NLE CA

MS1 MT2

1.) The nurse caring for an adult client who is receiving TPN will need to monitor for which of the following metabolic
complications?
a. Hypoglycemia and hypercalcemia b. Hyperglycemia and hypokalemia
c. Hyperglycemia and hyperkalemia d. Hyperkalemia and hypercalcemia

2. A client is undergoing thyroid tests (T3, T4, TSH) for hypothyroidism. Which of the following laboratory test results are
indicative of hypothyroidism?
a. Elevated T3 & T4 levels and normal TSH b. Normal T3 & T4 levels and elevated TSH
c. Elevated T3 & T4 levels and decreased TSH d. Decreased T3 & T4 levels and elevated TSH

3. The client with diabetes mellitus developed diabetic ketoacidosis. Which of the following results of laboratory test
should the nurse not expect?
a. Elevated serum glucose b. Increased acidity c. low carbon dioxide d.high carbon dioxide

4. A client who has type 1 DM is admitted to the hospital for major surgery. Before surgery, the client’s insulin
requirements are elevated but well-controlled. Postoperatively, the nurse anticipates that the client’s insulin
requirements will:
a. Decrease b. Fluctuate c. increase sharply d. remain elevated

5. A client has just undergone the transphenoidal resection of a pituitary adenoma. The nurse includes which of the
following in the plan of care?
a. Remove nasal packing in 12 hours b. Observe the client for frequent swallowing
c. Remind the client to cough and breathe deeply d. administer acetylsalicylic acid for a severe headache

6. A client with Cushing’s syndrome is being instructed by the nurse regarding follow-up care. Which statement by the
client indicates the need for further instruction?
a. “I should avoid contact sports” b. “I should avoid foods rich in potassium”
c. “I should check my ankles for swelling” d. “I should check my blood sugar regularly”

7. Late in the post-operative period after resection of an aldosterone-secreting adenoma, the nurse expects the client’s
blood pressure to:
a) Gradually return to near normal levels
b) Rise quickly above the preoperative levels
c) Fluctuate greatly during the entire period
d) Drop very low, then increase rapidly to normal levels

8.) When assessing the laboratory values of a client with type 2 DM, the nurse expects the results to reveal:
a) Ketones in the blood but not the urine
b) Glucose in the urine but not in the blood
c) Urine and blood positive for glucose and ketones
d) Urine negative for ketones and glucose in the blood

9.) Arterial blood gases reflect a pH of 5.28, PCOs of 50 and HCO3 of 24, to which of the following patients would
these ABGs most likely belong?
a) Type 1 diabetic with blood glucose of 546mg/ (metabolic acidosis)
b) Highly anxious with a panic attack and hyperventilation in progress
c) Alzheimer’s with recent overdose of aspirin related to arthritic pain
d) Post-op with gastric suction, nauseated and vomiting around the NG tube

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10.) The nurse is assigned to care for an acutely ill patient with thyrotoxicosis. Which of the following assessment
findings by the nurse would indicate worsening of the patient’s condition?
a. The heart rate is 100 beats per minute b. The patient is displaying symptoms of angina
c. The temperature is 98.6F d. The patient is sleeping soundly

11.) A nurse is obtaining a history from a client admitted to the hospital with a cerebral thrombotic stroke. The nurse
collects data from the client, knowing that, before this type of stroke, the client likely experienced:
a. No symptoms at all b. Throbbing headaches
c. Transient hemiplegia and loss of speech d. Unexplained episodes of loss of consciousness

12.) After striking his head on a tree while falling from a ladder, a young man age18 is admitted to the emergency
department. He’s unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the
client?
a. Give him a barbiturate b. Place him on mechanical ventilation
c. Perform a lumbar puncture d. Elevate the head of his bed

13.) The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms
would the nurse expect to find?
a. Vision changes b. Absent deep tendon re exes
c. Tremors at rest d. Flaccid muscles

