1 . When a nurse is tried under criminal law, the nurse is being brought to trial by: [Hint]
A. society as a whole.
B. the plaintiff's lawyer.
C. an organization.
D. an individual.
Ans: A
2 . The newly licensed practical/vocational nurse begins work on a hospital unit where LPNs/LVNs are allowed to start intravenous fluids. The physician orders intravenous fluids to be started on one of this nurse's assigned clients. Which of the following actions would be most necessary on the part of this newly hired and newly licensed nurse before starting an intravenous on the client? [Hint]
A. Check the hospital policy and check on any certification required.
B. Ask another nurse to do a supervised check on administering IVs.
C. Ask one of your nursing-school instructors to refresh your skills.
D. Take a continuing-education IV course to make sure you have the skills.
Ans: A
3. When working as a licensed vocational nurse, you determine that your client scheduled for surgery does not understand the physician's earlier explanation of the surgery. The client is asking many questions about the risks and seems worried. Which of the following actions would be best on your part? [Hint]
A. Quickly explain the surgery procedures and the risks to the client.
B. Cancel the surgery.
C. Ask your supervising RN to explain the surgery procedure and its risks.
D. Notify the physician.
Ans:D
4 . You are the nurse working with an elderly, competent client who refuses a vitamin B injection ordered by the physician. The family insists that this injection be given, and you give it while the client is objecting. Even though the client improves, the client contacts a lawyer. From your knowledge of nursing and the law, you realize that you: [Hint]
A. did the right thing because the client improved.
B. should have had the family put their request in writing.
C. have commited an assault against the client.
D. have committed an act of battery against the client.
Ans:D
5. When an LVN/LPN is working for a health-care organization that has professional liability insurance, the nurse needs to base a decision on whether to buy individual professional liability insurance on which of the following things? [Hint]
A. the possibility that the organization could countersue the nurse in a lawsuit
B. the cost of professional liability insurance to the nurse
C. the amount and type of coverage the health-care organization carries
D. the number of hours worked and the type of nursing work
Ans:A
6. When documenting an assigned client's record during and at the end of the shift, the nurse must keep in mind which of the following facts?[Hint]
A. In order to get the care done for all assigned clients, the charting must be as brief as possible.
B. The proper format, such as SOAP or PIE, as chosen by the hospital, must be adhered to.
C. The chart is a legal document and may be all a nurse has to support care that was given if called to court.
D. Clients need to be assessed and the care documented at least once every hour during the shift.
Ans: C
7. When the licensed practical/vocational nurse is checking the physician's orders against the medication record prior to setting up medications, the nurse discovers a medication error made on the previous shift. The nurse reports this error to the supervising nurse. Which of the following persons will need to fill out an incident report? [Hint]
A. licensed practical/vocational nurse who discovered the error
B. licensed nurse who committed the medication error the previous shift
C. supervising nurse who is in charge of the nursing care unit
D. primary nurse assigned to this client the previous day
Ans: A
8. You are a student nurse working as a part-time or temporary nursing assistant in a nursing home. The nurse on duty asks you to insert a nasogastric tube in a patient. You have recently passed an examination on putting in a nasogastric tube. Which of the following actions is best on your part? [Hint]
A. Go ahead and insert the nasogastric tube.
B. Ask the nurse to supervise you while you insert the tube.
C. Call your school instructor for help with your decision.
D. Tell the nurse that you cannot legally insert this tube.
Ans: D
9. According to the nursing code of ethics, when working as a nurse and a conflict comes up between your client's needs and what the family and/or the physician wants, and/or the hospital policies, your first loyalty is to the: [Hint]
A. hospital.
B. client.
C. family.
D. physician.
Ans: B
10. Which of the following strategies can most help you as a nurse to enhance your ethical practice and client advocacy? [Hint]
A. reading a book on religions of the world
B. examining and clarifying your own values
C. talking with peers about their beliefs and values
D. buying a nursing book on ethical decisions
Ans: B
11. Which of the following actions by a practical/vocational nursing student represents the best example of deductive reasoning? [Hint]
