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1- Which of the following anatomical terms best describes the motion in the picture above: a- Adduction b- Abduction c- Supination d- Pronation 2- Which of the above locations represents the best sites to inspect chest retractions in a child with lower respiratory tract disorder: a- A&B b- B&C c- C&D 1 d- D&E 3- Your patient's finger stick blood sugar at 07:30 is 300 mg/dl, according to the following sliding scale; how many unites you would give your patient: a- 6 i.u b- 8 i.u c- 14 i.u d- 18 i.u 4- The nurse is caring for a diabetic child whose 11 a.m. blood glucose monitoring check is 269 mg/dL. The physician orders the following coverage schedule: 150 to 200 mg/dL-2 units of Humulin R 201 to 250 mg/dL-4 units of Humulin R 251 to 300 mg/dL-6 units of Humulin R 301 to 350 mg/dL-8 units of Humulin R 351 to 399 mg/dL-I0 units of Humulin R Over 400 mg/dL-call the physician According to the coverage schedule; how many unites you would give your patient: a- 4 units b- 6 units 2 c- 8 units d- 10 units 5- The following syringe contains morphine sulphate in a concentration of 2 mg/cc, how much total morphine this syringe contains: a- 0.5 mg b- I mg c- 2 mg d- 4 mg 6- The following syringe contains 2 gm of morphine sulphate, how many grams are there in 1 ml: a- 0.5 gm b- 1 gm c- 2 gm d- 4 gm 7- The following condition may develop in females due to an increase in the production of which of the following hormones: a- Androgens b- Progesterone c- Estrogen d- Growth 8- What is the name of the process of movement of a dissolved substance (solutes) from an area of high concentration to an area of low concentration: 3 a- Effusion b- Diffusion c- Emulsion d- Excretion 4 9- Which of the following is the incision site for an open cholecystectomy operation: a- 1 b- 2 c- 3 d- 4 10- Which of the following is the incision site for an open gastrectomy operation: a- 1 b- 2 c- 3 d- 4 11- Which of the following is the incision site for surgical appendectomy operation: a- A b- B c- C d- D 5 6 12- What is the most probable type of arrhythmia in the following ECG (lead II): a- Atrial fibrillation b- Atrial flutter c- Ventricular fibrillation d- Supra-ventricular fibrillation 13- What is the most probable type of arrhythmia in the following ECG (lead VI): a- Atrial fibrillation b- Atrial flutter c- Ventricular tachycardia d- Supra-ventricular fibrillation 14- The following picture suggests that the patient has: a- Renal disease b- Hepatic disease c- Pulmonary disease d- Cerebral disease 15- A patient with colostomy, what type of stool you should suspect: a- With a sigmoid colostomy, the feces are formed b- With a descending colostomy, the feces are semiformed c- With a transverse colostomy, the feces are unformed 7 d- With an ascending colostomy, the feces are fluid 8 16- When a patient is vomiting postoperatively, which of the following positions would the nurse use to protect the patient? a- c- b- d- 17 - The following picture represents the pain distribution of which nerve affection: a- C2 b- C6 c- T3 d- T6 18- On assessing the client's pressure ulcer (see photo), the nurse would document this as which stage: a- Stage I b- Stage II c- Stage III d- Stage IV 9 10 19- The following picture represents an auto immune disease known as: a- Psoriasis b- Systemic Lupus Erythematosus c- Molluscum Contagiosum d- Eczema 20- What is the name of the equipment this picture shows? a- Oropharyngeal airway (OPA) b- Nasopharyngeal airway (NPA) c- Laryngeal mask airway (LMA) d- Urinary catheter 21- A client is being prepared for a thoracentesis. A nurse assists the client to which position for the procedure: a- Lying in bed on the affected side b- Lying in bed on the unaffected side c- Sims' position with the head of the bed flat d- Prone with the head turned to the side and supported by a pillow 11 22- A nurse is preparing to insert a nasogastric tube into a client. The nurse places the client in which position for insertion: a- Right side b- Low Fowler's c- High Fowler's d- Supine with the head flat 23- A nurse develops a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan will be included: a- Out-of-bed activities as desired b- Bedrest with the affected extremity kept flat c- Bedrest with elevation of the affected extremity d- Bedrest with the affected extremity in a dependent position 24- A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is transferred to the delivery room table, and the nurse places the client in the: a- Trendelenburg's position with the legs in stirrups b- Semi-Fowler position with a pillow under the knees c- Prone position with the legs separated and elevated d- Supine position with a wedge under the right hip 25- The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client: a- Side-lying on the operative side b- On the nonoperative side with the legs abducted 12 c- Side-lying with the affected leg internally rotated d- Side-lying with the affected leg externally rotated 26- Which of the following is the best position to increase the brain perfusion (cerebral perfusion): a- Prone b- Supine c- Semi- Fowler's d- Trendelenburg's 27- A nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse places the client in which position: a- Left Sims' position b- Right Sims' position c- On the left side of the body, with the head of the bed elevated 45 degrees d- On the right side of the body, with the head of the bed elevated 45 degrees 28- A client has just returned to a nursing unit after an above-knee amputation of the right leg. A nurse places the client in which position: a- Prone b- Reverse Trendelenburg's c- Supine, with the amputated limb flat on the bed d- Supine, with the amputated limb supported with pillows 29- A nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse develops a 13 postoperative plan of care for the client and includes which of the following in the plan: a- Maintain the client in a prone position b- Elevate and immobilize the grafted extremity c- Maintain the surgical extremity in a flat position d- Keep the surgical extremity covered with a blanket 30- A nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral artery. The nurse checks the physician's prescription and plans to allow which client position or activity following the procedure: a- Bedrest in high Fowler's position b- Bedrest with bathroom privileges only c- Bedrest with head elevation at 60 degrees d- Bedrest with head elevation no greater than 30 degrees 31- After the client undergoes a total hip replacement, how should the nurse position the affected hip? a- Adduct the hip b- Abduct the hip c- Flex the hip d- Extend the hip 32- A client has an open reduction and internal fixation for a fractured hip. Postoperatively the nurse should position the client's affected extremity in: a- External rotation b- Slight hip flexion c- Moderate abduction 14 d- Anatomical body alignment 33- Which of the following positions should the nurse place a client for rectal tube insertion: a- left lateral position with hyperextension of right knee b- left lateral position with hyperflextion of left knee c- left lateral position with hyperflextion of right knee d- left lateral position with 15 hyperextension of left knee 34- Which of the following position is appropriate for the patient to use for selfadministration of fleet enema: a- Left lateral position right leg flex b- Face-down and leg flex c- Face upward and leg free (on back and flex hip and knee) d- Chest- knee position 35- The best position for a child with myelomeningocele is? a- Prone b- supine c- semi-fowler's d- modified trendelenburg 36- Unless the physician orders otherwise, in which position should the nurse place the infant during the postoperative period of surgical repair of the myelomeningocele: a- Supine b- Prone c- Right or left side-lying d- Whichever position is most comfortable for the infant 37- The nurse is caring for a client with an above-the-knee amputation (AKA). To prevent contractures, the nurse should: a- Place the client in a prone position 15-30 minutes twice a day b- Keep the foot of the bed elevated on shock blocks c- Place trochanter rolls on either side of the affected leg 16 d- Keep the client's leg elevated on two pillows 38- Postoperative nursing care of the infant following surgical repair of a cleft lip would include: a- Feeding the infant with a spoon to avoid sucking b- Positioning the infant on the abdomen to facilitate drainage c- Applying elbow restraints to protect the surgical area d- Providing minimal stimulation to prevent injury to the incision 39- The client has returned to the nursing unit following a right below-theknee amputation. How should the nurse position the client? a- Supine with head turned to the side b- With shock blocks placed under the foot of the bed c- Semi-sitting position with knees bent d- Left lateral with pillows between the knees 40- What position should the nurse place the head of the bed in to obtain the most accurate reading of jugular vein distention: a- High fowler's b- Raised 10 degrees c- Raised 30 degrees d- Supine position 41- Which of the following body positions is best for a patient with increased ICP: 17 a- Prone b- Trendelenburg c- HOB elevated 90 degrees and hips flexed d- HOB elevated 20 degrees 42- Immediately after a percutaneous liver biopsy, the nurse should place the client in which of the following positions: a- Left- sided lying b- Right- sided lying c- Lithotomy d- Trendelenburg 43- An adult has low back pain. Which position is likely to be most comfortable for the client: a- Prone b- Supine c- Side-lying with knees flexed d- Semi-sitting with legs extended 44- When planning the client's postoperative care, which is the least desirable position in which the nurse can place the client: a- Lying prone b- Lying supine c- Sitting in a chair d- Standing to shower 45- Which of the following is the appropriate position for a patient who is suffering from acute asthma attack is: 18 a- Right lateral b- Supine c- High fowler d- Prone 46- A patient with COPD is admitted to the hospital. How can the nurse best position the patient to improve gas exchange: a- Sitting up at the bedside in a chair and leaning slightly forward b- Resting in bed with the head elevated to 45 to 60 degrees c- In the Trendelenburg's position with several pillows behind the head d- Resting in bed in a high-Fowler's position with the knees flexed 47- Following a tympanoplasty, the nurse should maintain the client in which position: a- Semi-Fowler's with the operative ear facing down b- Low Trendelenburg's with the head in neutral position c- Flat with the head turned to the side with the operative ear facing up d- Supine with a small neck roll to allow for drainage 48- Which of the following is the proper position for a patient undergoing a cardiac surgery: a- Supine b- Prone c- Lateral 19 d- Fowler's 49- A nurse is caring for a toddler after surgical repair of a cleft palate. The nurse should position the child: a- On his back b- On his stomach c- On his back with his head slightly elevated d- For comfort 50- The nurse observes that the infant's anterior fontanelle is bulging after placement of a ventriculoperitoneal shunt. The nurse positions this infant: a- Prone, with the head of the bed elevated b- Supine, with the head flat c- Side-lying on the operative side d- In a semi-fowler's position 51- A nurse is providing care for a client following surgery to remove a cataract from the right eye. In which position should the nurse place the client? a- Right-side lying b- Prone c- Supine d- Trendelenburg's 52- An adult is admitted for a neurological workup and is scheduled for a spinal tap. When preparing the client for the procedure, the nurse should position the client in which position: a- Prone b- On the side with knees drawn up to chest 20 c- Lithotomy d- Semi-sitting 53- When suctioning the oropharynx, which of the following is the proper position of the patient: a- Prone b- Supine c- Semi- Fowler's d- Trendelenburg's 54- To prevent headache after spinal anesthesia the patient should be positioned: a- Semi- fowler's b- Flat on bed for 6 to 8 hours c- Prone position d- Modified Trendelenburg 55- If a patient develops autonomic hyperreflexia the first action his caring nurse should take is to: a- Elevate head of bed 90 degree (move from supine to sitting) b- Make the bed in flat position c- Apply ice on the axillary and groin d- But the patient in trendelenburg position 56- To protect susceptible patients in the hospital from aspiration pneumonia, the nurse will plan to: a- Turn and reposition immobile patients at least every 2 hours. b- Position patients with altered consciousness in lateral positions. c- Monitor frequently for respiratory symptoms in patients who are immunosuppressed. 21 d- Provide for continuous subglottic aspiration in patients receiving enteral feedings. 57- Which nursing action is essential when providing continuous enteral feeding? a- Elevating the head of the bed b- Positioning the patient on the left side c- Warming the formula before administrating it d- Hanging a full day's worth formula at one time 58- Which of the following positions is appropriate for the patient who has hypovolemic shock: a- Prone b- Supine c- Semi-fowler's d- Flat with elevating the feet 59- When caring for a patient admitted post-stroke (CV A) who has altered consciousness, the nurse should place the patient in which position: a- Side-lying b- Supine c- Prone d- Semi-fowler's 60- A nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions: a- "I should not sleep on my left side." b- "I should not sleep on my right side. " c- "I should not sleep with my head elevated." 22 d- "I should not wear my glasses at any time." 61- The day after an amputation, the client begins to hemorrhage from his stump. What action should the nurse take first: a- Apply a pressure dressing to the stump b- Place a tourniquet above the stump c- Notify the physician d- Apply an ice pack to the stump 62- A 72-year-old male client has a total hip replacement for long-standing degenerative bone disease of the hip. When assessing this client postoperatively, the nurse considers that the most common complication of hip surgery is: a- Pneumonia b- Hemorrhage c- Wound infection d- Pulmonary embolism 63- The nurse is caring for a client who had a right below-the-knee amputation three days ago. The client complains of pain in the right foot and asks for pain medication. What nursing action is appropriate initially? a- Elevate the stump b- Administer a placebo c- Administer ordered medications d- Encourage the client to discuss his feelings 23 64- During the assessment of an injury for a possible fracture, which of the following manifestations would make you suspicious that a fracture has occurred: a- Impaired sensation b- Hotness c- Loss of function d- Pointed tenderness 65- A client who has had an above-the-knee amputation develops a dimesized bright red spot on the dressing after 45 minutes in the postanesthesia recovery unit. The nurse should: a- Elevate the stump b- Reinforce the dressing c- Call the surgeon d- Draw a mark around the site 66- How you will interfere to relieve swelling of the lower extremity in a cast for 3 days now: a- Change the cast b- Call the doctor c- Elevate the extremity d- Give massage 67- The nurse is developing a bowel-retraining plan for a client with multiple sclerosis. Which measure is likely to be least helpful to the client: a- Limiting fluid intake to 1000mL per day b- Providing a high-roughage diet c- Elevating the toilet seat for easy access 24 d- Establishing a regular schedule for toileting 68- A diabetic patient with foot gangrene undergone above knee amputation, while the nurse changing the dressing he complains of pain on the same knee which was amputated. What should the nurse do: a- Inform physician about it b- Re-do dressing to Assessment the wound c- Psychiatry consultation to the patient because he wound above knee d- Give analgesic as needed 69- A diabetic patient with foot gangrene undergone above knee amputation he complain of pain and swelling at the wound site which is oozing bus and has a bad odor, the physician ordered cephalexin and metronidazole. Which of the following you should do immediately: a- Give cephalexin direct first action b- Give metronidazole direct first action c- Do wash on wound with N/Sand put bacitracin d- Do wash on wound with N/Sand put hydrocortisone 70- The physician has prescribed a cleansing enema to a client scheduled for colon surgery. The nurse would place the client: a- Prone b- Supine c- Left sim's ( left lateral) d- Dorsal recumbent 71- At which side of the patient will the nurse stand when inserting a rectal enema: a- Right side b- Left side 25 c- Any side d- Both sides 72- While undergoing a soapsuds enema, the client complains of abdominal cramping. The nurse should: a- Immediately stop the infusion b- Lower the height of the enema container c- Advance the enema tubing 2 to 3 inches d- Clamp the tubing 73- The nurse must administer an enema to an adult patient with constipation. Which of the following would be a safe and effective distance for the nurse to insert the tubing into the patient's rectum: a- 1:2 cm b- 3:4 cm c- 5.5:6.5 cm d- 6.5:8 cm 74- The nurse is caring for a patient receiving IV furosemide (Lasix) 40 mg and Enalapril (Vasotec) 5 mg PO bid for ADHF with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is: a- Weight loss of2 pounds overnight. b- Improvement in hourly urinary output. c- Reduction in systolic bp. d- Decreased dyspnea with the head of the bed at 30 degrees. 