1. Which of the following indicates equipment malfunction and requires nurse’s intervention?
a. Bubbling in the suction control chamber in a client with closed chest tube drainage.
b. Inflation of the reservoir bag during inspiration in a partial rebreather mask.
c. Delivery of positive pressure on inspiration in a positive-end-expiratory pressure (PEEP).
d. Opening of the one-way valve between the mask and reservoir bag during inhalation of a non-rebreather mask.
Rationale: D. Valves should open during expiration and closes during inhalation to prevent exhaled air from entering the reservoir bag. (Saunders © 2005, p. 732)
2. A nurse caring a client who had undergone venography an hour ago should instruct the client to
a. Perform ROM exercises on both legs
b. Increase fluid intake
c. Elevate legs with pillow
d. Apply ice packs to the insertion site
Rationale: b. Venography involves the injection of radiopaque substance in the veins for better visualization.
3. An 81-year-old man with pelvic fracture is brought to the ER by his daughter. When asked how the injury occurred, the daughter says that his father slid in the bathroom. On examination, the nurse finds old and new lesions in the client’s back. Which of the following most appropriately show how the nurse should document these findings?
a. “Multiple lesions at various stages of healing caused by elderly abuse.”
b. “Lesions on the back with due to unknown causes.”
c. “Seven lesions on the back at various stages of healing.”
d. “Several lesions in the back caused by cigarette.”
Rationale: C. Documentation must reflect accuracy; it should be objective, concise, and complete. It must reflect current status. It should only include what is only given in the information and nurses should not make personal judgment on the issue.
4. Following a bowel resection a client is attached to a nasogastric tube with intermittent suction. Which of the following assessment will assure the nurse that the equipment is functioning well?
a. The client has active bowel sounds
b. The client’s drainage is coffee colored
c. The client’s abdomen is soft
d. The client’s gag reflex gradually resumes
Rationale: C. the purpose of NGT is to decompress and drain air and fluid in the stomach to keep the abdomen soft and prevent overdistention. (Saunders © 2005, p. 234)
5. The parents ask the purpose of the CPAP while their child is attached to an apnea monitor. The nurse correctly states that:
a. “The CPAP will maintain the positive airway pressure”
b. “The CPAP will stimulate the child to breathe during apneic episodes”
c. “The CPAP will permit the child to lengthen its inspiratory and expiratory phase”
d. “The CPAP will allow the child to continuously sleep without any disturbance”
Rationale: A. The complete name of CPAP is Continuous positive airway pressure. It’s use is to maintain the alveoli in an expanded state. (NSNA p292)
6. A patient with hyperparathyroidism is about to undergo a Bone Scan procedure. Which of the following client statement indicates a correct understanding about the procedure?
a. “I will receive a small amount of dye”
b. “I need to isolate for 48 hours”
c. “I will be on NPO for 8 hours”
d. “I will have a scanning procedure before I void”
Rationale: A. A tracer dose of radioactive isotope is injected intravenously. Only fluids for 4 hours is withheld before the procedure. The isotope is excreted in the urine and feces within 48 hours and is not harmful to others, thus no isolation is necessary. From 1-3 hours after the injection, the client will void, and then the scanning procedure is performed. (Saunders p.999)
7. A client post cholecystectomy has just been given analgesics to have his incentive spirometry exercises. Which of the following techniques indicates proper use of your incentive spirometry?
a. Place in mouth, exhale normally, and inhale normally
b. Place in mouth, exhale slowly, and inhale slowly
c. Exhale slowly, place in mouth, and inhale normally
d. Place in mouth, inhale slowly, and exhale slowly
Rationale: D. Place in mouth, inhale slowly to raise and maintain the flow rate indicator between 600-900 marks. Hold breath for 5 seconds, and then exhale through pursed lips. Repeat process 10 times every hour. (Saunders p.210)
8. A patient with COPD is receiving 35% of O2 via Venturi mask. The patient becomes agitated and irritable. Which of the following should be done first?
a. Place o2 saturation on the hand affected with Raynauds disease
b. Check the tubing for kinks
c. Increase the oxygen received by the patient
d. Ambu bag the patient
Rationale: B. The first thing to do is always assessment. Check for possibility of kink tubes. Measurement of oxygen saturation is measured by the use of pulse oximetry. Do not select an extremity with an impediment to blood flow like that of Raynauds disease. Increasing oxygen level with rather be useless if there is kinking. Ambu bagging is not a priority. Assessment is always done first. (Saunders p.729)
9. A patient with just had nephrostomy due to bladder cancer. Which of the following is included in the care of nephrostomy tube. Select all that applies.
a. Using the stomach or side lying when sleeping
b. Irrigating 5 ml of fluid every 2-3 hours every day
c. Pin the bag at the level of the bladder
d. If pressure or obstruction occur, flush it with 30 ml
e. Secure the tube at the thigh
Rationale: A, E. The patient can assume prone or side lying position because the incision is done at the flank area.. Never irrigate a nephrostomy tube without specific order and always keep the drainage bag below the waist. (Brunner p.1299-1302)
10.Which of the following action constitute the Patient Self Determination Act (PSDA)?
a. Promoting the development of advance directives
b. Obtaining informed consent before any surgery
c. Encouraging every patient to signs for an organ donation
d. Giving federal standards for living wills
Rationale: B. PSDA promotes decision making prior to need. The focus of PSDA is health care decision making. It emphasizes the need for patient education in order to support the individuals treatment decision. (Cliffs Test Prep NCLEX © 2008, p. 17)
1. Which of the following medication order requires the nurse to verify the physician?
a. Administering 50 mg nitroprusside (Nipride) via an infusion pump through a peripheral IV line in a client with primary hypertension.
b. Administering 200 mg PO bid a day of carbamazepine (Tegretol) in a 12 year old child exhibiting generalized tonic-clonic seizure.
c. Administering 20 mg PO tid of baclofen (Lioresal) in a Multiple Sclerosis client with spasticity.
d. Administering 25 mg carbidopa and 100 mg levodopa (Sinemet) PO tid in a client with idiopathic Parkinson’s disease.
Rationale: A. Nitroprusside (Nipride) is used to lower blood pressure quickly in hypertensive emergencies not in primary hypertension. (Nursing Drug Handbook © 2003, p. 298)
2. A client was prescribed with ibuprofen 500 mg tid for long-term control of rheumatoid arthritis. Which of the following will the nurse instruct the client to report?
a. Abdominal pain
b. Black tarry stool
Rationale: B. Ibuprofen is an NSAID drug that can cause peptic ulceration and bleeding. Identifying signs and symptoms of GI bleeding must be immediately reported. (Nursing Drug Handbook © 2003, p. 356)
3. Which of the following client statement requires further teaching regarding the use of indomethacin (Indocin)?
a. “I should report any increase in my weight to the health care provider.”
b. “I need to limit my intake of green leafy vegetables.”
c. “I can take the drug without meal if I am not hungry.”
d. “I have to consult my health care provider about taking OTC cough remedies.”
Rationale: C. This drug causes GI upset and bleeding and must be taken with food always. This can also cause sodium retention thus choice A is also appropriate. Remaining choices has no relevance in the drug. (Nursing Drug Handbook © 2003, p. 358)
4. A client is taking cyclobenzapine (Flexeril) shows appropriate understanding of the teaching when he states
a. “I should count my pulse regularly and report if it is 60 beats and below.”
b. “I will chew sugarless gum for dry mouth.”
c. “I will limit my intake of high fiber foods to decrease the episodes of diarrhea.”
d. “I will expect to experience urinary retention while taking the drug.”
Rationale: B. This is a muscle relaxant that causes dry mouth, tachycardia, palpitations, constipation, and urinary retention or frequency. (Nursing Drug Handbook © 2003, p. 574)
5. What should a nurse include in the discharge instructions of a client taking alendronate (Fosamax)?
a. Avoid OTC vit.D supplement
b. Take the drug with a glass of milk 30 minutes before meals
c. Lie at least 30 minutes after taking the dug to facilitate transport and absorption
d. Administer the drug preferably in the morning before meals
Rationale: D. Fosamax should be taken in the morning 30 minutes before any meals with only a full glass of plain water. Client should remain in an upright position for 30 minutes to prevent reflux causing esophageal irritation. (Nursing Drug Handbook © 2003, p. 358)
6. A nurse monitoring an MI client taking metoprolol should report presence of
a. Pulse of 65 beats/minute
b. BP of 148/86 mmHg
c. +2 pitting edema
d. RR of 20
Rationale: C. Presence of +2 pitting edema may indicate fluid retention and signals progression of the client’s condition to heart failure. (Nursing Drug Handbook © 2003, p. 295)
7. The client is being treated with Vancomycin for MRSA. After a few minute of the infusion the client suddenly develops a maculopapular rash in the face and neck. Which of the following actions should the nurse take first?
a. Administer antihistamine such as Benadryl
b. Check the respiratory rate and BP of the client
c. Turn off the infusion
d. Call the doctor
Rationale: C. The client is exhibiting Red-Man Syndrome caused by rapid infusion of vancomycin. Priority action is to stop the infusion then notify the physician. (Nursing Drug Handbook © 2003, p. 217)
8. A client with ESRD is receiving an order for erythropoietin (Epogen) SQ. the nurse should teach the client to report
b. Nausea and vomiting
c. Decreased urination
d. Severe headache
Rationale: D. Severe headache may indicate an impending seizure which is one of the life-threatening reaction of the drug. Itching and decreased urination is expected in a client with ESRD. (Nursing Drug Handbook © 2003, p. 358)
9. Which of the following should the nurse emphasize in a client to report while taking Vancomycin?
a. Decreased urine output
b. Presence of tinnitus
d. Weight loss
Rationale: A. Vancomycin is highly nephrotoxic and a decrease in urine output may indicate disturbance in the renal function. Although the drug can also cause tinnitus (ototoxic) but nephrotoxicity is more life-threatening. (Nursing Drug Handbook © 2003, p. 217)
10. Which instruction should be given to a client taking a long-term atorvastatin (Lipitor)?
a. Have your hearing acuity evaluated every 6 months
b. Obtain a periodic eye examination
c. Avoid foods which are rich in HDL
d. Watch out for bleeding tendencies
Rationale: B. Long-term use of Lipitor causes opacity of the eye lenses or cataract symptoms.
11. A patient is regularly taking steroids. The nurse suspects adrenal insufficiency when she observed
a. Generalized muscle weakness
b. Frequent urination
d. Periorbital edema
Rationale: C. Adrenal insufficiency is characterized by hypotension that leads to shock. Generalized muscle weakness, although correct is a vague manifestation. (Saunders © 2005, p. 633)
12. Steroid is prescribed for a client after an organ transplant. The nurse expects the client to manifest which electrolyte imbalance?
a. hyperkalemia and hypocalcemia
b. hypokalemia and hyperphosphatemia
c. hyperglycemia and hypercalcemia
d. hypernatremia and hypoglycemia
Rationale: B. Steroid causes elevated blood glucose and sodium and a decrease in potassium and calcium. Phosphate is expected to increase once calcium is depleted since these two electrolytes are inversely proportional with each other. (Saunders © 2005, p. 92, 634)
13. A client is being treated for heart failure with bumetamide (Bumex). Which of the following assessment findings best indicate to the nurse that the drug is effective?
a. The client’s weight had decreased
b. The client’s urinary output is 1,500 ml/ day
c. The client’s crackles decreases during auscultation
d. The client had a pitting pedal edema
Rationale: C. Although client’s weight decreases and urine output increases because of the diuretic effect of the drug, these are not the best indicator that the cleint’s condition had improved. Decreasing lung crackles signifies that the pulmonary edema is improving. (Nursing Drug Handbook © 2003, p. 826)
14. What would the nurse expect in a client with continuous epidural anesthesia to report?
Rationale: D. Epidural anesthesia causes hypotension and the client becomes sleepy and lethargic. Headache is not expected since the dura matter is not penetrated. (Saunders © 2005, p. 301)
15. A schizophrenic patient is receiving long-term antipsychotic medication. The nurse is aware of possible development of NMS when she noticed?
a. Temperature of 38.90C
b. Muscle weakness
c. Inability to concentrate
Rationale: A. The cardinal symptom of NMS is hyperthermia/fever. (Saunders © 2005, p. 1134)
1. While monitoring a client after craniotomy, the nurse notes that the client’s urine specific gravity is decreasing and is currently 1.005. The nurse understand that this is due to
a. Fast infusion rate of IV fluids.
b. Overproduction of vasopressin by the hypothalamus.
c. Rapid renal excretion in response to hydration.
d. Hyposecretion of antidiuretic hormone in the body.