A. observing that a client is constipated then doing some data gathering on client's health practices
B. assessing a client using Maslow's Hierarchy, then defining client's problem in terms of nutrition
C. suspecting that a client is not being truthful and checking other sources for information
D. identifying several alternative courses of action and deciding on the best course of action
Ans: B
12. In the daily practice of nursing, nurses use critical thinking in: [Hint]
A. setting priorities for the day.
B. every decision that is made.
C. calling the pharmacy to obtain a medication.
D. checking supplies in the client's room.
Ans: A
13. When the nurse problem solves and has implemented a solution from several solutions identified, the nurse most needs to do which of the following things?[Hint]
A. Discard the solutions that were not selected for implementation.
B. Implement a second solution, comparing its usefulness with the first solution.
C. Evaluate the effectiveness of the solution implemented.
D. Consider the problem solving completed in this case.
Ans: C
14. Using Strader's seven-step decision-making process, the nurse needs to first identify the purpose. What must the nurse do next? [Hint]
A. Decide who will be involved in the decision.
B. Enlist the cooperation of the client.
C. Set the criteria.
D. Identify solutions.
Ans: C
15. Nurses, as they progress in their education, will most likely do which of the following things? [Hint]
A. Learn to develop a personal theory of nursing.
B. Become less interested in bedside nursing.
C. Lose their ability to think critically in clinical areas.
D. Have increased enjoyment when doing paperwork.
Ans: A
16. When nurses assist clients in exploring their lifestyle habits and health behaviors to identify health risks, nurses are most likely to use which of the following models? [Hint]
A. medical model
B. wellness models
C. psychosocial model
D. physiological model
Ans: B
17. The lowest level of needs in Maslow's Hierarchy of Needs is which of the following? [Hint]
A. safety and security needs
B. love and belonging needs
C. physiologic needs
D. self-esteem needs
Ans: C
18. In Hildegard Peplau's Interpersonal Relations Model, the focus is on which of the following? [Hint]
A. individual
B. community
C. larger society
D. Family
Ans: A
19. In Virginia Henderson's 1966 definition of nursing, a person/client has which of the following numbers of fundamental needs ? [Hint]
A. 7
B. 14
C. 18
D. 22
Ans: B
20. Which of the following therorists stressed energy fields in their nursing theory?[Hint]
A. Dorothea Orem
B. Helen Neuman
C. Rosemarie Parse
D. Martha E. Rogers
Ans: D
31. Which of the following reasons is the most important, as well as the most widely accepted, reason for nurses using nursing process? [Hint]
A. Increase the unique body of knowledge known as nursing.
B. Help clients meet their actual and potential health problems.
C. Communicate with other members of the team.
D. Standardize the care of clients with the same diagnoses.
Ans: C
32. The primary source of data for the client's database is which of the following sources? [Hint]
A. nurse's recording of health history
B. recent clinic or hospital records
C. physician's history and physical
D. Client
Ans: B,D
33. Which of the following statements best describes a wellness nursing diagnosis for an individual, family, or community? [Hint]
A. clinical judgment of transition to a higher level of wellness
B. nursing judgment that in some area no pathology exists
C. a judgment that in some area there is more wellness than illness
D. statement of an area of family strength to use in interventions
Ans: A
34. When reading the nursing-care plan of a newly assigned client prior to caring for this client, the LPN/LVN will notice that potential problems are stated using how many parts in the statement? [Hint]
A. One
B. Two
C. Three
D. Four
Ans: B
35. The physician writes an order for "progressive ambulation, as tolerated." The RN writes an order for "Dangle for 5 min. 12 h post op and stand at bedside 24 h post op." The LVN assigned to care for this client should do which of the following? [Hint]
A. Call the physician for clarification of the ambulation orders.
B. Check with the State Board of Nursing for an opinion.
C. Check client's vital signs before dangling or standing client.
D. Dangle or stand client only if they are agreeable to this.
Ans: C
36. When does the nurse chart an intervention that involves administering medication to a client? [Hint]
A. before the end of shift
B. before the next dose of medication or treatment is due
C. within one hour
D. Immediately
Ans: D
37. When writing goals/outcomes for clients, the nurse should do which of the following? [Hint]
A. Combine related diagnoses and write a goal or goals for this set.
B. Write goals that the treatment team believes are important.
C. Involve the client in determining the goals/desired outcomes.
D. Combine no more than two nursing diagnoses per goal.
Ans: C
38. The client you are assigned to has four nursing diagnoses. Which of the following would you assign the highest priority? [Hint]
A. chest pain related to cough secondary to pneumonia
B. self-care deficit related to activity intolerance secondary to sleep-pattern disturbance
C. risk for altered family processes secondary to hospitalization
D. self-esteem deficit situational
Ans: A
39. Which of the following activities on the part of the nurse most demonstrates individualization of the nursing-care plan for a client? [Hint]
A. Include client's preferred times of care and methods used.
B. Write the care plan instead of taking it off the computer.
C. Use a care plan from a book but add some things to it.
D. Select nursing diagnoses that match the client's problems
Ans: A.
