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❍ A. Hypertension
102. The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventric-ular response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for:
❍ A. Peaked P wave
❍ B. Elevated ST segment
❍ C. Inverted T wave
❍D.Prolonged QT interval
103. Lidocaine is a medication frequently ordered for the client experiencing:
❍A. Atrial tachycardia
❍ B. Ventricular tachycardia
❍ C. Heart block
❍ D. Ventricular brachycardia
104. The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes:
❍ A. Rotating application sites
❍ B. Limiting applications to the chest
❍ C. Rubbing it into the skin
❍ D. Covering it with a gauze dressing
105. The physician prescribes captopril (Capoten) 25mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten?
❍ A. Tinnitus
❍ B. Persistent cough
❍C. Muscle weakness
❍ D. Diarrhea
106. The client is admitted with a BP of 210/100. Her doctor orders furosemide (Lasix) 40mg IV stat. How should the nurse administer the prescribed furosemide to this client?
❍ A. By giving it over 1–2 minutes
❍ B. By hanging it IV piggyback
❍ C. With normal saline only
❍ D. With a filter
107. The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin?
❍ C. Streptokinase
❍ D. Sodium warfarin
108. The nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
❍ A. The client receiving linear accelerator radiation therapy for lung cancer
❍ B. The client with a radium implant for cervical cancer
❍ C. The client who has just been administered soluble brachytherapy for thyroid cancer
❍ D. The client who returned from placement of iridium seeds for prostate cancer
109. The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
❍ A. The client with Cushing’s disease
❍ B. The client with diabetes
❍ C. The client with acromegaly
❍ D. The client with myxedema
110. The charge nurse witnesses the nursing assistant hitting the client in the long-term care facility. The nursing assistant can be charged with:
❍ A. Negligence
❍ B. Tort
❍ C. Assault
111. Which assignment should not be performed by the licensed practical nurse?
❍ A. Inserting a Foley catheter
❍ B. Discontinuing a nasogastric tube
❍ C. Obtaining a sputum specimen
❍ D. Starting a blood transfusion
112. The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
❍ A. Continue to monitor the vital signs
❍ B. Contact the physician
❍ C. Ask the client how he feels
❍ D. Ask the LPN to continue the post-op care
113. The nurse is caring for a client with B-Thalassemia major. Which therapy is used to treat Thalassemia?
❍ A. IV fluids
❍ B. Frequent blood transfusions
❍ C. Oxygen therapy
❍ D. Iron therapy
114. The child with a history of respiratory infections has an order for a sweat test to be done. Which finding would be positive for cystic fibrosis?
❍ A. A serum sodium of 135meq/L
❍ B. A sweat analysis of 69 meq/L
❍ C. A potassium of 4.5meq/L
❍ D. A calcium of 8mg/dL
115. The nurse caring for the child with a large meningomylocele is aware that the priority care for this client is to:
❍ A. Cover the defect with a moist, sterile saline gauze
❍ B. Place the infant in a supine position
❍ C. Feed the infant slowly
❍ D. Measure the intake and output
116. The nurse is caring for an infant admitted from the delivery room. Which finding should be reported?
❍ A. Acyanosis
❍ B. Acrocyanosis
❍ C. Halequin sign
❍ D. Absent femoral pulses
117. The nurse is aware that a common mode of transmission of clostridium difficile is:
❍ A. Use of unsterile surgical equipment
❍ B. Contamination with sputum
❍ C. Through the urinary catheter
❍ D. Contamination with stool
118. The nurse has just received the change of shift report. Which client should the nurse assess first?
❍ A. A client 2 hours post-lobectomy with 150ml drainage
❍ B. A client 2 days post-gastrectomy with scant drainage
❍ C. A client with pneumonia with an oral temperature of 102°F
❍ D. A client with a fractured hip in Buck’s traction
119. A client has been receiving cyanocobalamine (B12) injections for the past six weeks. Which laboratory finding indicates that the medication is hav-ing the desired effect?
