1. While assessing a client with diabetes mellitus, the ANS: C
nurse observes an absence of hair growth Signs of chronic arterial insufficiency include decreased hair growth in the legs and
on the client's legs. What additional assessment provides feet,
further data to support this absent or decreased pedal pulses, infection in the foot, poor wound healing,
finding? thickened nails,
a. Palpate for the presence of femoral pulses bilaterally. and a shiny appearance of the skin (C). Femoral pulses (A) should still be palpable
b. Assess for the presence of a positive Homan's sign. in the
c. Observe the appearance of the skin on the client's legs. diabetic with chronic arterial insufficiency. A positive Homan's sign is an indicator of
d. Watch the client's posture and balance during deep
ambulation vein thrombosis (B). (D) would probably not be affected significantly by chronic
arterial
insufficiency.
2. The healthcare provider prescribes 15 mg/kg of ANS: C
Streptomycin for an infant weighing 4 pounds. 4 lbs / 2.2 = 1.8 kg. 1.8 x 15 = 27 mg (C).
The drug is diluted in 25 ml of D5W to run over 8 hours. NOTE, the fact that the drug is diluted in 25 ml of D5W, is not relevant to the
How much Streptomycin will the calculation
infant receive? requested
a. 9 mg.
b. 18 mg.
c. 27 mg.
d. 36 mg
In assessing a client with preeclampsia who is receiving ANS: C
magnesium sulfate, the nurse The client is exhibiting symptoms of magnesium sulfate toxicity--decreased reflexes
determines that her deep tendon reflexes are 1+; (normal is
respiratory rate is 12 breaths/minute; +2), a low normal respiratory rate (normal is 12 to 20 breaths/min), a less than
urinary output is 90 ml in 4 hours; magnesium sulfate level average
is 9 mg/dl. Based on these urinary output (30 ml/hour is average), and a low magnesium sulfate level (normal is
findings, what intervention should the nurse implement? 4 to
a. Continue the magnesium sulfate infusion as prescribed. 8mg/dl). Based on these findings, the nurse should stop the infusion (C). (A) is
b. Decrease the magnesium sulfate infusion by one-half. contraindicated. (B) would not fully alleviate the magnesium sulfate toxicity
c. Stop the magnesium sulfate infusion immediately. symptoms. (D)
d. Administer calcium gluconate immediately. (the antagonist for magnesium sulfate) would be indicated if the respiratory rate
were less
than 12 breaths/minute.
A client is on a mechanical ventilator. Which client ANS: A
response indicates that the neuromuscular This medication causes paralysis (A) following intravenous injection. Peak effects
blocker tubocurarine chloride (Tubarine) is effective? persist for
a. The client's expremities are paralyzed. 35 to 60 minutes. (B and C) would not be possible if the medication is effective. The
b. The peripheral nerve stimulator causes twitching. Glasgow
c. The client clinches fist upon command. coma scale is used to evaluate the neurological status of the client and does not
d. The client's Glagow Coma Scale score is 14 evaluate the
effectiveness (D) of this medication.
5. An elderly female client comes to the clinic for a regular ANS: B
check-up. The client tells the nurse Frequent and/or large doses of acetaminophen can cause an increase in liver
that she has increased her daily doses of acetaminophen enzymes,
(Tylenol) for the past month to indicating possible liver damage (B). If the client reported unusual bleeding, or an
control joint pain. Based on this client's comment, what increase in
previous lab values should the nurse aspirin usage, it would be important for the nurse to assess for increased bleeding
compare with today's lab report? and monitor
a. Look at last quarter's hemoglobin and hematocrit, (A and/or C). (D) is not affected by increases in acetaminophen doses.
expecting an increase today due
to dehydration.
b. Look for an increase in today's LDH compared to the
previous one to assess
for possible liver damage. c. Expect to find an increase in
today's APTT as compared to last quarter's due
to bleeding.
d. Determine if there is a decrease in serum potassium
due to renal compromise.
