A. a gastrostomy tube that is clamped.
B. the patient coughing blood-tinged secretions from the tracheostomy.
C. the patient positioned in a lateral position with the head of the bed flat.
D. 200 ml of serosanguineous drainage in the patient's portable drainage device.
1. A
78-year-old does not want to eat lunch and complains that the food that
is serve does not taste good. Consistent with knowledge about
age-related changes to taste, the nurse may find that the client is more
willing to eat.
A) Greasy foods
B) Sour foods
C) Sweet foods
D) Salty foods.
3. The
nurse is preparing a discharge plan to a female client with peptic
ulcer for the dietary modification she will need to follow at home.
Which of the following statements indicates that the client understands
the instruction of the nurse?
A) "I should not drink alcohol and caffeine."
B) "I should eat a bland, soft diet."
C) "It is important to eat six small meals a day."
D) "I should drink several glasses of milk a day."
4. A
client has disabling attacks of vertigo. The nurse suspects that the
client has Meniere's disease. The nurse is aware that the diet of the
client must be modified. Which of the following is the best diet for the
client?
A) High protein
B) Low Carbohydrates
C) Low Sodium
D) Low Fat
5. Which of the following is the most common surgical procedure for chronic otitis media?
A) Myringotomy
B) Ossiculoplasty
C) Mastoidectomy
D) Tympanoplasty
6. A
community health nurse is teaching smoking cessation program to a group
of healthy adult smokers. What type of prevention activity is this?
A) Primary
B) Secondary
C) Tertiary
D) None of the above
7.
A female client with breast cancer is currently receiving radiation
therapy for treatment. The client is complaining of apathy, hard to
concentrate on something, and feeling tired despite of having time to
rest and more sleep. These complains suggest symptoms of:
A) Hypocalcemia
B) radiation pneumonitis
C) advanced breast cancer
D) fatigue
A) Hypocalcemia
B) radiation pneumonitis
C) advanced breast cancer
D) fatigue
8. The
nurse is removing the client's staples from an abdominal when the
client cough continuously and the incision splits open exposing the
intestines. Which of the following is the immediate nursing action of
the nurse?
A) Call the surgeon to come to the client's room immediately
B) Have all visitors and family member leave the room
C) Press the emergency alarm to call the resuscitation team
D) Cover the abdominal organs with sterile dressing moistened with sterile normal saline.
9. Which of the following signs and symptoms would indicate that a client has benign prostatic hypertrophy (BPH)?
A) Hematuria
B) Flank pain
C) Impotence
D) Difficulty starting the urinary stream
10.
A male client is receiving chemotherapy for lung cancer. He asks the
nurse how the drug will work. Which of the following is the correct
response of the nurse?
A) "Chemotherapy affects all rapidly dividing cells."
B) "Structure of the DNA is altered."
C) "Chemotherapy encourages cancer cells to divide."
D) "Cancer cells have susceptible drug toxins
A) "Chemotherapy affects all rapidly dividing cells."
B) "Structure of the DNA is altered."
C) "Chemotherapy encourages cancer cells to divide."
D) "Cancer cells have susceptible drug toxins
11. A
client will be receiving general anesthesia. The nurse reviews the
laboratory result of the client and found out that the serum potassium
level is 5.8 mEq/L. What should be the nurse's initial response?
A) Send the client to surgery
B) Notify the anesthesiologist
C) Call the surgeon
D) Send the client to surgery
12. The
nurse is instructing the unlicensed assistant on how to care for a
client with chest tubes that are connected to water seal drainage. Which
of the following instruction would be appropriate for the nurse to give
the unlicensed assistant?
A) Mark the time and amount of drainage collected in the container
B) Raise the collection apparatus to the height of the bed to measure the fluid level.
C) Milk the test tubes every 4 hours
D) Attach the chest tubes to bed linen to avoid tension of the tubing
13. After
the first three dose of Paroxetine (Paxil) 20 mg, the client complains
that the medication upsets his stomach. Which of the following
instructions would the nurse give to the client?
A) "Take the medication with 4 ounces of orange juice."
B) "Take the medication an hour before breakfast."
C) "Take the medication at bedtime."
D) "Take the medication with some foods.
14. The
nurse is developing a teaching plan for a client who will undergo a
stapedectomy for treatment of otosclerosis. Which point should the plan
include?
a. ringing in the ears is common after surgery
b. vertigo and dizziness are common after surgery
c. hearing should return immediately after surgery
d. excessive drainage is common after surgery
15. The
nurse is caring for a client with a diagnosis of detached retina. Which
assessment sign would indicate that bleeding has occurred as a result
of the retinal detachment?
a) total loss of vision
b) a reddened conjunctiva
c) a sudden sharp pain in the eye
d) complaints of a burst of black spots or floaters
16. The
client sustains a contusion of the eyeball following a traumatic injury
with a blunt object. Which intervention is initiated immediately?
a) notify the physician
b) apply ice to the affected eye
c) irrigate the eye with cool water
d) accompany the client to the emergency room
17. The
client arrives in the emergency room with a penetrating eye injury from
wood chips that occurred while cutting wood. The nurse assesses the eye
and notes a piece of wood protruding form the eye. What is the initial
nursing action?
a) apply an eye patch
b) perform visual acuity tests
c) irrigate the eye with sterile saline
d) remove the piece of wood using a sterile eye clamp
18. The
client arrives in the emergency room after sustaining a chemical eye
injury from a splash of battery acid. The initial nursing action is to:
a) begin visual acuity testing
b) cover the eye with a pressure patch
c) swab the eye with antibiotic ointment
d) irrigate the eye with sterile normal saline
19. The
nurse is caring for a client after a lung lobectomy. The nurse notes
fluctuating water levels in the water-seal chamber of the client's chest
tube. What action should the nurse take?