26 75- The nurse in preparing to insert RYLE'S tube (NGT) into an infant, the nurse knows that the length of the tube should be taken as following: a- From the nose down to the chin and then to the umbilicus b- From the nose to the earlobe and then to the xiphoid process c- From the nose to the mouth to the xiphoid process d- From the nose to the earlobe to the umbilicus 76- The nurse is caring for a client who has had a chest tube inserted and connected to water seal drainage. The nurse determines the drainage system is functioning correctly when which of the following is observed: a- Continuous bubbling in the water seal chamber b- Fluctuation in the water seal chamber c- Suction tubing attached to a wall unit d- Vesicular breath sounds throughout the lung fields 77- The nurse is caring for a client who has just had a chest tube attached to a water seal drainage system. To ensure that the system is functioning effectively the nurse should: a- Observe for intermittent bubbling in the water seal chamber b- Flush the chest tubes with 30-60 ml of NSS every 4-6 hours c- Maintain the client in an extreme lateral position d- Strip the chest tubes in the direction of the client 78- The nurse enters the room of a client who has a chest tube attached to a water seal drainage system and notices the chest tube is dislodged from the chest. The most appropriate nursing intervention is to: a- Notify the physician b- Insert a new chest tube 27 c- Cover the insertion site with petroleum gauze d- Instruct the client to breathe deeply until help arrives 79- Which type of isolation category is indicated for patient with tuberculosis: a- Airborne isolation b- Strict isolation c- Reverse isolation d- Contact isolation 80- While attempting to get out of bed, a patient accidentally disconnects the chest tube from the Pleur-evac drainage system. Which of the following actions should the nurse take first? a- Insert the end of the chest tube in a container of sterile solution b- Clamp the chest tube near the Pleur -evac drainage system c- Raise the end of the chest tube above the level of the insertion of the chest tube d- Apply pressure dressing to the chest tube insertion site 81- Which type of isolation category is indicated for a burn patient: a- Airborne isolation b- Strict isolation c- Reverse isolation d- No isolation required 82- Which type of isolation category is indicated for patient with diphtheria: 28 a- Airborne b- Droplet c- Contact d- Blood 83- A 68-years-old woman diagnosed with thrombocytopenia due to acute lymphocytic leukemia is admitted to the hospital. The nurse should assign the patient to a: a- To a private room so she will not infect other patients and health care workers. b- To a private room so she will not be infected by other patients and health care workers. c- To a semiprivate room so she will have stimulation during her hospitalization. d- To a semiprivate room so she will have the opportunity to express her feelings about her illness. 84- A nurse who begins to administer medications to a client via a nasogastric feeding tube suspects that the tube has become clogged. The nurse should take which safe action first: a- Aspirate the tube b- Flush the tube with warm water c- Prepare to remove and replace the tube d- Flush with a carbonated liquid such as cola 29 85- Which of the following instructions is appropriate for the nurse to give to a female client a who complains of abdominal upset after cholecystectomy operation: a- Increase fluid intake b- Avoid fatty meals c- Increase protein intake d- Daily exercise 86- Which of the following pulses should be checked before administrating Digoxin: a- Apical pulse b- Radial pulse c- Femoral pulse d- Dorsalis pedis pulse 87- Which of the following interventions must the nurse take when administrating digoxin to the patient: a- Give him the medication with a glass of orange juice b- Check him for signs of hypokalemia before giving the medication c- Instruct him to place the medication under the tongue d- Withhold the medication if his pulse is less than 60 beats/ minute 88- The nurse must withhold Digoxin from a patient if his pulse rate is: a- Less than 45/m b- More than 60/m c- Less than 60/m d- More than 100/m 30 89- The nurse is assessing the client for possible evidence of digitalis toxicity. The nurse acknowledges that which is included in the signs and symptoms for digitalis toxicity: a- Pulse (heart) rate of 100 beats/min b- Pulse of 72 with an irregular rate c- Pulse greater than 60 beats/min and irregular rate d- Pulse below 60 beats/min and irregular rate 90- A newly admitted client takes digoxin 0.25 mg/day. The nurse knows that the serum therapeutic range for digoxin is: a- 0.1 to 1.5 ng/mL b- 0.5 to 2.0 ng/mL c- 1.0 to 2.5 ng/mL d- 2.0 to 4.0 ng/mL 91- A patient complains of severe pain which he stated to be 9/10, the physician ordered morphine 50 mg IV every 4 hours, the last dose was given 2 hours ago, what is the best action his caring nurse would take: a- Give another dose of morphine b- Inform the doctor to change the order c- Distract the patient by TV, radio or games for 2 hours d- Ignore the patient completely 92- The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia (hyperreflexia)? a- Tachycardia b- Hypotension c- Hot, dry skin d- Throbbing headache 31 93- Which of the following is the best way for long term feeding for a patient experiencing severe dysphagia: a- NGT b- Naso-dudenal tube c- Gastrostomy d- Parenteral 94- Patient records are as following, he had 650cc of IV fluid (n/s), 50 ml of orange Juice in the NG tube, 100 water with the medications, and urinate 500 cc, and 100 cc collected in the G bag. What is the total intake for this patient? a- 800 cc b- 650 cc c- 200 cc d- 600 cc 95- The physician ordered to give the patient 10,000 unit of heparin, the preparation available is 40,000/ml. how much would the nurse give this patient: a- 4 ml b- 2.5 ml c- 0.25 ml d- 25 ml 96- The nurse is caring for a client with a fracture. The client develops a deep vein thrombosis in the opposite extremity. Physician orders include a heparin drip of D5W 250 mL with heparin 12,500 units at 16 mL/hr. How many units of heparin is this client receiving per hour: a- 200 unit/h 32 b- 400 unit/h c- 600 unit/h d- 800 unit/h 97- A patient suffers from diarrhea and muscle weakness, the nurse would assess this patient for which of the following abnormal laboratory blood tests: a- Blood calcium b- Blood magnesium c- Blood potassium d- Blood sodium 100- When assessing for therapeutic effects of mannitol, the nurse would expect to see: a- Decreased intracranial pressure b- Decreased excretion of therapeutic medications c- Increased urine osmolality d- Decreased serum osmolality 101- Which drug would be used to treat a patient who has increased intracranial pressure (ICP) resulting from head trauma after an accident: a- Mannitol b- Atropine sulfate c- Epinephrine hydrochloride d- Sodium bicarbonate 102- Which of the following is the drug of choice for treatment of cerebral edema: 33 a- Mannitol b- Atropine sulfate c- Epinephrine hydrochloride d- Sodium bicarbonate 103- The nurse would assess which laboratory value to determine the effectiveness of intravenous heparin: a- Complete blood count (CBC) b- Activated partial thromboplastin time (aPTT) c- Prothrombin time (PT) d- BUN 104- The antidote to heparin is: a- Aspirin b- Vitamin k c- Warfarin d- Protamine sulfate 105- How do we monitor the effectiveness of Coumadin (Warfarin): a- Monitor vital signs b- PT/INR c- Weight d- Ask the patient how they feel 106- Which medication is used to treat a patient suffering from severe adverse effects of a narcotic analgesic: a- Naloxone (Narcan) 34 b- Acetylcysteine (Mucomyst) c- Methylprednisolone (Solu-Medrol) d- Protamine sulfate 107-A patient who has been anticoagulated with warfarin (Coumadin) is admitted with gastrointestinal bleeding. The nurse will anticipate administering which substance: a- Vitamin E b- Vitamin K c- Protamine sulfate d- Calcium gluconate 108- While admitting a patient for treatment of an acetaminophen overdose, the nurse prepares to administer which of the following medications to prevent toxicity: a- Naloxone (Narcan) b- Acetylcysteine (Mucomyst) c- Methylprednisolone (Solu-Medrol) d- Vitamin K 109- If the nurse gave a patient antihypertensive drug that is prescribed for another patient, what should she do: a- Ignore what she has done b- Call urgent CPR c- Document that in nursing report d- Inform doctor after 2 days 110- When a physician orders an arterial blood gas, which artery is the appropriate one to use to obtain the specimen: 35 a- Cerebral artery b- Radial artery c- Carotid artery d- Ulnar artery 111- A client has an order to have a set of arterial blood gases (ABG's) drawn. The intended site is the radial artery. The nurse ensures that which of the following is positive before the ABGs are drawn a- Homan's sign b- Brodzinski's sign c- Babinski reflex d- Allen's test 112-A client is scheduled for blood to be drawn from the radial artery for an ABG determination. A nurse assists with performing Allen's test before drawing the blood to determine the adequacy of the: a- Ulnar circulation b- Carotid circulation c- Femoral circulation d- Brachial circulation 113- A nurse has administered approximately half of an enema solution to a preoperative client when the client complains of pain and cramping. Which nursing action is the most appropriate: a- Raise the enema bag so that the solution can be instilled quickly. b- Clamp the tubing for 30 seconds and restart the flow at a slower rate. c- Reassure the client and continue the flow. 36 d- Discontinue the enema and notify the physician 114- When caring for a client who is receiving total parenteral nutrition (TPN), which of the following complications would be most important for the nurse to assess: a- Chest pain b- Hemorrhage and air embolus c- Pneumonia and hyperglycemia d- Electrolyte imbalance and sepsis 115- A client has a nasogastric tube after a gastric resection. The nurse should expect to observe: a- Vomiting b- Gastric distention c- Intermittent periods of diarrhea d- Bloody drainage for the first 12 hours 116- While assessing a client with hypoparathyroidism, the nurse taps the client's facial nerve and observes twitching of the mouth and tightening of the jaw. The nurse would document this finding as which of the following: a- Positive Trousseau's sign b- Positive Chvostek's sign c- Tetany d- Hyperactive deep tendon reflex 117 - Which of the following clinical manifestations of type 2 diabetes occurs if glucose levels are very high: a- Hyperactivity b- Blurred vision 37 c- Oliguria d- Increased energy 118- Which of the following would the nurse expect to find in a client with severe hyperthyroidism: a- Tetany b- Buffalo hump c- Exophthalmos d- Striae 119- A client is receiving long-term treatment with high-dose corticosteroids. Which of the following would the nurse expect the client to exhibit: a- Weight loss b- Pale thick skin c- Hypotension d- Moon face 120- After undergoing a thyroidectomy, a client develops hypocalcemia and tetany. Which electrolyte should the nurse anticipate administering: a- Sodium phosphorus b- Sodium bicarbonate c- Calcium gluconate d- Potassium chloride 121- The nurse who elicits a positive Chvostek's sign would suspect that the patient has which condition: a- Hyperkalemia b- Hypocalcemia 38 c- Hypercalcemia d- Hypernatremia 122- Which of the following is the best method to decrease confusion and irritability for asthmatic patient: a- Give antibiotic b- Give sedative c- Give vasodilator d- Give oxygen 123- Which one of the baseline vital signs that has the most effect on sp02: a- Heart rate b- Respiratory rate c- Blood pressure d- Temperature 124- A patient is admitted to the emergency department with a stab wound to the right chest. Air can be heard entering his chest with each inspiration. To decrease the possibility of a tension pneumothorax in the patient, the nurse should: a- Position the patient so that the right chest is dependent. b- Administer high-flow oxygen using a non-rebreathing mask. c- Cover the sucking chest wound with an occlusive dressing. d- Tape a nonporous dressing on three sides over the chest wound. 125- A client with pneumonia has a temperature of 102.60 F (39.2 0 C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care: a- Position changes every 4 hours. 39 b- Nasotracheal suctioning to clear secretions. c- Frequent linen changes d- Frequent offering of a bedpan 126- The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). PH 7.35; PC02 62; P02 70; HC03 34 the nurse should: a- Apply a 100% non-rebreather mask. b- Assess the vital signs. c- Reposition the client. d- Prepare for intubation 127- If the nurse notes the following symptoms after the client begins taking sertraline (Zoloft), which one is most likely drug-related: a- Polyuria b- Diplopia c- Drooling d- Insomnia 128- Which of the following diets would be most appropriate for a client with chronic obstructive pulmonary disease (COPD): a- Low-fat, low-cholesterol diet. b- Bland, soft diet. c- Low-sodium diet. d- High-calorie, high-protein diet. 129- The physician has prescribed sertraline (Zoloft) 50 mg daily for a client with depression. Which finding should be reported to the physician? a- The client takes Tagamet (cimetidine) for acid reflux 40 b- The client takes the medication with meals c- The client takes the medication once a day at bedtime d- The client takes Aleve (naproxen) for arthritis 130- A patient was diagnosed with depression 6 weeks ago, and was prescribed anti-depressant drug.1 week ago the patient started to complain of irritability and had difficult sleep for only 3 hours daily. Which of the following is the best nursing action: a- Inform the doctor to increase the dose b- Ignore the patient complaint c- That's a side effect of the medication d- Give the patient hypnotics 131- 16 years old girl tried to suicide by taking a large amount of valium (benzodiazepines), the nurse knows that the antidote for this drug is: a- Flumazenil b- Benztropine c- Meperidine d- Naloxone 132- The nurse would expect to find which information when reviewing the history of a client diagnosed with multiple sclerosis: a- Visual problems b- Increased sensitivity to pain c- Ascending weakness and numbness d- Confusion and disorientation 133- The antidote for morphine overdose is: a- Naloxone (Narcan) b- Flumazenil (Romazicon) 41 c- Benztropine (Cogentin) d- Meperidine (Demerol) 134- The nurse assesses a respiratory rate of 10 on a client with cancer who has just received a hydromorphone hydrochloride (Dilaudid) injection. Which drug should the nurse be prepared to administer: a- Naloxone (Narcan) b- Flumazenil (Romazicon) c- Benztropine (Cogentin) d- Meperidine (Demerol) 135- Which of the following drugs is the antidote for magnesium toxicity: a- Calcium gluconate (Kalcinate) b- Hydralazine (Apresoline) c- Naloxone (Narcan) d- Rho (D) immune globulin (RhoGAM) 136-A client with myasthenia gravis is suspected of having cholinergic crisis. Which of the following indicate that this crisis exists: a- Ataxia b- Mouth sores c- Hypotension d- Hypertension 137-A client with myasthenia gravis is receiving pyridostigmine (Mestinon). The nurse monitors for signs and symptoms of cholinergic crisis caused by overdose of the medication. The nurse checks the medication supply to ensure that which medication is available for administration if a cholinergic crisis occurs: 42 a- Vitamin K b- Atropine sulfate c- Protamine sulfate d- Acetylcysteine (Mucomyst) 138- Which of the following is the purpose of providing atropine prior to anesthesia and surgery: a- To decrease salivation (decrease secretions) b- To increase blood pressure c- To facilitate breathing d- To decrease muscle tone 139-A client is diagnosed as having secondary Cushing's syndrome. The nurse knows that the client has most likely been taking which medication: a- Estrogen b- Penicillin c- Lovastatin d- Prednisone 140- A patient has the following preoperative medication order: morphine 10 mg with atropine 0.4 mg 1M. The nurse informs the patient that this injection will: a- Decrease nausea and vomiting during and after surgery b- Decrease oral and respiratory secretions, thereby drying the mouth c- Decrease anxiety and produce amnesia of the preoperative period d- Induce sleep, so the patient will not be aware during transport to the operating room 141- A 40-year-old woman is admitted in labor with high blood pressure, edema, and proteinuria. She is started on magnesium sulfate. The nurse caring for her should be sure to keep which drug at the bedside: 43 a- Calcium gluconate b- Naloxone (Narcan) c- Phenytoin (Dilantin) d- Glucose 142- Which of the following diets would be most appropriate for a patient has Cushing syndrome: a- High protein diet b- High potassium diet c- High calcium diet d- High iron diet 143- Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site: a- Deltoid b- Triceps c- Vastus lateralis d- Biceps 144- Which of the following interventions should be taken to help an older client to prevent osteoporosis: a- Decrease dietary calcium intake