14.) A client with a diagnosis of Guillain-Barre syndrome is being admitted to the hospital. The client’s chief complaint is
an ascending paralysis that has reached waist level. The nurse is asked to prepare for the admission of the client and
plans to have which item available for emergency use?
a. Cardiac monitor and intubation tray b. Blood pressure cuff and flashlight
c. Nebulizer and pulse oximeter c. Flashlight and incentive spirometer

15.) A client is experiencing diabetes Insipidus secondary to cranial surgery. The nurse who is assisting with caring for
the client plans to implement which of the following anticipated prescribed therapies?
a. Fluid restriction b. Administering diuretics
c. Increased sodium intake d. Intravenous (IV) replacement of fluid losses

16.) The nurse has given the male client with Bell’s palsy instructions on preserving muscle tone in the face and
preventing denervation. The nurse determines that the client needs additional information if the client states that he or
she will
a. Exposure to cold and drafts
b. Massage the face with a gentle upward motion
c. Perform facial exercises
d. Wrinkle the forehead, blow out the cheeks and whistles

17.) The nurse is leading a support group for clients affected with myasthenia gravis. For what group of individuals
does the nurse understand that the incidence of myasthenia gravis is highest?
a. Males ages 15 to 35 b. Children ages 5 to 15
c. Females ages 20 to 30 d. oth sexes equally before age 40

18.) The most significant initial nursing observation that needs to be made in a client with MG would include:
a. Ability to chew and speak distinctly
b. Degree of anxiety about her diagnosis
c. Ability to smile and close her eyelids
d. Respiratory exchange and ability to swallow

19.) Which of the following is of highest priority in the care of client with Parkinson?
a. Positioning b. Encouraging independence

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 c. Increase activity d. Aspiration prevention

20.) A nurse is assisting with planning home care for a client with a C5 spinal cord injury and suggests which client
outcome for the plan of care?
a. Maintains intact skin b. Regains bladder and bowel control
c. Performs activities of daily living independently d. Independently transfers to and from a wheelchair

21.) Positioning the client’s head is most important after craniotomy primarily to:
a. Maintain a patent airway b. Facilitate venous drainage
c. Provide for client comfort d. Prevent hemorrhage from the suture line

22. The client is prescribed phenytoin (dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates
that the client understands the discharge teaching concerning this medication?
a. “I will brush my teeth after every meal” b. “I will check my Dilantin level daily”
c. “My urine will turn orange while on Dilantin” d. “I won’t have any seizures while on this medication”

23.) A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the
medication therapy is ineffective if an assessment reveals:
a. Skin rash b. Peripheral edema c. A dry cough d. Postural hypotension

24.) The nurse is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse
should encourage the client to:
a. Avoid focusing on his weight b. Increase his activity level
c. Follow a regular diet d. Continue leading a high stress lifestyle

25.) The nurse is assigned to care for a client who has an inoperable abdominal aortic aneurysm (AAA). The nurse is
asked to reinforce teaching and tells the client about the need for:
a. Antihypertensives b. Bedrest c. Restricting fluids d. Maintaining a low fiber diet

26.) The nurse is caring for client with myocardial infarction. She knows that an increased restlessness in a client with
tachycardia following an anterior myocardial infarction is due to which of the following reason?
a) Decreased ventricular filling time results in decrease venous return and cerebral
b) Palpitations increase anxiety and cause a heavy sensation
c) Decreased ventricular filling time always result in decrease cardiac output and tissue perfusion
d) A significant decrease in stroke volume may occur, causing a decrease in cardiac output

27. In evaluating the effects of nitroglycerin, the nurse should know that it reduces preload and relieves angina by:
a) Increasing atrioventricular contraction and heart rate
b) Increasing contractility and slowing heart rate
c) Decreasing venous return through vasodilation
d) Decreasing contractility and oxygen consumption

28.) In planning discharge care for a client after treatment for hypertension, the nurse should emphasize
a. Medication scheduling and side effects b. The need to change jobs
c. The importance of smoking less d. Sexual activity restrictions

29.) During a predischarge teaching session, the nurse tells a client who has had vein ligation surgery that elastic
stocking are best applied:
a) Before rising in the morning, to prevent pooling of the blood in the lower extremities
b) After showering and application of skin care to legs, to prevent undue dermal irritation
c) After 15 minutes of vigorous leg exercises designed to increase blood ow
d) Only when the client plans to be standing for an extended period of time, because undue constriction of the
veins can cause recurrence of varicosities.