40. You are doing the evaluation step of the nursing process and find that two of the goals for the client have not been met. Which of the following actions would be best on your part? [Hint]
A. Stop working on these goals, as evaluation is the last step.
B. Assess client's motivation for complying with the care plan.
C. Reassess problem and then review care plan and revise as needed.
D. Determine if the client has a knowledge deficit causing nonattainment.
Ans: C
41 . When you discover an electrical fire and decide you need a fire extinguisher, you will need to find a fire extinguisher that is rated for which class of fire? [Hint]
A. Class A
B. Class B
C. Class C
D. Class E
Ans: C
42 . Which of the following statements is an OBRA regulation that the nurse must keep in mind when considering applying a restraint to a client? [Hint]
A. Apply physical restraints as a first-choice intervention in fall prevention.
B. The physician's order for restraints must be time limited.
C. Verbal or telephone orders for restraints must be signed within 72 hours.
D. Restraints cannot be applied if a family member objects.
Ans: B
43 . When restraining a client in bed with a sleeveless jacket (vest) with straps, you will do which of the following things? [Hint]
A. Tie the straps to the side rails.
B. Tie the straps to the movable part of the bed frame.
C. Tie the straps with a square knot.
D. Tie the straps with a quick-release knot.
Ans: D
44 . When you encounter the victim of an electrical-current injury who is still holding an electrical appliance, you would do which of the following things first? [Hint]
A. Move the client to a safe place immediately.
B. Unplug the electrical cord before moving client.
C. Shut off the electrical current.
D. Check for a carotid pulse and for respirations.
Ans: C
45 .When instructing the family of a client who has diabetes with neuropathy causing impaired skin sensitivity, you would stress the importance of which one of the following things in regard to showering or bathing? [Hint]
A. cleaning the tub or shower with full-strength peroxide
B. drying well after the shower or bath
C. applying lotion after the shower or bath
D. a method for assuring the water temperature is not hot
Ans: D
46 . The nurse finds that an assigned client is restless, agitated, and confused and is thinking of restraining the client. Which of the following questions is most important for the nurse to ask? [Hint]
A. "Which restraint is most appropriate?"
B. "Will I be able to get an order for a restraint?"
C. "What is the underlying cause of the restless, agitated, confused behavior?"
D. "Could I try some medication to relax the client prior to using restraints?"
Ans: C
47 . The nurse giving discharge instructions advises the client to get out of bed slowly and to get up in stages from lying to sitting to standing. The client understands that the reason for doing this is: [Hint]
A. to prevent falls.
B. to improve circulation.
C. as a warm-up exercise.
D. to increase oxygenation.
Ans: A
48 . Which of the following interventions on the part of the nurse would most help a confused ambulatory client find their room? [Hint]
A. having large room numbers on the door
B. placing a picture on the door
C. giving hourly reorientation to the correct room
D. pinning the client's room number on their attire
Ans: B
49 . When assessing the noise level that clients are exposed to, the nurse is aware that levels below which of the following number of decibels is usually safe in terms of hearing? [Hint]
A. 85
B. 95
C. 110
D. 120
Ans: A
50 . One of your assigned clients who is scheduled for radiation therapy asks you to stay with her during radiation because she is scared. Your best response to this request would be which of the following responses? [Hint]
A. "Let's think of how to reduce your fear, as I must stay a distance away."
B. "I will be right there with you, and I will hold your hand so you won't be afraid."
C. "It is not necessary to be afraid, as nothing bad will happen to you."
D. "I will see if I can get permission from your doctor and the X-ray department."
Ans: A
51 . A true pathogen will cause disease or infection: [Hint]
A. in a healthy person.
B. only in an immuno-compromised person.
C. in persons with allergy to the pathogen.
D. in very few people.
Ans: A
52 . A client asks you to explain viruses. Which of the following statements would be true and therefore best to include in your answer? [Hint]
