2024-2025 NCLEX Comprehensive Review Study Guide With Answers-265 Solved Questions

NCLEX Review Study Guide Comprehensive 2024/2025
100% VERIFIED ANSWERS
1. A client with diabetes mellitus calls the clinic nurse and reports that she has been vomiting
during the night and now has diarrhea. Which question does the nurse make a priority of asking
the client?
Answer: "Have you tested your blood glucose?"
2. A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift,
and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12
hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the
client's Foley catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the
end of the evening shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals
155 mL for the 24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL.
What is the client's total intake during the 24-hour period?
Answer: 1670mL
3. A client with heart failure suddenly experiences profound dyspnea, pallor, audible wheezing,
and cyanosis, and the nurse suspects pulmonary edema. The nurse would first:
Answer: Raise the head of the client's bed
4. A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For
which adverse effect of cisplatin will the nurse assess the client?
Answer: Hearing loss
5. Alendronate (Fosamax) is prescribed for a client with postmenopausal osteoporosis. The nurse
provides information on the medication to the client. When does the nurse tell the client to take
the alendronate?
Answer: Every morning before breakfast, with a full glass of water

6. A client with emphysema is receiving theophylline (Theo-24). While providing dietary
instructions, the nurse tells the client that it is acceptable to consume:
Answer: Apple juice
7. A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT).
Which of the following diagnoses, if noted on the client's record, would indicate a need to
contact the physician who is scheduled to perform the ECT?
a) Hypertension
b) Glaucoma
c) Recent stroke
d) Diabetes mellitus
Answer: c) Recent stroke
8. An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which
of the following characteristics of the disorder does the nurse expect the client to exhibit? Select
all that apply.
a) Nausea
b) Eye pain
c) Vomiting
d) Headache
Answer: a) Nausea
b) Eye pain
c) Vomiting
d) Headache
9. The nurse administers intravenous morphine sulfate to a client in pulmonary edema. For which
intended effect of the medication does the nurse monitor the client?
Answer: Relief of anxiety

10. An emergency department nurse is told that a client with carbon monoxide poisoning
resulting from a suicide attempt is being brought to the hospital by emergency medical services.
Which intervention will the nurse carry out as a priority upon arrival of the client?
Answer: Administering 100% oxygen
11. A client with agoraphobia will undergo systematic desensitization through graduated
exposure. In explaining the treatment to the client, the nurse tells the client that this technique
involves:
Answer: Gradually introducing the client to a phobic object or situation in a predetermined
sequence of least to most frightening
12. A client with a medical history of diabetes mellitus is found to have sarcoidosis, and oral
prednisone is prescribed. The nurse provides instructions to the client about the medication and
tells the client to:
Answer: Closely monitor the blood glucose level
13. Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the
nurse perform as a priority before administering the medication?
Answer: Checking the client's blood pressure
14. A client who has undergone abdominal hysterectomy asks the nurse when she will be able to
resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed:
Answer: In about 6 weeks, when the vaginal vault is satisfactorily healed
15. A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a
prescribed medication is higher than the normal dose. The nurse calls the physician's answering
service and is told that the physician is off for the night and will be available in the morning. The
nurse should:
Answer: Ask the answering service to contact the on-call physician

16. A hospitalized female client with mania enters the unit community room and says to a client
who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the
appropriate response by the nurse?
Answer: "Don't say that. If you can't control yourself, we'll help you."
17. A client with HIV infection who has been found to have histoplasmosis is being treated with
intravenous amphotericin B (Fungizone). Which parameter does the nurse check to detect the
most common adverse effect of this medication?
Answer: Intake and output
18. A nurse is gathering subjective and objective data from a client with suspected rheumatoid
arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that
apply.
a) Fatigue
b) Low-grade fever
c) Joint stiffness
d) Weight loss
e) Anemia
Answer: a) Fatigue
b) Low-grade fever
19. Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides
information to the client about the adverse effects of the medication and tells the client to contact
the physician immediately if she experiences:
Answer: Neck stiffness or soreness
20. A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The
nurse monitoring the client notes uterine hypertonicity and immediately:
Answer: Stops the oxytocin infusion