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30.) A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most
concerned about with this tachycardia?
a) It can develop into ventricular fibrillation at any time
b) It is almost impossible to convert to a normal rhythm
c) It is uncomfortable for the client, giving a sense of impending doom
d) It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia

31.) A client seeks treatment in a physician’s office for unsightly varicose veins, and sclerotherapy is recommended.
Before leaving the examining room, the client says to the nurse, “Can you tell me again how this, sclerotherapy, is
done?” Which of the following statements would reflect accurate teaching by the nurse?
a) “The varicosity is surgically removed.”
b) “The veins is tied off at the upper end to prevent stasis from occurring”
c) “The vein is tied off at the lower end to prevent stasis from occurring.”
d) “An agent is injected into the vein to damage the vein wall and close the vein off.”

32. On a routine visit to the physician, a client with chronic arterial occlusive disease reports stopping smoking after 4
years. To relieve symptoms of intermittent claudication, a condition with chronic arterial occlusive disease, the nurse
should recommend which additional measures?
a) Taking daily walks
b) Engaging in anaerobic exercises
c) Reducing daily fat intake to less than 45% of total calories
d) Avoiding foods that increase levels of high-density lipoproteins (HDLs)

33.) The nurse assesses a client for signs and symptoms of shock and respiratory failure by initially evaluating which
parameters?
a) Vital signs, tidal volume, and vital capacity
b) Hemodynamic status, pulse oximetry values and vital capacity
c) Vital signs, pulse oximetry values and hemodynamic status
d) Tidal volume, maximal voluntary ventilation and arterial blood gas

34.) A client is admitted in the emergency department with possible pulmonary edema. Upon admission assessment,
the nurse knows that which signs and symptoms are associated with the disease process?
a) Confusion, stupor, increased crackles, rapid pulse, ashen nail beds
b) Anxiety, sudden breathlessness, slow pulse, and blood-tinged mucus
c) Restlessness, slow pulse, slow breathing, and reddened skin
d) Restlessness, anxiety, cold hands, and sudden breathlessness

35.) A nurse who is caring for a client with respiratory disease has just received the recent ABG result. The nurse
knows that which of these results are associated with respiratory acidosis?
a) A low pH, low bicarbonate, and a low or normal partial pressure of carbon
b) A low pH, high or normal bicarbonate, and a high partial pressure of carbon
c) A low pH, low bicarbonate, and a high or normal partial pressure of carbon
d) A high pH, low bicarbonate, and a low or normal partial pressure of carbon dioxide

36. A client develops acute respiratory distress and a tracheostomy is performed. Which intervention is most important
for the nurse to implement when caring for this patient?
a) Suctioning via the tracheostomy every hour
b) Applying a sterile occlusive dressing
c) Encouraging a fluid intake of 3L per day
d) Use cotton balls with hydrogen peroxide when cleaning the stoma

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37. A nurse is caring for a client with chest tube drainage. If fluctuation in the water-seal compartment of a closed chest
drainage system has stopped, the nurse would:
a) Increase the wall suction above 20cm water pressure
b) Raise the apparatus above the chest to move fluid
c) Ask the client to cough and take a deep breath
d) Vigorously strip the tube to dislodge a clot

38.) Sir T with a history of emphysema is in acute respiratory failure with respiratory acidosis. Oxygen is administered at
2LPM by nasal cannula. Four hours later, the nurse identifies that the client has increased restlessness and confusion
followed by a decreased respiratory rate and lethargy. The nurse should:
a. Question the client about the confusion b. Increase the oxygen in small increments
c. Percuss and vibrate the client’s chest wall d. Discontinue or decrease the oxygen ow rate