❍ A. Neutrophil count of 60%
❍ B. Basophil count of 0.5%
❍ C. Monocyte count of 2%
❍ D. Reticulocyte count of 1%
120. The nurse is providing discharge teaching for a client taking dissulfiram (Antabuse). The nurse should instruct the client to avoid eating:
❍ A. Peanuts, dates, raisins
❍ B. Figs, chocolate, eggplant
❍ C. Pickles, salad with vinaigrette dressing, beef
❍ D. Milk, cottage cheese, ice cream
121. A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?
❍ A. The client is observed shaving only one side of his face.
❍ B. The client is unable to distinguish between two tactile stimuli presented simultaneously.
❍ C. The client is unable to complete a range of vision without turning his head side to side.
❍ D. The client is unable to carry out cognitive and motor activity at the same time.
122. A client with acute leukemia develops a low white blood cell count. In addition to the institution of isolation, the nurse should:
❍ A. Request that foods be served with disposable utensils
❍ B. Ask the client to wear a mask when visitors are present
❍ C. Prep IV sites with mild soap and water and alcohol
❍ D. Provide foods in sealed, single-serving packages
123. A new nursing graduate indicates in charting entries that he is a licensed registered nurse, although he has not yet received the results of the licensing exam. The graduate’s action can result in a charge of:
❍ A. Fraud
❍ B. Tort
❍ C. Malpractice
❍ D. Negligence
124. The nurse is assigning staff for the day. Which client should be assigned to the nursing assistant?
❍A. A 5-month-old with bronchiolitis ❍B.A 10-year-old 2-day post-appendectomy
❍ C. A 2-year-old with periorbital cellulitis
❍ D. A 1-year-old with a fractured tibia
125. During the change of shift, the oncoming nurse notes a discrepancy in the number of percocette listed and the number present in the narcotic drawer. The nurse’s first action should be to:
❍ A. Notify the hospital pharmacist ❍ B. Notify the nursing supervisor ❍ C. Notify the Board of Nursing
>❍ D. Notify the director of nursing
126. Due to a high census, it has been necessary for a number of clients to be transferred to other units within the hospital. Which client should be transferred to the postpartum unit?
❍ A. A 66-year-old female with gastroenteritis
❍ B. A 40-year-old female with a hysterectomy
❍ C. A 27-year-old male with severe depression
❍ D. A 28-year-old male with ulcerative colitis
127. A client with glomerulonephritis is placed on a low-sodium diet. Which of the following snacks is suitable for the client with sodium restriction?
❍ A. Peanut butter cookies
❍ B. Grilled cheese sandwich
❍ C. Cottage cheese and fruit
❍ D. Fresh peach
128. A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first?
❍ A. A client with a stroke with tube feedings
❍ B. A client with congestive heart failure complaining of night-time dyspnea
❍ C. A client with a thoracotomy six months ago
❍ D. A client with Parkinson’s disease
129. A client with cancer develops xerostomia. The nurse can help alleviate the discomfort the client is experiencing associated with xerostomia by:
❍ A. Offering hard candy
❍ B. Administering analgesic medications
❍ C. Splinting swollen joints
❍ D. Providing saliva substitute
130. The nurse is making assignments for the day. The staff consists of an RN, an LPN, and a nursing assistant. Which client could the nursing assistant care for?
❍ A. A client with Alzheimer’s disease ❍ B. A client with pneumonia
❍ C. A client with appendicitis
❍ D. A client with thrombophlebitis
131. The nurse is caring for a client with cerebral palsy. The nurse should pro-vide frequent rest periods because:
❍ A. Grimacing and writhing movements decrease with relaxation and rest.
❍ B. Hypoactive deep tendon reflexes become more active with rest.
❍ C. Stretch reflexes are increased with rest.
❍ D. Fine motor movements are improved by rest.