b- Increase sedentary lifestyles c- Increase dietary protein intake d- Encourage regular exercise 145-An adult is admitted with heart failure. The nurse notes that he has neck vein distention and slight peripheral edema. The nurse knows that these signs indicate which of the following: a- Pneumothorax 44 b- Right-sided heart failure c- Cardiogenic shock d- Left-sided heart failure 146- An adult client is admitted with a diagnosis of left-sided congestive heart failure. Which assessment finding would most likely be present? a- Distended neck veins b- Dyspnea c- Hepatomegaly d- Pitting edema 147- When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands opened, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes: a- Moro Reflex b- Babinski reflex c- Grasping Reflex d- Tonic Neck Reflex 148- A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse interprets these results as: a- Metabolic acidosis b- Metabolic alkalosis c- Respiratory acidosis d- Respiratory alkalosis 149- A patient has the following ABG results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HC03 16 mEq/L. The nurse interprets these results as: 45 a- Respiratory acidosis b- Respiratory alkalosis c- Metabolic acidosis d- Metabolic alkalosis 150- The nurse forgot to give the patient his prescribed drug, when the head nurse asked who is responsible for this the nurse replayed that was my wrong this considered: a- Responsibility b- Ignorance c- Abandonment d- Honor 151- When the patient vomits postoperatively, the most important nursing objective is to prevent: a- Dehydration b- Aspiration c- Rupture of suture line d- Met. Alkalosis 152- The nurse is discussing dietary sources of iron with a client who has iron deficiency anemia. Which menu, if selected by the client, indicates the best understanding of the diet? a- Milkshake, hot dog, and beets b- Beef steak, spinach, and grape juice c- Chicken salad, green peas, and coffee d- Macaroni and cheese, coleslaw, and lemonade 153- A client is recovering from abdominal surgery and has a large abdominal wound. A nurse encourages the client to eat which food item that is naturally high in vitamin C to promote wound healing: 46 a- Milk b- Oranges c- Bananas d- Chickens 154- Which of the following reflexes is considered a normal reflex of the newborn: a- Moro reflex b- Rooting reflex c- Planter reflex d- Tonic neck reflex 155- Patient with aortic aneurysm, which of the following is the most dangerous complications: a- Embolism b- Rupture c- Stenosis d- Hypotension 156- 56 years old patient suffers from heart failure, when the nurse examines his lungs she noticed the presence of crackles which means that the patient has: a- Right-sided- failure b- Left-sided- failure c- Biventricular failure d- Congestive heart failure 157- The nurse teaches a client with chronic obstructive pulmonary disease (COPD) to assess for signs and symptoms of right-sided heart failure. 47 Which of the following signs and symptoms should be included in the teaching plan: a- Clubbing of nail beds b- Hypertension c- Peripheral edema d- Increased appetite 158-A surgery procedure that must be done within 24 hours is called: a- Selective surgery b- Elective surgery c- Urgent surgery d- Emergency surgery 159-Early sign of ARDS in a patient at risk: a- Elevated CO2 level b- Hypoxia not responsive to O2 (cyanosis) c- Metabolic acidosis d- Severe, unexplained light imbalance 160- A nurse is assessing a female client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome: a- Bilateral wheezing b- Inspiratory crackles c- Intercostal retractions d- Increased respiratory rate 161-36 years old male patient complaining of fever and headache for 3 days now, when examining this patent which of the following signs would indicate that this patient may has meningitis: 48 a- Positive Kernig's sign b- Negative Brodzinski's sign c- Positive homan's sign d- Negative Kernig's sign 162-A patient presented with high fever, headache, vomiting and neck stiffness for the past 3 days, which of the following is the first diagnostic intervention for this patient: a- Urine and stool analysis b- Lumber puncture with CSF aspiration c- Complete blood count d- Chest and abdomen x-ray 163-MRSA (methicillin resistant Staphylococcus aureus) is transmitted by: a- Contact b- Airborne c- Droplet d- Standard 164- What is the best indicator of effective treatment of CHF in patient taking Lasix? a- Calculating total intake daily b- Weighting himself daily c- Calculating urine output daily d- Assessing fluid status daily 165- What supplemental medication is most frequently ordered in conjunction with furosemide (Lasix)? a- Chloride 49 b- Digoxin c- Potassium d- Sodium 166- What is the first intervention for a client experiencing myocardial infarction? a- Administer morphine b- Administer oxygen c- Administer sublingual nitroglycerine d- Obtain an electrocardiogram 167- Which type of medications is commonly used to treat rheumatoid arthritis? a- Glucocorticoids b- Non- steroidal ant- inflammatory drugs (NSAIDs) c- Antimalarial drugs d- Gold salt 168-A male client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond? a- Notify the physician b- Reposition the tube c- Irrigate the tube d- Increase the suction level 169-Postoperatively, patient is expected to void after: a- 6-8 hours 50 b- 2-4 hours c- 12-24 hours d- 10-12 hours 170- A female client has severe menstrual pain, which of the following drugs you would recommend for this patient to relieve her dysmenorrhea: a- Ibuprofen b- Zantac c- Aspirin d- Cortisone 171- The nurse must suction a child with a tracheostomy. Interventions should include: a- Encouraging the child to cough to raise the secretions before suctioning b- Selecting a catheter with a diameter three fourths as large as the diameter of the tracheostomy tube c- Ensuring that each pass of the suction catheter take no longer than 5 seconds d- Allowing the child to rest after every five times the suction catheter is passed 172-A 40 years old female complains of abdominal pain. It is worse after eating, especially if she has a meal that is spicy or high in fat. She has tried over-thecounter antacids, but they have not helped the pain. After examining her abdomen, you strongly suspect cholecystitis. Which sign on examination increases your suspicion for this diagnosis: a- Psoas sign b- Rovsing' s sign 51 c- Murphy's sign d- Grey turner's sign 173- Which pulse should the nurse palpate during rapid assessment of an unconscious male adult? a- Radial b- Brachial c- Femoral d- Carotid 174- The most important nursing measure in the prevention of thrombophlebitis for the post-partum mother is: a- Elastic stocking b- Early ambulation c- Anticoagulants d- Isometric exercises 175- Which of the following is the best aid to prevent breast cancer: a- Teaching women about breast cancer b- Public knowledge about chemotherapy c- To eat fruits and vegetables only d- Encourage women to perform self-breast examination monthly 176- Which of the following factors would contribute to a high risk pregnancy: a- Blood type 0 positive b- First pregnancy at 33 years old c- History of allergy to honey bee pollen d- History of insulin dependent DM 52 177- When the nurse puts an infant with high temperature in cold water in order to lower his temperature, she knows that the mechanism of heat loss is called: a- Evaporation b- Conduction c- Radiation d- Convection 178- A child is admitted to the hospital with a diagnosis of Wilm's tumor, Stage D. Which of the following statements most accurately describes this stage: a- The tumor is less than 3 em. in size and requires no chemotherapy b- The tumor did not extend beyond the kidney and was completely resected c- The tumor extended beyond the kidney but was completely resected d- The tumor has spread into the abdominal cavity and cannot be resected 179- When assessing a 12 year old child with Wilm's tumor, the nurse should keep in mind that it most important to avoid which of the following: a- Measuring the child's chest circumference b- Palpating the child's abdomen c- Placing the child in an upright position d- Measuring the child's occipitofrontal circumference 53 180- The nurse is teaching a 45 year old woman how to increase the potassium in her diet. The woman says she knows bananas are high in potassium, but she doesn't like their taste. What foods should the nurse recommend the client include in her diet: a- Carrots, broccoli, yogurt b- Rhubarb, tofu, celery c- Potatoes, spinach, raisins d- Onions, com, oatmeal 181- When developing a plan of care for a patient with SIADH (syndrome of inappropriate antidiuretic hormone secretion), which interventions will the nurse include: a- Encourage fluids to 2000 ml/day b- Long-term fluid restriction c- Monitor for increased peripheral edema d- Keep head of bed elevated to 30 degrees 182-A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? a- Infusing LV. fluids rapidly as ordered b- Administering glucose-containing LV. fluids as ordered c- Restricting fluids d- Encouraging increased oral intake 183-How streptococci infection is transmitted from person to another: a- Airborne b- Contact c- Slandered 54 d- Blood 184-A hospitalized client is found to be comatose and hypoglycemic with a blood sugar of 50 mg/dL. Which of the following would the nurse do first? a- Infuse 1000 mL D5W over a 12-hour period b- Encourage the client to drink orange juice with added sugar c- Check the client's urine for the presence of sugar and acetone d- Administer 50% glucose intravenously 185- A patient receives TPN, which of the following nursing actions is important to minimize the risk for fluid volume excess: a- Increase diuretic dose if swelling occurs b- Limit the amount of free water in relation to sodium intake c- Monitor his or her skin turgor d- Weigh the patient daily on the same scale 186- Which of the following findings would most likely indicate the presence of a respiratory infection in a client with asthma: a- Cough productive of yellow sputum b- Bilateral expiratory wheezing c- Chest tightness d- Respiratory rate of 30 breaths/ minute 187- When teaching a mother how to administer eye drops, where should the nurse tell her to place them? a- In the conjunctival sac that is formed when the lower lid is pulled down b- Carefully under the eye lid while it is gently pulled upward c- On the sclera while the child looks to the side d- Anywhere as long as drops contact the eye's surface 55 188- One nursing intervention for patient with asthma is to facilitate removal of secretions. This can be done by: a- Encourage the patient to perform slow and shallow breathing b- Encourage the patient to increase fluid intake c- Encourage the patient to hyperventilate d- Encourage the patient to decrease fluid intake 189- The nurse is caring for a 6-year-old boy following revision of ventricuioperitoneal shunt. An expected nursing intervention is: a- Request for an x-ray to evaluate shunt placement b- Daily measurement of head circumference c- Frequent palpation of the fontanels d- Maintaining the child in a prone position 190-the patient have an itchy, erythematous, vesicular, weeping, and crusting patches on his skin which skin disease is this considered: a- Psoriasis b- Impetigo c- Eczema d- Urticaria 191-Giving an intramuscular injection to an infant in the Gluteus Maximus muscle may produce an injury to which of the following nerves: a- Femoral nerve b- Sciatic nerve c- Vagus nerve d- Popliteal nerve 56 192- Which of the following is one of the side effects of albuterol nebulizer: a- Hypertension b- Hypotension c- Fast irregular heart beats d- Tachypnea 193- A patient, age 49, returns from the postanesthesia care unit after a total abdominal hysterectomy and bilateral salpingo-oophorectomy to treat cervical cancer. Which nursing intervention has the highest priority at this time? a- Monitor the patient for indications of hemorrhage b- Assess the patient's pain level and response to analgesics c- Encourage the patient to do deep breathing and leg exercises d- Provide emotional support to the patient 194- When planning the care of a client who has undergone an abdominal hysterectomy, which nursing measure is most helpful for preventing postoperative complications and facilitating an early discharge? a- Reestablishing oral fluids and nutrition b- Promoting ambulation and movement c- Maintaining accurate intake and output d- Exploring feelings about altered image 195- Which of the following is considered one of the common complications following abdominal total hysterectomy: a- DVT b- Paralytic ileus c- Constipation d- Perforation 57 196-A client had a hysterectomy 10 hours ago. The nurse assesses the client and finds that her blood pressure has fallen abruptly. Which action by the nurse is most appropriate at this time? a- Continue to monitor the blood pressure every 15 minutes b- Document the information on the client's chart c- Inform the surgeon about the client's condition d- Change the client to a Fowler's position 197- The nurse is teaching a client regarding risk factors for stroke (CVA). The greatest risk factor is which of the following: a- Diabetes b- Heart disease c- Renal insufficiency d- Hypertension 198- The nurse recognizes that the most common type of brain attack (CVA) is related to which of the following: a- Ischemia b- Hemorrhage c- Headache d- Vomiting 199-A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse will assess for other signs and symptoms of: a- Cachexia b- Parkinson's syndrome c- Myxedema d- Scleroderma 58 200- A 32 year-old man is brought to the emergency department by a friend with whom he had been playing football with earlier that evening. His symptoms came on after twenty minutes of the football match. He appears anxious and restless. Auscultation of the lung reveals wheezing on exhalation. The patient states that he is unable to get a full breath of air. He had this problem as a child a couple of times after exercising in cold weather. Blood pressure 126/72 mmhg Heart rate 90/min Respiratory rate 28/min shallow Temperature 37.0C tympanic Oxygen saturation 94% on room air Which position is the best for this patient? a- Supine b- Reverse Trendelenburg's c- Prone d- High fowler's 201- A 43 years- old man is 30- hour post- operative following placement of a partial thickness skin autograft for a burn injury on the lower anterior leg. During a routine assessment, the nurse observes the wound is bleeding continuously. What is the priority nursing action? a- Use a pen to outline and monitor the area b- Perform a wound swab for laboratory analysis c- Incise and drain fluids from the wound bed d- Apply firm and direct pressure for 10 minutes 59 202-Coarse hair may indicate: a- Dehydration b- Inflammation c- Under nutrition d- Anemia 203- The nurse performs a home visit for a 32 years- old woman who had given birth to her first infant three days before. The mother has concerns about breastfeeding and the nurse observes the infant feeding. The mother sits supported upright with cushions and the infant positioned in a cradle hold. The infant's head and body are aligned against the mother's abdomen. The infant sucks intermittently with the lips turned outwards and the nipple in the mouth. Which intervention is most appropriate? a- Reposition the infant b- Assist the infant to turn lips inwards c- Ensure the latch includes the areola d- Stimulate the infant to suck constantly 204- A 52 year- old woman is scheduled to undergo an abdomino- perineal resection in three days for removal of a cancer of the rectum. The nurse reviews the care plan with the patient. The patient will receive prophylactic antibiotics and will be given a mechanical bowel preparation the day before. Which additional preparation should the patient undertake at this time? a- Wear pressure stockings b- Perform leg strengthening exercises c- Maintain high- protein, low- residue diet 60 d- Take daily ferrous iron tablets 205-A patient is preparing for a scheduled hip replacement. Which lab value should be reported to the physician? Test Sodium Potassium Calcium Magnesium Result 145 2.9 2.80 4.8 Normal values 134-164 mmol/L 3.5-5.1 mmol/L 2. 