39.) A client recovering from pulmonary edema is preparing for discharge. The nurse plans to teach the client to do
which of the following to manage or prevent recurrent symptom after discharge?
a) Take a double dose of the diuretic if peripheral edema is noted
b) Withhold prescribed digoxin (lanoxin) if slight respiratory distress occurs
c) Weigh himself or herself on a daily basis
d) Sleep with the head of bed flat

40.) The client diagnosed with sinusitis who has undergone a Caldwell Luc procedure is complaining of pain. Which
intervention should the nurse implement first?
a. Administer the narcotic analgesic IVP b. Perform gentle oral hygiene
c. Place the client in a semi-Fowler’s position d. Assess the client’s pain

41. A total laryngectomy and radical neck dissection are scheduled for a client with cancer of the larynx. When
reinforcing the surgeon’s statements to the client, the nurse should review what the surgery entails and what abilities
will be lost. The discussion should focus on what abilities will be retained, such as the ability to:
a. Blow the nose b. Sip through a straw
c. Chew and swallow food d. Smell and differentiate odors

42.) A client with a flail chest caused by four fractured rib segments is experiencing severe pain when trying to breathe.
The nurse observes the client for which characteristics of a flail chest?
a. Cyanosis and slow respiration b. Slight tachypnea with shallow breaths
c. Pallor and paradoxical chest movement d. Severe dyspnea and paradoxical chest movement

43.) The nurse is developing a plan of care for a client with multiple myeloma and includes which priority intervention
in the plan?
a. Encouraging fluids b. Providing frequent oral care
c. Coughing and deep breathing d. Monitoring the red blood cell

44. Skin reactions are common in radiation therapy. Nursing responsibilities on promoting skin integrity should be
promoted apart from: BONUS
a) Avoiding the use of ointments, powders and lotion to the area
b) Using soft cotton fabrics for clothing
c) Washing the area with a mild soap and water

45.) A nurse is caring for a client with metastatic breast cancer. The client describes a new and sudden sharp pain in the
back. Based on the assessment finding, which of the following is the priority nursing intervention?
a) Document the findings
b) Place a heating pad on the client’s back
c) Notify the physician
d) Administer pain medication

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46.) Which of the following is the purpose of cytoreductive (debulking) surgery for ovarian cancer?
a) Cancer control by reducing the size of the tumor
b) Cancer prevention by removing precancerous tissue
c) Cancer cure by removing all gross and microscopic tumor cells
d) Cancer rehabilitation by improving the appearance of a previously treated body Part

47.) A nurse teaches skin care to a client receiving external radiation therapy. Which of the following statements if made
by the client would indicate the need for further instruction?
a. “I will handle the area gently” b. “I will avoid the use of deodorant.”
c. “I will limit my sun exposure to 1 hour daily.” d. “I will wear loose- fitting clothing.”

48.) A nurse is caring for a client who had just a mastectomy. The client has a Jackson-Pratt drain. The nurse instructs the
client to avoid which of the following?
a) Elevation of the arm when lying or sitting
b) Emptying the drain to prevent infection
c) Full range-of-motion exercises of the upper arm
d) Applying lotion to the area after the incision heals

49.) A male client with squamous cell carcinoma of the tongue is to be treated with interstitially implanted radon seeds.
The type of accommodations the nurse should plan for after seed implantation is a:
a) Room with clients receiving the same therapy
b) Private room to diminish the radioactivity others receive
c) Semiprivate room to diminish the risk of sensory deprivation
d) Four -bed room so that he will not be in an unfamiliar environment

50.) A client with a history of chronic myelogenous leukemia and splenomegaly is admitted to the hospital. What should
the nurse expect to identify when completing an admission assessment of this client?
a) Increased urinary output
b) Tender mass in the left upper abdomen
c) Increased erythrocytes, platelets, and granulocytes
d) Polydipsia, increased appetite and urinary frequency