132. The physician has ordered a culture for the client with suspected gonor-rhea. The nurse should D size culture of:
❍ A. Blood
❍ B. Nasopharyngeal secretions
❍ C. Stool
❍ D. Genital secretions
133. Which of the following post-operative diets is most appropriate for the client who has had a hemorrhoidectomy?
❍ A. High-fiber
❍ B. Lactose free
❍ C. Bland
❍ D. Clear-liquid
134. The client delivered a 9-pound infant two days ago. An effective means of managing discomfort from an episiotomy is:
❍ A. Medicated suppository
❍ B. Taking showers
❍ C. Sitz baths
❍ D. Ice packs
135. The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:
❍ A. Take the blood pressure, pulse, and temperature
❍ B. Ask the client to rate his pain on a scale of 0–5
❍ C. Watch the client’s facial expression
❍ D. Ask the client if he is in pain
136. The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal pH 7.36, CO2 45, O2 84, bicarb 28. The nurse would assess the client to be in:
❍ A. Uncompensated acidosis
❍ B. Compensated alkalosis
❍ C. Compensated respiratory acidosis
❍ D. Uncompensated metabolic acidosis
137. The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion?
❍ A. The security guard
❍ B. The registered nurse
❍ C. The licensed practical nurse
❍ D. The nursing assistant
138. The physician has ordered sodium warfarin for the client with thrombophlebitis. The order should be entered to administer the medication at:
❍ A. 0900
❍ B. 1200
❍ C. 1700
❍ D. 2100
139. A 25-year-old male is brought to the emergency room with a piece of metal in his eye. The first action the nurse should take is:
❍ A. Use a magnet to remove the object.
❍ B. Rinse the eye thoroughly with saline.
❍ C. Cover both eyes with paper cups.
❍ D. Patch the affected eye.
140. To ensure safety while administering a nitroglycerine patch, the nurse should:
❍ A. Wear gloves while applying the patch.
❍ B. Shave the area where the patch will be applied.
❍ C. Wash the area thoroughly with soap and rinse with hot water.
❍ D. Apply the patch to the buttocks.
141. The client with Cirrhosis is scheduled for a pericentesis. Which instruc-tion should be given to the client before the exam?
❍ A. ―You will need to lay flat during the exam.‖
❍ B. ―You need to empty your bladder before the procedure.‖
❍ C. ―You will be asleep during the procedure.‖
❍ D. ―The doctor will inject a medication to treat your illness dur-ing the procedure.‖
142. The client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test?
❍ A. Atropine sulfate
❍ B. Furosemide
❍ C. Prostigmin
❍ D. Promethazine
143. The first exercise that should be performed by the client who had a mas-tectomy 1 day earlier is:
❍ A. Walking the hand up the wall
❍ B. Sweeping the floor
❍ C. Combing her hair
❍ D. Squeezing a ball
144. Which woman is not a candidate for RhoGam?
❍ A. A gravida 4 para 3 that is Rh negative with an Rh-positive baby
❍ B. A gravida 1 para 1 that is Rh negative with an Rh-positive baby
❍ C. A gravida II para 0 that is Rh negative admitted after a stillbirth delivery
❍ D. A gravida 4 para 2 that is Rh negative with an Rh-negative baby
145. Which laboratory test would be the least effective in making the diagno-sis of a myocardial infarction?
❍ A. AST
❍ B. Troponin
❍ C. CK-MB
❍ D. Myoglobin
146. The client with a myocardial infarction comes to the nurse’s station stat-ing that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using?
❍ A. Rationalization
❍ B. Denial
❍ C. Projection
❍ D. Conversion reaction
147. The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while the client is receiving TPN?
❍ A. Hemoglobin
❍ B. Creatinine
❍ C. Blood glucose
❍ D. White blood cell count
148. The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client’s ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge?