15-2.62mmol/L 1.2-2 mmol/L a- Sodium b- Calcium c- Potassium d- Magnesium 206- A nurse is admitting a six month- old infant with pneumonia. Which of the following interventions supports this infant's emotional needs? a- Allow the parents to leave the room during painful procedures b- Encourage parents to distract the infant from crying c- Interview the patents to learn the infant's comforting habits d- Enforce strict visiting schedule and routines 207- While caring for a patient in the post- anesthesia care unit (PACU) who has developed hypovolemic shock, a nurse should position the patient: a- Flat with legs elevated b- In trendelenburg position c- With the head of the bed elevated 45 degrees 61 d- Completely flat 208- A five years - old child girl had presented with tenderness, headache and petechiae. She was pale and complains of joint pain. On palpation there was an enlarged spleen, liver and lymph nodes. A lumbar puncture showed central nervous system involvement. The child underwent chemotherapy treatment and is now attended by the nurse for regular routine examinations. Which condition would require more attention from the nurse? a- Increased leukocytes b- Lack of muscle coordination c- Bleeding while brushing teeth d- Occasional nausea and vomiting 209-During the evaluation at a community clinic, the patient completes the medical history. Which of the following is NOT a risk factor for an acute myocardial infarction? a- Coronary artery disease b- Smoking c- Hemophilia d- Hyperlipidemia 210- A postoperative patient has the nursing diagnosis of ineffective tissue perfusion. To assess for tissue perfusion the nurse should check all of the following except: a- Skin and nail bed color b- Temperature of extremities c- Respiratory rate 62 d- Peripheral pulses 211-A patient visits the clinic for a 2- week checkup after a corneal transplantation (keratoplasty). The nurse observes the patent's sclera is red and the patient complains of the eye feeling irritated. The nurse suspects the patient may have: a- Infection b- Hemorrhage c- Graft rejection d- Postoperative glaucoma 212- The nurse is assessing a patient who just had surgery under general anesthesia. The patient's respiration rate is 4 per minute and the O2 saturation on 3L per minute of oxygen via nasal cannula is 84%. The nurse is awaiting the results of an arterial blood gas (ABG) and anticipates that which of the following will be ELEVATED? a- Arterial oxygen saturation (SaO2) b- Hydrogen ion concentration (PH) c- Partial pressure of arterial oxygen (PaO2) d- Partial pressure of arterial carbon dioxide (PaCO2) 213-During the immediate postoperative period, a patient reveals an oxygen saturation of 91 %. The nurse should: a- Position the patient on the left side b- Administer supplemental oxygen c- Continue to provide supportive care 63 d- Lower the temperature of the room 214- The nurse performs an assessment of a 23 year- old man who believes that people are spying on him. During the interview, he keeps his eyes to the floor and answers questions awkwardly. He has never had an intimate relationship and avoids contact with his family members. He has never been employed and tells the nurse that he is not looking for a job. The nurse considers Erickson's theory of psychosocial development. Which stage is this patient most likely experiencing? a- Autonomy versus shame and doubt b- Initiative versus guilt c- Trust versus mistrust d- Identity versus confusion 215-A 32 year- old woman with a motor neuron disease has progressive weakness of cranial nerves V, IX, XII. She has recently been experiencing sudden outbursts of crying and laughing. Both stroke and myasthenia gravis have been ruled out. Which voluntary muscle activity would be most significantly impacted? a- Walking b- Swallowing c- Breathing d- Smelling 216- Causes of primary hypothyroidism in adults include: a- Malignant or benign thyroid nodules b- Surgical removal or failure of the pituitary gland c- Surgical removal or radiation of thyroid gland d- Autoimmune-induced atrophy of the gland 64 217-A 72-year-old patient is diagnosed with hypothyroidism, and levothyroxine (Synthroid) is prescribed. During initiation of thyroid replacement for the patient, it is most important for the nurse to assess: a- Mental status b- Nutritional level c- Cardiac function d- Fluid balance 218-A client presents with Hypocalcemia, hyperphosphatemia, muscle cramps, and positive Trousseau's sign. What diagnosis does this support? a- Diabetes insipidus b- Conn's syndrome c- Hypoparathvroidism d- Acromegaly 219- The nurse acknowledges that the first-line drug for treating of client's blood pressure might be which drug: a- Diuretic b- Alpha blocker c- ACE inhibitor d- Alpha/beta blocker 220- The nurse is teaching a client about clopidogrel (plavix). What is important information to include? a- Constipation may occur b- Hypotension may occur c- Bleeding may increase when taken with aspirin d- Normal dose is 25 mg tablet per day 65 221- The nurse knows that the client's cholesterol level should be within which range: a- 150 to 200 mg/dL b- 200 to 225 mg/dL c- 225 to 250 mg/dL d- Greater than 250 mg/dL 222- The nurse is performing an assessment in a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is: a- Eye pain b- Floating spots c- Blurred vision d- Diplopia 223- A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for: a- Hyperalbuminemia b- Thrombocytopenia c- Hypokalemia d- Hypercalcemia 66 224-Adult patient complains of diarrhea, vomiting, abdomen cramp and pain within the past 2 weeks. The patient reported that the pain increases when he eats and relieves when he passes stool. Which of the following may be the cause: a- Appendicitis b- Crohn' s disease c- Ectopic pregnant d- Cholecystitis 225- When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following: a- Turn the neonate every 6 hours b- Encourage the mother to discontinue breast-feeding c- Notify the physician if the skin becomes bronze in color d- Check the vital signs every 2 to 4 hours 226- After 3 days of breast-feeding, a postpartum patient reports nipple soreness. To relieve her discomfort, the nurse should suggest that she: a- Apply warm compresses to her nipples just before feedings b- Lubricate her nipples with expressed milk before feeding c- Dry her nipples with a soft towel after feedings d- Apply soap directly to her nipples, and then rinse 227- Which of the following interventions would be helpful to a breastfeeding mother who is experiencing engorged breasts: a- Applying ice b- Applying a breast binder c- Teaching how to express her breasts in a warm shower d- Administering bromocriptine (Parlodel) 67 228- What type of milk is present in the breasts 7 to 10 days postpartum? a- Colostrum b- Hind milk c- Mature milk d- Transitional milk 229- Which of the following is a sign of rejection after a renal transplantation operation: a- Decrease potassium b- Decrease sodium c- Decrease creatinine d- Decrease urine out put 230- Which of the following is among the signs of magnesium toxicity: a- Cardiac arrhythmia b- Loss of deep tendon reflex c- Patient confusion and irritability d- Respiratory failure 231-A nurse is caring for a client who has a potassium level of 5.4 mEqlL. The nurse should assess the client for: a- ECG changes b- Constipation c- Polyuria d- Hypotension 68 232-Moderate to severe hypokalemia in a patient will cause the nurse to observe: a- Muscle spasms and slow respirations b- Muscle weakness and cardiac dysrhythmias c- Confusion and irritability d- Vomiting and diarrhea 233- Which of the following electrolytes decrease would cause PVC (premature ventricular contraction): a- Potassium b- Sodium c- Calcium d- Magnesium 234- Which of the following electrolytes decrease would cause recurrent vomiting and general weakness: a- Potassium b- Sodium c- Calcium d- Magnesium 235- The nurse is educating a couple who has had difficulty with conception. The client asks about the hormone, which is responsible for the production of eggs. The nurse answers that this hormone is called: a- Melanocyte-stimulating hormone b- Luteinizing hormone (LH) c- Follicle-stimulating hormone (FSH) d- Interstitial cell-stimulating hormone (ICSH) 69 236- The patient has an order to receive 45 mg of prednisone by mouth daily. Available are 10-mg tablets. How many tablets should the nurse prepare to give? a- 1.6 b- 2 c- 4.5 d- 6 237- The nurse caring for a 54-year-old patient hospitalized with diabetes mellitus would look for which of the following laboratory test results to obtain information on the patient's past glucose control: a- Prealbumin level b- Urine ketone level c- Fasting glucose level d- Glycosylated hemoglobin level 238- Which laboratory test is most important for the nurse to monitor to determine how effectively the client's diabetes is being managed? a- Fasting blood glucose b- Blood chemistry profile c- Complete blood count d- Glycosylated hemoglobin (HbAlc) 239-Blood sugar for new employee at company with sedentary life style and obese and by result of Fasting blood Sugar 6.9 mmol (abnormal reading) what is the best next step to do to estimate his blood sugar condition: a- Draw blood sample for HbAlc b- Repeat the test for the next 2 days c- Estimate the postprandial sugar level d- Write a recommendation note for not hiring him 70 240- HbA1c as a measurement instrument for glucose level in the blood, it measures blood glucose level within: a- Last 3 months b- Last 5 months c- Last 7 months d- Last 1 year 241- Which laboratory test indicates liver cirrhosis? a- Decreased red blood cell count b- Decreased serum acid phosphatase level c- Elevated white blood cell count d- Elevated serum aminotransferase 242- Which statement best describes the difference between the pain of angina and the pain of myocardial infarction: a- Pain associated with angina is relieved by rest b- Pain associated with myocardial infarction is always more severe c- Pain associated with angina is confined to the chest area d- Pain associated with myocardial infarction is referred to the left arm 243- The nurse is developing a bowel-retraining plan for a client with multiple sclerosis. Which measure is likely to be least helpful to the client? a- Limiting fluid intake to 1000mL per day b- Providing a high-roughage diet c- Elevating the toilet seat for easy access d- Establishing a regular schedule for toileting 71 244- Which organism is responsible for the onset of rheumatic fever? a- Staphylococcus aureus b- Listeriosis c- Group A β-hemolytic streptococcus d- Epstein-Barr virus 245-For what reason are patients instructed to do Kegel exercises when they are discharged after childbirth: a- They help her get back in shape b- They prevent her breasts from becoming engorged c- They help strengthen the perineal muscles d- They help reduce strain on the back 246- You are preparing to discharge a patient who suffered third degree burn, which of the following instructions is appropriate to give the patient to decrease infection: a- You must take large amount of fluids b- You should wash your hands thoroughly c- You better increase vitamin intake d- You should avoid fatty meals 247- The most effective procedure to prevent spared of infection is: a- Wearing gloves b- Using antiseptic c- Sterilization d- Hand washing 72 248- What is the normal pulse range for an adult? a- 120 to 160 beats per minute b- 90 to 140 beats per minute c- 60 to 100 beats per minute d- 50 to 80 beats per minute 249- A four year- old girl was playing outside in a park when she came running to her mother crying and holding her right, upper arm. Two hours later they presented to the emergency department. There was a swelling over the upper right arm, with pain and itching at the site as well as swelling of the oral mucosa. The child seems anxious. What is the next most appropriate step in management? a- Administer subcutaneous epinephrine b- Maintain a patent airway c- Administer oral diphenhydramine d- Prepare intubation equipment 250- A 65 year- old man presents with a resting tremor in the right forearm. An assessment of gait reveals decreased arm swinging and slight dragging of the foot on the right side. His body movements are slow. He has not been sleeping well at night for the past six months due to leg pain and says that he feels constantly tired and weak. He reports that he has not suffered any recent fall and that the symptoms seem to be slowly worsening. Which medication is most likely to be administered? a- Levodopa b- Haloperidol c- Phenytoin d- Benzodiazepine 73 251- When planning discharge teaching for the parent of an infant with bronchiolitis, the nurse should EMPHASIZE: a- Use of supplemental oxygen at night b- Frequent hand washing c- Sleeping in the supine position d- Rice- thickened formula during night- time feedings 252-A home care nurse visits a diabetic patient who was started on insulin injections. Upon examination, the nurse observes small lumps and dents on the right upper arm where the patient has injected insulin. What is the BEST nursing intervention? a- Refer the patient to a dermatologist for diabetic cellulitis b- Instruct the patient to rotate the sites of injection c- Refer the patient to an endocrinologist for better control of glucose level d- Instruct the patient to inject in the muscular area instead of the subcutaneous area 253-A patient has an order for 1000 milliliters (ml) of intravenous (IV) fluid to infuse over eight hours. The available IV tubing has a drip factor of 10 gtts/ml. Which of the following rates is correct? a- 125 ml/hour b- 125 drop/minute c- 21 drops/minute d- 21 ml/hour 74 254- When is the correct time for the nurse to administer the child's morning dose of a combination regular and NPH insulin? a- 30 minutes before breakfast is served b- 15 minutes before breakfast is served c- 30 minutes after breakfast is served d- 15 minutes after breakfast is served 255- The client has an order for administration of 10 units of regular insulin to be given at 7:00 a.m. The nurse should offer a snack at: a- 3:00 p.m. b- 1:00 p.m. c- 11:00 a.m. d- 9:00 a.m. 256- The client is being treated with PH insulin at 8:00 a.m. The nurse should offer a snack at: a- 9:00 a.m. b- 11:00 a.m. c- 6:00 p.m. d- 2:00 p.m. 75 257-A client with diabetes comes to the emergency department. The nurse obtains a blood glucose measurement with a glucometer and notes that it is 510 mg/dL. The physician orders I.V. insulin. Which type of insulin can be given both intravenously and subcutaneously? a- Regular b- NPH c- Lente d- 70/30 258-1f a client with type 1 (insulin-dependent) diabetes mellitus receives 5 units of NPH insulin every morning at 7 a.m., the nurse should closely monitor the client for signs of hypoglycemia at what time: a- 3:00 p.m. b- 12:00 a.m. c- 7:30 a.m. d- 10:00 p.m. 259- NPH is an example of which type of insulin: a- Short-acting b- Intermediate-acting c- Rapid-acting d- Long-acting 76 260- A 70 years- old woman presents with increasing dyspnea on exertion. She feels breathless and restless while performing household tasks, such as making the bed and sweeping the floor. Her previous medical history includes a myocardial infarction at 57 years old. She sleeps with her head elevated on three pillows. Examination reveals bilateral basal crackles and cold, damp skin. Blood pressure 172/94 mmhg Heart rate 94/min Respiratory rate 36/min Temperature 37.1 C Oxygen saturation 90% on room air Which heart chamber most likely failed first? a- Right atrial b- Right ventricle c- Left ventricle d- Left atrial 261- The nurse is preparing a discharge plan for a 65 year- old man with a new diagnosis of congestive heart failure. The discharge orders include furosemide 40 milligrams by mouth twice per day. The nurse recommends food to reduce unwanted medication side effects. Which of the following food would be most appropriate to include in the teaching plan? a- Green and leafy vegetables b- Bananas and oranges c- Chicken and fish d- Whole wheat grains 77 262- A child comes into the clinic with several lesions to the scalp. The round lesions have dandruff like scaling with hair loss. What is the MOST likely diagnosis for this skin condition? a- Impetigo b- Ringworm (tinea capitis) c- Pediculosis capitis d- Scabies 263- A 40 years- old woman suffered an automobile accident one month ago. The accident resulted in a C-4 spinal cord injury. Her preventive care includes independent daily performance of coughing and deep breathing. Which range- of- motion exercise would be most beneficial for this patient? a- Active b- Passive c- Combined d- Resistive 264- A nine year- old girl has a nursing diagnosis of altered body image related to changes in appearance secondary to varicella infection. The child's body is covered with a rash and many large, weeping pustules. The nurse provides counseling to the mother who is concerned that the child will develop scarring. Which intervention is most appropriate? a- Keep the skin out of direct sunlight b- Apply calamine lotion to skin every two hours c- Wash pustules with soap and keep dry d- Soak in colloidal oatmeal bath three times daily 78 265-A nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse expects to find: a- Weight gain in arms and legs b- Thick, coarse skin c- Hypotension d- Deposits of adipose tissue in the trunk and dorsocervical area 266- Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury? a- Vitamin A b- Vitamin B c- Vitamin C d- Vitamin D 267-Sildenafil (Viagra) is prescribed to treat a client with erectile dysfunction. A nurse reviews the client's medical record and would question the prescription if which of the following is noted in the client's history: a- Neuralgia b- Insomnia c- Use of nitroglycerin d- Use of multivitamins 268- The physician ordered I liter of normal saline infusion for four hours, how much N/S should be delivered to the patient in one hour: a- 300 ml b- 250 ml c- 200 ml d- 150 ml 79 269- Best diagnostic test for suspected leukemia is: a- Bone marrow aspiration b- Blood chemistry c- CBC d- PT ANDPTT 270- The primary nursing goal when caring of a child with leukemia is to: a- Take vital signs b- Provide good nutrition c- Give analgesics d- Prevent infection 271- The oxygen flow rate for the nasal cannula is considered to be: a- 1-6 liter/m b- 3-8 liter/m c- 5 -1 0 liter/m d- 10-15 liter/m 272 -1f the client develops a thrombus in one of the leg veins, which client response would the nurse expect when eliciting Homans' sign? a- Sham, immediate calf pain b- Sudden numbness in the foot c- Inability to bend the knee when asked d- Tingling throughout the affected leg 80 273- When the