51.) A nurse is performing an assessment on a client with a diagnosis of pernicious anemia. Which abnormal finding
would the nurse expect to note in this client?
a. Shortness of breath on exertion b. Dyspnea
c. Paresthesia d. Dusky mucous membrane

52.) A 33 year old man is brought to the emergency room bleeding profusely from a stab wound in the left chest area.
The nurse’s assessments revealed a blood pressure of 80/50 mmHg and a pulse rate of 110 and a respiratory rate of 20.
The nurse should expect which of the following potential problems?
a. Hypovolemic shock b. Cardiogenic shock c. Neurogenic shock d. Septic shock

53.) A nurse reinforces home-care instruction to a client with Raynaud’s phenomenon and encourages the client to
engage in measures that will minimize the effects of the disorder. Which statement by the client indicates an
understanding of these measures?
a. “I will take daily cool baths.” b. “I will cut down on smoking.”
c. “I will eat a high-protein diet.” d. “I will keep my hands and feet warm and dry.”

54.) A client with sunburn of the chest, back, face and arms is seen urgent care. The nurse’s primary concern should
be:
a. Fluid resuscitation b. Infection c. Body image d. Pain management

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55.) When assessing a client with partial thickness burns over 60% of the body, which of the following should the nurse
report immediately?
a. Complaints of intense thirst b. Moderate to severe pain
c. Urine output of 70ml the 1st hour d. Hoarseness of the voice

56.) A client is admitted to the hospital following a burn injury to the left hand and arm. The client’s burn is described as
white and leathery with no blisters. Which degree of severity is this burn?
a. First degree burn- puwa2 b. Second degree burn
c. Third degree burn- no blister d. Fourth degree burn

57.) Which sign indicates adequate intravenous fluid replacement for a client with a 30% total body surface area burn?
a. Slowing of a previously rapid pulse b. Urinary output of 15 to 20 mL/hr
c. Increasing hematocrit level d. Central venous pressure progressing from 5 to 1 mm

58.) The nurse has a serum potassium of 6.2 during the early hours after an extensive burn. Which of the following
order would the nurse question? Check: calcium, ventolin, insulin
a. Insulin and glucose IV b. Calcium gluconate IV
c. Third degree burn d. Lasix IV

59.) A 34 year old woman is rescued from a house fire at 2AM and arrives at the emergency department at 3AM. The
cleitn weighs 132 pounds and is burned over 30% of her body. How much lactated Ringer’s solution should be infused
within the next 8 hours?
a. 1800mL b. 3600mL c. 5400mL d. 7200mL

60.) The male had abdominal surgery and is now diagnosed with peritonitis. Which assessment data support the client’s
diagnosis of peritonitis?
a) Absent bowel sounds and potassium level of 3.9 mEq/L
b) Abdominal cramping and hemoglobin of 14mg/dL
c) Profuse diarrhea and stool specimen shows campylobacter
d) Hard, rigid abdomen and white blood cell count of 22,000mm

61.) The nurse is caring for a client recovering from abdominal surgery, while ambulating, the client complains to the
nurse that she has a dull ache in her leg.
The nurse should:
a) Place the patient on bed rest and elevate the foot of the bed six inches
b) Ask the patient to remain in bed and place a pillow under the knee to elevate her
c) Ambulate the patient as directed to prevent complications of bed rest
d) Obtain a thigh-high compression or elastic stockings and continue ambulating the client.