A. Do nothing, but continue to monitor the client.
B. Call the physician immediately.
C. Check the chest tube for a loose connection.
D. Add more water to the water-seal chamber
20. A
client with type 2 diabetes has a hemoglobin A1C level of 8.8 after 6
months of oral therapy with metformin (Glucophage®). The client tells
the nurse that she often forgets to take her medication and doesn't
really follow her diet. Which of the following is the nurse's best first
response?
A. "If you don't get control of your blood sugar, you'll need to take insulin."
B. "It can be hard to get used to having a disease like diabetes. What are some of the things you find challenging about it?"
C. "Uncontrolled diabetes can lead to eye problems and kidneys problems."
D. "Many people have diabetes."
21. The
nurse is teaching a client newly diagnosed with type 1 diabetes how to
self-administer subcutaneous insulin injections. How does the nurse best
evaluate the effectiveness of her teaching?
A. Have the client repeat the steps back to the nurse.
B. Give the client a written test on self-administration of insulin.
C. Ask the client to write out the steps for self-administration of insulin injections.
D. Ask the client to give a return demonstration of self-administration of insulin.
22. The
nurse is writing the teaching plan for a client undergoing a
radioactive iodine uptake test to study thyroid function. Which of the
following instructions should the nurse include?
A. "You need to stay at least 4 feet (1.2 m) away from other people after the test because you'll be radioactive."
B. "You need to lie very still on a stretcher that is placed in a long tube for the scan"
C. "Don't take any iodine or thyroid medication before the test."
D. "Schedule the bone scans before your radioactive iodine uptake test."
23. A
64-year-old patient with newly diagnosed acute myelogenous leukemia
(AML) who is undergoing induction therapy with chemotherapeutic agents
tells the nurse, "I feel so sick that I don't know if the treatment is
worth completing." The nurse's best response to the patient is
a. "I know you feel really ill right now, but after this therapy your disease will go into a remission and you will feel normal again."
b. "Induction therapy is very aggressive and causes the most side effects, so when this phase is completed you won't feel so ill."
c. "Your type of leukemia has an 80% survival rate if aggressive therapy is started, so the effects of treatment will be worth it to you."
d. "The chemotherapy is difficult, but it is necessary to put the disease into remission and give you time to make choices about your life.
24. The
nurse is assessing a patient with gastroesophageal reflux disease
(GERD) who is experiencing increasing discomfort. Which patient
statement indicates that additional patient education about GERD is
needed?
a. "I take antacids between meals and at bedtime each night."
b. "I quit smoking several years ago, but I still chew a lot of gum."
c. "I sleep with the head of the bed elevated on 4-inch blocks."
d. "I eat small meals throughout the day and have a bedtime snack.
25. A
patient with recurring heartburn receives a new prescription for
esomeprazole (Nexium). In teaching the patient about this medication,
the nurse explains that this drug
a. reduces the reflux of gastric acid by increasing the rate of gastric emptying.
b. coats and protects the lining of the stomach and esophagus from gastric acid.
c. treats gastroesophageal reflux disease by decreasing stomach acid production.
d. neutralizes stomach acid and provides
26. A
nurse is performing an initial post op assessment on a client following
upper GI surgery. The client has a NG tube to low, intermittent
suction. To best assess the client for the presence of bowel sounds, the
nurse should:
A. place the stethoscope to the left of the umbilicus.
B. turn off the nasogastric suction.
C. use the bell of the stethoscope.
D. turn the suction on the NG tube to continuous.
27. A
nurse is caring for a client diagnosed with Chron's disease, who has
undergone a barium enema that demonstrated the presence of strictures in
the ileum. Based on this finding, the nurse should monitor the client
closely for signs of:
A. peritonitis
B. obstruction
C. malaborsorption.
D. fluid imbalance.
28. While
conducting a home visit with a client who had a partial resection of
the ileum for Chron's Disease 4 weeks previously, a nurse becomes
concerned when the client states:
A. My stools float and seem to have fat in them.
B. I have gaiend 5 pounds since I left the hospital.
C. I am still avoiding milk products.
D. I only have 2 formed stools per day.
29. A
nurse is reviewing the history and physical of a teenager admitted to a
hospital with a diagnosis of ulcerative colitis. Based on this
diagnosis, which information should the nurse expect to see on this
client's medical record?
A. Abdominal pain and bloody diarrhea.
B. Weight gain and elevated blood glucose.
C. Abdominal distention and hypoactive bowel sounds.
D. Heartburn and regurgitation.
30. A
RN overhears a LPN talking with a client who is being prepared for a
total colectomy with the creation of an ileoanal reservoir for
ulcerative colitis. To decrease the client's anxiety, the RN should
intervene to clarify the information given by the LPN when the LPN is
heard saying:
A. this surgery will prevent you from developing colon cancer.
B. after this surgery you will no longer have ulcerative colitis.
C. when you return from surgery you will not be able to eat solid food for several days.
D. you will have an ileostomy when you return from the surgery.
31. The
nurse is assessing a client 24 hours following a cholecystectomy. The
nurse noted that the T tube has drained 750 mL of green-brown drainage
since the surgery. Which nursing intervention is appropriate?
A. Clamp the T tube
B. Irrigate the T tube
C. Notify the physician
D. Document the findings