Rationale: D. Brain trauma and surgical manipulation often alters the production of antidiuretic hormone leading to the development of diabetes insipidus. (Saunders © 2005, p. 632)
2. A client with T4 injury develops facial flushing and a BP of 206/110. After elevating the head of the bed, which action should the nurse perform next?
a. Informing the physician immediately
b. Palpating the bladder for distention
c. Administering emergency antihypertensive drug
d. Slowing the IV infusion
Rationale: B. This client is experiencing autonomic dysreflexia which can be caused by distended bladder or bowel. (Saunders © 2005, p. 950)
3. A client is admitted in the unit due to a motor vehicular accident the other day. As the nurse visits the client today she noticed that the client is talking to her friend and was attentive. Which of the following questions is appropriate for the nurse to ask?
a. “Do you experience headache?”
b. “Is your vision blurred?”
c. “Are you having difficulty concentrating?”
d. “Do you easily get tired?”
Rationale: A. Asking for feeling of headache will rule out for presence of increased intracranial pressure. (Saunders © 2005, p. 944)
4. A client was admitted with Bell’s palsy. What will be the nursing consideration for this patient?
a. Avoid sunlight
b. Manually close eyelid
c. Avoid frequent oral care
d. Nothing by mouth
Rationale: B. Patients with Bell’s palsy have inability to raise the eyebrows and close eyelids. The nurse needs to aid the patient in closing it. Other interventions include encouraging facial exercises, promote frequent oral care. The patient can eat but should chew on the unaffected side. P. 958 Saunders
5. The nurse doing the assessment for the patient with Bell’s palsy knows that the CN affected is:
a. CN 7
b. CN 8
c. CN 6
d. CN 5
Rationale: Bell’s palsy is caused by a lower motor neuron lesion of the 7th Cranial Nerve. P. 958 Saunders
6. The nurse is caring for Parkinson’s client. Which of the following does she need to intervene?
a. Rock back and forth to initiate movements
b. Using tap water to thin the liquid food
c. Position to prone without a pillow
d. Hold hands behind the back when standing
Rationale: B. Parkinson’s Disease patient have difficulty swallowing. Diluted liquid foods increases risk for aspiration. B, C, and D are correct management for the client. P. 958 Saunders
7. The nurse is preparing her discharge plan for a patient with Parkinson’s. Which is the correct teaching to aid in ambulation?
a. Tell the patient to start by rocking back and forth
b. Walk by starting with the left foot followed by the right
c. Exercise walking everyday
d. Provide crutches to aid in ambulation
Rationale: A. Rocking back and forth initiates movement. P. 2174 Black
8. A patient sustained a fall with C6 injury experiencing diaphoresis and piloerection. What should the nurse asses next?
a. weakness and LOC
b. urinary distention and fecal impaction
c. respiratory rate and depth
Rationale: A. The patient is manifesting the signs of Autonomic Dysreflexia, caused by distention of bladder or impacted rectum which may occur with injuries at T6 and above. Although B, C and D may be correct, the diagnosis should be confirmed first. P. 950 Saunders
9. A patient with C4 injury was placed under the care of the nurse. What should the nurse report to the physician?
a. tingling of fingers
b. experiencing pain at the shoulders
c. stuffy nose
d. constricted pupils
Rationale: C. Signs of Autonomic Dysreflexia includes: Hypertension, bradycardia, flushing of face and neck, severe headache, nasal stuffiness, piloerection, sweating, nausea, restlessness and dilated pupils. P. 950 Saunders
10. A patient has been newly admitted and suspected of having Multiple Sclerosis. Which of the following questions should the nurse ask to support the diagnosis?
a. “Do you have headaches?”
b. “Do you have problems with urination?”
c. “Does your tremors decrease with activity?”
d. “Do you have problems with increased sensitivity?”
Rationale: B. Patients with multiple sclerosis usually have bowel and bladder problems. It could either be retention or incontinence. Headaches is not a common sign of Multiple sclerosis. Tremors usually increases with activity thus the name, intentional tremors. There is an impaired sensation with this type of patient due to demyelinization.
1. A client is admitted to an emergency room and a diagnosis of myxedema is made. Which of the signs and symptoms will the nurse expect the client to manifest?
a. Slow pulse rate, anorexia, diarrhea, and cardiac failure
b. Generalized puffiness, slowed speech, lethargy, and decreased respirations
c. Decreased body temperature, weight loss, and increased respirations
d. Diaphoresis, constipation, and protruding eye balls
Rationale: B. (Saunders © 2005, p. 635)
2. A 28-year-old primigravida with type I DM visits the clinic at her 6 weeks gestation. Which of the following statements indicate that she understand the nurse’s teaching regarding her insulin needs during pregnancy?
a. “As the baby grows, I need more insulin because the baby is unable to produce insulin.”
b. “I need to increase my insulin requirement in the last trimester because of placental hormones in the body.”
c. “I need to lower my insulin dose since the baby uses up my extra glucose.”
d. “My insulin requirement will be the same as long as I maintain an adequate balance diet and exercise.”
Rationale: B. During pregnancy the placenta produces insulinase, an insulin antagonist, thus as pregnancy progresses an additional amounts of insulin is need by the mother. (Saunders © 2005, p. 281)
3. A client with type I DM demonstrates a hot skin and acetone odor breath. The nurse priority action at this time will be
a. Assessing for ABG
b. Administering Regular insulin
c. Checking for presence of urine ketones
d. Giving commercially prepared glucose tablets
Rationale: B. The client is showing manifestations of hyperglycemia with ketoacidosis. Immediate action should be administering insulin to prevent further ketoacidosis. (Saunders © 2005, p. 642)
4. A client with hypeglycemic hyperosmolar nonketotic syndrome (HHNS) in an unresponsive state is immediately hydrated in the ER. As the client is being treated the nurse will assess for
a. Lung sounds
b. Albumin level
d. Urine ketones
Rationale: A. The client must be closely watched for possible fluid overload and auscultation of lung sound can detect presence of fluid in the pulmonary system.
5. A client is suffering from a long-term diabetes mellitus type I. in order to prevent development of possible complications, the nurse should regularly monitor the client’s
a. Fasting blood sugar
b. Urine albumin level
c. Erythrocyte sedimentation rate (ESR)
d. Cholesterol level
Rationale: B. Common complication associated with long term DM is diabetic nephropathy. Monitoring changes in serum BUN and creatinine levels, and urine albumin will signify alteration in the kidney function. (Saunders © 2005, p. 643)
6. A client is diagnosed with hypothyroidism. The nurse attending the client must include which of the following intervention in her care plan?
a. Encourage high roughage in the diet
b. Provide a cold environment
c. Obtain I&O and weight daily
d. Serve high calorie foods
Rationale: C. Hypothyroid clients are at risk for cardiac problems thus I&O and weight gain must be monitored regularly to prevent further complication. (Saunders © 005, p. 635)
7. The nurse was assigned to a patient with adrenal insufficiency. What should be watched out for?
a. weight gain
d. muscle weakness
Rationale: C. Hypotension takes priority over muscle weakness since it may cause shock. Weight gain and edema is not evident in Addison’s. p. 633 Saunders
8. A patient with Addison’s disease is to undergo an Adrenalectomy. Which is the correct post-operative teaching?
a. Expect corticosteroid therapy for 6 months
b. wear mask when going outside
c. avoid sunlight
d. monitor for hypoglycemia
Rationale: B. The client should be protected from infection due to steroid therapy. Steroids are taken for life if bilateral adrenalectomy and up to 2 years if unilateral adrenalectomy. The patient should be moinitored for hypoglycemia, hyponatremia and hyperkalemia as side-effect of steroids. Photophobia is not a S/E. p. 635 Saunders
9. Which of the following laboratory result should the nurse expect for a patient with Diabetic Insipidus?
a. Increased Serum osmolality, Increased Urine Specific Gravity
b. Decreased Serum osmolality, Increased urine Specific Gravity
c. Decreased Urine Specific Gravity, Increased Serum osmolality
d. Decreased Urine Specific Gravity, Decreased Serum osmolality
Rationale: C. In Diabetes Insipidus, the urine specific gravity is 1.006 or less and an increase serum osmolality. P. 632 Saunders
10. The nurse assigned to a patient with SIADH would expect to find which of the following?
a. 122 meqs/L Na, Decreased serum osmolality
b. 135 meqs/L , Increased serum osmolality
c. 148 meqs/L, Increased Serum osmolality
d. 130 meqs/L, Decrease Serum osmolality
Rationale: SIADH causes decreased serum osmolality and hyponatremia. P. 633 Saunders.
11. Which is a priority nursing intervention for a client with SIADH?
a. provide a safe environment
b. limit oral fluid intake 1500 ml per day
c. monitor I&O closely
d. seizure precaution
Rationale: SIADH causes hyponatremia which may lead to seizure if not monitored. B, C, and D are also true, but A takes priority. P. 633 Saunders
1. A client is admitted to the unit with potassium level of 2.4 mEq/L. The nurse expects the ECG tracing to show the following changes, except
a. Tall T wave
b. ST segment depression
c. Prominent U wave
d. Inverted T wave
Rationale: D. ECG tracing of hypokalemia are ST segment depression, shallow, flat, or inverted T wave and prominent U wave. (Saunders © 2005, p. 91)
2. What assessment parameter indicates an effective fluid resuscitation in a client with severe dehydration?
a. Urine output of 30 ml/2 hr
b. Pulse of 95
c. Specific gravity of 1.040
d. Falling CVP readings
Rationale: B. The pulse is one indicator of optimum vascular fluid volume; the pulse rate decreases as the intravascular volume normalizes. (Mosby, p. 782)
3. Which parameter(s) is an important indicator of rapid fluid changes?
a. BUN and Creatinine
c. Skin turgor
Rationale: B. Straight As in F&E p.86
4. A priority nursing intervention for a client with hypervolemia involves:
a. establishing IV access with a large-bore catheter
b. drawing a blood sample for typing and crossmatching
c. monitoring respiratory status for s/s of pulmonary edema
d. encouraging the client to consume sodium-free fluids
Rationale: C. Straight As p.86
5.Rapid administration of hypotonic solutions to a severely dehydrated client should be avoided to prevent which complication?
a. Pulmonary edema
b. Cerebral edema
c. Heart failure
Rationale: B. Straight As p.86
6. The nurse has placed her client with hyperkalemia on a cardiac monitor. For which associated ECG abnormalities should the nurse be alert? SATA
a. Widened QRS
b. Prominent U wave
c. Shortened QT interval
d. Tall, tented T wave
e. Prolonged PR interval
f. Lengthened QT interval
Rationale: a, d, e. Straight As p. 134
7. Which nursing intervention is most appropriate for a client with hypercalcemia?
a. Ambulate the client as soon as possible
b. Encourage compliance with fluid restrictions
c. Maintain the client on strict bed rest
d. Encourage the consumption of green, leafy, vegetables
Rationale: A.Straight As p. 134
8. Signs and symptoms of acute hyperphosphatemia are usually caused by the effects of which electrolyte imbalance?
Rationale: B. Straight As p.134
9. Which signs and symptoms indicate hypermagnesemia?
a. Edema, tachycardia, and hypertension
b. Decreased mental function, muscle spasms, and seizures
c. Emotional lability, laryngeal stridor, and hyperactive DTR
d. Lethargy, slow, shallow respirations, bradycardia
Rationale: D. Straight As p. 135
10. In conditions of acidosis, which electrolyte imbalance should be expected?
Rationale: A. Straight As p. 164
1. A patient was prescribed with cap for fenestrated tracheostomy with cuff. Before placing the cap, what is the appropriate action to do?
