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1. A 40-year old client who is 20 weeks gestation has had an amniocentesis. Which of these findings, if present, requires immediate intervention?
The client reports vagina bleeding
the client describes mild intermittent, Braxton Hicks contraction
the lab results revealed some chromosomal abnormalities
the amniotic fluid contains fine languo hair
2. The mother of a two month old tells a nurse that the baby is consuming 6 ounces of plain commercial formula seven times a day, plus one ounce of cereal in the morning and at bedtime. Based on this information, the nurse should conclude that the babies diet is
too high in iron content
deficient in calcium
insufficient for the babies age and weight
too high in calories
3. The nurse give instruction to a client that needs to continue wound irrigations at home. Which of these actions, if observed by the nurse, would require further instructions?
The client irrigates the wound slowly and steadily, flushing away drainage and debris.
The client places a waterproof pad beside the wound before removing the dressing.
The client dons sterile gloves, and then opens a sterile syringe and solution container.
The client irrigates the would until the solution draining into the basin is clear.
4. When teaching a client that has been discharged with orders to continue with dressing changes, the nurse include which of these measures?
Demonstrating good hygiene technique.
Discussing surgical asepsis.
Describing the process of sterilization.
Demonstrating proper gloving technique.
5. A newly admitted client touches other clients on the head, speaks rapidly, wears several layers of clothing, and laughs continuously. Which of these manifestations should the nurse focus on first?
The clients’ dress.
The client’s affect.
Touching other patients on the head.
Rapid speech.
6. Which statement made by a client taking a diuretic, would the nurse recognize as indicative of the need for additional instructions?
“I eat one or two bananas every day.”
“I take all of my medications at bedtime, so I don’t forget them.”
“I weigh myself every day in the morning.”
“I will call my doctor if I have muscle weakness.”
7. A client has the following order for the regular insulin on a sliding scale:
Blood sugar 150-18 mg: Give 2 units regular insulin
Blood sugar 181-200 mg: Give 4 units regular insulin
Blood sugar 201-220 mg: Give 6 units regular insulin
Blood sugar above 220 mg: Call healthcare provider
At 11 A.M., the nurse obtains a finger stick glucose of 198 mg. The only syringe on hand is a three milliliter one. Regular insulin is available as 100 units per milliliter. How many milliliters should the nurse administer?
40
0.4
4
0.04
8. The nurse is monitoring a client that taking acetylsalicylic acid 975 mg daily for adverse effects, which include
Increased serum calcium levels.
Increasing heart failure.
Loss of joint mobility.
Occult blood in the stools.
9. When discussing the effects that drugs have on the brain, it is important for the nurse to understand whether these drugs enter the brain through which of these factors?
Electrical stimulation.
The brain tissue.
The blood-brain barrier.
Glucose-carrying cells.
10. The client is taking sublingual nitroglycerin. Which of these statements, if made by the client, indicates a need for additional teaching?
I know I should call my doctor if I feel lightheaded.
If I feel burning under my tongue, I should discontinue this medicine.
If the pain persists, I can take this medicine every five minutes for up to three doses.
I will immediately report a headache to my physician.
11. All of these patients have an order for IV morphine sulfate. Which of these clients would the nurse question the physician’s order of IV morphine?
A 78-year-old client that has sustained a hip fracture.
A 17-year-old client that has a head injury and is in severe pain.
A 32-year-old client that has mastectomy two days ago.
An 8-year-old client in sickie cells crisis that has a temperature of 160 (38 ).
12. The client is receiving a medication that is nephrotoxic. The nurse would hold the next schedule dose of medication if the client has which of the following laboratory results?
Decreased serum creatinine level.
Elevated serum bilirubin level.
Elevated blood urea nitrogen (BUN) level.
Decreased serum glutamic oxaloacetic transaminase (SGOT) level.
13. The client that is taking warfarin sodium develops a nosebleed. Which of these medications would the nurse prepare to administer?
Epinephrine.
Phytonadine.
Enoxaparin.
Protamine sulfate.
14. A client is to receive intermittent intravenous antibiotics in 100 mL D5W over one hour. When setting the infusion pump, a nurse would regulate the volume to be delivered ay which of these rates.
100 mL
200 mL
150 mL
50 mL
15. The client that underwent surgery is having pain and ask for pain medication. Before administering the medication, the nurse checks the client’s vital signs. Assessment data reveal: pulse = 100/minute, respirations = 32/minute and BP =134/92 mm Hg. Which of these actions would the nurse take?
Recheck the client’s vital signs in 30 minutes.
Give the pain medication to the client.
Ask if the client is feeling anxious.
Check the client’s dressing for bleeding.
16. The client is receiving enteric-coated medication. Which information would the nurse include in the client instructions about the medication?
The medication melts after being inserted into a body cavity.
The medication dissolves quickly if placed under the tongue
The medication needs to be shake thoroughly before administering
The medication dissolve when it reaches the small intestine.
17. Which of these responses, if made by the client, would indicate to the nurse that the client has given informed consent?
“I understand, but exactly will be done?”
“I realize the scar will be visible for a few weeks.”
“I’m in so much pain, I’ll sign anything.”
“My family wants me to go through with this.”
18. When the client that has acute postoperative pain receives morphine, the nurse would monitor the client for which of these conditions?
Respiratory depression.
Increased urinary output.