,6. Aspirin is prescribed for a 9-year-old child with ANS: C
rheumatic fever to control the inflammatory Ringing in the ears (tinnitus) (C) is an important sign of aspirin overdosage and
process, promote comfort, and reduce fever. What should be
intervention is most important for the reported immediately. Though a tepid sponge bath may lower the child's
nurse to implement? temperature, the
a. Instruct the parents to hold the aspirin until the child has prescription for aspirin should not be held (A). Aspirin should be taken with at least
first had a tepid sponge eight
bath. ounces of water to completely wash the tablet into the stomach and to help prevent
b. Administer the aspirin with at least two ounces of water GI
or juice. discomfort (B). Yellow halos are associated with Digoxin toxicity, not aspirin (D)
c. Notify the healthcare provider if the child complains of
ringing in the ears.
d. Advise the parents to question the child about seeing
yellow halos around objects
7. Which signs or symptoms are characteristic of an adult ANS: D
client diagnosed with Cushing's The classic picture of Cushing's syndrome in the adult is central-type obesity with
syndrome? thin
a. Husky voice and complaints of hoarseness. extremities (D), along with a "buffalo hump" in the supraclavicular area, heavy trunk,
b. Warm, soft, moist, salmon-colored skin. and
c. Visible swelling of the neck, with no pain. thin fragile skin. The symptoms described in (A) are clinical manifestations of
d. Central-type obesity, with thin extremities. hypothyroidism, and in (B) of hyperthyroidism. (C) may indicate a goiter or a tumor
of the
thyroid gland
8. A charge nurse agrees to cover another nurse's ANS: D
assignment during a lunch break. Based on the A pulse oximeter reading of 90% indicates an arterial blood gas of less than 80 to
status report provided by the nurse who is leaving for 100 and
lunch, which client should be checked should be assessed immediately (D). (A) is an expected finding. (B) is not an
first by the charge nurse? The client unusual finding.
a. admitted yesterday with diabetec ketoacidosis whose (C) is an expected finding for this client.
blood glucose level
is now 195 mg/dl.
b. with an ileal conduit created two days ago with a scant
amount of blood in
the drainage pouch.
c. post-triple coronary bypass four days ago who has
serosanguinous drainage
in the chest tube.
d. with a pneumothorax secondary to a gunshot wound
with a current pulse
oximeter reading of 90%.
9. An outcome for treatment of peripheral vascular disease ANS: A
is, "The client will have decreased Client behaviors indicating that the expected outcome of, "decreased venous
venous congestion." What client behavior would indicate to congestion" has
the nurse that this outcome has been met would include elevating the legs, increasing walking time, and an
been met? observable
a. Avoids prolonged sitting or standing. decrease in edema of the lower extremities (A). (B and C) would be appropriate for
b. Avoids trauma and irritation to skin. outcomes
c. Wears protective shoes. for, "Attains or maintains tissue integrity." (D) would be an appropriate outcome for,
d. Quits smoking "Demonstrates an increase in arterial blood supply to extremities."
10. The healthcare provider performs a paracentesis on a ANS: D
client with ascites and 3 liters of fluid Life-threatening complications such as hypovolemia and sepsis can occur following
are removed. Which assessment parameter is most critical a
for the nurse to monitor following paracentesis, and measurement of vital signs (D) will provide assessment data that
the procedure? will help
a. Pedal pulses. detect the occurrence of such complications. (A) might be assessed to check for
b. Breath sounds. circulation in
c. Gag reflex. the lower extremities, but are not indicated for postparacentesis assessment.