a. Hyperoxigenate the patient with 100% oxygen
b. Suction the clients throat
c. Deflate the cuff
d. Administer humidified oxygen directly into the T-piece
Rationale: C. Tracheostomy cuff must be deflated first before the tube is capped. (Saunders © 2005, p. 240)
2. A post-operative client has an order for arterial blood gas (ABG) evaluation. Result shows pH 7.35, HCO3 26 mmHg, pCO2 42 mmHg, pO2 90 mmHg. Based on the lab results, what is the appropriate action of the nurse at this time?
a. Start oxygen at 2-4 L/minute
b. Position the client in High Fowler’s
c. Document the findings in the chart
d. Assist the client to cough and deep breath
Rationale: C. The client shows no apparent respiratory problem and ABG are within normal limits thus appropriate action is to document the findings. (Saunders © 2005, p. 728)
3. A nurse is assigned to a patient with Status Asthmaticus, what needs to be reported immediately?
a. prolonged exhalation
b. labored breathing
c. engorged neck veins
d. absence of wheezing
Rationale: Absence of wheezing indicates worsening obstruction of the respiratory tract and is a sign of impending respiratory failure. Choices b,c and d are also signs of asthma but choice D takes priority. Brunner p. 595
4. Which indicates a correct understanding for a patient with Asthma?
a. Use bronchodilator before corticosteroids
b. Use corticosteroids before bronchodilators
c. Use bronchodilators and antihistamine
d. Use corticosteroids after antihistamines
Rationale: Bronchodilators is the priority management for Asthma patients to immediately relieve bronchoconstriction. Corticosteroids can be given in acute attacks also to decrease inflammation. Antihistamines are only given in long-term therapy. P. 426 Saunders 3rd ed.
5. What needs to be reported for a patient with pneumothorax?
a. absent breath sound
b. pain upon inspiration
c. shallow breathing
d. splinting chest
Rationale: Absent breath sounds indicates progression to respiratory distress and should be reported immediately. B, C and D are expected assessment findings for Pneumothorax.
6. A teenager with chronic asthma asks the nurse, “How come I make so much noise when I breathe.” The nurse’s best reply is:
a. It is the sound of air passing through fluid in your alveoli
b. It is the sound passing through fluid in your bronchus
c. It is the sound of air being pushed through narrowed bronchi on expiration
d. It is the sound of air being pushed past a narrowed larynx on inspiration
Rationale: C. Wheezing is produced when there is decreased expiratory flow.
7. Chest physiotherapy is a standard adjunct to the treatment of chronic asthma. When should the nurse administer the child’s bronchodilator in conjunction with postural drainage?
a. one hour before postural drainage
b. during postural drainage
c. one hour after postural drainage
d. between postural drainage treatments
Rationale: A. Bronchodilators are given before postural drainage so that they my fully dilate the bronchus and thus allow maximum removal of secretions.
8. Which school-related activity might the school nurse prohibit for a child with asthma?
a. The swim team.
b. the band
c. Pet show-and-tell day
d. An art class
Rationale: C. Animal dander can precipitate/ aggravate an asthmatic episode.
9. At home care instructions for a child with asthma include instructing the parents that use of a bronchodilator can result in:
a. decreased activity level
b. growth suppression
c. weight gain
Rationale: D. Insomnia is a noted side-effect of bronchodilators.
10. Which nursing diagnosis is most developmentally focused for an adolescent who has cystic fibrosis?
a. high risk for altered nutrition, less than body requirements
b. high risk for body-image disturbance
c. high-risk for infection
d. high-risk for aspiration
Rationale: B. Adolescents are acutely aware of every change in their bodies.
1. The nurse is assisting a client diagnosed with right sided cerebrovascular accident (CVA) in using cane. The nurse should teach the client which of the following actions?
a. Move cane 16 inches beside of the foot
b. Flex elbow at 150-300 angle
c. Hold cane in the right hand
d. Advanced left foot ahead of the cane
Rationale: B. Cane should be placed 4-6 inches to the side of the foot. Hold cane in the hand of the unaffected side. Cane should move together with the affected leg followed by the unaffected leg. (Saunders © 2005, p. 1006)
2. After medical intervention for a long bone fracture the nurse is instructed to watch for signs and symptoms of developing fat embolism. Which of the following observation should the nurse report?
a. Numbness and tingling sensation
b. Coolness and absence of pulse at the fracture site
c. Blanching of the skin
d. Petechial rashes on the chest and neck
Rationale: D. Petechiae are due to ruptured blood vessels caused by fat emboli. (Saunders © 2005, p. 1004)
3. A patient assigned to the nurse had an ORIF 2 days ago and complains of erythema on the chest. What should be the priority of the nurse?
a. Apply ointment on the chest
b. Report to the doctor
c. Tell client that it’s ok
d. Ask what she has taken for lunch
Rationale: B. Erythema on the chest indicates a fat embolism. This is a medical emergency. The nurse should notify the doctor immediately! p. 1004 Saunders
4. The nurse knows that which of the following is a sign of fat embolism?
a. petechiae & rashes on chest
c. abdominal pain
Rationale: S/S of fat embolism includes: restlessness, mental status changes, tachycardia, tachypnea, hypotension, dyspnea and petechial rashes over the upper chest and neck. p. 1004 Saunders
5. A patient with acute low back pain is seen in the clinic. One desired patient outcome was to use proper body mechanics at all times. Which finding would indicate that this goal was met?
a. The patient slides an object across the floor rather than lifting
b. To pick up an object off the floor, patient bends at waist and tightens the abdominal muscles
c. The patient twists at the waist while reaching for an object
d. The patient stands using a slouched position to reduce strain
Rationale: A. The use of good body mechanics and correct posture are essential when planning care for a patient with acute low back pain to prevent recurrent problems. NCLEX-RN Review Guide p. 283
6. Eight hours following a femur fracture, a patient complains of a sudden onset of dyspnea and severe chest pain. Which action should the nurse take first?
a. Administer oxygen and assess vital signs
b. Notify the physician and prepare to transfer the patient to ICU
c. Increase IV infusion and medicate for pain
d. Complete and document a head-to-toe assessment
Rationale: A. Based on the symptoms of dyspnea and chest pain which indicates fat embolism a potential complication of fractures, intervention priorities for the nurse would be to notify the physician immediately. Saunders p.1004
7. A nurse arrives at the scene of a motor vehicular accident. The patient is not breathing and there is a high index of suspicion for a cervical vertebrae fracture. What is the priority of care for this patient?
a. Place the patient in a hard cervical collar
b. Open the airway using the jaw-thrust maneuver
c. Assess the patient for other injuries
d. Complete a neurological assessment
Rationale: B. The prioritie of care at an accident scene are airway, breathing and circulation. For a patient who is not breathing and has suspected cervical injury, the jaw-thrust maneuver should be used to open airway. NCLEX-RN Review Guide p. 286
8. A patient has a short leg cast that has been newly applied to the lower extremity. Which finding would require immediate notification of the physician?
a. Patient report of a moderate pain level
b. Presence of dependent edema distal to the cast
c. Inability to flex or extend toes on the casted foot
d. Increased temperature of the affected extremity
Rationale: C. The application of a cast can result in compromise of the vascular and/or nerve function of the extremity. The lack of movement of an extremity could indicate a neurovascular compromise and should be reported to the physician immediately. NCLEX-RN Review Guide p. 286
9. The nurse is caring for a patient with an open fracture of the radius. The nursing diagnosis for the patient is risk for peripheral neurovascular dysfunction. Which intervention to perform?
a. Observe the condition of the fracture site for signs of infection
b. Assess the involved extremity for pain, pallor, paresthesia, pulse and temperature.
c. Perform ROM on the bilateral extremities
d. Check the bilateral radial and brachial pulses
Rationale: B. A neurovascular assessment of the involved extremity is the appropriate intervention for the diagnosis. NCLEX-RN Review Guide p. 284
10. The nurse is completing a neurovascular assessment of a fractured lower extremity after a surgical intervention to reduce the fracture. Which parameters are included as a part of a neurovascular assessment? SATA
c. Capillary refill time
Rationale: All. NCLEX-RN Review Guide p. 290
1. A nurse is developing a plan of care for a client with multiple myeloma. The nurse includes which of the following intervention in the plan of care?
a. Encourage to drink 8-10 glasses of water daily
b. Discourage long distance walking
c. Provide frequent oral care
d. Administer pain medication as prescribed
Rationale: B. Because of massive bone resorption, clients are at risk for pathological fractures, thus long distance walking are not recommended. Fluids must be up to 3-4 L/day to offset problems associated with hypercalcemia, hyperuricemia, and proteinuria. (Saunders © 2005, p. 587)
2. A client with cervical cancer is prescribed with an internal radiation implant. When caring for this client, the nurse should observe which of the following actions?
a. Limit time with the client for 1 hour per shift
b. Pregnant nurse can be assigned to the client as long as she is wearing dosimeter bandage
c. Place precaution signs on the client’s room
d. Individuals 16 years old and below may be allowed to visit as long as they maintain 6 feet distance from the client
Rationale: C. Caution sign keeps the personnel and visitors aware of the radiation risk. (Saunders © 2005, p. 583)
3. A nurse is giving home care instructions to a client who had radical mastectomy. Which of the following interventions should be included in the plan?
a. Apply cold compress to the affected arm
b. Wear long-sleeved blouses when going out
c. Avoid arm exercise for the first few months
d. Keep the affected arm elevated above the level of the heart
Rationale: B. Wearing long-sleeved blouses keeps the affected arm from being exposed to direct sunlight. (Saunders © 2005, p. 591)
4. A group of community health workers are conducting a health promotion program to keep the community aware of the risk factors of cancer. Which of the following clients identified by the health workers possesses the highest risk for CA?
a. 39 year-old consuming high selenium in her diet with history of ovarian cysts.
b. 40 year-old drinking 3-4 cups of coffee a day with family history of fibrocystic disease.
c. 45 year-old opera singer who consumes one glass of wine every night.
d. 28 year-old smoker with high meat consumption.
Rationale: A. Presence of pre-existing cysts with high selenium in the diet is the most at risk for CA.
5. Which statement made by a nursing student indicates an appropriate knowledge on the risk factor of bladder CA?
a. “Eating highly smoked and seasoned foods can increase the risk.”
b. “It is generally seen in elderly males age 60 and above.”
c. “Bladder trauma usually leads to bladder CA.”
d. “Cigarette smoking is one of the predisposing factors for bladder CA.”
Rationale: D. Bladder CA is commonly caused by cigarette smoking, exposure to industrial chemicals, and radiation. (Saunders © 2005, p. 596)
6. Oral radioactive iodine is prescribed as a mode of treatment for a client with thyroid cancer. The nurse understands the mechanism of this treatment and includes which of the following action in the care plan?
a. Limit client’s visitors per day
b. Wearing dosimeter film bandage when caring the client
c. Flushing urine in the toilet twice
d. Prepare long-handled forceps in the client’s bed side
Rationale: C. Oral radioactive does not pose a hazard of emitting radiation to anyone. Appropriate handling of body secretions must be carried out. (Saunders © 2005, p. 583)
7. The nurse provides care instructions to a client with Acute Myelogenous Leukemia (AML). Which statement by the client indicates appropriate understanding of the given instructions?
“I will use soft bristled toothbrush and avoid the use of dental floss.”
“I need to eat fresh fruits and vegetables.”
“I have to wear masks when going out.”
“I should avoid highly fibrous foods.”