62.) The client has just had surgery to create an ileostomy. The nurse assesses the client in immediate postoperative
period
a) Folate deficiency
b) Malabsorption of fat
c) Intestinal obstruction
d) Fluid and electrolyte imbalance

63.) The client had a new colostomy created 2 days ago and is beginning to pass malodorous flatus from the stoma.
What is the correct interpretation of the nurse?
a) This is normal, expected event
b) The client is experiencing early signs of ischemic bowel
c) The client should not have the nasogastric tube removed
d) This indicated inadequate preoperative bowel preparation

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64.) A nurse obtains an admission history for a client with suspected peptic ulcer disease (PUD). Which of the following
client factors documented by the nurse would increase the risk for PUD?
a) Recently retired from
b) Significant other has a gastric ulcer
c) takes ibuprofen (Motrin) for osteoarthritis
d) Occasionally drinks one cup of coffee in the morning

65.) In performing physical assessment of a client with a diagnosis of ulcerative colitis, the nurse would expect which
of the following findings?
a. Fibrous strictures b. Increased erythrocyte sedimentation rate
c. Frothy, fatty stools d. Increase haemoglobin

66.) A client progresses to a regular diet after a gastrectomy for gastric cancer. After eating lunch, the client becomes
diaphoretic and has palpitations. What probably caused these responses?
a) Intolerance to fatty foods
b) Extracellular fluid shift into the bowel
c) Dehiscence of the surgical incision
d) Diminished peristalsis in the small intestine

67.) A client 36 hours after intestinal resection moves into a sitting position in bed and immediately tells the nurse,
“Something just gave way under my dressing.” After examination, the nurse discovered that the incision had dehisced
and a loop of intestine is protruding. Which is the first action the nurse should take?
a) Notify the surgeon
b) Cover the protruding intestine with a sterile dressing wet with normal saline
c) Assist the client to a low Fowler’s position
d) Obtain a wound culture

68. In order to prevent hepatic encephalopathy

a. High CHO, High CHON and Iron b. High CHO, low CHON and Low Na
c. High CHON, low Na d. High CHO, high CHON in diet

69.) A client under treatment of GERD asks why she needs to avoid caffeine. What factor should the nurse base his
response?
a) Caffeine delays gastric emptying
b) Caffeine lowers LES pressure
c) Caffeine increases secretion of gastric acid
d) Caffeine thins the mucus coating of the esophagus

70.) A gastric analysis with a result of an excess gastric acid secretion could be the diagnostic of:
a. Chronic atrophic gastritis b. A duodenal cancer
c. Gastric carcinoma d. Pernicious anemia

71.) Which management is inappropriate when a lower blood ammonia level is the desired outcome in a client with
hepatic encephalopathy?
a. Prevent GI bleeding b. Reduction of dietary protein intake
c. Avoidance of enemas and cathartics d. Decrease in bacterial flora in the intestine

72.) Ascites may result because of the following except:

a) Leakage of fluid to the interstitial space
b) Increased hepatic lymph ow
c) Hypoalbuminemia
d) Increased portal venous pressure

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73.) Which are the risk factors for primary cancer of the liver?
a) Hepatitis C and cirrhosis
b) History of gastric cancer and alcohol abuse
c) Portal hypertension and exposure to environmental toxins
d) Smoking, hepatitis C and female gender

74.) A nurse is caring for a 2 hour postoperative transurethral resection (TUR) immediately reports to the charge nurse
the presence of large clots in the catheter and drainage bag. The nurse anticipates that the physician will:
a) Instill ice water into the bladder
b) Decrease the amount of fluid in the balloon of the indwelling catheter
c) Apply traction to the catheter by taping it to thigh
d) Order a potent vasoconstrictor to reduce hemorrhage

75.) The transurethral resection of the prostate is performed on a client with BPH. Following surgery, nursing care
should include
a) Changing the abdominal dressing
b) Maintaining patency of the cystostomy tube
c) Maintaining patency of a three-way Foley catheter for cystoclysis
d) Observing for hemorrhage and wound infection

76.) In the early postoperative period following the transurethral surgery, the most common complication the nurse
should observe for:
a. Sepsis b. Hemorrhage
c. Leakage around the catheter d. Urinary retention with overflow

77.) After undergoing transurethral resection of the prostate to treat benign prostatic hyperplasia, a male client returns
to the room with continuous bladder irrigation. On the first day after the surgery, the client reports bladder pain. What
should Nurse Julie do first?
a) Increase the IV ow rate
b) Notify the physician immediately
c) Assess the irrigation catheter for patency and drainage
d) Administer meperidine (Demerol), 50mg IM as prescribed.