21. A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb
on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has
left a persistent depression. On the basis of this finding, the nurse concludes that:
Answer: Pitting edema is present
22. A nurse is caring for a client with community-acquired pneumonia who is being treated with
levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to
the medication, does the nurse monitor the client?
a) Increased appetite
b) Fever
c) Weight gain
d) Decreased urination
Answer: b) Fever
23. A client receiving parenteral nutrition (PN) suddenly experiences chest pain and dyspnea, and
the nurse suspects an air embolism. The nurse immediately places the client in a lateral
Trendelenburg position, on the left side. What action does the nurse take next?
Answer: Clamping the intravenous catheter
24. A nurse is preparing a poster for a health fair booth promoting primary prevention of skin
cancer. Which of the following recommendations does the nurse include on the poster? Select all
that apply.
a) Use sunscreen with at least SPF 30
b) Seek medical advice if you find a skin lesion
c) Avoid tanning beds
d) Wear protective clothing and hats
Answer: a) Use sunscreen with at least SPF 30
b) Seek medical advice if you find a skin lesion
c) Avoid tanning beds
d) Wear protective clothing and hats

25. A nurse is providing instructions to a client with glaucoma who will be using acetazolamide
(Diamox) daily. Which of the following findings, an adverse effect, does the nurse instruct the
client to report to the physician?
a) Increased thirst
b) Dark urine
c) Mild headache
d) Slight dizziness
Answer: b) Dark urine
26. A nurse is providing morning care to a client who has undergone surgery to repair a fractured
left hip. Which item is most important for the nurse to use in turning the client from side to side
to change the bed linens?
Answer: Abduction device
27. A nurse is performing an assessment of a client being admitted to the hospital with a
diagnosis of multiple sclerosis. The client tells the nurse that she took baclofen (Lioresal) for the
past 9 months but completely stopped the medication 2 days ago because it was making her feel
weak. On the basis of this information, the nurse notes in the plan of care that the client should
be monitored most closely for:
Answer: Seizure activity
28. A nurse administers nitroglycerin sublingually to a client with angina pectoris who complains
of chest pain. The medication is ineffective, so the nurse prepares to administer a second dose.
Before administering the nitroglycerin, which action does the nurse make a priority?
Answer: Checking the client's blood pressure
29. A nurse provides information to a client with coronary artery disease (CAD) about smokingcessation measures. Which statement by the client indicates a need for further information?
Answer: "I should drink a cup of coffee if I feel the urge to smoke."

30. A client with myasthenia gravis who has been taking pyridostigmine bromide (Mestinon) for
the treatment of the disorder comes to the emergency department complaining of severe muscle
weakness, and cholinergic crisis is diagnosed. Which medication does the nurse prepare for
immediate use in treating the crisis?
Answer: Atropine sulfate
31. A rape victim being treated in the emergency department says to the nurse, "I'm really
worried that I've got HIV now." What is the appropriate response by the nurse?
Answer: "Let's talk about the information that you need to determine your risk of contracting
HIV."
32. A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to
include in the diet. The nurse tells the client that one food item high in calcium is:
Answer: Sardines
33. A nurse prepares to administer digoxin (Lanoxin) to a client with congestive heart failure.
Which vital sign must be checked before the medication is administered?
Answer: Apical pulse
34. A nurse provides home care instructions to a client with coronary artery disease (CAD) who
is being discharged from the hospital. Which statement by the client indicates a need for further
instruction?
Answer: "I need to participate in aerobic and weightlifting exercise three times a week."
35. A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical
ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this
type of tube, does the nurse implement?
Answer: Maintaining cuff pressure