nurse assesses the client for Homans' sign, which technique is most accurate? a- Have the client push each foot against the mattress. b- Have the client extend the legs and flex each foot toward the head c- Ask the client to sit up in bed and point all the toes forward d- Ask the client to contract the thigh muscles 274- The phase that include action of the nursing care plan is called: a- Implementation b- Diagnosis c- Assessment d- Evaluation 275-After vein ligation and stripping operation, the patient should: a- Wear elastic stocking b- Do exercises c- Rest the leg d- Avoid walking 276-Rabies disease is considered: a- Viral disease b- Bacterial disease c- Protozoan disease d- Fungal disease 277-A client receiving IV infusion. The skin around the IV insertion site is red, warm to touch and painful. The nurse should first: a- Discontinue the IV b- Slow the IV rate for 30 minutes then reassess the site c- Place a cold compression on the area 81 d- Place a warm compression on the area 278-Clients who have casts applied to an extremity must be monitored for complications. The most significant complication for which the nurse should assess the client's extremity is: a- Warmth b- Numbness c- Skin desquamation d- Generalized discomfort 279- A nurse is assessing the legs of a client who's 36 weeks pregnant. Which finding should the nurse expect? a- Absent pedal pulses b- Bilateral dependent edema c- Sluggish capillary refill d- Unilateral calf enlargement 280- Which of the following is the best nursing action to assess pulse in a toddler patient: a- Assess the brachial artery with the middle finger and index b- Assess the Dorsalis pedis artery with your palm c- Assess the carotid artery with the four fingers d- Assess the radial artery using three finger 281- One nursing intervention for patient with productive cough is to facilitate removal of secretions. This can be done by: a- Encourage the patient to perform slow and shallow breathing b- Encourage the patient to increase fluid intake c- Encourage the patient to hyperventilate d- Encourage the patient to decrease fluid intake 82 282-A nurse examines a client's level of responsiveness. She finds that the patient opens his eyes to verbal commands, obeys verbal commands, and is oriented to time, place, and person. What's the client's Glasgow Coma Scale: a- 11/15 b- 12/15 c- 13/15 d- 14/15 283-A 73 year old patient looks at you when you speak to her. When you ask her the date, she says "blue". You note left-sided weakness when she grips your fingers. What is her Glasgow Coma Score? a- 11/15 b- 12/15 c- 13/15 d- 14/15 284-A patient during examination opens his eyes in response to pain, makes no verbal response, but withdraws from pain. What is the Glasgow Coma Score (GCS) for this patient? a- 3 b- 5 c- 7 d- 11 285-A newborn APGAR score at 1 and 5 minutes is 5 and 10, half an hour later the baby became bluish in color with heart rate of 140/m, your first action would be: a- Estimate the score again b- Shower the baby with warm water c- Give oxygen immediately 83 d- Ignore the finding because it is normal 286- The primary critical observation for Apgar scoring is the: a- Heart rate b- Respiratory rate c- Presence of meconium d- Evaluation of the Mom reflex 287- When performing a newborn assessment, the nurse should measure the vital signs in the following sequence: a- Pulse, respirations, temperature b- Temperature, pulse, respirations c- Respirations, temperature, pulse d- Respirations, pulse, temperature 288- Within 3 minutes after birth the normal heart rate of the infant may range between: a- 100 and 180 b- 130 and 170 c- 120 and 160 d- 100 and 130 289- The expected respiratory rate of a neonate within 3 minutes of birth may be as /high as: a- 50 b- 60 c- 80 d- 100 84 290- When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority: a- Obtain a dextrostix b- Give the initial bath c- Give the vitamin K injection d- Cover the neonates head with a cap 291- Which of the following instructions are appropriate for the nurse to give the patient about the time of taking omeprazole tablet: a- Take the tablet during the meal b- Take the tablet 2 hours after the meal c- Take the tablet 30-45 minute before the meal d- Take the tablet before bed time 292- Patient obtained second degree burn to his abdomen and his entire back, according to rule of nine what is the percentage of burn of total body surface area: a- 9% b- 18% c- 27% d- 36% 293-R.T.A. Patient arrived to E.R, on examination the patient has increased heart rate, low blood pressure and decreased level of consciousness, you must think that the patient is developing: a- Coma b- UTI c- Shock d- Respiratory arrest 85 294- Which of the following disease has no vaccinations: a- Small pox b- Measles c- Poliomyelitis d- Chicken pox 295- The type of burn in which all the dermis and epidermis, is destroyed and there is involvement of underlying structures is called: a- Superficial or first degree bum b- Partial thickness or second degree bum c- Full-thickness or third degree bum d- Fourth degree bum 296- Which of the following is the drug of choice for treatment of rheumatic fever: a- Amoxicillin b- Azithromycin c- Cephalexin d- Penicillin 297- What disease is associated with a Vitamin C deficiency? a- Pellegria b- Neural tube defects c- Scurvy d- Pitted edema 86 298- A 59 year old woman is diagnosed with Hemolytic anemia. What foods would be recommended for her to eat: a- Fish oils b- Eggs, cheese c- Yellow fruits d- Grains, nuts 299- The physician orders an intradermal injection of 5 tuberculin units /0.l ml of tuberculin purified derivative. Which needle is appropriate for this injection: a- 12 gauge needle b- 18 gauge needle c- 22 gauge needle d- 26 gauge needle 300- Which nursing diagnosis takes priority for a newly diagnosed patient with a left- sided stroke? a- Risk of impaired swallowing related to absent gag reflex b- Risk for impaired skin integrity related to immobility c- Risk for infection related to invasive line placement d- Risk for impaired speech related to left sided stroke 301- When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care during the acute period of the stroke? a- Apply an eye patch to the left eye b- Approach the patient from the left side c- Place objects needed for activities of daily living on the patient's right side d- Reassure the patient that the visual deficit will resolve as the stroke progresses 87 302- A client with a serum glucose level of 618mg/dl is admitted to the facility. He's awake and oriented, has hot dry skin, and has the following vital signs: Temperature 38.10 C Heart rate 116 beats/minute Blood pressure 108/70 mm Hg Based on these assessment findings, which nursing diagnosis takes the highest priority? a- Deficient fluid volume related to osmotic diuresis b- Decreased cardiac output related to elevated heart rate c- Imbalanced nutrition: less than body requirements related to insulin deficiency d- Ineffective thermoregulation related to dehydration 303- A patient has a blood glucose level of 60mg/dl. The patient is to receive 15 g of carbohydrate if the blood glucose is less than 70mg/dl. How many mls of orange juice should the patient receive? a- 120 ml b- 90 ml c- 60 ml d- 30 ml 88 304-A patient has a blood glucose level of 60mg/dl. The patient is to receive 15 g of carbohydrate if the blood glucose is less than 70mg/dl. How many candies should the patient receive? a- 4 candies b- 6 candies c- 8 candies d- 10 candies 305- A patient is scheduled for a pneumonectomy in the morning. Which of the following diagnosis is the MOST likely indication for this type of surgery? a- Lung carcinoma b- Pulmonary tuberculosis c- Benign pulmonary nodule d- Mediastinal shift 306- The nurse is caring for a patient with a deep vein thrombosis (DVT). The patient's heparin sodium infusion has been discontinued and the patient is receiving prescribed warfarin sodium (Coumadin) The nurse should advise the patient that which of the following needs to be continued? a- Daily complete blood count (CBC) b- Laboratory tests for partial thromboplastin time (PTT) c- Strict Bedrest d- Wearing elasticized support stockings 89 307-A patient receiving a total parenteral nutrition through a central line suddenly has difficulty breathing and is restless. Chest auscultation reveals a heart murmur. Blood pressure 90/60 mmhg Heart rate 120/min Respiratory rate 22/min Temperature 37.1 C Oxygen saturation 90% on room air What is the most appropriate initial nursing action? a- Notify the physician b- Administer 100% oxygen by face mask c- Place patient in left side lateral decubitus d- Obtain stat blood glucose measurement 308-A 16 year- old boy fractured his right tibia and fibula during a football match. Eight weeks later, the fractures were successfully healed and the cast was removed. Which range- of- motion exercises would be most beneficial? a- Active b- Passive c- Combined d- Resistive 90 309- A 65 year- old woman who was diagnosed with hypothyroidism at the age of 45 is brought to the clinic by ambulance. On arrival, she had a severely decreased level of consciousness. Her breathing is shallow and irregular. The skin is cool, dry and pale. There is generalized non- pitting edema of all extremities and face. Blood pressure 70/40 mmhg Heart rate 60/min Respiratory rate 121 min Body temperature 35.5 C tympanic What is the most appropriate method to re-warm this patient? a- Warmed intravenous isotonic fluids b- Place the patient is a warm bath c- Apply heat packs to the head and neck d- Cover the patient with hospital blankets 310- The physician ordered a blood glucose test for the neonates the nurse knows the best site to puncture is usually: a- The lateral heel b- Anterior sole c- Finger tip d- Anterior scalp 91 311- The nurse is teaching a patient who was recently diagnosed with rheumatoid arthritis affecting the hands. Which of the following treatment should the nurse discuss with the patient at this time? a- Transcutaneous electric nerve stimulation (TENS) b- Iontophoresis c- Nonsteroidal anti-inflammatory drugs (NSAIDs) d- Synovectomy Problems A Altered tissue perfusion related to hypertension Fluid volume excess related to lower B extremity edema C Knowledge deficit related to disease process, hyper tension D Alternation in comfort related to chronic headaches The patient will Maintain blood pressure below 130/90 mmhg Not have signs of edema or unexpected weight gain Verbalize understanding of disease process, symptoms and medication management Report an absence of headaches each week 312-A patient has come to the clinic for follow- up one week after being discharged from the hospital for treatment of a hypertensive crisis. Blood pressure stabilized at 124/78 mm Hg. The patient reports feeling well, has no edema, no longer has daily headaches. Blood pressure is 156/90 mm Hg. During evaluation the patient admits to having stopped taking medication that had been ordered because headaches are no longer present. Unless the symptoms return, the patient states he will not be returning to the clinic. What should the nurse do? a- Resolve and discontinue the entire care plan per patient request, suggest psychology consult b- Resolve Band D; continue A and C c- Continue entire care plan as written d- Add a new problem to the care plan, non-compliance and interventions to determine potential reasons. 92 313- A 34 year- old quadriplegia patient resides at home with his wife. In order to prevent contractures of all extremities, the community care nurse will instruct the patient's wife in performance of: a- Active range of motion exercises b- Passive range of motion exercises c- Active- assistive range of motion exercises d- Resistive range of motion exercises 314-A six years- old patient has presented to the clinic with fever, malaise, and anorexia. The patient was treated 2 weeks ago for a streptococcal infection of the throat. The nurse should expect the physician to order what test? a- Electrocardiogram b- Jones test c- Spinal tap d- Heart biopsy 315-A 40 year- old woman presented with right hip pain. Palpation of the pelvic girdle is normal. An X- ray shows bone deformities, with osteolytic lesions and bone enlargement. The patient has not suffered any trauma and has been generally healthy. Which serum laboratory analysis would be most useful? a- Prothrombin time b- Alkaline phosphatase c- Acid phosphatase d- Parathyroid hormone 93 316-A client complains of itching about 20 minutes after he began his blood infusion, which of the following is the best nursing action his caring nurse must take: a- Stop the infusion immediately and call the physician b- Call the physician immediately and the stop the infusion c- Culminate the client and continue infusion d- Continue the infusion while monitoring the client closely 317- A 32 year- old woman with diabetes mellitus type 1 underwent a cholecystectomy and is now on day two of recovery. The patient's bowel sounds have returned and she has resumed a normal diet but has been finishing less than half of each meal on the tray. The nurse enters the room to perform a routine assessment and finds the patient confused and shaky Blood pressure 110/60 mmhg Heart rate 96/min Respiratory rate 22/min Temperature 37.0 Coral What is the most appropriate initial intervention? a- Administer glucagon b- Notify the physician c- Give an insulin injection d- Offer a glass of juice 318-A Cancer patient wants to stop chemotherapy and change to palliative care, this situation indicates which psychological status: a- Depression b- Hopelessness c- Anxiety d- Restlessness 94 319- What do we call the type of treatment of terminal illness patients? a- Conservative b- Curative c- Palliative d- Selective 320-Psychiatric patient appear violent for himself and others was put in the room alone during the period of exacerbation, then patient calm down and informed the nurse I am ok now let me with others, but the nurse refused that as a punishment way. At which underline Label will nurse accused under the court: a- Abandonment b- False imprisonment c- Negligence d- Duty to act 321- Which of the following actions is the first priority of care for a client exhibiting signs and symptoms of coronary artery disease? a- Decrease anxiety b- Enhance myocardial oxygenation c- Administer sublingual nitroglycerin d- Educate the client about his symptoms 322- What is the first intervention for a client experiencing MI? a- Administer morphine b- Administer oxygen c- Administer sublingual nitroglycerin d- Obtain an ECG 95 323-A patient complains of stable angina presented with chest pain. The physician ordered itroglycerine tablet sublingual. The nurse knows that the right dose to give the patient is: abcd- 0.1 mg 0.2 mg 0.4 mg 0.8 mg 324-Cancer patient during the shift and he surrounded by visitor and laughing loudly before the shift end patient call the nurse and asked for pain medication and said that his level of pain 8/10 (sever pain) patient appears not on pain, what is the best intervention for this situation: a- Give the patient extra dose of his pain medication b- Ask the patient about the last time he had his medication c- Ignore the patient as you are going to leave d- Check the patient's file for history of drug abuse 325-A patient with pain was prescribed Ibuprofen 300 mg q 4 hours PRN and morphine 5mg q 4 hours PRN. After 2 hours of receiving Ibuprofen the patient still complaining of pain, what is the best intervention: a- Wait 2 hours and give a second dose of ibuprofen b- Give the patient his dose of morphine c- Wait 1 hour and give the patient his morphine d- Ask the patient to bear the pain 326- Which instruction should a nurse give the parents of an infant undergoing cleft lip repair? a- Offer the pacifier as needed b- Lay the infant on his abdomen for sleep c- Sit the infant up for each feeding d- Loosen arm restraints every hour 96 327-Patient with abdominal incision, seven days postoperatively the patient has pain at the site of incision which increased by walking and the incision appear red and there's pus surrounding the incision site. This may indicate which of the following: a- Normal finding b- Inflammation of the incision c- Under nutrition d- Good indicator 328- A preschooler is admitted to the hospital the day before scheduled surgery. This is the child's first hospitalization. Which action will best help reduce the child's anxiety about the upcoming surgery: a- Begin preoperative teaching immediately b- Describe preoperative and postoperative procedures in detail c- Give the child dolls and medical equipment to play out the experience d- Explain that the child will be put to sleep during surgery and won't feel anything 329- Which teaching aid provided by the nurse is developmentally appropriate for a preschooler who is about to have a bone marrow puncture: a- Dolls or puppets b- Pamphlets or booklets c- Colored diagrams d- Commercial videotapes 330-A nurse is caring for an infant with spina bifida. Which assessment findings suggest hydrocephalus? a- Depressed fontanels and suture lines b- Deep-set eyes, which appear to look upward only c- Rapid increase in head size and irritability 97 d- Motor and sensory dysfunction in the foot and leg 331-Parents of a newborn with a unilateral cleft lip are concerned about having the defect repaired. The nurse explains that a child with a cleft lip usually undergoes surgical repair: a- Immediately after birth b- By 3 months of age c- After 12 months of age d- Varies in every case 332- The hepatitis B vaccine series should begin at what age: a- Newborn b- 2 months c- 6 months d- 12 months 333- A school age client admitted to the hospital because of decreased urine output and per-orbital edema and diagnosed with glomerulonephritis. Which of the following interventions would receive the highest priority: a- Monitoring the vital signs every 4 hours b- Monitoring intake and output every 12 hours c- Monitoring the client weight daily d- Monitoring serum electrolyte daily 334- The nurse is caring for a client with renal failure who is being treated with peritoneal dialysis. Which assessment before and after peritoneal dialysis is most valuable in evaluating the outcome of treatment: a- Pulse rate b- Body weight c- Abdominal girth 98 d- Urine output 335- Which finding provides the best evidence that peritoneal dialysis is achieving a therapeutic effect: a- Urine output increases b- Appetite improves c- Potassium level falls d- Red blood cell count is lower 336- When the nurse is advising the client about the potential complications associated with peritoneal dialysis, which complication is most important to include: a- Pulmonary edema b- Abdominal peritonitis c- Abdominal hernia d- Ruptured aorta 337- A client receiving hemodialysis treatment arrives at the hospital. He complains of shortness of breath, and pedal edema is noted. His last hemodialysis treatment was yesterday. Blood pressure 200/100 Heart rate 110/min Respiratory rate 36/m Oxygen saturation 890/0 on room air Which of the following interventions should be done first? a- Administer oxygen b- Elevate the foot of the bed c- Restrict the client's fluids d- Prepare the client for hemodialysis 99 338- Changes in personality and judgment are often associated with a lesion in which of the following: a- Frontal lobe b- Parietal lobe c- Broca's area d- Wernicke's area 339- Anterior lobe of the brain is responsible for which of the following: a- Personality b- Movement c- Speech d- Memory 340- A history of smoking, abnormal permanent enlargement of the alveoli, cough, and dyspnea suggest: a- Asthma b- Emphysema c- Chronic bronchitis d- Obstructive sleep apnea 341- Which of the following is the end of the first stage of labor: a- Cervix dilated to 10 cm b- Crowning of the presenting part c- Increased bloody show d- Contractions lasting up to 60 seconds 100 342- During the latent phase of the first stage of labor, how often should the nurse plan to assess the fetal heart rate? a- Every 5 to 15 minutes b- Every 15 to 30 minutes c- Every 30 to 60 minutes d- Every 60 to 90 minutes 343- The nurse explains that oxytocin (pitocin) is given after delivery of the baby and placenta for which purpose: a- To increase the blood pressure b- To prevent the uterus from inverting c- To decrease the likelihood of hemorrhage d- To prevent rupture of the uterus 344-A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery: a- The umbilical cord shortens in length and changes in color b- A soft and boggy uterus c- Maternal complaints of severe uterine cramping d- A sudden gush of dark blood from the introitus 345- Which vitamin deficiency increase the risk of neural tube defects: a- Folic acid b- Vitamin C c- Vitamin B12 d- Calcium 101 346-A client has been diagnosed with folic acid deficiency. The nurse's discharge teaching will focus on foods high in folic acid. Which of the following foods has the highest folic acid level: a- Citrus fruits b- Raisins c- Brewer's yeast d- Eggs 347- Which of the following is the recommended daily dose of folic acid during pregnancy: a- 200 meg b- 400 mcg c- 800 meg d- 1000 meg 348- Lochia normally disappears after how many days postpartum: a- 5 days b- 7-10 days c- 18-21 days d- 28-30 days 349- If the maintenance requirement of fluid for a child is 900 mil day, each daily feeding account 120 ml, what is the number of feeding is required to achieve this maintenance: a- 5 feedings b- 6 feedings c- 7 feedings d- 8 feedings 102 350- A 12 year- old patient had a cast removed from the left leg after wearing if for eight weeks. The patient wants to resume sports as soon as possible. In order to regain muscle strength lost while wearing cast, the nurse will instruct the patient in performance of: a- Resistive range of motion exercises to left leg b- Passive range of motion exercises to right leg c- Active- assistive range of motion exercises to the right leg d- Active range of motion exercises to both legs 351- A 31 years- old woman with diabetes type 1 presents to the clinic with fatigue, blurred vision, and loss of appetite. Her breath smells like fruit and she leaves the room twice during the examination to use the toilet. She has brought a little bottle of water with her that she finishes while at the clinic. She reports that she has had a cold for the past three days, but has not taken additional insulin during the illness Blood pressure 130/70 mmhg Heart rate 90/min Respiratory rate 20/min Body temperature 38.0 Coral What is the most appropriate nursing diagnosis a- Risk for impaired skin integrity related to circulation b- Deficient knowledge related to illness management c- Risk for fluid volume excess related to fluid intake d- Imbalanced nutrition related to decreased appetite 352- Adult patient suffers from hoarseness of voice, and difficulty in speech may be suffering from an injury of which of the following cranial nerves: a- IX c- XI b- X d- XII 103 353- The parent of a child with chronic asthma is hesitant to discipline because the child often doesn't feel well. The nurse should encourage the parent to: a- Set consistent behavior limits b- Be more lenient during times of illness c- Cherish the limited time the child has to live d- Avoid upsetting the child with limit- setting 354- A 55 year- old woman presented with pain in the joints of the hands. She feels generally tired and has had a low grade fever for the past week. On examination, the joints of the fingers on both hands are symmetrically swollen. Blood pressure Heart rate Respiratory rate Temperature Oxygen saturation 120/70 mmhg 82/min 18/min 38.0 C 99% on room air Which type of arthritis is most likely? a- Rheumatoid b- Septic c- Psoriatic d- Osteoarthritis 355- A patient presented to the office for a physical examination. The patient is found to be healthy and fit but occasionally drinks alcohol and has unprotected sex. What is the BEST nursing diagnosis? a- Health- seeking behavior b- Knowledge deficit, high- risk behaviors c- Low self- esteem d- Altered thought process 104 356- A seven year- old child presented to the emergency room with a fracture of the right arm. What would be the long- term goal for this patient? a- Patient verbalizes decreased pain level b- Nurse notes neurovascular checks are within normal limits c- Nurse notes decreased swelling of the right arm d- Patient performs activities of daily living without difficulty 357- The nurse is caring for a woman whose husband beats her regularly. Which is the most important long-term goal for this woman? a- Provide a long-term support group b- Help her feel like a survivor c- Point out the ways she behaved d- Be able to blame the abuser 358-ln what position should a dyspneic patient be placed? a- Prone b- Recumbent c- Semi-fowler's d- Trendelenburg 359-A nurse is admitting a two year- old child with an umbilical hernia. Which of the following interventions does NOT meet the child's developmental needs? a- Allowing the child to make choices when possible b- Providing rooming in the unlimited visitation c- Attempting to continue rituals used at home d- Maintaining strict bedrest 105 360- A six year- old boy is in the postoperative care unit following a tonsillectomy. The nurse observes that his gag reflex has returned and removes the artificial airway. The patient then begins to cry and tells the nurse that his throat hurts badly. What type of data is the patient providing the nurse? a- Objective b- Inferential c- Comparative d- Subjective 361-A first time mother of a three week- old breastfed baby brings the infant to the clinic and complains that her child has been forcefully vomiting after feeding. He was born 40 week's gestation. Weighing 3.6 kilograms. He is constantly hungry and irritable. Examination reveals a swollen abdomen and a palpable mass in the middle upper right quadrant. What is the most likely health problem? a- Intussusception b- Pyloric stenosis c- Gastroeosophageal reflux d- Diaphragmatic hernia 106 362-A home care nurse reviews the second follow- up laboratory test results of a patient with iron deficiency anemia. The nurse compares the recent laboratory results to the results taken 3 months ago. The patient has been eating food rich in iron as prescribed by the nutritionist. What can be inferred about the progress of the treatment by comparing the two laboratory values? Laboratory values three months prior Test Albumin Glucose HCT Hb Blood urea nitrogen Creatinine Current laboratory values Test Albumin Glucose HCT Hb Blood urea nitrogen Creatinine Result 35 5.3 0.32 121 6.1 60 Result 33 5.7 0.41 139 5.7 60 Normal value 34-56 g/L 3.5-6.5 mmol/L 0.41-0.50 120-140 g/L 2.8 to 8.9 mmol/L 58-145 µml/L Normal value 34-56 g/L 3.5-6.5 mmol/L 0.41-0.50 120-140 g/L 2.8 to 8.9 mmol/L 58-145 µmol/L a- Patient's uptake of iron by diet is sufficient, and no additional intervention is necessary b- Patient's uptake of iron by diet is sufficient, but additional intervention is necessary c- Patient's uptake of iron by diet is insufficient, and additional intervention is necessary d- Patient's uptake of iron by diet is insufficient, and the physician's immediate action is necessary 107 363- Which assessment finding would the nurse expect in an infant diagnosed with pyloric stenosis? abcd- Abdominal rigidity Ribbon-like stools Visible waves of peristalsis Rectal prolapse 364-A six year-old child with type 1 diabetes has an uncontrolled blood glucose level. The child has been given regular insulin with minimal change in glucose level in the first 30 minutes. Which type of insulin has an onset of 15 minutes and a duration of no more than 4 hours? a- Aspart (Novo log) b- Lispro (Humalog) c- Semilete d- Neutral protamine hagedom (NPH) Type of insulin Aspart (Novolog) Lipsro (Humalog) regular semilente NPH Lente Onset (minutes) 15 10-30 30-60 30-60 120 120 Maximal activity (hours) 1-3 1-2 2-4 2-4 4-12 8-10 Duration (hours) 3-5 2-4 6-9 10-12 24 24 365-A patient with cerebrovascular accident, left-sided hemiplegia, and aphasia has nursing diagnosis of risk for aspiration related to swallowing difficulties with a short-term goal that the patient will not aspirate. The patient has undergone insertion of a percutaneous gastric endoscopy and has all nutrition and fluid administered through the tube. The nurse should: a- Continue the care plan as written b- Discontinue the risk for aspiration diagnosis c- Revise the goals and interventions for the diagnosis 108 d- Add a nursing diagnosis of ineffective health maintenance 366-A nurse is evaluating a patient 5 days after a right total hip replacement. Which of the following goals is appropriate for the patient? a- Maintain abduction without dislocation b- Rest with legs elevated while sitting c- Tie shoes and put on undergarments without assistive devices d- Perform scissor-like exercises daily 367 - A three year- old child was admitted to the postoperative care unit following a heart transplant. The nurse administers cyclosporine by intravenous infusion. Fifteen minutes later the child has difficulty breathing, his skin feels cold and clammy and he appears restless. Which is the most appropriate initial nursing action? a- Ensure airway patency b- Administer oxygen therapy c- Discontinue intravenous infusion d- Administer intramuscular epinephrine 368- A 40 year-old woman is a gravida 2, para 2 and is currently trying to conceive. Her previous pregnancy resulted in the birth of a baby with cleft lip and palate. The patient is anxious and concerned about future pregnancies and the nurse provides genetic counseling and reassurance. Which food would most effectively prevent recurrence? a- Green vegetables and citrus fruit b- Eggs, milk and dairy products c- Wheat, corn, rice, oats and rye d- Beef, chicken and yellow vegetables 109 369- A 50 year-old woman presented with poor balance and coordination. She says that she has developed pain on the outer aspect of the thighs and the inner side of the arch of the foot. The nurse wishes to examine the integrity of the affected lumbar spinal nerve root and performs a deep tendon reflex examination. Which reflexes would most likely be diminished? a- Planter b- Brachioradialis c- Patellar d- Achilles tendon 370- When administrating an intramuscular injection to an infant, which of the following sites is appropriate for the nurse to use? a- Rectus femoris b- Deltoid c- Dorsogluteal d- Ventrogluteal 371- A 66 years-old woman is admitted to the hospital with a history of hypertension. She presented with breathing difficulties that worsen with activity and while sleeping. She is generally weak and feels that her heart misses beats and that it sometimes beats loudly. An electrocardiogram shows atrial fibrillation, right ventricular hypertrophy and deviation toward the right. Which nursing intervention is most appropriate for this patient? a- Provide a bedside commode (portable toilet) b- Place in right side-lying position c- Encourage family and friends to visit 110 d- Encourage independent hygienic activities 372- Oral iron supplements are prescribed for a 6-year-old child with iron deficiency anemia. The nurse instructs the mother to administer the iron with which of the following food item to enhance absorption of iron: a- Milk b- Water c- Apple juice d- Orange juice 373- 9 months old infant was brought to the hospital by his parents because he is crying most of the time. The examination revealed that he is suffering from otitis media. Which of the following instructions you would include in the care plan you suggest to the parents: a- Give antibiotic as prescribed b- Try to calm down your baby c- Wash the ears regularly d- Ignore the child's pain 374-A child with pneumonia was prescribed penicillin injection. Before giving the injection to the child the nurse performed skin allergy test which showed that the child has penicillin allergy. Which of the following is the next step the nurse should take: a- Stop the treatment and inform the doctor b- Administer penicillin intramuscular c- Postpone the does until the child is well d- Ignore the test result and give the injection 111 375- The following table represents the blood pressure value for a patient in 3 successive days. Regarding the information given in the tablet, this patient is considered: a- Normal blood pressure b- Pre-hypertension c- Hypertensive d- Hypotensive First day Second day 120/80 122/87 Third day 133/88 376-A patient with pneumonia with excessive mucous in the left lung, which of the following is the best position to facilitate drainage of the mucous from the lower left lung: a- On the right side with trendelenburg position b- On the left side with elevation of HOB c- On the right side with elevation of the HOB d- On the left side with trendelenburg position 377-A patient complains of left eye redness and itching, the doctor told you to put atropine eye drops for the patient to examine his eye. The nurse should instill the eye drops into: a- The left eye b- The right eye c- Both right and left eyes d- Neither of the eyes 112 378- The district nurse visits a 30 year-old woman at home following the delivery of her second child, a full term girl. Following the delivery of her first child, she had developed a breast infection and stopped breastfeeding because of the pain. She asks the nurse how she can best prevent it with this infant. What is the most appropriate response? a- Provide feeding on demand b- Apply vitamin E cream to the nipples c- Request a prophylactic antibiotic d- Apply heat to the breasts after feeding 379- In planning home care for an immunocompromised child, the nurse instructs the parents to use cream or emollients to prevent or manage dry and cracked skin. A parent will BEST demonstrate understanding of the rationale for this be stating: a- Creams will prevent breaks in the skin and decrease the chance of infection b- Pleasantly scented creams will mask other less pleasant smells c- Micronutrients in the creams will help prevent malnutrition d- Creams will help prevent dehydration when my child does not drink enough 380- The nurse is teaching a patient about spironolactone (Aldactone). Which of the following instructions should review with the patient? a- Increasing the intake of foods that are high in potassium b- Taking the medication right before going to sleep c- Avoid seasonings that are labeled as salt substitutes d- Scheduling the medication so that a multivitamin is taken an hour later 113 381- A 49 year-old man with a diagnosis of alcoholic cirrhosis and ascites is discharged from the hospital with a priority nursing diagnosis of altered nutrition, less than body requirements. Which dietary plan is most appropriate? a- Low-protein, low sodium b- Low sodium, high- protein c- High- protein, low potassium d- Low potassium, high protein 382-A patient who is 4 days postoperatively