, he began to have
(Zocor)? hallucinations again, which action should be done by the
a. Lowers LDL level, increase HDL level, and slows nurse first?
progression of coronary artery disease. Adverse a. Ignore the hallucinations and proceed with the
effects may include myopathy, and interaction
hepatotoxicity b. Recognize the patient’s anxiety the proceed with
b. Lowers LDL, triglycerides, and apolipoprotein B the interaction
levels by blocking absorption in the c. Let the hallucinations be the center or topic of
gastrointestinal tract. Minimal adverse effects the interaction
have been identified. d. Ask for help
c. Lowers LDL cholesterol and VDL triglyceride
levels; raises HDL. May cause severe flushing 26. Your patient has been admitted in preterm labor and is
d. Reduces VLDL and increases HDL levels. receiving magnesium sulfate as a tocolytic. You prepare her
Gastrointestinal disturbances and an increased for the common side effects of this medication, which
risk of gallstones may occur. include drowsiness, lethargy, feeling warm and
a. Palpitations
19. A client is admitted with irritable bowel syndrome. The b. Muscular weakness
nurse would anticipate the client’s history to reflect which c. Tremulousness
of the following? d. Tachycardia
a. Pattern of alternating diarrhea and constipation
b. Chronic diarrhea stools occurring 10-12 times 27. A client has just been admitted after sustaining a second-
per day degree thermal injury to his right arm. Which of the
c. Diarrhea and vomiting with severe abdominal following nursing observations is most important to report
distention to the doctor?
d. Bloody stools with increased cramping after a. Pain around the periphery of the injury
eating b. Gastric pH less than 6.0
c. Increased edema of the right arm
20. The nurse is preparing to do postoperative assessment on d. An elevated hematocrit
a 5 year old child who has undergone tonsillectomy. During
the assessment, the nurse should be alert for bleeding.
Which signs and symptoms would indicate active bleeding? 28. Which drug would the nurse question?
(select all that apply) a. Prozac for client with bulimia
a. Drowsiness b. Seroquel for patient with undifferentiated
b. Dark red vomitus schizophrenia
c. Mouth breathing c. Olanzapine for OC
d. Frequent swallowing d. Buspar for client with anxiety
e. Frequent clearing of throat
29. A patient with Raynaud’s disease should be taught to avoid
21. The nurseis preparing to administer carvedilol (Coreg) to a which environmental factor?
patient. Which action should the nurse take first? a. High levels of smog
a. Find the results of the patient’s last blood b. Cold temperature
pressure measurement c. Exposure to secondhand smoke
b. Check the patency of the patient’s IV line d. Contact with pesticide
c. Assess the patient’s current pulse and blood
pressure 30. Which statement by a 7-year-old client would indicate an
d. Review the patient’s urine output as recorded by understanding of when to take medication (via inhaler)?
nurses on the previous shift. a. “After one puff, I can immediately give myself
another puff”
22. Who to see first? b. “I need to depress the top of the inhaler as I
a. Post colectomy with abdominal cramping begin to take a breath.”
b. Patient with post bone marrow transplant with c. “When I remove the inhaler, I can exhale through
diarrhea my mouth.”
c. Patient with cast 30 minutes ago with muscle d. “I need to inhale the medicine and then hold my
spasm breath to the count of 10.”
d. Patient chemo with n/v
31. To detect diabetic ketoacidosis (DKA), which of following
would you test for ketones?