Rationale: A. This client is at risk for bleeding and infection. Eating fresh fruits and vegetables are discouraged. High fiber foods must be encouraged to prevent constipation that may cause rectal trauma. Frequent oral hygiene is important to prevent infection. The use of soft bristled toothbrush and avoiding dental floss prevents gum bleeding. Visitors should be the one instructed to wear the mask. (Saunders © 005, p. 585)
8. A patient with leukemia was assigned to the nurse post bone marrow biopsy. What will be the correct nursing diagnosis?
a. Risk for infection R/T skin puncture
b. Risk for skin trauma R/T incision
c. Risk for hemorrhage
d. Impaired physical mobility
9. Which of the following indicates a correct understanding for a patient with cervical implant?
a. Limit her child to visit her 30 mins per shift/day
b. Stay 6 ft. (1.8m) away when visiting
c. Assist in ambulation
d. Wear gloves because of radioactive precautions when handling urine
Rationale: B. Radioactive precautions in a patient with cervical implant include distancing from the patient around 3-6 feet away. A child and a pregnant woman are contraindicated in visiting a patient with radioactive precautions. Only appropriate persons including health care providers and allowed visitors are limited to around 30 minutes per day. For nurses, it is equivalent to 30 minutes per shift. Ambulation is contraindicated because usually, the patient will be on complete bed rest. Ambulation will just dislodge the cervical implant. It is a sealed implant, therefore it will not contaminate body fluids and no radioactive precautions are necessary with the clients’ urine or excreta.
10. A patient who has cancer and having chemotherapy is constantly yelling and being rude to the nurse. When the nurse went out, the wife followed and asked for forgiveness. What is the best response for the nurse?
a. “I know that his anger is not really meant for me”
b. “It must be hard for you seeing your husband this way”
c. “It is okay, the behavior of your husband will come to pass”
d. “I am quite hurt but I understand your husband”
Rationale: B. Acknowledging the feeling of the wife and stating observations is therapeutic. Options A and D are nurse centered, not client centered which it non-therapeutic. Option C on the other hand is false reassuring.
1. The nurse is giving health instructions to prevent symptoms of Raynaud’s disease. The nurse should emphasize to the client which action?
a. Relaxation and smoking cessation
b. Avoiding high sodium and cholesterol diet
c. Wearing mittens and thick clothing
d. Performing brisk walk for 20 minutes daily
Rationale: A. Smoking and stress are the most common precipitating factor of Raynaud’s disease. (Saunders © 2005, p. 806)
2. A client with peripheral arterial disease complains of leg pain when walking and reports relief when in rest. The nurse’s correct intervention for the client will include
a. Elevating legs above the heart level when sleeping.
b. Massaging legs 3x a day.
c. Performing individualized exercise such as walking.
d. Applying warm compress 2x a day.
Rationale: C. Prescribed exercise such as walking will improve arterial flow through the development of collateral circulation. Encourage the client to walk to the point of claudication, stop, and rest, and then walk a little farther. (Saunders © 2005, p. 805)
3. Which of the following activities will constitute to primary hypertension?
a. Smoking marijuana 3x a week
b. Drinking alcoholic beverages of 5-6 cans/day
c. Eating canned foods every other day
d. Consuming -3 cups of coffee per day
Rationale: A. Risk factor for primary hypertension include smoking, consuming high fat and salty diet, race, age, gender, and heredity.
4. Which of the following is appropriate to ask in obtaining the history of a client with mitral valve stenosis?
a. “Are you taking any long term drug?”
b. “Have you experienced any childhood sickness?”
c. “Do you engage yourself in smoking?”
d. “Are you consuming high fat foods?”
Rationale: B. To determine the history of mitral stenosis the nurse must ask the client if he had any childhood sickness such as tonsillitis since inflammation of the mitral valve results from streptococcal infection. (Saunders © 2005, p. 801)
5. A patient with CHF and Hypertension have a laboratory result of: Sodium-138, Potassium- 1.5 and an elevated Cholesterol. Based on the results, what drugs should you not give? Select all that applies.
Rationale: A, B, D. Kayexelate and Lasix depletes Potassium and administering Digoxin in hypokalemia increases toxicity. Simvastatin and Lipitor have no known affects in Potassium.
Mosby’s drug guide for nurses.
6. A patient with pacemaker was assigned to the nurse. When does the nurse need to intervene?
a. “I will remind the airport security for having a pacemaker”
b. “I will avoid sexual intercourse because it might dislodge my pacemaker”
c. “I need to avoid contact sports”
d. “I should come back to my health care provider about 10 years to have a battery change”
Rationale: B. Sexual activities need not to be avoided because it will not likely dislodge the pacemaker. The patient should be cautious when entering magnetic fields to include airport security or theaters. Contact sports are avoided because it could directly hit the area of the pacemaker site and could cause malfunction. Certain types of pacemaker usually have a lifetime of 10 years before the battery is replaced.
7. Which is a correct understanding regarding MI?
a. Weight daily
b. Use salt substitutes
c. Administer Digoxin to prevent cardiac dysrrhytmias
d. Sexual activity can be resumed after the patient can step a flight of stair
Rationale: A. Daily weight is necessary to monitor because a complication of Mi is congestive heart failure. Any increase in body weight may signify the development of CHF due to water retention. Salt substitutes are usually withheld because the patient could suffer from hypertension. Digoxin is withheld because the heart needs rest. Digoxin has a positive inotropic effect causing stress to the heart. Sexual activity is resumed if the patient can climb a flight of stairs usually, not a single stair only. Usually this happens after 4-6 weeks after the acute attack.
8. Which of the following patients is at High risk for Coronary Arterial Disease (CAD)?
a. Myocardial Infarction (MI) with High LDL
b. COPD with high LDL
c. Pancreatitis with high LDL
d. Herniated nucleus pulposus with high HDL
Rationale: A high LDL and a cardiovascular problem increases the risk with coronary artery disease. Other options do not pertain to a cardiovascular disorder.
9. What is the correct teaching for a patient with CAD?
a. “ I will exercise 2x a day for 3x a week”
b. “ I will avoid eating canned goods “
c. “ I will limit eating fatty foods“
d. “ I will increase my fluid intake”
Rationale: C. The usual cause of CAD are atherosclerosis and arteriosclerosis. The usual factor is because of hyperlipidemia. Between sodium and fat and increasing fluid intake, fatty ingestion is a priority and is more relevant to the occurrence of CAD.
10. A patient with a history of Hypertension, admitted due to social withdrawal and decrease ADL. Which to assess first?
b. Lifestyle and sleep patterns
c. Level of cognition
d. Social Life
Rationale: A. Physiologic needs first. The patient had history of hypertension. Secondary assessments include options B, C, D.
1. The nurse is caring for a patient with Acute Glomerulonephritis. What is the manifestation of this disease? Select all that applies.
a. Periorbital edema
Rationale: A, B, and C are manifestations of AGN. P. 866 Saunders
2. A patient with ESRD was placed under the care of the nurse. In monitoring for the client, which of the following is the complication of uremia?
a. dry mucus membrane
b. BP of 100/80
c. RR of 22
d. Increase Urinary Output
Rationale: A. Urate crystals are excreted through the skin and may cause skin breakdown, rash, and uremic frost. The nurse should provide good skin care and oral hygiene. P. 858 Saunders
3. Before discharging a client after prostatectomy, the nurse renders several teachings to prevent complication. Which client statement will indicate that the client fully understands the teachings?
a. I can sit at my reclining chair for a short period of time while watching TV
b. I can resume weight bearing exercises after 1 week
c. I can drive during our interstate trips with my family
d. I can resume sexual intercourse after a week
Rationale: Avoid long auto trips, vigorous exercise, heavy lifting (heavier than 10 lbs), and sexual intercourse for about 3 weeks or until medical permission, because they may increase tendency to bleed. Davis 2008, p. 544
4. Which of the following would a nurse expect in a patient post-hemodialysis 1hr ago to report?
c. Absence of pruritus
d. feeling of lightness
Rationale: Therapeutic effects of Hemodialysis are removal of waste products from the body, restoration of fluid and electrolyte and acid-base imbalance and reversal of untoward manifestations of irreversible renal failure. Pruritus may still occur for reasons not yet understood. (Black p.61)
5. A client with failure response to hemodialysis submitted for kidney transplantation. Proper instructions were given post-operatively which will include:
a. Avoiding large groups of people
b. Avoiding people with contagious disease
c. Wearing sun shield protection when going out
d. Limiting consumption of fluids
Rationale: Infection is the leading cause of morbidity and mortality after transplantation due to immunosuppressive regimen the client is undergoing to prevent transplant rejection. P. 2434 Black
6. The most potentially dangerous complication of peritoneal dialysis is
a. abdominal pain
b. GI bleeding
d. muscle cramps
Rationale: C. p. 515 NCLEX-RN lippincott’s
7. After completion of dialysis, the nurse would expect the client to exhibit
b. Weight loss
d. Increased Urine Output
Rationale: B. p. 515 NCLEX-RN lippincott’s
8. The client with CRF complains that he feels nauseated at least part of everyday. The nurse should explain that the nausea is the result of:
a. acidosis caused by his medications
b. accumulation of waste products in his blood
c. chronic anemia and fatigue
d. excess fluid load
Rationale: B. p. 515 NCLEX-RN lippincott’s
9. Correct teaching reinforcement for a client 5 days post-op after prostatectomy will include
a. void of 6 hours
b. fluid intake of 900 ml/day
c. kegel exercises every hour
d. self-catheterization, intermittent
Rationale: Perineal (kegel) exercise must be initiated 1-2 days after surgery to reduce stress incontinence problem. Fluids must be pushed and needs to void as soon as urge is felt. (Davies 2008, p.594)
10. When developing a plan of care, the nurse considers that stress incontinence is best defined as involuntary loss of urine associated with:
a. a strong urge to urinate
b. overdistention of the bladder
c. activities that increase abdominal pressure
d. obstruction of urethra
Rationale: C. p. 516 NCLEX-RN lippincott’s
1. The nurse in the burn unit is assigned to a patient with 2o burn. Which of the following is a correct assessment finding for the client?
a. painless with grayish
b. with pain and skin blanches with pressure
c. with pain eased by cooling
d. erythematous with blisters
Rationale: D. 2o burns are painful, reddish and with blisters. Choice A is a manifestation of 3o burn and B&C are manifestation of 1o degree burn. P. 544 Saunders
2. A patient with Acne vulgaris is taking Isotretinoin(Accutane). Which is a correct teaching made by the nurse?
a. It worsens with exposure to sunlight
b. Expect outcome within 2 weeks of antibiotics
c. Avoiding chocolates will help lessen the disease
d. Use facial scrubs to clean face
Rationale: Accutane causes skin dryness and continuous exposure to sunlight may worsen the condition. Improvement can be seen 4 to 6 weeks from the start of therapy. The face should not be scrubbed. Chocolates has no effect on acne. P. 542 Saunders.
3. A patient with scabies was placed under the care of the nurse. What should the nurse expect to see?
a. thread-like lesions
b. silvery scale at the shaft of the hair
c. small flaky rashes
d. golden brown skin pigmentation.
Rationale: A. Scabies is manifested as thread-like lesions.
4. A child weighing 27 kg is admitted to the burn unit with 3rd-degree burns to the chest, face, and extremities. During the acute phase (i.e. first 48 hours)of a major burn injury, which assessment findings should the nurse immediately report?
a. Temp of 100o F
b. Edema of the hands and feet
c. Urinary Output of 150 ml in 8 hours
d. Decreased sensation in the extremities
Rationale: C. Fluid volume replacement and urinary output is very important in burn client. A child weighing less than 30kg should produce 1-2 ml/kg/h of urine. P. 96 NCLEX RN review Guide
5. Upon assessment of a burn victim, the nurse finds reddened skin with mild edema. Thin-walled blisters are present, and the patient complains of pain. These assessment findings are indicative of which types of burn injury?
b. Superficial partial thickness
c. Deep partial thickness
d. Full thickness
Rationale: B. A superficial partial thickness burn is characterized by reddened skin and a blistering wound that blanches with pressure. p. 195 NCLEX RN Review Guide
6. A 37-year-old man is seen in the outpatient clinic for treatment of psoriasis. The nurse should anticipate which of the following findings in this man?
a. Intense pain.
b. Discolored nails.
c. Abdominal lesions.
d. Hyperpigmented skin.