78.) The nurse should know that a client is experiencing chronic renal failure if which of the following symptoms are
present?
a. Nausea and vomiting b. Asterixis and confusion- hepatic encephalopathy
c. Kussmaul breathing and drowsiness d. Pruritus and drowsiness- too much phosphate

79.) A client has returned from surgery after the insertion of ureteral stent for ureteral trauma from a GUNSHOT wound.
What is the desired outcome?
a) Urine output of greater than 0.5ml/kg/hr within the first 6 hours
b) Absence of hematuria
c) Foley and stent drainage collecting into one urinary drainage system
d) Tachycardia reflecting increased renal perfusion

80.) The nurse is caring for a 45 year old client who had a nephrectomy because of cancer of the kidney. Which factor
influences the client’s ability to deep breathe and cough postoperatively?
a) Location of surgical incision
b) Increased anxiety about the prognosis
c) Inflammatory process associated with surgery
d) Pulmonary congestion from postoperative medications

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81.) The client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is
tachycardic, pale and anxious. The nurse suspects air embolism. Which of the following is the priority action of the nurse
at this time?
a) Discontinue dialysis and notify the physician
b) Monitor vital signs every 15 minutes for the next hour
c) Continue dialysis at a slower rate after checking the lines for air
d) Bolus the client with 500 mL of normal saline to break up the air embolus

82.) The client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client’s
temperature is 98.5F. The nurse next assesses the client to determine a history of:
a. Pyelonephritis- backpain b. Glomerulonephritis- backpain
c. Injury to the bladder d. Renal cancer in the client’s family

83.) A client is in the acute phase in rheumatoid arthritis. Which of the following should the nurse identify as lowest
priority in the plan of care?
a) Relieving pain
b) Preserving joint function
c) Maintaining usual ways of accomplishing tasks
d) Preventing joint-deformity

84.) To reduce symptoms of early morning stiffness in a client who has rheumatoid arthritis, the nurse can encourage
the client to:
a) Take a warm bath in the morning
b) Put joints through passive range of motion (ROM) exercises before trying to move them actively
c) Sleep with a hot pad
d) Take two aspirins before arising and wait for 15 minutes before attempting Locomotion

85.) What assessment finding would prompt the nurse to suspect compartment syndrome in a client with a long leg
cast?
a. Presence of foot pallor b. Severe, unrelieved pain
c. Spastic movement of the toes d. Absence of pedal pulse

86.) A nurse is conducting a health screening for osteoporosis. Which of the following clients is at greatest risk of
developing this disorder?
a) A 25 year old woman who jogs
b) A 36 year old woman who has asthma
c) A 70 year old man who consumes excess alcohol
d) A sedentary 65 year old woman who smokes cigarette

87.) A nurse has given instructions to a client returning home after kneearthroscopy. The nurse determines that the
client understands their instructions if the client states that he or she will:
a) Resume regular exercise the following day
b) Stay off the leg entirely for the rest of the day
c) Report fever or site in ammation to the physician
d) Refrain from eating food for the remainder of the day

88.) The client is complaining of joint stiffness, especially in the morning. What diagnostic test would the nurse expect
the health care provider to order to rule out osteoarthritis?
a) Full body magnetic resonance imaging scan
b) Serum studies for synovial uid amount
c) X-Ray of the affected joints
d) Serum erythrocyte sedimentation rate (ESR)

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89.) A female client is admitted to the hospital with an acute episode of rheumatoid arthritis asks why her roommate,
who also has arthritis, goes to physical therapy everyday and she does not. The most appropriate response by the nurse
is:
a) “It depends on your physician’s decision.”
b) “Her condition is much more advanced than yours.”
c) “Your joints are still in amed and physical therapy can be harmful”
d) “Physical therapy is an aspect of rheumatologic care that is important.”