after a total hip replacement surgery, is obese and has not been able to ambulate since the surgery. The patient is now diaphoretic, has chills, and complains of pain in the thigh. The MOST likely cause is: a- Wound infection b- Deep vein thrombosis (DVT) c- Pulmonary edema d- Dehydration 383- Which statement by the patient with hyperlipidemia shows a basic understanding of the disease and its treatment? a- Exercises has no effect on cholesterol levels b- Hyperlipidemia is usually asymptomatic until significant target organ damage is done c- HDL cholesterol level of greater than 60mg/dL increases the chance of coronary artery disease d- Cholestyramine (questran) should be taken in the morning with other medications 114 384- Which of the following describe the correct sequence of nursing process: a- Assessment, planning, diagnosis, implementation and evaluation b- Planning, assessment, diagnosis, implementation and evaluation c- Planning, diagnosis, implementation, assessment and evaluation d- Assessment, implementation, evaluation, planning and diagnosis 385-A 14 year-old boy presented to the emergency department. He complains of having progressively worsening stomach pain for the past eight hours. On assessment, the pain is localized in the lower right quadrant. He rates it as a level ten on the one-ten pain scale. Abdominal palpation shows rebound tenderness in the lower right quadrant, and positive McBurney and psoas signs. Blood pressure 134-78 mmhg Heart rate 88/min Respiratory rate 24/min Temperature 38.2 C Test result normal values WBC 12.4 4-10.5 X 109 Which intervention would be most appropriate to alleviate this patient's pain? a- Apply warm packs to affected area b- Maintain semi-fowler's with legs up c- Withhold solids and liquids d- Administer analgesics 115 386-Female patient with a diagnosis of atrial fibrillation, the physician ordered you to give her digoxin IV, but the patient refused to be injected and told that she feel she is going to vomit, what you should do: a- Change the IV digoxin to oral form b- Force the patient to accept the medication c- Inform the doctor about the situation d- Don't give any medications to this patient 387-40 years old client complaining from abdominal pain, laboratory result for stool analysis showed that there's occult blood in the stool. Which of the following procedure would help for diagnosis of this patient: a- Abdominal ultrasound b- Abdominal x ray c- Colonoscopy d- MRI 388-A 7-year-old client is brought to the E.R. He's tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and a nonproductive cough. He recently had a cold. From his history, the client may have which of the following: a- Acute asthma b- Bronchial pneumonia c- Chronic obstructive pulmonary disease (COPD) d- Emphysema 389- Which of the following is a priority goal for the client with COPD: a- Maintaining functional ability b- Minimizing chest pain c- Increasing carbon dioxide levels in the blood d- Treating infectious agents 116 390- A 34-year-old woman with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. Based on these findings, what action should the nurse take to initiate care of the client: a- Initiate oxygen therapy and reassess the client in 10 minutes. b- Draw blood for an ABG analysis and send the client for a chest x-ray. c- Encourage the client to relax and breathe slowly through the mouth d- Administer bronchodilators 391- Which of the following is the best breathing pattern you should teach a client with COPD: a- Pursed-lip breathing b- Deep breathing c- Abdominal breathing d- Slow lite breathing 392-A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: a- Promote oxygen intake b- Strengthen the diaphragm c- Strengthen the intercostal muscles d- Promote carbon dioxide elimination 117 393-An infant with tetralogy of Fallot is experiencing an attack involving cyanosis and dyspnea. Which position should the infant be placed in: a- Fowler's b- Knee-chest c- Trcndelcnburg's d- Prone 394-A client is unresponsive and has been brought to the emergency department. Initial laboratory results reveal: Serum K + 3.6 mmol/L Glucose 26 mg/dl Hemoglobin 12. 6 gm/dl Carbon dioxide 26. 2 mmol/L. The nurse will anticipate: a- Dextrose by mouth b- 50% dextrose IV c- 1 unit of packed cells d- 10 mEq of KCl over 0.5 hour 395- When a client has a nephrostomy tube, the priority nursing care is to: a- Ensure drainage of urine b- "Milk" the tube every 2 hours c- Keep an accurate record of intake and output d- Instill 2 ml of normal saline solution every shift 118 396- Which of the following is the most common symptom of myocardial infarction (MI): a- Chest pain b- Dyspnea c- Edema d- Palpitations 397- A client has surgery for a perforated appendix with localized peritonitis. In which position should the nurse place the client: a- Sims position b- Trendelenburg c- Semi-fowlers d- Dorsal recumbent 398- Which of the following position should the client with appendicitis assume to relieve pain: a- Prone b- Sitting c- Supine d- Lying with legs drawn up 399-A women breast feed her infant for one or two hours and her infant cries most of the time and she feels pain in her breast, which of the following instructions are appropriate for the nurse to give the mother: a- Regulate breast feeding every 3 hours b- That's normal feeding problem c- Shift to bottle feeding d- Start weaning your baby 119 400- While caring for a child with a ventriculoperitoneal shunt revision, the nurse finds the patient lying with the head and feet flexed back. The nurse should call for help and prepare for a (n): a- Spinal tap b- Shunt culture c- Electrocardiogram d- Ventricular tap 401- While assessing a child with pulmonary stenosis, the nurse should give PRIORITY to: a- Deep tendon reflexes b- Urinary output c- Exercise tolerance d- Pattern of food intake 402- A 25 years-old male patient suffered a spinal cord injury at the T -4 level and is being cared for in hospital. The nurse enters the patient's room and finds the patient sitting upright and looking anxious and restless. He complains of sudden headache and nausea. Sweat forms on his forehead yet his feet are cool to touch Blood pressure 150/100 mmhg Heart rate 55/min Respiratory rate 28/min Temperature 37.1C What nursing intervention is initially most appropriate? a- Assess for a full bladder b- Lower the head of the bed 30 degrees c- Loosen clothing and bed sheets d- Apply heating pad to lower extremities 120 403- An 80 year-old man presents to the hospital with chronic fatigue, dyspepsia and constipation. On examination he is jaundiced, has red palms, dilated veins around the umbilicus, the abdomen is very distended and he has black, tarry stool on a rectal exam. He is noted to be lethargic and have a flat tone. A paracentesis reveals clear colored fluid with low protein content. What is most likely diagnosis? a- Gilbert's syndrome b- Thalassemia c- Sickle cell crisis d- Cirrhosis 404Admission Report at 22:4500:45 .m. Diagnosis 14 years old Remains febrile, maximum temperature this Bacterial admitted shift 39.3C pneumorua 18 hours ago Respiration rate 12-14 per minute Heart rate 100-180 per minute Blood pressure level within baseline normal range Next dose of intravenous anti-infective is due at 08:00 (8:00 a.m.) Refer to the accompanying figure. The nurse should plan to monitor which of the following at least every 4 hours? a- Vital signs b- Urinary output c- Food intake 121 d- Level of activity 405- Which instruction take priority in reducing anxiety related to surgery? a- Surgical procedure and postoperative exercises b- Risk of infection after surgery c- Advanced directive and what it means d- Pre-operative laboratory result and what to expect on it 406- When caring for a patient with an ostomy, the nurse knows that extra protection for peristomal skin is MOST important for those patients with a (an): a- Ileostomy b- Ascending colostomy c- Transverse colostomy d- Sigmoid colostomy 407- Which of the following nursing diagnosis takes PRIORITY for a patient admitted to the critical care unit with diabetic ketoacidosis? a- Deficient fluid volume secondary to hyperglycemia b- Risk of infection secondary to weakened immune system c- Deficient knowledge of cause and prevention d- Imbalanced nutrition related to hyperglycemic state 122 408-A 69 year-old man is admitted to the intensive care unit following cardiac surgery. Two hours after admission, the nurse performs a routine assessment and notes the patient's chest tube drainage is 200 milliliters and a dark red color. He has had 60 milliliters output from the indwelling urinary catheter Blood pressure 138/68 mmhg Heart rate 76/min Respiratory rate 16/min Body temperature Oxygen saturation 37.0C oral 94% 6L/min nasal cannula Which finding should be reported to the doctor? a- Dark red chest tube drainage b- Urinary output c- Oxygen saturation d- Chest tube output volume 409- To minimize a toddler from scratching and picking at healing skin graft, the nurse should utilize: a- Mild sedatives b- Hand mittens c- Punishment for picking d- Distractions 123 410- The following pain medications are ordered for a patient who had a right leg amputation: Oxycodone 5 mg every 4 hours as needed and morphine 5 mg every 4 hours as needed. The nurse administered oxycodone 2 hours ago, but the patient reports pain rated 8 on a scale of 0 (no pain) to 10 (severe pain) as the dressing change begins After evaluating the effectiveness of the pain medication, what action should the nurse take? Blood pressure Heart rate Respiratory rate Temperature 169/98 mmhg 112/min 22/min 36.7C a- Administer additional oxycodone 5 mg b- Administer morphine 5 mg c- Change the dressing quickly d- Ask the patient to wait 2 hours 411-A 55 year-old man presented to the clinic with complaints of numbness and tingling in his feet for the past 3 months. He appears thin and his skin is pale. Examination confirms the loss of vibration sense. He also has altered proprioception. He had a subtotal gastrectomy two years ago (see lab results) Test MCH HCT 0.31 MCV Reticulocyte count result 2.72 normal values 1.45-2.01 fmol/cell 0.41-0.50 81-97 fl 0.5%-2.50/0 105 1.5 Which supplement would most likely improve his condition? a- Iron b- B12 c- Folate d- Calcium 124 412-A 35 year-old man is hospitalized following a blunt chest injury. He has chest pain, breathing difficulty and asymmetrical lung expansion. Chest auscultation reveals decreased lung sounds on the left side. The jugular veins are distended and there is tracheal deviation to the right. Blood pressure 92/54 mmhg Heart rate 120/min Respiratory rate 24/min Temperature 36.2C SaO2 88% on oxygen Which initial intervention is most appropriate? a- Send patient for X-ray examination b- Administer bronchodilators c- Administer intravenous fluid bolus d- Prepare for needle decompression 413-A patient is being followed in the clinic for hypertension, adult onset diabetes, and obesity. The patient is apathetic about learning about nutritional guidelines to reach the goals of weight loss and consumption of a healthy diet. The patient admitted to eating "whatever is put in front of me" Which of the following actions would the nurse take? a- Collaborate with the patient to set goals b- Add a nursing diagnosis of non-compliance c- Refer for psychiatric screening for depression d- Discuss nutritional interventions with the spouse 125 414- The nurse is measuring the chest tube drainage of a patient who had open heart surgery 4 hours ago. Which of the following is the MAXIMUM hourly amount of chest tube drainage is expected in this timeframe? a- 100 ml b- 200 ml c- 300 ml d- 400 ml 415-A nurse is caring for a three year-old child with a fractured arm. Which of the following interventions is the MOST appropriate for pain management? a- Administer analgesics when necessary b- Assess pain once a shift c- Anticipate pain and intervene early d- Encourage the use of self-quieting techniques 416-After a hearing restoration operation, a patient has no signs of complications and soon recovers. Which of the following is an expected outcome 5 days after the hearing restoration surgery? a- Regain full hearing b- Minimal facial nerve paralysis c- Minimal urinary incontinence d- Ambulates without difficulty 126 417A B C D E F G Goals for the next three months, the patient with: Not have any migraine headaches Decrease the number of migraine headache Learn to tolerate her migraine headaches Continue to take prescribed preventative medications daily Initiate complementaty pain management strategies as needed Wean self from all pain medications Keep a pain diary and recognize triggers and auras before migraine headache commence An adolescent patient with a history of migraine headaches for the past year has been followed for pain management. The headaches have decreased in severity and now occur only occasionally What are the BEST three long term goals? a- A, D,F b- B, D, F c- C, E, F d- D, E, G 418-A community health nurse visits a patient who had a cerebrovascular accident. The patient is at risk for deficient fluid volume due to voluntary reduction of fluid intake to avoid the use of the bathroom. The nurse educates the patient on the importance of drinking fluids and maintaining hydration/ Which of the following indicates the efficacy of the nursing intervention? a- Amber color urine b- Respiration of 35 c- Tacycardia d- Moist mucous membrane 127 419-A patient with diabetes mellitus and multiple sclerosis has been prescribed baclofen (Lioresal). The nurse knows this medication may result in? a- Increased insulin needs b- Renal failure c- Optic neuritis d- Muscle tremors 420- A B C D E F Nursing diagnosis Impaired physical mobility Activity intolerance Alternation of comfort Risk of alternation in skin integrity Knowledge deficit Decreased cardiac cutout A patient with Alzheimer's disease and severe cardiomyopathy presents to the hospital with a fractured left hip. The patient is on bed rest until a cardiologist clears the patient to have surgery. Which nursing diagnosis have the highest priority? a- E and F b- D and C c- C and F d- D and F 128 421-A 19 year-old woman telephones the nurse and complains of difficulty of breathing. The symptoms developed while exercising that morning. She has a productive cough with thick mucus secretions and wheezing. The nurse hears that the breathing problems do not interfere with talking on the phone. The woman plans to attend the clinic but must wait for two hours before she can be driven there. Which treatment should be recommended first by the physician? a- Purse-lip breathing b- Deep breathing and coughing c- Decrease physical activity d- B2 agonist administration 422- A patient is recovering from surgery using spinal anesthesia. The patient developed a spinal headache. Which of the following nursing actions would be MOST appropriate? a- Elevate the head of the bed 30 degrees b- Keep the patient well hydrated c- Limit intake of salty foods d- Lower the temperature of the room 423-A patient is preparing for a total knee replacement. During the preoperative interview process the patient reports an allergic reaction to penicillin. Which of the following is considered a side effect and not a true allergy to medication? a- Shortness of breath b- Tingling lips and tongue c- Rash d- Upset stomach 129 424-Prior to providing care for a hospitalized infant, the nurse who focuses on preventive measures must: a- Introduce self to parents b- Perform hand hygiene c- Have a witness present d- Assess the child's developmental level 425- As identified by Dr. Elizabeth Kubler-Ross, which stage of dying is characterized by the transition from, "NO, not me" to "Yes, me, but ... " a- Anger b- Depression c- Acceptance d- Bargaining 426- A 50 year-old male presents to the medical office 3 weeks after cardiac surgery with complaints of a feeling of weakness, difficulty breathing, and joint pains. Upon examination the nurse finds a fever and a friction rub on auscultation of the chest. The nurse recognizes that the MOST likely surgical complication is: a- Neuropsychological dysfunction b- Postpericardiotomy syndrome c- Cardiac tamponade d- Phrenic nerve damage 130 427-A patient with heart failure has the following vital signs, which of these vital signs should be reported to the physician prior to administrating the next dose of digoxin? Blood pressure 136/84 mmhg Heart rate 48/min Respiratory rate 20/min Temperature 37.1C a- Blood pressure b- Pulse c- Temperature d- Respiratory rate 428- The floating ribs that are not attached with sternum are: a- Ribs 7&8 b- Ribs 9&10 c- Ribs 11&12 d- Ribs 9&10&11&12 429-A pediatric nurse is providing medication instructions to the mother of a 13 year-old boy who is starting anti-depressant therapy. The mother appears unfocused, agitated and confused and asks the nurse to repeat the instructions several times. She tells the nurse that she is concerned that she might administer the medication incorrectly. The nurse is concerned that the mother is not following the instructions. Which intervention would be most appropriate? a- Reassure her that doubts are normal b- Reinforce the importance of correct dosage c- Refocus the teaching with printed material d- Take a small break and the continue 131 430-A child is treated for superficial (first-degree) thermal burns to the thigh. The child is in great discomfort and does not eat. Which