Rationale: B. A yellow discoloration of the nails is frequently seen in psoriasis. (NSNA, pg. 421)
7. The physician prescribes coal tar preparations as part of the treatment plan for a man who has psoriasis. The nurse should include which statement5 in the teaching plan for this client?
a. Ingest the coal tar with liberal amounts of water.
b. Eat a high-carbohydrate diet.
c. Restrict activity for 24 hours.
d. Avoid sunlight immediately after the treatment.
Rationale: D. Sunlight should be avoided after a coal tar treatment. (NSNA, pg. 421)
8. An adult’s shirt catches on fire and is now in flames. He panics and runs into his neighbor’s yard. Which of the following interventions is appropriate?
Select all that apply:
( ) a. Dousing the flames with water.
( ) b. Removing his burned clothing.
( ) c. Removing his jewelry.
( ) d. Rolling him on the ground.
Rationale: ACD.Dousing the flames should be selected. This is an appropriate way to smother the flames. Removing his jewelry should be selected. Hot metal jewelry could increase burning. Rings should be removed before edema occurs. Rolling him on the ground should be selected because it will smother flames. (NSNA, pg. 421)
9. A 78-year-old man is admitted with severe flame burns resulting from smoking in bed. The nurse can expect his room environment to include
a. Strict isolation techniques and policies.
b. A semi-private room.
c. Liberal unrestricted visiting.
d. Equipment shared between the client and the other burn client in the unit.
Rationale: A. Isolation is thought by some clinicians to reduce the incidence of cross contamination significantly. However, methods vary drastically from one center to another. The single most effective technique to prevent transmission of infection is handwashing. (NSNA, pg. 421)
10. A 60-year-old farmer presents with a diagnosis of basal cell epithelioma. The lesion would most likely be described as
a. Dome shaped, shiny with a well-defined border.
b. Poorly marginated, flat red area.
c. Red, dark blue or purple macules.
d. Erythema, edema, and blisters.
Rationale: A. The most common presentation of BSE is a nodular lesion that is dome-shaped papules with well-defined borders. The lesions can have a pearly or shiny appearance because it does not keratinize. (NSNA, pg. 421)
1. Following an acute episode of pancreatitis the nurse needs to report immediately if she observed?
a. Jaundice with pruritus
b. Severe abdominal pain
c. Rapid respirations
d. Muscle twitching
Rationale: D. Hypocalcemia occurs in pancreatitis and is manifested by tetany, irritability, jerking, muscular twitching, mental changes and psychotic behavior. (Mosby © 2003, p. 531)
2. The nurse cares for a patient with pancreatitis. The following assessment findings was documented and endorsed, what to prioritize?
a. blood sugar of 250
b. periumbilical region ecchymosis
c. pain on RUQ, radiating to shoulder
d. pain @ RLQ upon palpation
Rationale: B. Cullen’s sign indicates severe hemorrhagic pancreatitis and may lead to shock. This takes priority. P. 1291 Black
3. Which of the following drug the nurse needs to question if given in patient with liver cirrhosis?
c. B1 thiamine
Rationale: Fentanyl (Darvon) is metabolized extensively in the liver which may further aggravate the condition of the patient. Neomycin helps in excreting ammonia. Mosby’s Drug Guide for Nurses.
4. The nurse was assigned a patient with acute appendicitis complaining pain of 9 in a scale of 1-10 in the RLQ. Which of the following assessment findings need to be reported immediately?
a. pain while moving
b. absent bowel sounds
c. loss of appetite
Rationale: B. Absent bowel sounds indicates peritonitis due to rupture of appendix and should be reported immediately. A, C and D are also manifestations of appendicitis. P. 812-814 Black.
5. A patient for cholecystectomy was admitted. What should the nurse follow-up?
a. “I developed a rash at my back before when I was operated”
b. “I developed nausea and vomiting when opioids were administered to me before”
c. “I experienced severe pain before because I took Morphine”
d. “I developed steatorrhea”
Rationale: A. The patient is at risk for anaphylactic shock. This should be further investigated to prevent this possible life threatening complication. Nausea and vomiting is a normal side effect of opiods. Severe pain can happen with cholecystitis because Morphine could cause spasm on Sphincter of Oddi, but this will not need follow up because …
6. Patient wants to drink fluids after cholecystectomy, what to know first?
a. decrease abdominal distention
b. presence of bowel sounds at all four quadrants
c. decrease salivation
d. absence of pain
7. The nurse cares for a patient with diverticulitis, what is a correct understanding?
a. I will avoid drinking milk
b. I will use over the counter laxatives
c. I will increase bulk in my diet
d. I will limit my food consumption
8. The infant has surgery to repair the cleft lip. The nurse observes that the infant is having difficulty breathing postoperatively. Which of the following measures would be most helpful in bringing relief?
a. Raising the infant’s head
b. Turning the infant onto the abdomen
c. Administering oxygen per mask
d. exerting downward pressure on the infant’s chin
9. Which of the following methods would the nurse use to feed an infant after surgical repair of the cleft lip?
a. gastric gavage
b. intravenous fluids
c. a rubber-tipped medicine dropper
d. a bottle with a lambs nipple
Rationale: C. A rubber-tipped medicine dropper has been found to be a satisfactory method for feeding an infant who has had surgical repair of cleft lip. (Lippincott NCLEX-RN, p. 284)
10. The child is eventually admitted to the hospital for repair of the cleft palate. Which of the following eating utensils would be most appropriate for the child on the second day after the surgery?
b. drinking tube
c. rubber-tipped Asepto syringe
d. large-hole nipple
Rationale: A. A cup is the preferred eating utensils after repair of the cleft palate. (Lippincott NCLEX-RN, p. 284)
1. A group of health care volunteer is conducting seminar sessions to an elderly age 65. What action is appropriate for the team to include in enhancing learning of the client?
a. Talk to them in a loud voice
b. Link new information with related old information
c. Give additional pamphlets to read at home
d. Provide a detailed information during the topic
Rationale: B. Elderly are able to comprehend and remember old information since they have short-term memory deficit. Linking new and old information will facilitate understanding and retention. (Saunders © 2005, p. 389)
2. The nurse is performing assessment in an older client. Which observation will the nurse consider as part of the physiological changes in elderly?
a. The client is requesting for an increased seasoning in his food.
b. The client is holding newspaper nearer his face.
c. The client is standing with increased spinal curvature.
d. The client places the speaker of the radio directly in his ear.
Rationale: A. Geriatric clients normally have diminished taste perception. (Saunders © 2005, p. 389)
3. An Alzheimer’s patient is brought in the hospital by his 2 adult children whom he lives with. Assessment findings reveal 2 stage II pressure ulcer and 1 stage I pressure ulcers. He is experiencing urinary incontinence and some dry stools are seen in his skin. After rendering appropriate intervention, what is the next appropriate action to do?
a. Insert indwelling catheter
b. Ask the patient who is he living with
c. Talk to the patient alone in the room
d. Assist the family member for referral to home health care facility
Rationale: D. The patient’s assessment findings are suggestive of physical neglect. After the necessary action given by the nurse, it is also the responsibility of the nurse to suggest and assist family members for possible referral to a health care facility where in the client’s needs can be attended.
4. Appropriate safety precaution in a blind client at night.
a. Assist in voiding every 4 hours
b. Place siderails in an upright position when sleeping
c. Provide non-slipped shoes
d. Leave the room well-lighted
Rationale: B. Raising the siderails prevents the blind elderly from falling when sleeping. Assisting the client to void every 4 hours may disrupt the clients sleep. Non-slipped shoes and well-lighted room are least helpful in a sleeping client.
5. Based on the primary cause for skin changes in older adults, the intial nursing assessment of an elderly with dry skin would include:
a. Presence of age spots
b. A diet history
c. History of prior sun exposure
d. Medications taken as a younger adult
Rationale: C. Dry skin is primarily cause by sun exposure experienced during early years. P. 710 Davis 2006
6. While reading a newspaper, the nurse would expect to see older adults with presbyopia hold the newspaper:
a. close to their face
b. In their lap
c. Directly under the light
d. At arm’s distance from their face
Rationale: D. Presbyopia or farsightedness begins around 40 years and is considered age-related change in the eye. P. 710 Davis 2006
7. An 80 y.o man is admitted with a vertebral compression fracture after lifting groceries from table. Which condition is the most frequent cause of osteoporosis in the over-80 age group?
a. glucocorticoid use
b. testosterone deficiency
c. excessive alcohol use
d. idiopathic osteoporosis
Rationale: D. The cause of osteoprosis would be considered idiopathic in an 80-yo-man unlike in a woman following menopause. P. 710 Davis 2006
8. When testing the sensory response of a 75 yo client to dull or sharp objects, which finding would be considered normal? The client is:
a. Able to identify location of touch correctly but not the type of sensation
b. Able to identify type of sensation correctly but not the location
c. Able to identify both type and location correctly but the response is slow
d. Unable to identify sensation in any area
Rationale: C. The speed of nerve impulse decreases with aging. P. 710 Davis 2006
9. The greatest reduction in falls and improved safety for the elderly client with Parkinson’s disease would occur with:
a. Discouraging the client from wearing slippers
b. Buying shoes that fit snugly
c. Raising the height of toilet seats
d. Client holding hands behind back when walking
Rationale: C. Most falls in elderly, including those with Parkinson’s dse occur in the bathroom. There is a loss of muscle strength in legs with normal aging. P. 710 Davis 2006
10. The nurse knows that elders often have difficulty reading because of an age-related decrease in tear production called “dry eye”. The most appropriate intervention for dry eye is to:
a. Encourage eye drops
b. Encourage reading indoors only
c. Empathize with them
d. Encourage them to get new eyeware
Rationale: A. The primary symptom and discomfort of “dry eye” is dryness. Eye drops with saline restore and lubricate the eye, and reduce itchiness. P. 710 Davis 2006
1. The nurse should ask which of the following questions to assess for latex allergy?
a. “Have you experienced working in a health care facility?”
b. “Do you have allergy to citrus fruits?”
c. “What kind of work do you have?”
d. “Are you taking any herbal medicines?”
Rationale: B. The best way to know latex allergy is to assess for citrus fruit allergy since they are at high risk. (Saunders © 2005, p. 1041)
2. The nurse is caring for a patient with peripheral arterial disease experiencing intermittent claudication. What is the appropriate intervention to relieve pain?
a. Elevate leg at the level of the heart when sleeping
b. Massage and warm compress every 2- 3 minutes
c. Elevate feet above the heart level
d. Enocurage exercise.
Rationale: A. Intermittent claudication indicates an adequate blood supply. Leg can be elevated when resting and sleeping but not above the heart level. Warm compress can be given intermittently and not frequently to decrease risk of burning. Exercise is a correct intervention but it does not relieve pain.
3. What will be the correct teaching for patient with SLE?
a. Avoid exposure to sunlight
b. Increase protein in the diet
c. Encourage vigorous exercises
d. Cold treatments for chronic pain in arthritis
4. Within 20 minutes of the start of transfusion, the client develops a sudden fever. The most appropriate initial response by the nurse is to
a. Force fluids.
b. Continue to monitor the vital signs.
c. Increase the flow rate of IV fluids.
d. Stop the transfusion.
Rationale: D. Sudden development of fever during a blood transfusion may be indicative of a pyrogenic reaction. The most appropriate nursing action is to discontinue the blood flow to prevent a more severe reaction. (NSNA, pg. 284)
5. The nurse has been teaching an adult who has iron deficiency anemia about those foods that she needs to include in her meal plans. Which of the following, if selected, would indicate to the nurse that the client understands the dietary instructions?
a. Coffee and tea.
b. Bananas and nuts.
c. Dairy products.
d. Citrus fruits and green leafy vegetables.
