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51. A nurse is caring for an older adult client who has hypothyroidism. Which of the following findings should the nurse expect? 1. Bradycardia 2. Weight-loss 3. Increased temperature 4. Restlessness 52. A nurse is contributing to the plan of care or a client who has developed an infectious wound with foul-smelling drainage. Which of the following actions should the nurse include in the plan of care? 1. Administer antibiotic therapy before culturing the client’s wound. 2. Instruct visitors to perform hand hygiene for 5 seconds after leaving the client’s room. 3. Discard soiled wound care supplies in a trash receptacle outside the client’s room. 4. Place the client in a private room with a private bathroom. 53. A nurse is assisting a provider with removing a client´s lower-leg cast. Which of the following statements by the nurse is appropriate? 1. ´´You should avoid elevating your leg while sitting.´´ 2. ´´You can expect your leg muscles to look a little swollen.´´ 3. ´´You should hold still to prevent injury to your skin.´´ 4. ´´You can expect to feel pressure when we cut the cast.´´ 54. A nurse is reinforcing teaching with a client and her partner about performing chest physiotherapy at home. Which of the following statements by the client indicates an understanding of the teaching? 1. ´´I will need to change my position multiple times during the procedure.´´ 2. ´´I will wear a sweatshirt during the procedure.´´ 3. ´´I should eat a small meal prior to the procedure.´´ 4. ´´I should take a prescribed bronchodilator following the procedure.´´ 55. A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse auscultates hypoactive bowel sounds, and the client reports cramping abdominal pain. Which of the following actions should the nurse take first? 1. Offer an analgesic medication. 2. Request the client to be NPO. 3. Administer a glycerine suppository. 4. Ambulate the client in the hallway. 56. A nurse is reviewing the results of a client´s fecal occult blood screening test. Which of the following findings from the client’s history should the nurse identify as potentially causing a false-positive result? 1. The client has a history of breast cancer. 2. The client consumed citrus juice 3 days before the test. 3. The client takes ibuprofen for headaches. 4. The client had a hemorrhoidectomy 1 year ago. 57. A nurse is reinforcing teaching about home safety measures with a client who is visually impaired. Which of the following instructions should the nurse include? 1. Leave doors slightly ajar. 2. Use low-wattage light bulbs. 3. Place throw rugs over electrical cords. 4. Mark the edges of steps. 58. A nurse is caring for a client who is experiencing muscle spasms and has a new prescription for an aquathermia pad. Which of the following actions should the nurse take? 1. Cover the paid prior to use. 2. Fill the pad with sterile water. 3. Use safety pins to secure the pad in place. 4. Apply the pad for 45 min at a time. 59. A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements by the client indicates an understanding of the teaching? 1. ´´I should place an aspirin in the pouch to eliminate odor.´´ 2. ´´I should avoid broccoli and chewing gum.´´ 3. ´´I should clean around the stoma with moisturizing soap.´´ 4. ´´I should decrease the amount of fresh fruit in my diet.´´ 60. A nurse is supervising an assistive personnel(AP) providing care for a group of clients. For which of the following actions should the nurse intervene? 1. The AP plans to assist a client who had hip arthroplasty to a bedside commode. 2. The AP plans to turn a client who has paraplegia every 2 hr. 3. The AP prepares to provide wound irrigation to a client who has a decubitus ulcer. 4. The AP prepares to obtain the blood pressure of a client who had peritoneal dialysis. 61. A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan to take? 1. Implement contact precautions. 2. Maintain the client in a supine position. 3. Apply petroleum jelly to the client´s nares. 4. Initiate precautions. 62. A nurse is reinforcing teaching with a client who has heart failure and a new prescription for furosemide. The nurse should instruct the client to monitor for which of the following adverse effects? 1. Agitation 2. Ringing in ears 3. Rhinitis 4. Metallic taste 63. A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection? 1. Changed mental status 2. Diminished reflexes 3. WBC count 9,000/mm3 4. Temperature 37.3 degrees celsius(99.1 degrees Fahrenheit) 64. A nurse is reinforcing teaching with a group of clients who are at risk for coronary heart disease due to hypercholesterolemia. Which of the following information should the nurse include in the teaching? 1. Include fish in the diet two times per week. 2. Increase intake of dairy products 3. Limit servings of meat per meal to 113 to 170 g(4 to 6 oz). 4. Cook with coconut oil. 65. A nurse is preparing a client who has acute appendicitis for surgery. Which of the following actions should the nurse take? 1. Apply a heat pack to the client´s lower abdomen. 2. Administer an enema to the client. 3. Give the client a clear liquid diet. 4. Place the client in semi-Fowler’s position. 66. A nurse on a medical-surgical unit is caring for an older adult client who has developed due to a urinary tract infection. A member of the client’s family tells the nurse not to perform any ´´heroic measures´´ to keep the client alive. Which of the following responses by the nurse is appropriate? 1. ´´Ýou should contact the client’s attorney to document your wished legally.´´ 2. ´´Why do you believe treatment would not benefit the client?