A. "Viruses are the most common agent causing infection."
B. "Viruses are commonly found in the intestinal tract."
C. "Viruses must enter into living cells to reproduce."
D. Candida is one of the most common viruses."
Ans: C
53 . The nursing supervisor has asked the staff to reduce the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing iatrogenic infections? [Hint]
A. teaching correct hand washing to assigned clients
B. using correct procedures in starting and caring for an intravenous infusion
C. properly bagging soiled linens and disposed items used for a client in isolation
D. isolating a client who has just been diagnosed as having tuberculosis
Ans: B
54 . Your assigned client has encephalitis, and there are other cases in the community. In a team meeting regarding your client and prevention of other cases of encephalitis, the nurse supervisor talks about breaking the chain of infection at the second link: the reservoir. You realize the nurse supervisor is talking about which of the following things? [Hint]
A. an area for the storage and filtering of water
B. a place where the microorganism enters the body
C. the place where the microorganism naturally lives
D. the microorganism itself
Ans: C
55 .On a home visit, you notice some dust on a vent in your client's room and on the windowsill. Which of the following methods would you teach the family to use for removing dust? [Hint]
A. Use a damp cloth to remove the dust.
B. Use a feather duster to remove dust.
C. Vacuum up the dust.
D. Use a broom covered with a cloth.
Ans: A
56 . A client asks you how to best prevent vaginal infections. Your best answer would include which of the following statements? [Hint]
A. "I would suggest a vinegar douche."
B. "The pH of the vaginal secretions stops many disease-producing bacteria."
C. "Drinking cranberry juice will prevent most all of the vaginal infections."
D. "Your doctor can prescribe a medication that will prevent vaginal
E. infections."
Ans: B
57 .You would refer to the early phase of scar tissue formation as which of the following kinds of tissue? [Hint]
A. Keloid
B. Cicatrix
C. granulation
D. Fibrous
Ans: C
58 . Which of the following situations represents the best example of passive immunity? [Hint]
A. a child receiving a vaccination for measles
B. an infant receiving breast milk from the mother
C. production of antibodies by a person with infection
D. a person receiving antibiotics for an infection
Ans: B
59 . You are working with a client who has cancer and is undergoing treatment. The client complains of a loss of appetite. You will most need to make certain that your client eats which one of the following foods? [Hint]
A. fresh fruits
B. raw vegetables
C. carbohydrates
D. Protein
Ans: D
60 .Your assigned client has a leg ulcer that has a dressing on it. During your assessment, you find that the dressing is wet. The client admits to spilling water on the dressing. What action would be best on your part? [Hint]
A. Reinforce the dressing with a dry dressing.
B. Remove wet dressing and apply new dressing.
C. Dry the dressing with a hair dryer.
D. Let the room air dry the dressing.
Ans: B
61 A fellow nurse who is working on another unit asks to read the chart of your assigned client. Which one of the following criteria would enable the nurse to have access to the chart? [Hint]
A. Be unrelated to the client.
B. Have a current nursing license.
C. Have client's verbal permission.
D. Be directly involved in client's care.
Ans: D
62 . When charting in the client's record or chart, the nurse most needs to do which one of the following things? [Hint]
A. Date and sign each entry.
B. Chart every two hours.
C. Use ballpoint pen and not pencil.
D. Cross out errors so others can't read them.
Ans: A
63 . While giving a shift report on your assigned client, you realize that you forgot to record a nursing procedure done on your client. Which of the following methods of documentation would be best on your part? [Hint]
A. Write the procedure between the two lines of your shift documentation closest to the occurrence.
B. Find a blank space in your earlier charting, and chart the procedure in that space.
C. Tell the oncoming nurse to chart the procedure for you and to cite the time it was done.
D. Chart the current date and time and "Late entry," indicating when and what was done.
Ans: D
64 . One of your assigned clients gets up to go to the bathroom without calling you. The client falls to the floor and calls for help. You answer the call and alert your supervisor. After assuring that the vital signs are normal and there does not appear to be any injuries, you are told to fill out an incident report. In addition to noting that the client was found on the floor, which of the following statements would you most need to record in the nursing notes for the client? [Hint]