d. Vital signs Reduction of (B)
may occur as the result of decreased fluid in the peritoneal cavity, but is a desired
outcome,
not a complication, of this procedure. (C) is not affected by a paracentesis
procedure
, 11. The nurse is administering sevelamer (RenaGel) ANS: B
during lunch to a client with end stage renal RenaGel is an intestinal phosphate binder and should be taken with meals to
disease (ESRD). The client asks the nurse to bring the prevent
medication later. The nurse should contributing to the hyperphosphatemia (B), associated with ESRD. (A, C, and D) are
describe which action of RenaGel as an explanation for not the
taking it with meals? therapeutic actions of RenaGel
a. Prevents indigestion associated with ingestion of spicy
foods.
b. Binds with phosphorus in foods and prevents
absorption.
c. Promotes stomach emptying and prevents gastric reflux.
d. Buffers hydrochloric acid and prevents gastric erosion
12. The nurse formulates a nursing diagnosis of, "High risk ANS: B
for ineffective airway clearance" for The client with myasthenia gravis experiences fatigue and muscle weakness, which
a client with myasthenia gravis. What is the most likely is likely
etiology for this nursing diagnosis? to result in a diminished cough effort (B). (A, C, and D) are not common in clients
a. Pain when coughing. with
b. Diminished cough effort. myasthenia gravis
c. Thick dry secretions.
d. Excessive inflammation
13. Following a CVA, the nurse assess that a client ANS: A
developed dysphagia, hypoactive bowel sounds The nurse should question the administration of a tube feeding into the GI tract (A),
and firm, distended abdomen. Which prescription for the which may result
client should the nurse question? in vomiting and aspiration, because the client is exhibiting signs of decreased
a. Continous tube feeding at 65 ml/hr via gastrostomy. peristalsis and
b. Total parenteral nutrition to be infused at 125 ml/hour. possible bowel obstruction. (B) provides a means of safely providing nutrition while
c. Nasogastric tube connected to low intermittent suction. GI tract function
d. Metoclopramide (Reglan) intermittent piggyback is inhibited. (C) benefits the client by reducing any excess gastric contents. (D)
helps stimulate
peristalsis
14. A client's telemetry monitor indicates the sudden onset ANS: D
of ventricular fibrillation. Which The client would have no palpable pulse (D), because ventricular fibrillation is
assessment finding should the nurse anticipate? chaotic
a. Bounding erratic pulse. electrical activity which does not produce cardiac output. This is a medical
b. Regularly irregular pulse. emergency which
c. Thready irregular pulse. requires immediate treatment to prevent death. (A, B, and C) are not typical of
d. No palpable pulse. pulses in
ventricular fibrillation.
5. In assessing a 70-year-old female client with ANS: D
Alzheimer's disease, the nurse notes that she has Angular stomatitis at the corners of the mouth is caused by poor dietary intake of
deep inflamed cracks at the corners of her mouth. What vitamin B2
intervention should the nurse include (riboflavin) and B6 (pyridoxine) (D). (A) would irritate them. Although a vitamin C
in this client's plan of care? supplement would be beneficial, (B) would burn the client's mouth and make her
a. Scrub the lesions with warm soapy water. less likely to
b. Encourage the client to drink orange juice for added eat. The client is not likely to have an infection, but if the cracks at the corners of her
vitamin C. mouth
c. Notify the healthcare provider of the need for oral do become infected, antibiotics in the form of a cream would be more appropriate
antibiotics. (C).
d. Ensure that the client gets adequate B vitamins in foods
or supplements
6. A young adult female client is seen in the emergency ANS: C
department for a minor injury following Even if the client has not been seriously hurt, she has been inconvenienced by the
a motor vehicle collision. She states she is very angry at incident and
the person who hit her car. What is it is appropriate for her to be angry. The nurse can clarify the client's feelings (C).
the best nursing response? (A) is a
a. "You are lucky to be alive. Be grateful no one was barrier to communication and shames the client for feeling angry. (B) changes the
killed." subject and
b. "I understand your car was not seriously damaged." does not address the client's anger--even minor car repairs can cause major
c. "You are upset that this incident has brought you here." inconveniences.
d. "Have you ever been in the emergency department (D) does not address the client's feelings and may bring up unpleasant memories
before?" the
client does not wish to share at this time.