36. Ergotamine (Cafergot) is prescribed to a client with cluster headaches. Which of the
following occurrences does the nurse tell the client to report to the physician if she experiences
them while taking the medication?
a) Nausea
b) Increased sensitivity to light
c) Numbness and tingling of the fingers or toes
d) Mild fatigue
Answer: c) Numbness and tingling of the fingers or toes
37. A nurse who will be staffing a booth at a health fair is preparing pamphlets containing
information regarding the risk factors for osteoporosis. Which of the following risk factors does
the nurse include in the pamphlet? Select all that apply.
a) Smoking
b) High alcohol intake
c) White or Asian ethnicity
d) Regular exercise
e) Low calcium intake
Answer: a) Smoking
b) High alcohol intake
c) White or Asian ethnicity
38. A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD).
The client says to the nurse, "I'm really thirsty — may I have something to drink?" Before giving
the client a drink, the nurse should:
Answer: Check for the presence of a gag reflex
39. A nurse provides information to a client who will be undergoing endoscopic retrograde
cholangiopancreatography (ERCP). The nurse tells the client that:
Answer: Dye may be injected during the procedure to permit visualization of the pancreatic and
biliary ducts

40. Cascara sagrada has been prescribed for a client with diminished colonic motor response as a
means of promoting defecation. The nurse provides information to the client about the
medication and tells the client to:
Answer: Increase fluid intake
41. A nurse provides instruction to a pregnant woman about foods containing folic acid. Which
of these foods does the nurse tell the client to consume as sources of folic acid? Select all that
apply.
a) Spinach
b) Legumes
c) Whole grains
d) Apples
e) Dairy products
Answer: a) Spinach
b) Legumes
c) Whole grains
42. A client with a history of angina pectoris tells the nurse that the chest pain usually occurs
with moderate to prolonged exertion and is generally relieved by nitroglycerin or rest. Which
type of angina does the nurse recognize in the client's description?
Answer: Stable
43. A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse
determines that the client is gaining a therapeutic effect from the medication after noting:
Answer: Improved swallowing function
44. A child is brought to the emergency department by ambulance after swallowing several
capsules of acetaminophen (Tylenol). Which medication does the nurse prepare, anticipating that
it will be prescribed to treat the child?
Answer: Acetylcysteine (Mucomyst)

45. A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work
and worried about how he will care financially for his wife and three small children. On the basis
of the client's concern, which problem does the nurse identify?
Answer: Anxiety
46. A male client arrives at the emergency department and reports to the nurse, "I woke up this
morning and couldn't move my arms." He also tells the nurse that he works in a factory and
witnessed an accident 3 weeks ago in which a fellow employee's hands were severed by a
machine. What is the priority response by the nurse?
Answer: Assessing the client for organic causes of loss of arm movement
47. After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a
feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which
immediate intervention does the nurse prepare the client?
Answer: Replacement of the uterus through the vagina into a normal position
48. A client arrives in the emergency department and tells the nurse that she is experiencing
tingling in both hands and is unable to move her fingers. The client states that she has been
unable to work because of the problem. During the psychosocial assessment, the client reports
that 2 days earlier her husband told her that he wanted a separation and that she would have to
support herself financially. The nurse concludes that this client is exhibiting signs compatible
with:
Answer: Conversion disorder
49. A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of
the surgery. The client later asks the nurse to explain again how the prostate is going to be
removed. The nurse tells the client that the prostate will be removed through:
Answer: A lower abdominal incision
50. A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How
does the nurse interpret this finding?