Rationale: D. Dark, leafy green vegetables (as well as meats, eggs, legumes, and whole-grain or enriched breads and cereals) are rich in iron. In addition, both citrus foods and gren leafy vegetables are high in vitamin C, which aids in iron absorption. (NSNA, pg. 285)
6. In assessing clients for pernicious anemia, the nurse should be alert for which of the following risk factors?
a. Positive family history.
b. Infectious agents or toxins.
c. Acute or chronic blood loss.
d. Inadequate dietary intake.
Rationale: A. There is a familial predisposition for pernicious anemia, and although the disease cannot be prevented, it can be controlled if detected and treated early. (NSNA, pg. 285)
7. A client has been scheduled for a Schilling’s test. The nurse should instruct the client to
a. Administer a fleets enema the evening before the test.
b. Empty his bladder immediately before the test.
c. Take nothing by mouth for 12 hours prior to the test.
d. Collect his urine for 12 hours.
Rationale: C. The client is to fast for 12 hours prior to the test. No food or drink is permitted. Following administration of the vitamin B12 dose, food is delayed for 3 hours. (NSNA, pg. 285)
8. A 40-year-old woman with aplastic anemia is prescribed estrogen with progesterone. The nurse can expect that these medications arte given for which of the following reasons?
a. To enhance sodium and potassium absorption.
b. To promote utilization and storage of fluids.
c. To regulate fluid balance.
d. To stimulate bone growth.
Rationale: D. In aplastic anemia, the bone marrow elements (electrolytes, leukocytes, and platelets) are suppressed. Drugs like estrogen and progesterone work to stimulate bone growth. Estrogen and progesterone also stop menstruation so there is less blood loss. (NSNA, pg. 285)
9. Which of the following lab value profiles should the nurse know to be consistent with hemolytic anemia?
a. Decreased RBC, increased bilirubin, decreased hemoglobin and hematocrit, increased reticulocytes.
b. Increased RBC, decreased bilirubin, decreased hemoglobin and hematocrit, increased reticulocytes.
c. Decreased RBC, decreased biliribin, increased hemoglobin and hematocrit, decreased reticulocytes.
d. Increased RBC, increased bilirubin, increased hemoglobin and hematocrit, decreased reticulocytes.
Rationale: A. Decreased RBCs are result of the excessive destruction of the red blood cells, with this destruction, there is a subsequent decrease in both hemoglobin and hematocrit. The reticulocyte count is high because the numbers of immature RBCs are increased when RBC are being destroyed. (NSNA, pg. 285)
10. In planning care for a client who has had a splenectomy, the nurse should be aware that this client is most prone to developing
a. Urinary retention.
b. Congestive heart failure.
d. Viral hepatitis.
Rationale: C. Following a splenectomy, immunologic deficiencies may develop, and vulnerability to infection is greatly increased. The postsplenectomy client is highly susceptible to infection from organisms such as Pneumococcus. A preventive measure is immunization with Pneumovax. (NSNA, pg. 285)
1. The nursing staff on an inpatient psychiatric facility has received the following client under her care. Which of the following should the RN see first?
a. A client with manic bipolar disorder with a morning lithium level of 1.3 mEq/L.
b. A schizophrenic client receiving chlorpromazine (Thorazine) with a WBC of 6,000 cells/uL.
c. A client with major depression who is scheduled for ECT this morning.
d. A schizoaffective client receiving risperdone (Risperdal) exhibiting tardive dyskinesia.
2. The nurse is reviewing the chart of all the 1 day-old infants in the nursery room. Which of the following infants need further assessment?
a. An infant born to a diabetic mother with blood glucose of 50 mg/dl.
b. An infant born to an addicted mother with a heart rate of 128 beats per minute.
c. An infant born to a pre-eclamptic mother with a hematocrit of 50%.
d. An infant delivered via C-section with an RR of 82 rates per minute.
Rationale: D. Respirations with a rate of 82 per minute is not normal in a 1 day old infant. Assessment of any underlying cause must be done. Other infants are normal. (Saunders © 2005, p. 347, 337)
3. The following clients are brought to the ER with common complains of acute abdominal pain. Which of the following client will require immediate attention?
a. A 28-year-old client with a BP of 100/50, pulse of 96, and abdominal distention.
b. A 30-year-old with temperature of 990F, amber-colored urine with bloating.
c. A 16-year-old with decreased urine output and dysuria.
d. A 45-year-old with respirations of 24, flatulence, and vomiting.
Rationale: A. Decreased blood pressure, increasing pulse rate, and abdominal distention are symptoms of altered bowel function and possible shock that requires immediate attention.
4. The ER staff is practicing its annual disaster drill. According to disaster triage, which of the following clients should be cared last?
a. A client with open tension pneumothorax with repiratory distress.
b. A client with multiple protruding fractures of the tibia and fibula.
c. A client with smoke inhalation injury.
d. A client with 70% TBSA full thickness burn.
Rationale: D. This client should be cared last because he requires the greatest expenditure of resources and has the least chances of survival. (Saunders © 2005, p. 75)
5. Which of the following client should a nurse give priority attention?
a. Client with Myasthenia gravis with drooling saliva
b. Client with Parkinson’s disease exhibiting muscle rigidity and jerky movement.
c. COPD client with difficulty breathing and nasal flaring while ambulating in the hallway.
d. Huntington’s client complaining of muscle stiffness and pain.
Rationale: A. This client is at risk for aspiration since they suffer from voluntary muscle weakness and must be cared for first. Dyspnea is normal in expected client. (Saunders © 2005, p. 956)
6. During a disaster drill, which client should the nurse prioritize?
a. Client with apnea and dilated pupils.
b. Client with open fracture in the right arm and chest incision with pain on inspiration.
c. Client vomiting with large amounts of coffee colored vomitus.
d. Client with chest injury and already restless.
Rationale: B. This client has the highest chance of survival.
7. Which of eh following client in the unit will require immediate attention of the nurse?
a. CHF client with cough and difficulty breathing
b. ESRD client with increasing pedal edema
c. Acute pancreatitis client with muscle jerking
d. DM ketoacidosis client with glucose of 200 mg/dl
Rationale: A. This client is experiencing breathing problem due to pulmonary edema cayused by left ventricular failure. Under the rule of ABC breathing problem must be attended first.
8. Which of the following children in the ER should the nurse attend first?
a. A child with silvery scales and reddened round plaque on the scalp and arms.
b. A child with white patches on the tongue that bleeds when scraped.
c. A child with oozing maculopapular lesions and some crust forming.
d. A child with multiple reddened wheals on the chest, back, and groin.
Rationale: B. Oral thrush with signs of bleeding is an urgent concern. Other children may need treatment but not an urgent concern since they don’t report any life-threatening complains.
9. The following clients are brought in the ER. Which of the following will you assess first?
a. Male complaining of right scrotal pain 3 hours ago
b. Client complaining of diarrhea with trace of blood
c. BPH with difficulty initiating a stream of urine and reported a decrease of urine output in the past 4 days
d. Client with migraine headache who is complaining of severe nausea
Rationale: B. This client needs immediate attention since he is at risk for F&E imbalance secondary to diarrhea and possible development of shock as manifested by bleeding. Other clients should be assessed soon but do not have needs as urgent as this client.
10. A nurse is caring the following client in the step down unit. Which client should the nurse prioritize?
a. Posy MI 3 days ago with 2-3 PVC’s per minute
b. Client with multiple sclerosis having fever and complains of flank pain
c. Client with radioactive implant for cervical cancer with her grandchildren sitting at the foot of the bed
d. Client with heart failure who has atrial fibrillation at rest
Rationale: A. PVC occurring in the setting of MI can lead to ventricular tachycardia/ventricular fibrillation (cardiac arrest) so rapid treatment is necessary.
11. A woman was admitted with severe abdominal pain and shoulder pain. She also reported small amounts of bright red vaginal bleeding. The following orders are made by the physician. Which of the following should be carried out first?
a. Perform C&S test of the urine
b. Administer pain medication
c. Establish IV line
d. Submit for an ultrasound
Rationale: C. The client’s complain is suggestive of fallopian tube rupture and the client is at risk for shock due to the presence of internal bleeding. IV line is important to secure fluid replacement and prevent the development of shock. IV can also be used for the administration of medication so it serves a double purpose.
12. An unconscious client is admitted after a vehicular accident. Which of the following observation will require the nurse to report immediately?
a. Pupil 5mm dilated and brisk
b. Extension of the upper extremities during suctioning
c. Conjugate eye movement with rapid nystagmus during ear irrigation
d. Absence of bowel sound during auscultation
Rationale: B. Normal pupil size ranges from 3-7 mm. Abnormal positioning such as decorticate rigidity indicates diffuse brain injury. Conjugate eye movement with rapid nystagmus towards the direction of the ear irrigated is a normal findings during a caloric test.
13. A CCU nurse is assessing a patient with implantable cardiac defibrillator. What should be the first thing to do?
a. Assess for any sudden syncope, SOB and tachycardia if a patient detects arrhythmia.
b. Assess first the red bracelet indicating the patient has implantable Cardiac defibrillator (ICD).
c. Assess first the patient regarding discharge instructions regarding possible deactivation of his ICD from electromagnetic fields such as audible tone which may be heard when he approaches a strong magnetic field.
d. Assess the patient regarding diagnostic procedure teaching such as metal casing of the generator which may scatter x-rays making the CT scan difficult to read.
14. What to assess first on the nurses round?
a. A 28 year old male patient with Type 1 Diabetes who is restless and agitated.
b. A 31 year old female who had an appendectomy 2 days ago, who experiences pain of 8 out of 10.
c. A 49 year old male patient with TURP who has difficulty voiding and experiences burning urination.
d. A 39 year old schizoaffective patient who develops insomnia and constipation
15. A 41 year old female patient experienced a close head injury after a motor vehicle accident. What should the ICU nurse do first?
a. Put restraints as ordered by the doctor.
b. Ask a family member to stay with the patient.
c. Ask for sedation orders from the physician.
d. Place room at the end of the hallway.
16. The nurse is prioritizing patients, what needs further investigation?
a. HbA1c of 9%
b. BUN of 24 mg/dl
c. Creatinine of 1 mg/dl
d. Na of 144 mg/dl
17. A CHN nurse is visiting patients 3 miles apart, which of the following should you attend first?
a. A patient who experiences fever and chills after chemotherapy
b. An elderly patient having dysuria and difficulty voiding
c. A patient taking heparin and coumadin who accidentally breaks her radius and ulna and reports to put pressure on the wound for 5 minutes.
d. A patient who has a chronic cough with rhinorrhea.
18. The nurse is performing his/her nursing care , which of the following needs further teaching?
a. The nurse is suctioning the tracheostomy tube while the cuff is deflated.
b. The nurse notices the partial rebreather mask bag is INFLATING when the COPD patient INHALES.
c. The nurses that the patient’s weight is on his axilla and not on his hands when using his crutches.
d. The nurses observes that the patient is doing self catheterization using clean technique and not sterile.
19. Which of the following should the nurse prioritized when assessing a diabetic patient?
a. His blood sugar is 180 mg/dl with peripheral neuritis and experiencing right sided chest pain
b. His blood sugar is 495 mg/dl and experiencing increased agitation
c. His blood sugar is 415mg/dl and is experiencing thirst.
d. His blood sugar is 65 mg/dl and is experiencing hunger.
20. A month old is diagnosed with child abused (physical). Which of the following symptoms should the nurse prioritized?
a. Battle sign (mandibular fracture)
b. Retinal hemorrhage (Raccoons sign)
c. Rhinorrhea with decreased level of consciousness
d. Scald burns and wounds on various stages of healing.
21. Which of the following patients should the nurse prioritize first?
a. A 48 year old female patient post lumbar puncture with a pain scale of 3 out of 10.
b. A 52 year old patient post MI with pulseless tachycardia
c. 14 year old adolescent sitting at the edge of the bed with cervical implant
d. A 17 year old anorexia nervosa who had a fluid and electrolyte imbalance of Na = 134 meqs/dl
22. Which of the following patients should the nurse see first?
a. 4 mos old infant with closed head injury with HR of 65 bpm
b. 68 y.o. reports difficulty initiating urine or 4 days
c. 48 year old post MI with morphine drip
d. 78 yo male with TURP complaining of reddish pink or hematuria for 4 hours
1. A hospitalized client is ready for discharge today. While the nurse is preparing the client she hears the client saying, “I will kill my boss as soon as I go out here because of kicking me unreasonably from my job.” Appropriate action for the nurse to do is
a. Recommend to postpone the client’s discharge schedule.
b. Call the nursing supervisor to inform appropriate legal authorities that will give necessary precautionary measures.
c. Ask another nurse to escort the client out of the hospital.
d. Contact support group that the client can freely attend when home.