nurse observes an absence of hair growth Signs of chronic arterial insufficiency include decreased hair growth in the legs and
on the client's legs. What additional assessment provides feet,
further data to support this absent or decreased pedal pulses, infection in the foot, poor wound healing,
finding? thickened nails,
a. Palpate for the presence of femoral pulses bilaterally. and a shiny appearance of the skin (C). Femoral pulses (A) should still be palpable
b. Assess for the presence of a positive Homan's sign. in the
c. Observe the appearance of the skin on the client's legs. diabetic with chronic arterial insufficiency. A positive Homan's sign is an indicator of
d. Watch the client's posture and balance during deep
ambulation vein thrombosis (B). (D) would probably not be affected significantly by chronic
arterial
insufficiency.
2. The healthcare provider prescribes 15 mg/kg of ANS: C
Streptomycin for an infant weighing 4 pounds. 4 lbs / 2.2 = 1.8 kg. 1.8 x 15 = 27 mg (C).
The drug is diluted in 25 ml of D5W to run over 8 hours. NOTE, the fact that the drug is diluted in 25 ml of D5W, is not relevant to the
How much Streptomycin will the calculation
infant receive? requested
a. 9 mg.
b. 18 mg.
c. 27 mg.
d. 36 mg
In assessing a client with preeclampsia who is receiving ANS: C
magnesium sulfate, the nurse The client is exhibiting symptoms of magnesium sulfate toxicity--decreased reflexes
determines that her deep tendon reflexes are 1+; (normal is
respiratory rate is 12 breaths/minute; +2), a low normal respiratory rate (normal is 12 to 20 breaths/min), a less than
urinary output is 90 ml in 4 hours; magnesium sulfate level average
is 9 mg/dl. Based on these urinary output (30 ml/hour is average), and a low magnesium sulfate level (normal is
findings, what intervention should the nurse implement? 4 to
a. Continue the magnesium sulfate infusion as prescribed. 8mg/dl). Based on these findings, the nurse should stop the infusion (C). (A) is
b. Decrease the magnesium sulfate infusion by one-half. contraindicated. (B) would not fully alleviate the magnesium sulfate toxicity
c. Stop the magnesium sulfate infusion immediately. symptoms. (D)
d. Administer calcium gluconate immediately. (the antagonist for magnesium sulfate) would be indicated if the respiratory rate
were less
than 12 breaths/minute.
A client is on a mechanical ventilator. Which client ANS: A
response indicates that the neuromuscular This medication causes paralysis (A) following intravenous injection. Peak effects
blocker tubocurarine chloride (Tubarine) is effective? persist for
a. The client's expremities are paralyzed. 35 to 60 minutes. (B and C) would not be possible if the medication is effective. The
b. The peripheral nerve stimulator causes twitching. Glasgow
c. The client clinches fist upon command. coma scale is used to evaluate the neurological status of the client and does not
d. The client's Glagow Coma Scale score is 14 evaluate the
effectiveness (D) of this medication.
5. An elderly female client comes to the clinic for a regular ANS: B
check-up. The client tells the nurse Frequent and/or large doses of acetaminophen can cause an increase in liver
that she has increased her daily doses of acetaminophen enzymes,
(Tylenol) for the past month to indicating possible liver damage (B). If the client reported unusual bleeding, or an
control joint pain. Based on this client's comment, what increase in
previous lab values should the nurse aspirin usage, it would be important for the nurse to assess for increased bleeding
compare with today's lab report? and monitor
a. Look at last quarter's hemoglobin and hematocrit, (A and/or C). (D) is not affected by increases in acetaminophen doses.
expecting an increase today due
to dehydration.
b. Look for an increase in today's LDH compared to the
previous one to assess
for possible liver damage. c. Expect to find an increase in
today's APTT as compared to last quarter's due
to bleeding.
d. Determine if there is a decrease in serum potassium
due to renal compromise.