A. "Incident report completed."
B. the reason the client was unattended
C. the vital signs and assessment of the client
D. location of the incident report
Ans: C
65 . When the physician telephones to order a therapy such as a medication for the client of a student nurse, who is the best person to take this telephone order?[Hint]
A. whoever is authorized by hospital policy
B. the student nurse giving the client's care
C. the student nurse's instructor
D. any licensed nurse on duty
Ans: A
66 . The nurse is sending some lab results to the primary physician's office. The nurse most needs to do which of the following things? [Hint]
A. Make a note that the fax was sent and what time it was sent in the nurses' notes.
B. Document a follow-up telephone call verifying the receipt of information and who received it.
C. Leave a note to the physician in the client's record saying what information was faxed and when.
D. Check with the laboratory to see if they have already provided the physician with the results.
Ans: B
67 . In the Problem Oriented Medical Record documentation system (POMR), which of the following answers best represents the person or persons who may contribute to the problem list representing the client's physiologic, psychologic, social, cultural, spiritual, developmental, and environmental needs? [Hint]
A. the primary nurse
B. the assigned social worker
C. registered nurses and the physician
D. all caregivers
Ans: D
69 . When working in a facility that uses focus charting, the nurse will use which of the following as a focus of care? [Hint]
A. problems identified in the initial assessment
B. maximum level of functioning
C. client identified goals and objectives
D. client concerns and strengths
Ans: D
70 . When the nurse's assigned client is being discharged to another institution or a home setting where a visit by the community health nurse is required, which of the following information is most likely to be included in the discharge and referral summaries? [Hint]
A. unresolved health-care problems and continuing care needs
B. an assessment of the family's financial assets and deficits
C. a copy of the discharge order signed by the physician
D. a new plan of care for the client and the family
Ans: B
71 . Which of the following words represents the basic unit of all life and is the simplest structure that possesses all the characteristics of life: organization, metabolism, responsiveness, homeostasis, growth, and reproduction? [Hint]
A. the cell
B. a gene
C. a chromosome
D. the organelles
Ans: A
72 . Which of the following cells of the body are in almost constant mitosis? [Hint]
A. nerve cells
B. stomach cells
C. muscle cells
D. renal cells
Ans: B
73 . Where is ribosomal RNA used in protein synthesis produced? [Hint]
A. organelles
B. mitochondria
C. Golgi apparatus
D. Centrioles
Ans: D
74 . Tissue in the urinary bladder called transitional epithelium is best described in which of the following ways? [Hint]
A. changes from cuboidal to columnar
B. are single layer and not stratified
C. contain a special elastic substance to aid in expansion
D. change shape depending on the bladder's fullness
Ans: D
75 . When teaching someone about endocrine glands, which of the following statements could you use? [Hint]
A. "The endocrine glands include sweat and sebaceous glands."
B. "Endocrine glands all have at least one duct."
C. "Hormones are carried away from the endocrine gland by the blood."
D. "There is no epithelial tissue in endocrine glands."
Ans: C
76 . The vocal cords have and function with which of the following kinds of tissue?[Hint]
A. liquid connective tissue
B. hard connective tissue
C. fibrous connective tissue
D. soft connective tissue
Ans: C
77 . The thoracic and abdominopelvic cavities are divided by which of the following body structures? [Hint]
A. rib cage
B. diaphragm
C. sternum
D. Stomach
Ans: B
78 . The body's biggest organ is which of the following components of the body?[Hint]
A. large intestine
B. the skin
C. small intestine
D. Kidneys
Ans: B
79 . The skeletal system acts as a storehouse for calcium, which is a very important component in muscle contractions, as well as which of the following activities in the body? [Hint]
A. producing testosterone
B. preventing seizures
C. making lymph
D. blood clotting
Ans: D
80 . When reading an autopsy report, the nurse encounters the term "mid-sagittal plane." This nurse understands that this means the body was viewed using a plane that matched which of the following descriptions? [Hint]