of the following diagnosis should receive PRIORITY? a- Altered nutrition b- Impaired skin integrity c- Risk of infection d- Acute pain 431-A 3-week-old infant is hospitalized with jaundice. When considering the fluid needs relative to body size of the infant as compared to the fluid needs of an adult. The nurse knows this infant requires: a- Less fluids b- More fluids c- Same amount of fluids d- Much less fluids 432- Which of the following statement is most accurate? a- Girls have more ADHD than boys b- Boys are more frequently diagnosed with chronic illnesses c- Boys are less frequently diagnosed with chronic illnesses d- Girls have more other chronic illness than ADHD 132 433- What is the percentage of boy with attention deficit hyperactivity disorder? a- 12% b- 16% c- 8% d- 4% 434- The nurse is observing a detailed neurological assessment on a client with a suspected brain tumor. When performing the Romberg test, the client sways when the eyes are both open and closed. What does this indicate? a- The problem is probably in the cerebellum b- It is a position sense abnormality c- This is not an abnormal test result d- The client has lost proprioception 435-An 18 year-old woman who broke her right ankle is seen in the physician's office one week after the cast was removed. Which of the following is the short term goal for this patient? a- Walk 100 feet with crutches b- Walk completely independent c- Relieve the pain 133 d- Strict bedrest 436-A client with multiple sclerosis has been prescribed the drug baclofen (Lioresal). What is the action of this drug? a- Reduces spasticity b- Skeletal muscle relaxation c- Immune suppression d- Prevents viral infections 437- What is the average incubation period of Hepatitis A? a- 30 days b- 60 days c- 50 days d- 14 days 438-After the health care team meets to discuss the client's nursing needs, the nursing diagnosis "Disturbed body image" is added to the care plan. The best rationale for adding this nursing diagnosis to the care plan in the case of a female is that females with Cushing's syndrome typically experience which physiologic effect? a- Masculine characteristics b- Heavy menstrual flow c- Extreme weight loss d- Large, pendulous breasts 134 439- A 64-year-old client with uterine cancer is scheduled to undergo an abdominal hysterectomy under general anesthesia. Before the client returns from the postanesthesia care unit, the registered nurse asks the licensed practical nurse to help revise the care plan for the client who has undergone a hysterectomy. Which nursing diagnosis is most appropriate for the nurse to add to the client's care plan at this time? a- Risk for ineffective airway clearance b- Risk for imbalanced nutrition c- Ineffective coping d- Impaired verbal communication 440- The nurse initiates a teaching plan for the client with Parkinson's disease. Which instruction should be the nurse's priority in this situation? a- Steps to enhance the client's immune system b- Importance of maintaining a balanced diet c- Need to remove all safety hazards d- Importance of social interactions 441- The charge nurse enters the nursing diagnosis "Risk for ineffective airway clearance related to an inability to swallow" on the client's care plan. Which nursing intervention is most appropriate for managing the identified problem? a- Keeping the client supine b- Removing all head pillows c- Performing oral suctioning d- Providing frequent oral hygiene 135 442- The client has returned from surgery with a leg cast, and the nurse is assisting the client back to bed. Which of the following would the nurse identify as the highest priority when documenting the postoperative circulation status of the recently casted extremity? a- Adequate neurovascular functioning b- Minimal pain on movement c- Vital signs within normal limits d- No drainage noted on the case 443-After X-rays are taken of the head, neck, and spine, the client is diagnosed with a head injury and admitted for inpatient care. When assessing the client with a head injury, which of the following should receive priority attention? a- Lung sounds b- Clarity of speech c- Mobility of fingers d- Pupillary responses 444- The client experiencing a severe allergic reaction becomes pulseless. The nurse shakes the client, shout the client's name but gets no response, and activates the emergency medical response system. Which nursing action becomes the next priority? a- Administer a single blow to the sternum b- Give two quick breaths that make the chest visibly rise c- Begin chest compressions at a rate of 100 per minute d- Administer an epinephrine (Adrenalin) injection 136 445-A 50-year-old client is scheduled for a heart transplant tomorrow. The night nurse is asked to review the surgical procedure with the client. Because of the client's anxiety, the client has difficulty comprehending the nurse's information. During the postoperative period, what is the best rationale for the nurse frequently assessing the client's fluid status? a- Urine retention is common after a heart transplant b- Urine output is an indication of perfusion to the kidneys c- Hydration determines when the client needs to be transfused d- Hydration indicates when fluids should be increased 446-A nurse is assigned to care for a patient with a diagnosis of thrombotic stroke. The nurse knows that this type of stroke is MOST LIKELY caused by: a- Blockage of large vessels as a result of atherosclerosis b- Emboli produced from valvular heart disease c- Decreased cerebral blood flow due to circulatory failure d- A temporary disruption in oxygenation of the brain 447-A nurse obtains a urine dipstick analysis sample from a 35 year-old woman who reports having burning sensation with urination and a sense of urgency and frequency. She had been diagnosed with the condition six months previously and was prescribed a course of antibiotics. Urinal sis Colour Odour Appearance Leukocyte esterase Nitrites Results Dark yellow Abnormal Turbid Positive Positive Normal values Straw-coloured Almost nothing Clear Negative Negative Which type of pharmacological treatment is most likely? a- Anti-viral b- Anti-fungal c- Anti-bacterial d- Anti-parasitic 137 448- A 30 year-old woman has been prescribe albuterol PRN and prophylactic inhaled corticosteroids to be taken once per day. She has been taking the prophylactic as prescribed but has needed to use albuterol more often than usually. She has a chronic cough and often has air hunger. Which intervention is initially most appropriate? a- Refer for a chest X-ray b- Administer magnesium sulfate c- Assess peak flow measure d- Perform arterial blood gas sampling 449- Which of the following drugs is not used in the treatment of pulmonary embolism? a- Heparin b- Warfarin c- Digoxin d- Streptokinase 450-A home care patient with chronic obstructive pulmonary disease (COPD) reports an upset stomach. The patient is taking theophylline (Theo-Dur) and triamcinolone acetonide (Azmacort), The nurse should instruct the patient to take: a- Theo- Dur on an empty stomach b- Theo- Dur and Azmacort at same time c- Theo- Dur and Azmacort 12 hours apart d- Theo-Dur with milk or crackers 138 451-A 65 year-old woman presented to her care provider with complaints of bright red blood in the stool, a loss of appetite, a feeling of fullness and fatigue. She had lost 5 kilograms in the past three weeks without dieting. A faecal occult blood test is positive and the patient is scheduled for additional screening test. Which screening test is most likely for this patient? a- Barium enema b- Colonoscopy c- Endoscopy d- Computed tomography scan 452-A baby girl was born prematurely at 33 weeks gestation due to placenta abruption. She is now two months old and has a potential hearing deficit. In the neonatal intensive care unit (NICU) she had passed the initial screening tests for hearing but has significant risk factors that suggest further evaluation. Which autonomic reflex should be further evaluated? a- Moro b- Babinski c- Pupillary d- Tonic neck 453-A 45 year-old woman presented with a generalized rash that is not itchy. She reports that she has had the problem for the past 15 years. Examination reveals a well-outlined, reddish plaque over the right gluteal fold. The plaque has scales over it and is cracked in some areas. Which intervention is initially appropriate? a- Apply topical cream to the affected area b- Expose area to sunlight for twenty minutes daily c- Maintain immunosuppressant therapy regimen d- Increase dietary intake of vitamin A 139 454- The patient is receiving mechanical ventilation set at fraction of inspired oxygen (FiO2) 100%. The nurse should understand that which of the following can improve this patient's oxygenation? a- Adding positive end expiratory pressure (PEEP) b- Place the patient in trendelenburg position c- Increasing the FiO2 d- Suctioning the patient hourly 455-A nurse is caring for a 3-week-old infant who just admitted to the hospital. Which of the following nursing interventions does NOT support this infant's basic emotional and social needs? a- Provide for continual contact between parents and infant b- Actively involve parents in caring for the infant c- Keep the infant's environment quite, dim and free of sensory stimulation d- Foster infant-sibling relationships as appropriate 456-A community health nurse is teaching a health class about infectious diseases process. The nurse instructs the class that rabies would be considered which of the following type of infection? a- Viral b- Protozoan c- Fungal d- Bacterial 140 457-A couple who wants to conceive but has been unsuccessful during the last 2 years has undergone many diagnostic procedures. When discussing the situation with the nurse, one partner states, "We know several friends in our age group and all of them have their own child already, why can't we have one?" Which of the following would be the most pertinent nursing diagnosis for this couple? a- Fear related to the unknown b- Pain related to numerous procedures c- Ineffective family coping related to infertility d- Self-esteem disturbance related to infertility 458- A 64 year old male client with a long history of cardiovascular problem including hypertension and angina is to be scheduled for cardiac catheterization. During pre-cardiac catheterization teaching, the nurse should inform the client that the primary purpose of the procedure is: a- To determine the existence of CHD b- To visualize the disease process in the coronary arteries c- To obtain the heart chambers pressure d- To measure oxygen content of different heart chambers 459- A gravida 3 para 2 is admitted to the labor unit. Vaginal exam reveals that the client's cervix is 4cm dilated. The patient complains of pain which she stated to be 7/l0.at this time and until a full cervix dilatation is achieved, what is the priority nursing goal for such patient at this time is: a- Pain management b- Prevent fetal distress c- Preparing the patient for anesthesia d- Keeping this patient NPO 141 460-A client with iron deficiency anemia is scheduled for discharge. Which instruction about prescribed ferrous gluconate therapy should the nurse include in the teaching plan? a- "Take the medication with an antacid." b- "Take the medication with a glass of milk." c- "Take the medication with cereal." d- "Take the medication on an empty stomach." 46l-After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not strong enough to dilate the cervix. Which of the following would the nurse anticipate doing? a- Obtaining an order to begin IV oxytocin infusion b- Administering a light sedative to allow the patient to rest for several hour c- Preparing for a cesarean section for failure to progress d- Increasing the encouragement to the patient when pushing begins 462-A 24 year-old woman was prescribed loratidine (Claritin) 10 mg tablet q 12 hours a.c. for allergy. The nurse reviews the medication order and explains to the patient the relation of this drug to meals is as following: a- The drug is to be taken after meals b- The drug is to be taken during meals c- The drug is to be taken before meals d- The drug is to be taken away from meals 142 463-An elderly client is experiencing an alteration in his equilibrium and coordinated muscle movements. The nurse realizes that these functions are controlled by which area of the nervous system? a- Brain stem b- Cerebrum c- Diencephalon d- Cerebellum 464-A 32-year-old female is admitted for a hemorrhoidectomy. During the nursing assessment, all of the following factors are elicited. Which one is most likely to have contributed to the development of hemorrhoids? a- The client states that she usually cleans herself from back to front after a bowel movement b- The client says her mother and grandmother had hemorrhoids c- The client has had four pregnancies d- The client eats bran every day 465- A client who has hepatitis A asks, "How could I have gotten this disease?" what is the nurse's best response? a- You may have eaten contaminated food b- You could have contracted the disease by using intravenous drugs c- You must have received and infected blood d- You could have contracted the disease by engaging in unprotected sex 466-A client undergoes right mastectomy for carcinoma. When teaching the client post-mastectomy exercises, it is important for the nurse to: a- Exercise both arms simultaneously b- Exercise the right arm only c- Have the client wear a sling between exercise periods d- Wait until the incision has healed 143 467- The following picture represents a newborn reflex known as? a- Rooting reflex b- Moro reflex c- Grasping reflex d- Startle reflex 468- The nurse is caring for a client who has had a right modified radical mastectomy this morning. Which exercise should the nurse encourage the client to perform this evening? a- Hair combing exercises with the right arm b- Wall climbing exercises with the right arm c- Movement of the fingers and wrists of the right arm d- Exercises of the left arm only 469- A 38-year-old client who has mitral stenosis is hospitalized for a valve replacement. Which condition is the client most likely to report having had earlier in life? a- Meningitis b- Syphilis c- Rheumatic fever d- Rubella 144 470-An 82-year-old woman who has Alzheimer's disease is admitted to the acute care unit. She frequently gets out of bed and wanders in the hall, unable to find her way back to her room. She even gets in the beds of other clients. What nursing action is most appropriate for this client? a- Restrain her so she will not wander in the halls b- Ask her roommate to call the nurse whenever she leaves the room c- Punish her when she gets in a bed other than her own d- Put her favorite picture on the door to her room a- 471-A 35-year-old man is admitted with severe renal colic. The nurse should monitor this man for possible complications. Which of the following is a Oliguria complication of renal colic? b- Anemia c- Polyuria d- Hypertension 472-A nurse discusses high-risk complications with a group of women at a prenatal clinic. Which client would the nurse identify as being at highest risk for developing complications during pregnancy? a- A 25-year-old gravida I client b- A client with the placenta implanted on the fundus of the uterus c- A client who has nausea and vomiting during the first trimester d- A 30-year-old client with DM 145 473-A 56 year-old man was brought to the emergency room by his relatives, on examination he appears sick and has severe weakness. One of his relatives told the nurse that the man eats nearly nothing and have been crying most of the time for 3 months now since he lost his son in an accident. The nurse knows that this patient is suffering from: a- Mania b- Insomnia c- Depression d- Schizophrenia 474- Which of the following drugs is used for the treatment of digitalis toxicity? a- Protamine sulfate b- Streptokinase c- Theophylline d- Digoxin immune Fab 475-A female client is admitted with a diagnosis of acute renal failure. She is awake, alert, oriented, and complaining of severe back pain, nausea and vomiting and abdominal cramps. Blood-pressure Pulse 110 Respiratory rate Temperature Sodium Potassium 100/70 mm Hg 30 38°C oral 120 mEq/L 5.2mEq/L Urinary output for the first 8 hours is 50 ml The client is displaying signs of which electrolyte imbalance? a- Hyponatremia b- Hyperkalemia c- Hyperphosphatemia d- Hypercalcemia 146 Some important notes to remember Renal failure - acute: low protein, high carbohydrate, low sodium (oliguric phase), high protein, high calorie, restricted fluid (diuretic phase) Renal failure - chronic: low protein, low sodium, low potassium Normal color of stoma (colonostomy): pink or red Teething starts at: 7 months and till 16 months After Laparoscopic cholecystectomy: patient regain normal activity after 12-14 days After renal surgery the most common complications: DVT Typhoid: transmission (contact) - isolation (contact isolation) Food rich in vitamin C: orange, Broccoli, strawberries, tomato MRSA isolation: contact Complication of hemorrhoidectomy: infection and thrombosis HCV transmitted by: blood Test to assess anemia patient: ferritin and hemoglobin Psoriasis takes the shape of: scales Normal capillary refill: less than 3 seconds Child has limb swelling and ascites, the main cause of swelling: Increased hydrostatic pressure Sign of malnutrition for child: open fontanel, low weight for his age 147