,6. Aspirin is prescribed for a 9-year-old child with ANS: C
rheumatic fever to control the inflammatory Ringing in the ears (tinnitus) (C) is an important sign of aspirin overdosage and
process, promote comfort, and reduce fever. What should be
intervention is most important for the reported immediately. Though a tepid sponge bath may lower the child's
nurse to implement? temperature, the
a. Instruct the parents to hold the aspirin until the child has prescription for aspirin should not be held (A). Aspirin should be taken with at least
first had a tepid sponge eight
bath. ounces of water to completely wash the tablet into the stomach and to help prevent
b. Administer the aspirin with at least two ounces of water GI
or juice. discomfort (B). Yellow halos are associated with Digoxin toxicity, not aspirin (D)
c. Notify the healthcare provider if the child complains of
ringing in the ears.
d. Advise the parents to question the child about seeing
yellow halos around objects
7. Which signs or symptoms are characteristic of an adult ANS: D
client diagnosed with Cushing's The classic picture of Cushing's syndrome in the adult is central-type obesity with
syndrome? thin
a. Husky voice and complaints of hoarseness. extremities (D), along with a "buffalo hump" in the supraclavicular area, heavy trunk,
b. Warm, soft, moist, salmon-colored skin. and
c. Visible swelling of the neck, with no pain. thin fragile skin. The symptoms described in (A) are clinical manifestations of
d. Central-type obesity, with thin extremities. hypothyroidism, and in (B) of hyperthyroidism. (C) may indicate a goiter or a tumor
of the
thyroid gland
8. A charge nurse agrees to cover another nurse's ANS: D
assignment during a lunch break. Based on the A pulse oximeter reading of 90% indicates an arterial blood gas of less than 80 to
status report provided by the nurse who is leaving for 100 and
lunch, which client should be checked should be assessed immediately (D). (A) is an expected finding. (B) is not an
first by the charge nurse? The client unusual finding.
a. admitted yesterday with diabetec ketoacidosis whose (C) is an expected finding for this client.
blood glucose level
is now 195 mg/dl.
b. with an ileal conduit created two days ago with a scant
amount of blood in
the drainage pouch.
c. post-triple coronary bypass four days ago who has
serosanguinous drainage
in the chest tube.
d. with a pneumothorax secondary to a gunshot wound
with a current pulse
oximeter reading of 90%.
9. An outcome for treatment of peripheral vascular disease ANS: A
is, "The client will have decreased Client behaviors indicating that the expected outcome of, "decreased venous
venous congestion." What client behavior would indicate to congestion" has
the nurse that this outcome has been met would include elevating the legs, increasing walking time, and an
been met? observable
a. Avoids prolonged sitting or standing. decrease in edema of the lower extremities (A). (B and C) would be appropriate for
b. Avoids trauma and irritation to skin. outcomes
c. Wears protective shoes. for, "Attains or maintains tissue integrity." (D) would be an appropriate outcome for,
d. Quits smoking "Demonstrates an increase in arterial blood supply to extremities."
10. The healthcare provider performs a paracentesis on a ANS: D
client with ascites and 3 liters of fluid Life-threatening complications such as hypovolemia and sepsis can occur following
are removed. Which assessment parameter is most critical a
for the nurse to monitor following paracentesis, and measurement of vital signs (D) will provide assessment data that
the procedure? will help
a. Pedal pulses. detect the occurrence of such complications. (A) might be assessed to check for
b. Breath sounds. circulation in
c. Gag reflex. the lower extremities, but are not indicated for postparacentesis assessment.
d. Vital signs Reduction of (B)
may occur as the result of decreased fluid in the peritoneal cavity, but is a desired
outcome,
not a complication, of this procedure. (C) is not affected by a paracentesis
procedure
, 11. The nurse is administering sevelamer (RenaGel) ANS: B
during lunch to a client with end stage renal RenaGel is an intestinal phosphate binder and should be taken with meals to
disease (ESRD). The client asks the nurse to bring the prevent
medication later. The nurse should contributing to the hyperphosphatemia (B), associated with ESRD. (A, C, and D) are
describe which action of RenaGel as an explanation for not the
taking it with meals? therapeutic actions of RenaGel
a. Prevents indigestion associated with ingestion of spicy
foods.