Answer: Uteroplacental insufficiency during a contraction
51. A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week
ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the
appropriate action on the part of the nurse
Answer: Place small pieces of tape over the rough edges of the cast
52. A nurse developing a plan of care for a client with HIV infection identifies several concerns.
List them in order of priority, from highest to lowest.
Answer: 1 Possible infection
2 Decreased nutrition
3 Fatigue
4 Despair
53. An emergency department nurse has a physician's prescription to irrigate a client's ears. List
in order of priority the steps that the nurse should take in performing this procedure.
Answer: 1 Use an otoscope to ensure that the tympanic membrane is intact.
2 Warm tap water to body temperature.
3 Fill an irrigating syringe with warm water.
4 Insert the irrigating solution by directing the solution toward the wall of the ear canal.
5 Document the completion of the procedure and how the client tolerated it.
54. The nurse is preparing to administer a tube feeding by way of a nasogastric tube. Which
action does the nurse carry out as a priority before starting the flow of the solution?
Answer: Checking for gastric residual volume and assessing tube placement
55. A client with schizophrenia says to the nurse, "I decided not to take my medication because it
can't help. I am the only one who can help me." Which nursing response is therapeutic in this
situation?
Answer: "Your doctor wants you to continue this medication because it's helping you. Do you
recall needing to be hospitalized because you stopped your medication?"

56. A client is brought to the emergency department by ambulance, and diabetic ketoacidosis is
suspected. Blood samples are taken, and the nurse obtains supplies that will be needed to treat
the client. Which type of insulin does the nurse take from the medication supply room for
intravenous (IV) administration?
Answer: Regular (Humulin R)
57. A nurse is assessing a client who is experiencing chest pain. Which of the following
observations indicates to the nurse that the pain is most likely a result of angina?
a) The pain is sharp and constant.
b) The pain is relieved by rest and nitroglycerin.
c) The pain radiates to the left arm and jaw.
d) The pain worsens with deep breathing.
Answer: b) The pain is relieved by rest and nitroglycerin.
58. While being seen by a physician, a client complains of persistent fever, malaise, and night
sweats. On physical examination, the physician palpates enlarged lymph nodes, and the client
states that the nodes are painless. Hodgkin's lymphoma is suspected, and several diagnostic
studies are performed. Which characteristic of this type of lymphoma does the nurse expect to
note while reviewing the results of the diagnostic studies?
Answer: Reed-Sternberg cells on biopsy of a lymph node
59. A client with chronic renal failure who will require dialysis three times a week for the rest of
his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't
really matter what I do if I'm never going to get better!" On the basis of the client's statement, the
nurse determines that the client is experiencing which problem?
Answer: Powerlessness
60. Tolbutamide (Orinase) is prescribed to a client whose type 2 diabetes mellitus has not been
controlled with diet and exercise alone. The nurse provides instructions to the client about the
medication. Which statement by the client indicates a need for further instruction?

Answer: "I can have a beer or glass of wine as long as I stay within my daily dietary
restrictions."
61. A client with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with
cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy.
What does the nurse instruct the client to do during chemotherapy? Select all that apply.
a) Drink copious amounts of fluid and void frequently
b) Avoid contact with any individual who has signs or symptoms of a cold
c) Eat a high-fat diet to maintain weight
d) Engage in strenuous exercise to boost energy levels
e) Keep all follow-up appointments for blood tests and evaluations
Answer: a) Drink copious amounts of fluid and void frequently
b) Avoid contact with any individual who has signs or symptoms of a cold
62. A nurse reviews arterial blood gas values and notes a pH of 7.50 and a PCO2 of 30 mm Hg.
The nurse interprets these values as indicative of:
Answer: Respiratory alkalosis
63. A school nurse observing a child with Down syndrome is participating in a physical
education class and notes that the child is experiencing a diminution in motor abilities. The nurse
asks to see the child and conducts an assessment, during which the child complains of neck pain
and loss of bladder control. What is the appropriate action by the nurse in this situation?
Answer: Contacting the child's physician to report the findings
64. A nurse is providing instruction about insulin therapy and its administration to an adolescent
client who has just been found to have diabetes mellitus. Which statement by the client indicates
a need for further instruction?
Answer: "I need to keep any unopened bottles of insulin in the freezer."