´´ 3. ´´The client’s condition is not critical enough to discuss these issues.´´ 4. ´´Let me check the client’s medical record for advance directives.´´ 67. A nurse is interpreting the results of a tuberculin skin test for a group of clients who received this test 48 hr ago. Which of the following clients should the nurse identify as having a positive test result? 1. A client whose injection site is scabbed. 2. A client whose injection site has an elevated area measuring 15 mm. 3. A client whose injection site is ecchymotic 4. A client whose injection site is firm and measures 3 mm. 68. A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema? 1. Keep both arms below the level of the client’s heart. 2. Obtain blood pressure readings using the client’s right arm. 3. Limit range-of-motion exercises with the affected arm. 4. Use the client’s left arm to obtain blood samples. 69. A nurse is collecting data from a female client who is postmenpausal. Which of the following should the nurse identify as a risk factor for the development of osteoporosis? 1. Long-term use of prednisone 2. Monthly vitamin B12 injections 3. Congenital heart murmur 4. History of kidney stones 70. A nurse is reviewing a client’s medical record. Which of the following findings is the priority for the nurse to report? 1. Urine output 200 mL/8hr 2. Potassium level 6.2 mEq/L 3. Abnormal hepatoiminodiacetic acid(HIDA) scan 4. A client’s rating of ear pain as 5 on a scale from 0 to 10. 71. A nurse is caring for a client who has a new diagnosis of tuberculosis(TB). The client asks the nurse why she needs to take four different anti tuberculosis medications. Which of the following replies should the nurse make? 1. ´´Taking several anti tuberculosis medications will protect your liver from toxic effects.´´ 2. ´´People who have a severe form of TB need several anti tuberculosis medications, but those who have less severe TB need just one medication.´´ 3. Adverse effects occur more often and are more severe when you take only one anti tuberculosis medication.´´ 4. ´´The organism that causes TB becomes resistant to anti tuberculosis medications when you only take one medication.´´ 72. A nurse is assisting with the plan of care or an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care? 1. Monitor the client for weight loss. 2. Check the client for increased hypopigmentation under the patch. 3. Advise the client about increased dry mouth. 4. Inform the client of the adverse effect of diarrhea. 74. A nurse is reinforcing teaching with a client who is postoperative following a tympanoplasty. Which of the following information should the nurse include? 1. Close mouth when sneezing. 2. Resume exercising in 10 days. 3. Plan to shampoo hair in 1 week. 4. Drink fluids through a straw. 75. A nurse is caring for a client who has cancer and has a WBC count of 4,000/mm3. Which of the interventions should the nurse take? 1. Decrease the client’s protein intake. 2. Encourage the client to eat a diet rich in whole grains. 3. Cleanse the client’s toothbrush with hydrogen peroxide. 4. Use a disposable razor to shave. 76. A nurse is assisting with the care of a client who is postoperative and has received fentanyl for pain management. In the event the client develops respiratory depression, the nurse should make sure that which of the following medications is available to administer? 1. Atropine 2. Naloxone 3. Flumazenil 4. Acetylcysteine 77. A nurse is reinforcing teaching with a client who has COPD and reports shortness of breath and little appetite. Which of the following instructions should the nurse include the teaching? 1. Eliminate dairy products. 2. Eat lighter, low-calorie foods first. 3. Limit fluid intake during meals. 4. Consume three regular meals daily. 78. A nurse is caring for a client who had a colon resection 2 days ago. When entering the client’s room, the nurse sees a protrusion of tissue from the incision. Which of the following is the appropriate nursing intervention? 1. Place the client on her left side. 2. Place the client in Trendelenburg position. 3. Cover the site with a sterile, saline-soaked dressing. 4. Cover the wound with a dry, sterile dressing. 79. A nurse is caring for a client who has chronic kidney disease. Which of the following interventions is appropriate? 1. Administer NSAIDs for discomfort. 2. Obtain the client’s daily weight. 3. Monitor the client for hypokalemia. 4. Offer the client a high-protein diet. 80. A nurse is preparing to obtain a postprandial blood glucose level from a client who has diabetes mellitus. Which of the following actions should the nurse take? 1. Hold the client’s finger in a dependent position. 2. Clean the client’s finger with hexachlorophene. 3. Apply the first drop of blood to the test strip. 4. Prick the central tip of the client’s finger. 81. A nurse is reinforcing discharge teaching with a client regarding self-administration of regular insulin. Which of the following instructions should the nurse include? 1. Plan to eat a snake 6 hr after insulin administration. 2. Warm the vial to dissolve any crystals that develop. 3. Store opened insulin vials at room temperature for up to 4 weeks. 4. Keep unopened insulin vials in the freezer. 83. A nurse is reinforcing discharge instructions with a client who is taking oral iron supplementation for anemia. Which of th4e following statements by the client demonstrates an understanding of the teaching? 1. ´´ I should notify my doctor if my stools turn black.´´ 2. ´´I should drink my liquid iron supplement undiluted.´´ 3. ´´I should take my supplement with an antacid to prevent an upset stomach.