b. Binds with phosphorus in foods and prevents
absorption.
c. Promotes stomach emptying and prevents gastric reflux.
d. Buffers hydrochloric acid and prevents gastric erosion
12. The nurse formulates a nursing diagnosis of, "High risk ANS: B
for ineffective airway clearance" for The client with myasthenia gravis experiences fatigue and muscle weakness, which
a client with myasthenia gravis. What is the most likely is likely
etiology for this nursing diagnosis? to result in a diminished cough effort (B). (A, C, and D) are not common in clients
a. Pain when coughing. with
b. Diminished cough effort. myasthenia gravis
c. Thick dry secretions.
d. Excessive inflammation
13. Following a CVA, the nurse assess that a client ANS: A
developed dysphagia, hypoactive bowel sounds The nurse should question the administration of a tube feeding into the GI tract (A),
and firm, distended abdomen. Which prescription for the which may result
client should the nurse question? in vomiting and aspiration, because the client is exhibiting signs of decreased
a. Continous tube feeding at 65 ml/hr via gastrostomy. peristalsis and
b. Total parenteral nutrition to be infused at 125 ml/hour. possible bowel obstruction. (B) provides a means of safely providing nutrition while
c. Nasogastric tube connected to low intermittent suction. GI tract function
d. Metoclopramide (Reglan) intermittent piggyback is inhibited. (C) benefits the client by reducing any excess gastric contents. (D)
helps stimulate
peristalsis
14. A client's telemetry monitor indicates the sudden onset ANS: D
of ventricular fibrillation. Which The client would have no palpable pulse (D), because ventricular fibrillation is
assessment finding should the nurse anticipate? chaotic
a. Bounding erratic pulse. electrical activity which does not produce cardiac output. This is a medical
b. Regularly irregular pulse. emergency which
c. Thready irregular pulse. requires immediate treatment to prevent death. (A, B, and C) are not typical of
d. No palpable pulse. pulses in
ventricular fibrillation.
5. In assessing a 70-year-old female client with ANS: D
Alzheimer's disease, the nurse notes that she has Angular stomatitis at the corners of the mouth is caused by poor dietary intake of
deep inflamed cracks at the corners of her mouth. What vitamin B2
intervention should the nurse include (riboflavin) and B6 (pyridoxine) (D). (A) would irritate them. Although a vitamin C
in this client's plan of care? supplement would be beneficial, (B) would burn the client's mouth and make her
a. Scrub the lesions with warm soapy water. less likely to
b. Encourage the client to drink orange juice for added eat. The client is not likely to have an infection, but if the cracks at the corners of her
vitamin C. mouth
c. Notify the healthcare provider of the need for oral do become infected, antibiotics in the form of a cream would be more appropriate
antibiotics. (C).
d. Ensure that the client gets adequate B vitamins in foods
or supplements
6. A young adult female client is seen in the emergency ANS: C
department for a minor injury following Even if the client has not been seriously hurt, she has been inconvenienced by the
a motor vehicle collision. She states she is very angry at incident and
the person who hit her car. What is it is appropriate for her to be angry. The nurse can clarify the client's feelings (C).
the best nursing response? (A) is a
a. "You are lucky to be alive. Be grateful no one was barrier to communication and shames the client for feeling angry. (B) changes the
killed." subject and
b. "I understand your car was not seriously damaged." does not address the client's anger--even minor car repairs can cause major
c. "You are upset that this incident has brought you here." inconveniences.
d. "Have you ever been in the emergency department (D) does not address the client's feelings and may bring up unpleasant memories
before?" the
client does not wish to share at this time.