A. This plane cuts the body horizontally.
B. This plane divides the body into front and back portions.
C. The body is separated into left and right equal portions.
D. The body is divided using an X across the chest.
Ans: C
81 . The nurse receives a report at the beginning of the shift and learns that the client scores 7 on the Glasgow Coma Scale. The nurse realizes that this client is at which of the following levels of consciousness? [Hint]
A. comatose
B. moderate disability
C. severe disability
D. fully alert
Ans: A,D
82 . You partially darken a room and ask the client to look straight ahead. You use a penlight and, approaching from the side you shine the light, it constricts. You remove the light and then shine it on the same pupil again. You also observe the response of the other pupil. You would normally find the other pupil doing which of the following things? [Hint]
A. not make any change in size
B. dilate in an oppositional response to the light
C. first constrict, then dilate larger than the other pupil
D. constrict in consensual response
Ans: D
83 . The nurse is preparing to do a focused assessment of the abdomen on an assigned client. Which of the following is most important for the nurse to do prior to the examination? [Hint]
A. Have client empty their bladder.
B. Gather equipment.
C. Place client in semi-Fowler's position.
D. Remove any dressings from abdomen.
Ans: A
84 . The physician of your assigned client tells you that the client has a heart murmur that can be detected by direct auscultation. You realize that the physician is telling you which of the following things? [Hint]
A. Use of a stethoscope is necessary to hear the murmur.
B. The murmur can be heard by using only the ear.
C. An ultrasound is necessary to find this murmur.
D. A Doplar device will be needed to find the murmur.
Ans: A
85 . When weighing a client daily, you will most need to weigh the client at which of the following times? [Hint]
A. when most rested
B. at the same time each day
C. after the shower or bath
D. when higher priorities are completed
Ans: B
86 . When counting the apical pulse during the physical assessment, it is the most accepted practice for the nurse to count the apical pulse in which of the following ways? [Hint]
A. for 15 seconds and multiply by four
B. for 30 seconds and multiply by two
C. for one minute, checking radial pulse at the same time
D. for one full minute
Ans: D
87. While listening to a client's lung sounds, you hear something that you believe is not normal, and you note that it is a continuous sound. You will chart this as which of the following findings? [Hint]
A. crackles
B. Rales
C. adventitious sounds
D. pleral friction rub
Ans: C
88 . When examining the client's abdomen, the nurse will most facilitate the examination by positioning the client in which of the following ways? [Hint]
A. supine with small pillows beneath knees and head
B. semi-Fowler's position with knees extended
C. sitting in the chair with legs elevated
D. supine with arms extended and hands behind head
Ans: A
89 . You highly suspect that your assigned client has abdominal distention. You most need to do and chart which of the following things? [Hint]
A. Have another nurse verify your suspicions.
B. Measure the abdominal girth at the umbilicus.
C. Measure abdominal girth at the most distended level.
D. Ask the client if they are distended.
Ans: C
90 . When a client's skin is dry, which of the following nursing interventions would be most helpful? [Hint]
A. Limit bathing to once or twice a week.
B. Bathing is daily, but no soap is used.
C. Bathing daily with mineral oil added to the water.
D. Bathing with lotion instead of water.
Ans: A
91. To protect the client's skin from injury during hygiene care, including bathing or showering, application of lotion, and bed making, you most need to do which of the following things? [Hint]
A. Cover your rings and bracelets with gloves.
B. Briskly dry client's skin after bath to ensure dryness.
C. Keep bottom sheets somewhat loose.
D. Cut your fingernails to a short length.
Ans: D
92. The skin produces and absorbs which of the following vitamins in conjunction with the ultraviolet rays of the Sun, which activate this particular vitamin's precursor present in the skin? [Hint]
A. vitamin D
B. vitamin C
C. vitamin E
D. vitamin K
Ans: A
93. You are working with a client who has dentures but does not wear them. When questioned about the reason for not wearing the dentures, the client says it makes him feel old. Which of the following responses would be best? [Hint]
A. "You are not really old."
B. "It is all right not to wear your dentures."
C. "You look better with dentures."
D. "Wearing dentures helps gums not to shrink."
Ans: D
94. When assessing the client's hair, you are especially looking for pediculosis capitis. If it is present, which of the following signs will you most likely find?[Hint]
A. Oval particles looking like dandruff on the hairs.
B. Crusts on the scalp, especially at the client's hairline.
C. Brown or black threadlike lesions.
D. Small insects with red legs.
Ans: A
95. You are preparing to bathe and wash the hair of an African American woman. Which of the following questions would be most important to ask the client?[Hint]
A. "Will you please unbraid your hair?"
B. "Do you have or want oil put on your hair and scalp?"
C. "Is it all right if I shampoo your hair twice?"
D. "Will you brush your hair before the shampoo?"
Ans: B
96. You need to remove the artificial eye of a client, and you need to clean it. Which of the following methods is recommended for removal? [Hint]