´´ 4. ´´I should increase my fiber intake while taking this supplement.´´ 84. A nurse is providing directions to an assistive personnel about moving a client up in bed. Which of the following statements should the nurse include? 1. ´´Place a pillow under the client’s head prior to repositioning.´´ 2. ´´Face in the direction of the client’s movements.´´ 3. ´´Keep your feet close together while moving the client.´´ 4. ´´Move the client’s arms to his sides prior to repositioning.´´ 85. A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take? 1. Replace the unit when the drainage chamber is full. 2. Clamp the tube for 30 min every 8 hr. 3. Monitor for at least 150 mL of drainage every hour. 4. Pin the tubing to the client’s bed sheets. 86. A nurse is providing care for a client who has hemophilia and is bleeding from a small laceration on his arm. After applying a sterile dressing, which of the following actions should the nurse take next? 1. Check whether the bleeding has stopped. 2. Maintain direct pressure over the site. 3. Obtain a radial pulse. 4. Reinforce the dressing over the site. 87. A nurse is reinforcing teaching with a client who has ovarian cancer and will receive chemotherapy through a peripherally inserted central catheter(PICC). Which of the following statements by the client indicates an understanding of the teaching? 1. ´´It’s okay to get the device wet when I shower.´´ 2. ´´I will wear an arm immobilizer to prevent dislodgement of this device.´´ 3. ´´I should pull the dressing away from the insertion site when I change it.´´ 4. ´´I will monitor my temperature for fever while I have this device.´´ 88. A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan? 1. Apply foam handles to the client’s eating utensils. 2. Have an assistive personnel feed the client. 3. Obtain a referral for physical therapy. 89. A nurse is reinforcing teaching with a client who has psoriasis. Which of the following treatment options should the nurse include in the teaching? 1. Oil-based ointment 2. Benzoyl peroxide 3. Phototherapy 4. Dermabrasion 90. A nurse is collecting data from a client who had a long arm cast applied 2 hr ago. Which of the following findings of the affected extremity should the nurse report to the provider? 1. The client’s fingers are cool to the touch. 2. The client´s capillary refill is 3 seconds. 3. The client reports increased pain at the area of the fracture. 4. The client reports severe itching under the cast. 91. A nurse is collecting data from a client who has Graves´ disease. Which of the following images should the nurse identify as an indication that the client is experiencing exophthalmos? 92. A nurse is preparing a client for a colposcopy following an abnormal Papanicolaou test. Which of the following actions should the nurse take? 1. Place the client in the Sims´ position. 2. Instruct the client to avoid using tampons following the procedure. 3. Reinforce teaching that the procedure involves dilation of the cervix. 4. Instill a vaginal cream prior to the procedure. 93. A nurse in a long-term care facility is collecting data from an older adult client. Which of the following findings indicates that the client might be dehydrated? 1. Recent onset of confusion 2. Decrease in pulse rate 3. Increase in blood pressure 4. Cool, clammy skin 94. A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan of care? 1. Instruct the client to shave with a disposable razor. 2. Initiate protective isolation for the client. 3. Administer ibuprofen for mild headache. 4. Check the client for ecchymosis. 95. A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider? 1. Ammonia 55 mcg/dt. 2. Bilirubin 1.0 mg/dL 3. Aspartate aminotransferase 34 units/L 4. Platelets 60,000/mm3 96. A nurse is caring for a client who is experiencing a generalized tonic-clonic seizure. Which of the following actions should the nurse take? 1. Apply restraints to the client 2. Place the client in the prone position 3. Insert a tongue blade into the client’s mouth 4. Administer an IV bolus of lorazepam 97. A nurse is caring for a client who is postoperative following a total thyroidectomy for hyperthyroidism. Which of the following findings should the nurse identify as the priority? 1. Moderate amount of serosanguineous drainage on dressings. 2. Report of a sore throat. 3. Serum calcium level 9.2 mg/dL. 4. Oral temperature 39 degrees celsius(102.2 degrees Fahrenheit). 98. A nurse on a medical-surgical unit has just received change-of-shift report for four clients. Which of the following tasks should the nurse assign to an assistive personnel? 1. Reinserting an NG tube for a client who requires gastric decompression. 2. Performing a closed catheter irrigation for a client who is postoperative. 3. Bathing a client who has hemiparesis following a stroke 4. Showing a client who has a new colostomy how to empty the pouch 99. A nurse is assisting with discharge teaching for a client who requires oropharyngeal suctioning at home. The nurse should ensure that which of the following equipment is available for use at home? 1. Oropharyngeal airway 2. Yankauer catheter 3. Water-soluble lubricant 4. Sterile gloves 100. A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following client statements indicates an understanding of the teaching? 1. ´´I should round the corners of my toenails with a nail file to prevent ingrown nails.´´ 2. ´´I should use my wrist to test the temperature of the water before bathing. ´´ 3. ´´I should apply a heating pad to my feet every night to help with circulation.´´ 4. ´´I should put lotion between my toes every day to prevent dryness and cracking.´´

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