❍ A. ―I live by myself.‖
❍ B. ―I have trouble seeing.‖
❍ C. ―I have a cat in the house with me.‖
❍ D. ―I usually drive myself to the doctor.‖
149. The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is:
❍ A. To lower the blood glucose level ❍ B. To lower the uric acid level
❍ C. To lower the ammonia level
❍ D. To lower the creatinine level
150. The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should:
❍ A. Document the finding
❍ B. Send a specimen to the lab
❍ C. Strain the urine
❍ D. Obtain a complete blood count
151. The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?
❍ A. A 10-year-old with lacerations of the face
❍ B. A 15-year-old with sternal bruises
❍ C. A 34-year-old with a fractured femur
❍ D. A 50-year-old with dislocation of the elbow
152. Which of the following roommates would be most suitable for the client with myasthenia gravis?
❍ A. A client with hypothyroidism
❍ B. A client with Crohn’s disease
❍ C. A client with pylonephritis
❍ D. A client with bronchitis
153. The nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?
❍ A. The graduate places the client in a supine position to read the manometer.
❍ B. The graduate turns the stop-cock to the off position from the IV fluid to the client.
❍ C. The graduate instructs the client to perform the Valsalva maneuver during the CVP reading.
❍ D. The graduate notes the level at the top of the meniscus.
154. The nurse is working with another nurse and a patient care assistant. Which of the following clients should be assigned to the registered nurse?
❍ A. A client 2 days post-appendectomy
❍ B. A client 1 week post-thyroidectomy
❍ C. A client 3 days post-splenectomy ❍ D. A client 2 days post-thoracotomy
155. Which of the following roommates would be best for the client newly admitted with gastric resection?
❍ A. A client with Crohn’s disease
❍ B. A client with pneumonia
❍ C. A client with gastritis
❍ D. A client with phlebitis
156. The nurse is preparing a client for mammography. To prepare the client for a mammogram, the nurse should tell the client:
❍ A. To restrict her fat intake for 1 week before the test
❍ B. To omit creams, powders, or deodorants before the exam
❍ C. That mammography replaces the need for self-breast exams
❍ D. That mammography requires a higher dose of radiation than x-rays
157. Which action by the novice nurse indicates a need for further teaching?
❍ A. The nurse fails to wear gloves to remove a dressing.
❍ B. The nurse applies an oxygen saturation monitor to the ear lobe.
❍ C. The
158. The graduate nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority?
❍ A. Maintaining the client’s systolic blood pressure at 70mmHg or greater
❍ B. Maintaining the client’s urinary output greater than 300cc per hour
❍ C. Maintaining the client’s body temperature of greater than 33°F rectal
❍ D. Maintaining the client’s hematocrit at less than 30%
159. The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin?
❍ A. Increasing the infant’s fluid intake
❍ B. Maintaining the infant’s body temperature at 98.6°F
❍ C. Minimizing tactile stimulation ❍ D. Decreasing caloric intake
160. A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?
❍ A. A client with AIDS being treated with Foscarnet
❍ B. A client with a fractured femur in a long leg cast
❍ C. A client with laryngeal cancer with a laryngectomy
❍ D. A client with diabetic ulcers to the left foot
161. The charge nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should:
❍ A. Change the nursing assistant’s assignment
❍ B. Explore the interaction with the nursing assistant
❍ C. Discuss the matter with the client’s family
❍ D. Initiate a group session with the nursing assistant
162. The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the reg-istered nurse?
❍ A. Notify the police department as a robbery
❍ B. Report this behavior to the charge nurse
❍ C. Monitor the situation and note whether any items are missing
❍ D. Ignore the situation until items are reported missing nurse elevates the head of the bed to check the blood pressure.
❍ D. The nurse places the extremity in a dependent position to acquire a peripheral blood sample.
163. Which client can best be assigned to the newly licensed nurse?
❍ A. The client receiving chemotherapy
❍ B. The client post–coronary bypass ❍ C. The client with a TURP
❍ D. The client with diverticulitis
164. The nurse has an order for medication to be administered intrathecally. The nurse is aware that medications will be administered by which method?
❍ A. Intravenously
❍ B. Rectally
❍ C. Intramuscularly
❍ D. Into the cerebrospinal fluid
165. The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
❍ A. The client is at risk for evisceration.
❍ B. The client will require frequent dressing changes.
❍ C. The straps provide support for drains that are inserted into the incision.
❍ D. No sutures or clips are used to secure the incision.