Constipation.
Hypertension.
19. Which postoperative complication in the first hour after surgery requires immediate intervention?
Serous draining on the dressing.
Dehiscence of a wound.
Vomiting.
Swelling of an extremely under a cast.
20 A client has a head injury is drowsy and lethargic and has clear nasal discharge. Which action would the nurse take?
Cover the nares with sterile gauze.
Obtain a specimen of the drainage for culture and sensitivity.
Test the drainage for glucose.
Cleanse the nostrils with sterile saline solution.
21. Which action would the nurse take initially if the client that is diagnosed with diabetes mellitus develops tremors and ataxia?
Measure the client’s blood sugar level.
Administer a concentrated form of glucose to the client.
Administer a prn dose of insulin.
Measure the client’s urine for ketones.
22. Which outcome criterion is appropriate for the client that has a nursing diagnosis of ineffective airway clearance?
Pulse oximetry level of 80%
Frequent coughing throughout the day.
Absence of wheezing throughout the lung fields.
Clear lung sounds on auscultation.
23. The client that has Acquired Immune Deficiency Syndrome (AIDS) is admitted to the hospital with a diagnosis of pneumocystis carinii pneumonia. When planning care for the client, the nurse would include which of these priority nursing measures?
Encouraging increased activity.
Promoting adequate sleep patterns.
Preventing pulmonary embolism.
Maintaining adequate oxygenation.
24. Which of these assessment findings in a client should a nurse recognize as indicative of early manifestation of hypoxemia?
Pallor.
Bradycardia.
Hypotension.
Restlessness.
25. A 40-year-old primigravida is hospitalized for severe pregnancy-induced hypertension (PIH). Which of these nursing actions should be accomplished first?
Start an IV for oxytocin administration.
Administer anti-hypertensive drugs.
Call the lab to draw blood.
Record baseline vital signs.
26. A 2-year-old child is admitted to the hospital with nephrotic syndrome. When admitting the client to the hospital, the nurse is most likely to obtain which statement from the client’s parent?
The child was treated for impetigo a couple weeks ago.
The child cries when voiding.
The child has had swollen eyes lately when waking up in the morning.
The child has lost weight over the last few days.
27. A client is admitted to the pediatric intensive care unit for observation of congestive heart failure secondary to viral cardiomyopathy. Which assessment finding is the nurse most likely to see?
Flushed face.
Sunken fontanel.
Weak peripheral pulses.
Cyanosis in the lower extremities.
28. The physician prescribes prostaglandin (PGE2) gel for a client being admitted for induction of labor. Which finding would best indicate that the prostaglandin gel is effective?
The client’s uterine contraction pattern is enhanced.
The client’s cervix is softened.
The client’s cervix is dilated.
The client’s uterus is softened.
29. When assessing a group of children, a nurse should recognize which child is at increased risk of developing a cute glomerulonephritis?
A 4-year-old child who had a streptococcal infection a week ago.
A 5-year-old child who has recurrent enuresis at night.
A 3-year-old child who has multiple urinary tract anomalies.
A 6-year-old child who had chicken pox infection two weeks ago.
30. Which assessment finding present in a primigravida, indicates that the client is experiencing true labor?
There is a progressive increase in effacement and cervical dilatation.
The pains are felt in the lower abdomen, back and groin.
The Braxton-Hicks contractions have become stronger and more frequent.
There is an increased of white mucus discharge.
31. Which of these fetal heart rate (FHR) patterns would indicate to a nurse that a bib-stress test (NST) is reactive?
The FHR decreases 15 beats/minute would remains decreased for 15 seconds.
The FHR remains unchanged with maternal movements.
The FHR does not change during fetal movements.
The FHR increase 15 beats/minute and remains elevated for 15 seconds.
32. A pregnant client tells a nurse that she thinks she has developed an allergy because her nose is often very congested. Which of these responses should the nurse make?
“This is not normal; perhaps you developed a chronic respiratory infection.”
“It is normal; the congestion is due to one of the hormones of pregnancy.”
“It is not unusual to develop allergies during pregnancy.”
“I will ask the doctor to prescribe a nasal decongestant for you.”
33. Which of these actions should a nurse take prior to giving diet instructions to pregnant clients?
Assess what the clients eat by taking a dietary history.
Instruct the clients to continue eating a normal diet.
Give the clients a list of foods so they can better plan their meals.
Emphasize to the clients that importance of limiting salt intake.
34. The mother of an 8-month-old child proudly tells the nurse in the well-baby clinic that the child eats very well. Laboratory reports confirm that the child has iron deficiency anemia. Considering this diagnosis, the nurse should give priority to which action?
Ask the mother if the child has been eating non-food substances like paint chips.
Tell the mother that the child will probably require a blood transfusion.
Refer the mother to the social worker for assessment of parenting abilities.
Provide the mother with a list of age-appropriate iron rich foods.
35. A client visits the clinic when she is 28 weeks pregnant. She says, “I usually swim twice a week in an outdoor pool. I guess that’s not too good an idea now.” Which response, if made by the nurse, is most appropriate?
“The chlorine used to purify the water may be hazardous to the developing fetus.”
“After the eighth month, this activity usually causes negative pressure on the uterus.”
“This activity can probably be continued throughout pregnancy.”
“The temperature of the water should be at or slightly above normal body temperature.”

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