90.) A client reports to the outpatient clinic for an eye examination, and a diagnosis of macular degeneration is made.
Which assessment question will most significantly elicit information regarding clinical manifestations associated with this
disorder?
a) “Have you had any blurred vision?”
b) “Do you have any pain in your eye?”
c) “Are you having difficulty seeing things out of the side of your eyes?”
d) “Does light bother you?”

91.) The client with detached retina is admitted to the nursing unit in preparation for a scleral buckling procedure.
Which of the following would the nurse anticipate to be prescribed?
a) Bathroom privileges only
b) Elevating the head of bed to 45 degrees
c) Placing an eye patch over the client’s affected eye
d) Wearing dark glasses to read or watch television

92.) A home care nurse is visiting a client with glaucoma who is receiving acetazolamide (Diamox) daily. Which of the
following would indicate to the nurse that the client is experiencing an adverse reaction related to the.
a. Diarrhea b. Lacrimation c. X-Ray of the affected joints d. Irritability

93.) Betaxolol hydrochloride (Betoptic) eye drops have been prescribed for the client with glaucoma. Which of the
following nursing action is the most appropriate related to monitoring for the side effects of this medication?
a. Monitoring the temperature b. Monitoring blood pressure
c. Assessing peripheral pulses d. assessing blood glucose level

94.) A 56 year old patient presents in triage with left-sided chest pain, diaphoresis and dizziness. This patient should be
prioritized into which category?
a. High urgent b. Urgent c. Non-urgent d.Emergent

95.) A cyanotic client with an unknown diagnosis is admitted to the emergency room. In relation to oxygen, the first
nursing action would be:
a. Wait until the client’s lab work is done
b. Not administer oxygen unless ordered by the physician
c. Administer oxygen at 2 Liters ow per minute
d. Administer oxygen at 10 liters ow per minute and check the client’s nail beds.

96.) Vanessa, a community health nurse conducts a health promotion program regarding testicular cancer to community
members. The nurse determines that further information needs to be provided if a community member states that
which of the following is a sign of testicular cancer?
a. Penile discharge b. Back pain
c. Painless testicular swelling d. Heavy sensation in the scrotum

97.) A female client has just been diagnosed with condylomata acuminate (genital warts). What information is
appropriate to tell this client?
a. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear
annually.

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b. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.
c. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have
sexual intercourse
d. The human papillomavirus (HPV)), which causes condylomata acuminate, can’t be transmitted during oral sex.

98.) A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the
triage nurse back to be seen first?
a. A 2 months old infant with a history of rolling off the bed and has bulging fontanels with crying.
b. A teenager who got a singed beard while camping
c. An elderly client with complaints of frequent liquid brown colored stools.
d. A middle aged client with intermittent pain behind the right scapula.

99.) The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put
first on the list to be discharged in order to make a room available for a new admission?
a. A middle-aged client with a history of being ventilator-dependent for over 7 years and admitted with bacterial
pneumonia five days ago
b. A young adult with diabetes mellitus type 2 for over 10 years and admitted with diarrhea 24 hours ago
c. An elderly client with a history of hypertension, hypercholesterolemia and lupus, and was admitted with Stevens-
Johnson syndrome that morning
d. An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago.

100.) Oxygen at the rate of 1.5L/min via usual cannula is prescribed for the client. Which of the following statements
best describes why oxygen therapy is maintained at a relative low level of concentration?
a. Oxygen will be lost at the patient’s nostril if given at a higher level in nasal cannula.
b. The patient’s long history of a respiratory problem indicates that he would be unable to absorb oxygen given at a
higher rate.
c. The cells in the alveoli are so damaged by the patient’s long history of a respiratory problem that higher levels of
oxygen and reduced levels of carbon dioxide are likely to cause the cells to burst
d. The patient’s respiratory center is so accustomed to high carbon dioxide and
low blood oxygen concentrations. That changing this concentration with oxygen therapy may eliminate the patient’s
stimulus to breathing.

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