65. A nurse preparing to administer digoxin (Lanoxin) to a client calls the laboratory for the
result of the digoxin assay performed on a specimen that was drawn at 6 a.m. The laboratory
reports that the result was 2.4 ng/mL. On the basis of this result, the nurse would:
Answer: Contact the physician
66. A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which
concern does the nurse recognize as the priority?
Answer: Decreased fluid volume
67. A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The
nurse provides information to the client about dietary and insulin needs and tells the client that
during the first trimester, insulin needs generally:
Answer: Decrease
68. A maternity nurse providing an education session to a group of expectant mothers describes
the purpose of the placenta. Which statement by one of the women attending the session
indicates a need for further discussion of the purpose of the placenta?
Answer: "The placenta maintains the body temperature of my baby."
69. A nurse is measuring intraocular pressure by means of tonometry in a client who has just
been found to have open-angle glaucoma. Which tonometry reading would the nurse expect to
note in this client?
Answer: 28 mm Hg
70. Iodine solution (Lugol solution) is prescribed to a client who is scheduled for subtotal
thyroidectomy. The client calls the nurse at the clinic and complains of a burning sensation in the
mouth and soreness of the gums and teeth. The nurse most appropriately tells the client:
Answer: To contact the physician
71. A client with chronic back pain asks a nurse about the use of complementary and alternative
therapies to treat the pain. The nurse would initially:

Answer: Identify the client's treatment goals
72. A child with growth hormone deficiency will be receiving somatropin
(Humatrope). The nurse provides information to the mother about the medication. Which of the
following laboratory values does the nurse tell the mother will require monitoring?
a) Thyroid-stimulating hormone (TSH)
b) Serum glucose levels
c) Complete blood count (CBC)
d) Liver function tests
Answer: a) Thyroid-stimulating hormone (TSH)
73. A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous
reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the
client?
Answer: Epistaxis
74. A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the
first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele's rule, the
nurse determines that the estimated date of delivery (EDD) is:
Answer: July 2, 2013
75. A nurse provides instructions to a client who has been prescribed lithium carbonate
(Lithobid) for the treatment of bipolar disorder. Which of these statements by the client indicate a
need for further instruction? Select all that apply.
a) "I need to avoid salt in my diet."
b) "It's fine to take any over-the-counter medication with the lithium."
c) "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be
concerned."
d) "I should maintain a consistent sodium intake."
e) "I need to drink plenty of fluids, especially in hot weather."
Answer: a) "I need to avoid salt in my diet."

b) "It's fine to take any over-the-counter medication with the lithium."
c) "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be
concerned."
76. An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic
dehydration. What findings does the nurse expect to note during the admission assessment?
Select all that apply.
a) Skin tenting
b) Flat neck veins
c) Weak peripheral pulses
d) Increased urine output
e) Elevated blood pressure
Answer: a) Skin tenting
b) Flat neck veins
c) Weak peripheral pulses
77. Warfarin sodium (Coumadin) is prescribed for a hospitalized client. While transcribing the
physician's prescription, the nurse notes that the client is taking levothyroxine (Synthroid) to
treat hypothyroidism. The nurse calls the physician to confirm the prescription for warfarin
sodium because:
Answer: Levothyroxine amplifies the effect of warfarin sodium
78. A nurse caring for a client with preeclampsia prepares for the administration of an
intravenous infusion of magnesium sulfate. Which of the following substances does the nurse
ensure is available at the client's bedside?
a) Calcium gluconate
b) Potassium chloride
c) Sodium bicarbonate
d) Vitamin K
Answer: a) Calcium gluconate