Rationale: B. Any forms of threat or harm that a client can inflict must be reported immediately so that involved persons will be given awareness.
2. A newly admitted Alzheimer’s client often wanders at night. Appropriate action for the nurse includes
a. Asking the physician to apply chest restraint
b. Placing the client in a private room at the end of the hallway
c. Asking if there are family member who can stay with the client
d. Obtaining a prescription for sedation
Rationale: C. the best action of the nurse at this time is to look for any family member who can observe and watched for the client. Sedation and restrains are inappropriate. The nurse might also overlook the client if it wanders when his room is placed at the end of the hallway. (Saunders © 2005, p. 1089)
3. Which of the following signs of sexual abuse is common?
a. frequent school absences
b. tired or falling asleep
c. frequent UTI
d. difficulty sitting
4. All of the following are tyramine rich foods except:
a. cream cheese and cottage cheese
b. swiss cheese and cottage cheese
c. cream cheese
5. Olanzapine (Zyprexia) #1 precaution and discharge teaching should be:
a. Avoid aged cheese
b. 2-4 weeks before taking the desired effect
c. avoid sudden changes in position and wear sunglass outdoors
d. seizure precaution if given more than 400mg/day
6. One of the following signs and symptoms of NMS are the following:
a. 140/100, tremors and seizures
b. 140/100, 40.8o C and seizures
c. 140/100, RR 34, PR 124
d. 140/100, tremors, RR 34
7. SATA regarding anti-convulsants
a. Phenytoin can only be mixed with any ISOTONIC SOLUTION an example is NSS or it will cause crystal formation
b. Carbamazepine should be assessed for CBC, esp WBC and neutrophils
c. Diazepam is also a muscle relaxant, an anti-depressant and a potent anxiolytic
d. Phenobarbital is both an anxiolytic and an anticonvulsant
e. Benzodiazepines are the best anticonvulsant drug for alcohol and cocaine withdrawal
8. The following are reversible degenerative disorders or types of dementia except:
a. Alzheimer’s disorder
b. syndenhams corea
c. huntington’s chorea
d. wernicke’s korsakoff
9. The #1 drug for Alzheimer’s is an
a. Anti-cholinesterase preferably Tacrine (Cognex)
b. Anti-cholinesterase preferably Physostigmine (pyrex)
c. Anticholinergic AtSO4
d. Anticholinesterase Gingko Biloba
10. The best nursing intervention for a client diagnosed with dementia with SUN DOWN Syndrome is having increase restlessness, insomnia, and anxiety during the night:
a. Decrease environmental stimukus and out a computerized bar code medical alert bracelet.
b. Decrease environmental stimulus and cold bed bath
c. Decrease environmental stimulus, no TV, radio and decrease lights
d. Decrease environmental stimulus and massage.
1. A client with type I DM wo is on her 3rd trimester of pregnancy is scheduled for cesarean delivery. Which of the following lab value will require the nurse to report?
a. WBC of 13,000 cells/uL
b. Glucose of 130 mg/dl
c. Platelet of 150,000 cells/uL
d. Hematocrit of 40%
Rationale: A. WBC is highly elevated suggesting possible current infection and must be reported. Other values are within normal limit. Glucose is within the acceptable limit in a diabetic pregnant woman. (Saunders © 2005, p. 115, 281)
2. A laboring mother is placed on an external fetal monitor after spontaneous rupture of her membrane. The nurse notes a non-periodic fetal heart deceleration and interprets it as variable deceleration. The nurse know that the probable cause of this is
a. Prolonged uterine contraction
b. Head compression on the cervix
c. Cord compression
d. Uteroplacental insufficiency
Rationale: C. Variable deceleration is caused by conditions that restrict blood flow through the umbilical cord. (Saunders © 2005, p. 299)
3. The nurse assesses the client for possible risk factors for PIH. Which of the following would be most important for the nurse to assess?
a. Fluid intake
b. Small-for-gestational-age fetus.
c. ABO incompatibility
Rationale: D. The most important assessment is checking the urine for proteinuria. Proteinuria, even in the absence of an elevated blood pressure, is indicative of PIH. (Lippincott 6th edition, pg.132)
4. The client’s baseline blood pressure at her initial visit at 12 weeks’ gestation was 110/70 mm Hg. During an assessment at 32 weeks’ gestation, which of the following data indicate mild PIH?
a. Swelling of fingers and ankles.
b. Blood pressure of 160/110 mm Hg on two separate occasions.
c. Elevated serum creatinine.
d. Proteinuria, more than 5 g in 24 hours.
Rationale: A. Generalized edema, with swelling of the face, hands, fingers, and ankles, often occurs with mild PIH. (Lippincott 6th edition, pg.132)
5. Two hours after admission, the physician orders 5% dextrose in Ringer’s solution and magnesium sulfate intravenously. Before administering the magnesium sulfate, the most important assessment for the nurse to make is the
a. Maternal urinary output.
b. Maternal respiratory rate.
c. Fetal position.
d. Fetal heart rate variability.
Rationale: B. A central nervous system depressant used as an anticonvulsant for severe PIH, magnesium sulfate may depress respirations to a dangerously low and even life-threatening level. This drug should not be administered without first consulting the physician if the client’s respiratory rate is below 12 to 14 breaths/minute. (Lippincott 6th edition, pg.133)
6. The client’s blood pressure climbs to 164/110 mm Hg. Which of the following symptoms would suggest to the nurse that the client may be about to convulse?
a. Decreased temperature.
b. Epigastric pain.
c. Urine output of 40 mL/hour.
d. Increased fetal movements.
Rationale: B. Epigastric pain or acute right upper quadrant pain as associated with an impending convulsion. (Lippincott 6th edition, pg.134)
7. If the client begins to convulse due to eclampsia, the nurse’s first action is to
a. Pad the side rails with pillows.
b. Insert a padded tongue blade into the mouth.
c. Place a pillow under the left buttock.
d. Suction the mouth and nasopharynx to keep the airway open.
Rationale: D. During a convulsion, it is most important to keep an open airway. Insertion of a padded tongue blade is not recommended. (Lippincott 6th edition, pg.134)
8. Fifteen minutes after an eclamptic seizure, the nurse should assess the client for
a. Uterine contractions.
b. Pretibial edema.
c. Facial flushing.
Rationale: A. After an eclamptic seizure, the nurse should assess the client for signs of abruption placenta, a potential complication. (Lippincott 6th edition, pg.134)
9. The nurse assesses the client for symptoms or abruption placenta, nothing especially
a. Excessive vaginal bleeding.
b. Abdominal rigidity.
c. Tetanic uterine contractions.
d. Preterm rupture of the membranes.
Rationale: The most typical symptom of abruption placenta is a rigid or boardlike uterus. (Lippincott 6th edition, pg.134)
10. If the client develops symptoms of disseminated intravascular coagulation (DIC), the nurse should pain to administer ordered
a. Intravenous dextrose solution.
b. Intravenous Ringer’s lactate solution.
c. Intravenous platelets.
d. Intravenous dextrose solution.
Rationale: C. Treatment of DIC includes treatment of the causative factor and replacement of maternal coagulation factors and support of physiologic functions. Replacement of depleted coagulation factors is usually done with whole blood infusion, fresh-frozen plasma, or platelets. (Lippincott 6th edition, pg.134)
1. Which of the following action promotes child safety?
a. Place infant rear facing in the front seat where the air balloon is located.
b. Put the crib mattress at the lowest position.
c. Adjust room heater to 540C.
d. Place gun with bullets in a special cabinet with locked.
Rationale: B. Infant should be placed rear facing at the back seat not in the front seat. Adjusting room heater up to 540C is too hot. Bullets must be removed in the gun before stored in the locked cabinet.
2. A nurse is counseling a mother having a child diagnosed with ADHD. The mother shows appropriate understanding of the disorder when she states
a. “I have to suffer for the consequence of my child’s hyperactivity.”
b. “My child can still perform age-appropriate task.”
c. “Regularly following the medication regimen will decrease my child’s hyperactivity.”
d. “The possibility of having another ADHD child is high since it is genetically inherited.”
Rationale: B. Children with ADHD has problem in attention span and impulsivity. Though they have short attention span they can still be trained to perform age-appropriate task. Medication such as Ritalin does not decrease hyperactivity but increases the the attention span of the child. (Saunders © 005, p. 406)
3. A 9-month old infant is brought to the ED to be evaluated for injuries after a bookcase fell on top of her. The parents report that the infant was pulling herself up by using the bookcase when it fell over on top of the infant. Which clinical findings would confirm the suspicion of potential maltreatment of the infant?
b. Hugging the mother tightly
c. Spiral fracture of the leg
d. Bend fracture of the fibula
Rationale: C. A spiral fracture is not the type of injury that would have occurred had a bookcase fallen on the infant. Spiral fracture indicates a twisting of the extremity, which is more indicative of maltreatment. P. 87 NCLEX-RN Review Guide Top Ten Questions
4. Which nursing action has the highest priority for a 14-month-old client admitted with burns to 40% of the body and smoke inhalation?
a. Maintain strict fluid restriction
b. Encourage play
c. Monitor respiratory status
d. Administer antibiotics
Rationale: C. Smoke inhalation most likely includes a thermal injury to the tracheobronchial tree. Swelling will occur, so the client’s respiratory status needs to be monitored closely. Sometimes endotracheal intubation is necessary to maintain a patent airway. P. 86 NCLEX-RN Review Guide Top Ten Questions
5. A 5yo client is admitted with deep partial-thickness and full-thickness burns of the chest from a firecracker explosion. Multiple dressing changes to the chest will be performed, and the expected patient outcome while hospitalized is the absence of a wound infection. Which intervention is most appropriate in meeting this outcome?
a. administer prophylactic antibiotics to prevent infection
b. gloves, gowns, masks, and caps worn during care and sterile gloves for dressing changes.
c. intubation and aggressive ventilatory management to reverse effects of inhalational burn injury.
d. use of good handwashing technique is adequate and is the only intervention that is needed.
Rationale: B. When involved with the direct care of a burn client, staff must wear gloves, caps, gowns, and masks to prevent an infection. Burn patients are susceptible to infections. Nevertheless, antibiotics are not administered until specific cultured and organisms are identified.
6. Which is a correct understanding on the contraindication for Varivax?
a. Patient with herpes zoster
b. immunocompromised patient.
c. Allergy to egg.
Rationale: B. Contraindications for Varicelle Vaccine (Varivax) includes pregnancy, immunocompromised patients and child receiving corticosteroids. (Saunders p.520.)
7. Which of the following should the nurse know about administering influenza vaccine (HiB)?
a. It cannot be given to patients with allergy to eggs
b. It is never given to pregnant women
c. Allergy to Aminoglycosides should be assessed
d. There is no noted contraindication for this.
Rationale: D. No contraindications have been identified for H. influenzae B Conjugate vaccine. Allergy to neomycin is a contraindication for MMR and IPV only. Saunders p. 520
8. Which of the following would indicate correct understanding regarding MMR vaccination?
a. Given in 1 month, 6 months, and 4&6 year old
b. Given at birth, 1 month, and 6 months
c. Given in 12-15 months, and 4-6 years old
d. Given in 12-18 months
Rationale: MMR is given two dosages. The first dose is given at 12-15 months and the second at 4-6 yo. Saunders 3rd edition p.520
9. A child is about to have another shot of MMR. When does the nurse need to intervene?
a. I had rashes the last time
b. I had fever on my last shot
c. I am allergic to eggs
d. I am not allergic to neomycin
Rationale: A. The patient had an allergic reaction the last time he had a shot. Since MMR contains neomycin, the patient should be assessed carefully first for any antibiotic allergies. P. 520 Saunders
10. Which approach should be included in the plan of care for a 14 yo client who is admitted following a sexual abuse incident?
a. Medicate the client with Ativan (Lorazepam).
b. Limit communication with the client’s parents and reinforce the secrets.
c. Encourage communication and listen attentively.
d. Encourage the client to immediately engage in normal routines and social activities.