166. A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate?
❍ A. Blood pressure every 15 minutes
❍ B. Insertion of a Levine tube
❍ C. Cardiac monitoring
❍ D. Dressing changes two times per day
167. The nurse is caring for a client with a diagnosis of hepatitis who is expe-riencing pruritis. Which would be the most appropriate nursing interven-tion?
❍ A. Suggest that the client take warm showers two times per day
❍ B. Add baby oil to the client’s bath water
❍ C. Apply powder to the client’s skin
❍ D. Suggest a hot-water rinse after bathing
168. The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough?
❍ A. Mask
❍ B. Gown
❍ C. Gloves
❍ D. Shoe covers
169. A client visits the clinic after the death of a parent. Which statement made by the client’s sister signifies abnormal grieving?
❍ A. ―My sister still has episodes of crying, and it’s been three months since Daddy died.‖
❍ B. ―Sally seems to have forgotten the bad things that Daddy did in his lifetime.‖
❍ C. ―She really had a hard time after Daddy’s funeral. She said that she had a sense of longing.‖
❍ D. ―She has not been saddened at all by Daddy’s death. She acts like nothing has happened.‖
170. The nurse is obtaining a history on an 80-year-old client. Which state-ment made by the client might indicate a potential for fluid and elec-trolyte imbalance?
❍ A. ―My skin is always so dry.‖
❍ B. ―I often use laxatives.‖
❍ C. ―I have always liked to drink a lot of ice tea.‖
❍ D. ―I sometimes have a problem with dribbling urine.‖
171. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client?
❍ A. Anger
❍ B. Mania
❍ C. Depression
❍ D. Psychosis
172. When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain?
❍ A. A history of radiation treatment in the neck region
❍ B. Any history of recent orthopedic surgery
❍ C. A history of minimal physical activity
❍ D. A history of the client’s food intake
173. The nurse on the 3–11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?
❍ A. Call the surgeon and ask him or her to see the client to clarify the information
❍ B. Explain the procedure and complications to the client
❍ C. Check in the physician’s progress notes to see if understand-ing has been documented
❍ D. Check with the client’s family to see if they understand the procedure fully
174. The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery?
❍ A. Hearing aid
❍ B. Contact lenses
❍ C. Wedding ring
❍ D. Artificial eye
175. A client is 2 days post-operative colon resection. After a coughing episode, the client’s wound eviscerates. Which nursing action is most appropriate?
❍ A. Reinsert the protruding organ and cover with 44s
❍ B. Cover the wound with a sterile 44 and ABD dressing
❍ C. Cover the wound with a sterile saline-soaked dressing
❍ D. Apply an abdominal binder and manual pressure to the wound
176. The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor:
❍ A. That cannot be assessed
❍ B. That is in situ
❍ C. With increasing lymph node involvement
❍ D. With distant metastasis
177. A client with cancer is to undergo an intravenous pyelogram. The nurse should:
❍ A. Force fluids 24 hours before the procedure
❍ B. Ask the client to void immediately before the study
❍ C. Hold medication that affects the central nervous system for 12 hours pre- and post-test
❍ D. Cover the client’s reproductive organs with an x-ray shield.
178. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for:
❍ A. Trendelenburg position
❍ B. Ice to the entire extremity
❍ C. Buck’s traction
❍ D. An abduction pillow
179. The nurse is performing an assessment on a client with possible perni-cious anemia. Which data would support this diagnosis?
❍ A. A weight loss of 10 pounds in 2 weeks
❍ B. Complaints of numbness and tingling in the extremities
❍ C. A red, beefy tongue
❍ D. A hemoglobin level of 12.0gm/dL
180. A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session?
❍ A. ―You will be sitting for the examination procedure.‖
❍ B. ―Portions of the procedure will cause pain or discomfort.‖
❍ C. ―You will be asleep during the procedure.‖
❍ D. ―You will not be able to drink fluids for 24 hours following the study.‖
181. The nurse is caring for a client scheduled for a surgical repair of a sacu-lar abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?