79. A client with hypoparathyroidism is taking calcium gluconate to treat hypocalcemia. The
client calls the clinic nurse and complains of becoming constipated since starting the medication.
The nurse tells the client to:
Answer: Increase intake of high-fiber foods
80. The wife of a client with diabetes mellitus calls the nurse and reports that her husband's blood
glucose level is 60 mg/dL and that her husband is awake but groggy. The nurse tells the client's
wife to immediately:
Answer: Place some honey in her husband's mouth, between his gums and cheek
81. A nurse is reviewing the medical record of a client with a suspected systemic lupus
erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the
client's medical record? Select all that apply.
a) Fever
b) Vasculitis
c) Abdominal pain
d) Hyperglycemia
e) Hypertension
Answer: a) Fever
b) Vasculitis
c) Abdominal pain
82. A nurse is providing information to a client who will be self-administering regular insulin
about storage of the insulin. The nurse tells the client:
Answer: That the vial in current use may be kept at room temperature for as long as 1 month
without significant loss of activity
83. A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal
carcinoma of the breast notes documentation of the presence of peaud orange skin. On the basis
of this notation, which finding would the nurse expect to note on assessment of the client's
breast?

Answer: Pick the photo that has the nipple that resembles a sunburned orange peel. Peau orange
means orange peel in French.
84. Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse?
Answer: Multiple sexual partners
85. A client with tuberculosis will be taking pyrazinamide (Pyrazinamide), and the nurse
provides instructions about the adverse effects of the medication. For which of the following
occurrences does the nurse tell the client to contact the physician?
a) Mild headache
b) Yellow skin
c) Nausea
d) Increased appetite
Answer: b) Yellow skin
86. A nurse is preparing the room of a client in skeletal traction who will be admitted to the
nursing unit. Which item for use by the client does the nurse identify as the most important?
Answer: Trapeze bar
87. A client has been scheduled for an electronystagmography (ENG), and the nurse provides
instructions to the client about the test. Which statement by the client tells the nurse that the
client understands the instructions?
Answer: "I need to not drink coffee before the test."
88. A client calls the emergency department and tells the nurse that he may have come in contact
with poison ivy while trimming bushes in his yard. The nurse tells the client to immediately:
Answer: Get into the shower and rinse the skin for at least 15 minutes
89. A nurse checking the fundus of a postpartum woman notes that it is above the expected level,
at the umbilicus, and that it has shifted from the midline position to the right. The nurse's initial
action should be:

Answer: Helping the woman empty her bladder
90. A client is receiving an intravenous infusion of alteplase (tissue plasminogen activator,
recombinant; tPA). For which adverse effect of the medication does the nurse monitor the client
most closely?
Answer: Bleeding
91. A nurse is monitoring a client who has undergone subtotal thyroidectomy for signs of
postoperative complications. Which of the following findings would be a matter of concern for
the nurse as an indication of hypocalcemia?
a) The client complains of a tingling sensation around the mouth.
b) The client reports feeling fatigued.
c) The client has a slight sore throat.
d) The client exhibits a mild increase in heart rate.
Answer: a) The client complains of a tingling sensation around the mouth.
92. A nurse has provided information about exercise to a client with a diagnosis of degenerative
joint disease (osteoarthritis). Which of the following types of exercise does the nurse tell the
client to avoid?
a) Low-impact exercise
b) High-impact exercise
c) Flexibility exercises
d) Strength training
Answer: b) High-impact exercise
93. A nurse is performing an assessment of a client with Ménière disease. Which question does
the nurse ask to elicit data about the manifestations of this disease?
Answer: "Do you have episodes of dizziness?"

94. A client who has undergone knee-replacement surgery will be self-administering enoxaparin
sodium (Lovenox) at home. The nurse teaches the client about the medication and tells the client
to:
Answer: Lie down to administer the subcutaneous injection
95. A nurse assessing the wound of a client with a stage 3 pressure ulcer and notes that the
wound bed is pale. The nurse interprets this finding as a possible indication that:
Answer: The client's hemoglobin level is low
96. A nurse, performing an assessment of a client who has been admitted to the hospital with
suspected silicosis, is gathering both subjective and objective data. Which question by the nurse
would elicit data specific to the cause of this disorder?
Answer: "Have you ever worked in a mine?"
97. A nurse is preparing to care for a preschool-age child with sickle cell anemia who is
experiencing Vaso occlusive pain. Which method of assessing the degree of pain the child is
experiencing is most appropriate?
Answer: Asking the child to point to the face, on a spectrum ranging from smiling to very sad,
that best describes the pain
98. A home care nurse prefills syringes containing NPH (Humulin N) and regular (Humulin R)
insulin for a client with diabetes mellitus who will be administering his own insulin but has
difficulty seeing and accurately preparing doses. The nurse places the medication in the client's
refrigerator with the syringes:
Answer: In a vertical position with the needles pointing up
99. Ciprofloxacin hydrochloride (Cipro) is prescribed to a client with a urinary tract infection.
The nurse, providing instruction about the medication, tells the client that it is best to take the
medication:
Answer: 2 hours after meals