A. Put pressure on either side of the eye and pop it out.
B. Apply pressure directly above the eye.
C. Apply pressure directly to the eye with a small rubber bulb.
D. Apply pressure with a rubber bulb to lower half of the eye.
Ans: C
97. It is most likely that an acutely ill client will need the room temperature set at which of the following temperatures? [Hint]
A. 64 degrees F
B. 68 degrees F
C. 74 degrees F
D. 78 degrees F
Ans: D
98. You are cleaning a client's partial dentures, which have a metal clasp. Which of the following actions are best on your part? [Hint]
A. Place a washcloth in the sink where you are cleaning.
B. Remove the partial dentures by the metal clasp.
C. Use hot water to rinse the dentures after cleaning.
D. Soak the partial plate with the metal clasp overnight.
Ans: A
99. A nurse getting report at the beginning of shift learns that an assigned client has hyperpyrexia. The nurse realizes that this client is experiencing which of the following signs or symptoms? [Hint]
A. extreme bleeding of the gums
B. a very high fever, such as 41°C or 105.8°F
C. waxy flexibility of the muscles
D. third-degree burns over much of the body
Ans: B
100. You are ready to take the client's oral temperature. You ask this client how long it has been since drinking something hot or cold or smoking. The client admits having just drunk a cup of hot coffee. You will wait how long before taking the temperature? [Hint]
A. 5 minutes
B. 10 minutes
C. 20 minutes
D. 30 minutes
Ans: D
101. In which of the following clients is a rectal temperature most usually contraindicated? [Hint]
A. client who has had a myocardial infarction
B. client with Parkinson's disease
C. client who is prone to seizures
D. client with neuropathology associated with diabetes
Ans: A
102. When taking a radial pulse for half a minute, the nurse finds it to be irregular. Which of the following would be best for the nurse to do next? [Hint]
A. Take the radial pulse for one minute.
B. Check the carotid pulse to see if it is irregular.
C. Assess the apical pulse.
D. Chart the radial pulse and the irregularities.
Ans: C
103. The nurse wants to check the popliteal pulse. This pulse can be better palpated if the nurse does which of the following things? [Hint]
A. Ask the client to extend the knee.
B. Have the client flex the knee.
C. Press lightly on the right side of the front of the knee.
D. Palpate more deeply than for other pulses.
Ans: B
104. The nurse positioning a client after surgery will take into account that the position, which most often predisposes a client to physiologic processes that suppress respiration, is which of the following positions? [Hint]
A. Fowler's position
B. Prone
C. Supine
D. left side lying down
Ans: C
105. The nurse is taking the client's blood pressure. The physician asks for the pulse pressure. To obtain the pulse pressure, the nurse will have to do which of the following things? [Hint]
A. Obtain a pulse-pressure machine.
B. Subtract the diastolic blood pressure from the systolic.
C. Subtract the systolic blood pressure from the diastolic.
D. Take client's apical pulse and subtract it from systolic.
Ans: B
106. The nurse notices that the client has a hematocrit of 70 percent. This level of hematocrit will most likely affect the vital signs in which of the following ways?[Hint]
A. The blood pressure will be elevated.
B. The pulse will be low.
C. Temperature will be elevated.
D. Blood pressure will be low.
Ans: A
107. The nurse finds that a newborn has a mean systolic pressure of 75 mmHg. How would this blood pressure be best described? [Hint]
A. Normal
B. slightly low
C. very low
D. slightly high
Ans: A
108. When working with clients experiencing pain, you will define their pain in regard to whether they have pain or not and how intense it is based on which of the following things? [Hint]