❍ A. Assessment of the client’s level of anxiety
❍ B. Evaluation of the client’s exercise tolerance
❍ C. Identification of peripheral pulses
❍ D. Assessment of bowel sounds and activity
182. A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The dysrhythmia most commonly seen during suc-tioning is:
❍ A. Bradycardia
❍ B. Tachycardia
❍ C. Premature ventricular beats
❍ D. Heart block
183. The nurse is performing discharge instruction to a client with an implantable defibrillator. What discharge instruction is essential?
❍ A. ―You cannot eat food prepared in a microwave.‖
❍ B. ―You should avoid moving the shoulder on the side of the pacemaker site for 6 weeks.‖
❍ C. ―You should use your cell phone on your right side.‖
❍ D. ―You will not be able to fly on a commercial airliner with the defibrillator in place.‖
184. Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:
❍ A. A cephalhematoma
❍ B. Molding
❍ C. Subdural hematoma
❍ D. Caput succedaneum
185. A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included in the plan?
❍ A. Closed chest drainage
❍ B. A tracheostomy
❍ C. A Swan Ganz Monitor
❍ D. Percussion vibration and drainage
186. The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis?
❍ A. Foul breath
❍ B. Dysphagia
❍ C. Diarrhea
❍ D. Chronic hiccups
187. The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is:
❍ A. The baby is dehydrated.
❍ B. The baby is hypoglycemic.
❍ C. The baby is allergic to the formula the mother is giving him.
❍ D. A loss of 10% is normal in the first week due to meconium stools.
188. The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet?
❍ A. Roasted chicken
❍ B. Noodles
❍ C. Cooked broccoli
❍ D. Custard
189. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period?
❍ A. Teaching how to irrigate the illeostomy
❍ B. Stopping electrolyte loss in the incisional area
❍ C. Encouraging a high-fiber diet
❍ D. Facilitating perineal wound drainage
190. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided?
❍ A. Bran
❍ B. Fresh peaches
❍ C. Cucumber salad
❍ D. Yeast rolls
191. A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining informa-tion regarding this diagnosis?
❍ A. ―Tell me about his pain.‖
❍ B. ―What does his vomit look like?‖
❍ C. ―Describe his usual diet.‖
❍ D. ―Have you noticed changes in his abdominal size?
192. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a seri-ous side effect of this drug?
❍ A. Uric acid of 5mg/dL
❍ B. Hematocrit of 33%
❍ C. WBC 2000 per cubic millimeter
❍ D. Platelets 150,000 per cubic millimeter
193. A client is admitted with a Ewing’s sarcoma. Which symptoms would be expected due to this tumor’s location?
❍ A. Hemiplegia
❍ B. Aphasia
❍ C. Nausea
❍ D. Bone pain
194. A infant weighs 7 pounds at birth. The expected weight by 1 year should be:
❍ A. 10 pounds
❍ B. 12 pounds
❍ C. 18 pounds
❍ D. 21 pounds
195. The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside?
❍ A. A pair of forceps
❍ B. A torque wrench
❍ C. A pair of wire cutters
❍ D. A screwdriver
196. The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client?
❍ A. Rest in bed after taking the medication for at least 30 minutes.
❍ B. Avoid rapid movements after taking the medication.
❍ C. Take the medication with water only.
❍ D. Allow at least 1 hour between taking the medicine and taking other medications.
197. The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority?
❍ A. Starting an IV
❍ B. Applying oxygen
❍ C. Obtaining blood gases
❍ D. Medicating the client for pain
198. A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse?
❍ A. Taking the vital signs
❍ B. Obtaining the permit
❍ C. Explaining the procedure
❍ D. Checking the lab work
199. A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following?
❍ A. Hypernatremia
❍ B. Hypokalemia
❍ C. Myelosuppression
❍ D. Leukocytosis
200. The nurse is caring for a client scheduled for removal of the pituitary gland. The nurse should be particularly alert for:
❍ A. Nasal congestion
❍ B. Abdominal tenderness
❍ C. Muscle tetany
❍ D. Oliguria