Rationale: C. Asking a client to state in his or her own words the reason for seeking care provides the overall perception the client has regarding being admitted. P. 129 NCLEX-RN Review Guide Top Ten Questions
1. A client with history of taking long-term antiinfectives and diarrhea for 3 days is admitted in a semi-private ward. Which of the following is an appropriate roommate for this client?
a. Client with Clostridium deficile
b. Client with wound infected with VRE
c. Client with RSV infection
d. Client with MRSA
Rationale: A. Long term use of antiinfectives that results in diarrhea is suggestive of clostridium deficile infection. This two client must be placed in the same room since they have the same nature of the disease and requires enteric precaution. (Saunders © 005, p. 181)
2. A nurse received a call for massive admission due to vehicular accident. Because of the shortage of rooms she must decide which client can be discharged now. Which one will she choose?
a. A client admitted 12 hours ago due to asthma with status asthmaticus
b. A client who undergo right radical mastectomy 36 hours ago
c. A client with coronary artery bypass graft 2 days ago with temperature of 100.60F
d. A client who just returned after coronary artery arteriogram with pulse of 120 beats per minute
Rationale: B. This client has the most stable condition and does not show any problem or complication. Client with status asthmaticus must be continuously assessed. Presence of fever after a coronary artery bypass graft may signify infection. Pulse of 120 may indicate hemorrhage which is a common complication after coronary arteriogram.
3. Which of the following patients should be most appropriately be assigned in a private room?
a. A patient with Hepatitis B
b. A patient with Meningitis
c. A patient post hip prosthesis surgery
d. A patient with COPD
Rationale: B. A patient with Meningitis is usually placed on strict isolation because of its high incidence of transmitting a disease via respiratory transmission. Options A, C, and D can be placed together with other clients as appropriate.(Saunders p215 NSNA)
4. A nurse from the pediatric ward has floated to the Medical-Surgical ward due to lack in nursing staff. Which of the following clients can be assigned to this nurse?
a. A patient with acute myelogenous leukemia
b. A patient with chest tube drainage
c. A patient who is in labor with 8 cm cervical dilation
d. A patient with multiple sclerosis
Rationale: A. The incidence of leukemia is high amongst pediatric clients. Pediatric nurses are not experts regarding chest tube drainage care because this is usually common to adults or elderly who suffered from pneumothorax, hemothorax, empyema, or post lobectomy, segmental resection, or wedge resection. A client in labor is fit for a DR nurse. A patient with Multiple Sclerosis is fit for an MS nurse.
5. Which of the following clients can be placed together on the same room?
a. A patient with bacterial pneumonia and a patient with tuberculosis
b. A patient who has chickenpox and a patient who is to undergo paracentesis
c. A patient with Pediculosis and a patient with Scabies
d. A patient with Hyperthyroidism and a patient on mechanical ventilator
Rationale: C. Both of these patients condition is spread via contact transmission. They can be placed in the same room. In addition, both of these patients have the same drug of choice which is Lindane(Kwell). A client with bacterial pneumonia and a patient with tuberculosis cannot be joined together because they can spread via airborne-droplet transmission and there could be an interchange in microorganisms. A patient with chickenpox can transmit an infection via droplet, this should not be paired with a patient who is to undergo paracentesis. Patients with paracentesis are persons with liver disorders manifested by ascites. These type of persons are usually immunocompromised. A patient with Hyperthyroidism as much as possible should be placed in a less stimulating environment on a private room. A patient with mechanical ventilator will be a source of stimuli for this patient.
6. Which of the following clients could potentially be placed together as roommates for a patient with Bryant’s traction?
a. a 13 yo female leukemic client who underwent external radiation (teletherapy)
b. a 41 yo male AIDS patient with oral thrush
c. a 45 yo client who underwent unsealed internal radiation 3 days after.
d. a 27 yo client who has CAD
7. The nurse is deciding which room will she place a newly admitted patient whose laboratory testing indicates pancytopenia. All of these clients are already on the nursing unit. Which one will be the best roommate for the new patient?
a. the 69 yo patient with pulmonary edema who had a (+) lung infiltrates on the chest x-ray and afternoon grade fever
b. the 24 yo patient with rheumatic heart disease
c. the 4 yo patient who experiences dysuria with sero-sanguineous urethral discharge
d. the 42 yo patient with unexplained diarrhea and tenesmus
8. You are asked to rearrange the room assignment for several patients. Which two patients would be best suited to be placed in the same room?
a. a 45 y.o. female who developed latex allergies and folliculitis
b. a 67 y.o. female who had just finished bone marrow transplant
c. a 40 y.o. female with End Stage renal Disease
d. a 48 y.o. female experiencing chest pain due to pericarditis
9. A charge nurse in the medical-surgical unit is rearranging the patient to be roommates due to lack of rooms. Which two patients are best placed in the same room?
a. a 67 y.o. post-appendectomy patient experiencing moderate fever after 4 day stay in the hospital
b. a 38 y.o. female patient with 3o burn on the chest
c. an 11 year old girl with rubella
d. a 29 y.o. post-partum patient who had a 39.6o C of temperature after 4 days
10. The best roommate for a patient who is suffering form hepatitis E would be:
a. a 7 ½ y.o. boy with multi-resistant tuberculosis
b. a 6 ½ yo girl suffering from MRSA
c. an 11 year old girl with RSV (respiratory synctial virus)
d. An 8 y.o. boy with diarrhea caused by Clostridium difficile
11. The best roommate for a 9 year old leukemic patient is:
a. a 7 ½ y.o. boy with multi-resistant tuberculosis
b. a 6 ½ yo girl suffering from VRE
c. an 11 year old girl with legionnaire’s disease
d. An 8 y.o. boy with small pox
12. The best roommate for a 21 yo female with Hepatitis B sre the following except:
a. a 19 ½ yo female suffering form hepatitis C
b. a 19 yo male suffering from HIV
c. a 17 ½ yo male who is suffering from Hepatitis D
d. a 19 yo female suffering from rotavirus
13. What is the best roommate for a 29 yo girl with an open heart surgery?
a. a 41 yo with bacterial conjunctivitis
b. a 39 yo who is post radiation therapy
c. a 21 yo post pneumonectomy patient
d. a 37 yo with post appendectomy surgery
14. A nurse is deciding which roommate is best suited for a newly admitted patient whose laboratory result indicates an abnormal depression of all the blood components. All of these patients are already on the nursing unit. Which patients will the nurse place the new patient with?
a. The patient with cheesy white patches on the mouth
b. The patient with eclampsia
c. The patient with UTI
d. The patient with intussusception with greenish vomitus
15. All of the following are suited for a patient with Hepatitis A except:
d. Hemophilus influenza
1. Which of the following statement reflects appropriate knowledge of the family members who are taking care of a client with TB?
a. “We need to isolate him for at least 6 weeks.”
b. “He will be taking his medicines daily until his cough subsides.”
c. “We will buy him mask to protect ourselves.”
d. “We will provide him separate disposable plastic bags for his used tissues.”
Rationale: D. Respiratory isolation is not necessary and the client will unlikely infect anyone after 2-3 weeks of medication. Full course of medication must be completed even if cough already subsides. Client must be instructed to cover his mouth and nose when coughing/sneezing and to confine tissues to plastic bags. (Saunders © 2005, p. 741)
2. The nurse is caring for a client with Acquired Immune Deficiency Syndrome (AIDS). During a routine assessment which findings ill require the nurse to report immediately?
a. Non productive cough and chills
b. Draining purplish lesions on the skin
c. Dyspnea on exertion
d. Temperature of 380C
Rationale: A. The major source of mortality in AIDS patient is the presence of opportunistic infection such as pneumocystis cariini pneumonia. This usually has a cough at first symptoms which begins to non-productive cough then progresses to productive. Later signs include fever, dyspnea on exertion and finally dyspnea at rest. (Saunders © 005, p. 1043)
3. Which of the following action shows proper precautionary measure?
a. Wearing mask when caring a client with MRSA
b. Wearing particulate mask when entering the room of a client with measles
c. Wearing gloves in handling the food tray of a client with TB
d. Putting on a protective gown in changing the bed linen of a client with mumps
Rationale: B. Measles is transmitted via airborne or droplet spread. MRSA is contact precaution; TB is airborne; mumps is droplet spread. (Saunders © 005, p. 515)
4. All of the ff are true statements regarding standard precaution except:
a. Respiratory protection should be worn by all personnel and visitors before entering the room in a patient with an airborne infection such as pneumonic plague
b. The physical action of handwashing and rinsing of hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors and other antiseptic agents have poor activity against spores such as Clostridium difficille and anthrax
c. Protective shoe covers is a mandatory protective clothing for nurses who are exposed to a large amounts of blood such as trauma care rooms.
d. Hand washing is mandatory if the hands will be moving form a clean body site to a contaminated site during patient care.
5. Select all that applies to situation that needed handwashing:
a. before having direct contact with patients
b. after contact with blood, body fluids or mucus membranes, non-intact skin or wound dressing
c. after contact with patient’s skin (e.g. when taking pulse, BP or lifting the patient)
d. After removing gloves
e. before removing gloves
6. Determining patient placement are based on the following principles: SATA
a. Patient options for room sharing
b. Availability of single patient rooms
c. Risk factors for transmission in the infected patient
d. Route of transmission of the known/suspected infectious agent
e. Age bracket of individuals
7. All of the following applies to Universal Precautions except:
a. Universal precautions DO NOT APPLY to feces, nasal secretions, sputum, tears and vomitus unless stained or contain blood
b. Universal precautions is mandatory in dental setting
c. Universal precautions do not apply to vaginal secretions, cerebrospinal, synovial, peritoneal, pleural and amniotic fluids unless with blood.
d. gowns should be fluid proof resistant when handling arterial lines that is potential for splashes or spills
8. Gloving is mandatory on the following situations: Check all that applies:
a. touching blood and body fluids
b. Handling soiled items contained with blood
c. Training in phlebotomy
d. performing finger and or heel sticks on infants and children
9. The following equipments should be worn during procedures such as bronchoscopy, suctioning, ET intubation, dialysis, manipulation of arterial lines. SATA
a. disposable mask
b. disposable cotton base gowns
c. disposable face shields
d. disposable goggles
e. disposable gloves
10. All of the ff should be given NEUTROPENIC PRECAUTIONS: except:
d. 3o burns
e. Hodgkin’s disease
f. elderly and infants
11. All of the ff are true for reverse isolation except:
a. if the patient must be moved to another room the nurse should make sure the patient should wear a mask
b. it is both the medical personnel and the patient that should put a GOWN, MASK and GLOVES when handling the patient.
c. Do not perform invasive procedures such as urethral catheterization unless necessary
d. cooked fruits and vegetables are allowed to be given to severely immunocompromised patient.
12. Lately the Multiple Drug Resistant Organisms (MDROs) are on the rise such as VRE, MRSA, and VRSA. The ff patients should be constantly monitored by the nurse for potentially developing colonization. SATA
a. ICU patients who have prolonged ET intubation
b. Patients who have prolonged indwelling catheters
c. Recent surgeries
d. Patients who are in traction
13. All of the following are true regarding gloving except
a. do not wear the same pair of gloves for the care of more than one patient.
b. do not wash gloves for the purpose of reuse since this practice has been associated with transmission of pathogens
c. wear one of the following gadgets when in contact with patients with TB: mask, face shield, goggles, gloves and gown.
d. gloves should be worn in non-intact skin and mucous membranes but not on an intact skin.