A. nursing experience and expertise
B. the underlying cause of the pain
C. whatever the experiencing person says it is.
D. current medical and pharmacological research
Ans: C
109. When pain impulses are transmitted via the A-delta fibers, which of the following types of pain will your client have? [Hint]
A. sharp, pricking pain
B. throbbing pain
C. burning pain
D. intermittent stabbing pain
Ans: A
110. Your assigned client, who has been talking with the doctor about pain control, later asks you what the doctor meant by "pain threshold." Which of the following would be the best reply? [Hint]
A. the point at which pain medication brings relief
B. the maximum amount of pain a person can tolerate
C. the amount of pain the average person can tolerate
D. the amount of pain stimulation that it takes to cause pain
Ans: D
111. Which one of the following four clients is most likely to tolerate pain best? [Hint]
A. a client with rheumatoid arthritis
B. a client who has terminal cancer in stage 1 of grief
C. an athlete having a knee surgery to prolong his career
D. a client who has a migraine headache
Ans: C
112. You are caring for a client who has just returned from surgery and has received intravenous morphine minutes before leaving the recovery room. You need to assess the client's pain now and again at which of the following times? [Hint]
A. in 20 to 30 minutes
B. in one hour
C. in two hours
D. in 3 to 4 hours
Ans: A
113. Your assigned client seems to be getting a lot of attention from his mother when he complains of pain. The mother may be encouraging which of the following types of gains? [Hint]
A. primary gains
B. secondary gains
C. narcissistic gains
D. egocentric gains
Ans: B
114. When giving a client a diagnosis of acute pain, the nurse "using NANDA diagnostic categories" will use this diagnosis only when the pain last no longer than which of the following lengths of time? [Hint]
A. 3 days
B. 2 weeks
C. 1 month
D. 6 months
Ans: D
115. The nurse visiting a client and the client's family in the home teaches family members to massage the client's back and enlists their aid in providing backrubs. Which of the following reasons most likely represents the main reason the nurse has enlisted the aid of the family? [Hint]
A. It may diminish feelings of helplessness in family members.
B. The client may need a backrub when the nurse is gone.
C. Backrubs reduce the need for addicting medications.
D. The client will be able to get more sleep and rest.
Ans: A
116. Which of the following people have the largest percentage of water in their bodies? [Hint]
A. fat men
B. lean men
C. lean women
D. fat women
Ans: B
117. When talking with a client about complete and incomplete proteins, which of the following would you use as the best example of a complete protein? [Hint]
A. olives
B. rice
C. eggs
D. Nuts
Ans: C
118. In instructing a client on cholesterol, the nurse will teach which of the following things? [Hint]
A. The body does not need cholesterol.
B. Most cholesterol in the body is destroyed in the small intestine.
C. The majority of cholesterol in the body comes from eating fatty foods.
D. Most cholesterol is synthesized in the liver.
Ans: D
119. A client asks which of the vitamins can be stored in the body. Which of the following answers by the nurse would be correct? [Hint]
A. C
B. B1 thiamine
C. Biotin
D. D
Ans: D
120. The newborn infant's stomach capacity is approximately which of the following in milliliters? [Hint]
A. 50
B. 90
C. 120
D. 160
Ans: B
121. You are feeding a newborn infant in the nursery, as the mother is having some procedure done at this time. Before the infant finishes taking the contents of the bottle of formula, the infant slowly stops sucking and falls asleep. Which of the following actions would be best on your part? [Hint]
A. Wake the baby by tickling the bottoms of the feet and then try feeding.
B. Wait about 30 minutes, then try to get the infant to take the formula.
C. Report this feeding behavior to the supervisior immediately.
D. Discontinue the feeding and allow the infant to sleep at this time.
122. The nurse will teach clients to use which of the following groups from the food pyramid in the greatest amounts? [Hint]
A. carbohydrates such as grains, potatoes, and rice
B. vegetables and fruits
C. milk and milk products
D. proteins such as meat and meat products
123. You are working with a client who is on a full liquid diet. The client is demanding some ice cream. Which of the following responses on your part would be best? [Hint]
A. Tell the client that ice cream is not allowed on a full liquid diet.
B. Call the physician and report the client’s demands.
C. Get the client some plain vanilla ice cream.
D. Ask the supervising nurse to talk with the client.
Ans: C
124. The phosphate level of a newborn is best described in which of the following ways when comparing the newborn's phosphate level with that of an adult?[Hint]
A. nearly half that of the adult
B. about one fourth that of an adult
C. nearly twice that of an adult
D. approximately the same as an adult
Ans: C
125. The nurse is checking the placement of a nasogastric tube prior to giving medication and a feeding. Which of the following is the preferred and most accurate method of testing? [Hint]
A. Insert 5 to 20 mm of air into the tube while listening over the stomach with a stethoscope.
B. Aspirate 20 to 30 ml of gastrointestinal secretions and test the pH.
C. Insert 15 to 20 cc of water into the stomach and listen with the stethoscope.
D. Place an open end of the tube into a glass of water and check for bubbles.
Ans: B.