100. A nurse, providing information to a client who has just been found to have diabetes mellitus,
gives the client a list of symptoms of hypoglycemia. Which of the following answers by the
client, on being asked to list the symptoms, tells the nurse that the client understands the
information? Select all that apply.
a) Hunger
b) Weakness
c) Blurred vision
d) Increased thirst
e) Frequent urination
Answer: a) Hunger
b) Weakness
c) Blurred vision
101. A nurse developing a nursing care plan for a client with abruptio placentae includes initial
nursing measures to be implemented in the event of the development of shock. After contacting
the physician, which of the following does the nurse specify as the first action in the event of
shock?
a) Administering oxygen
b) Starting an IV infusion
c) Placing the client in a lateral position with the bed flat
d) Monitoring fetal heart rate
Answer: c) Placing the client in a lateral position with the bed flat
102. A nurse provides home care instructions to a client who has undergone fluorescein
angiography. The nurse determines that the client needs further instruction if the client states that
he must:
Answer: Contact the physician if the skin appears yellow
103. A mother calls the emergency department and tells the nurse that her 3-year-old child drank
ammonia from a bottle while the mother was cleaning house. The nurse tells the mother to
immediately:

Answer: Encourage the child to drink water or milk in small amounts
104. A nurse taking the vital signs of a client immediately after she has delivered a newborn
notes that the client's heart rate is 110 beats/min. The nurse would first:
Answer: Check the uterus and amount of lochia discharge
105. A nurse is caring for a client who sustained a missed abortion during the second trimester of
pregnancy. For which finding indicating the need for further evaluation does the nurse monitor
the client?
Answer: Spontaneous bruising
106. A nurse is performing an assessment of a client with suspected pheochromocytoma. Which
clinical manifestation does the nurse expect to note?
Answer: A blood pressure higher than the normal range
107. A client with acute gouty arthritis is being started on medication therapy with indomethacin
(Indocin). The nurse, providing medication instructions, and tells the client to take the
medication:
Answer: With food
108. A nurse is assessing a client who has been taking amantadine hydrochloride (Symmetrel) for
the treatment of Parkinson's disease. Which finding from the history and physical examination
would cause the nurse to determine that the client may be experiencing an adverse effect of the
medication?
Answer: Bilateral lung wheezes
109. A community health nurse is preparing a poster for a health fair that will include
information about the ways to prevent ear infection or ear trauma. Which prevention measures
does the nurse include on the poster? Select all that apply.
a) Keep the volume of headphones at the lowest setting.
b) Avoid environmental conditions involving rapid changes in air pressure.

c) Clean the external ear and canal daily in the shower or while washing the hair.
d) Use cotton swabs to clean inside the ear canal.
e) Ensure regular check-ups with an audiologist.
Answer: a) Keep the volume of headphones at the lowest setting.
b) Avoid environmental conditions involving rapid changes in air pressure.
c) Clean the external ear and canal daily in the shower or while washing the hair.
110. The blood serum level of imipramine is determined in a client who is being treated for
depression with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the
basis of this result, the nurse should:
Answer: Document the laboratory result in the client's record
111. A nurse is monitoring a pregnant client with suspected partial placenta previa who is
experiencing vaginal bleeding. Which of the following findings would the nurse expect to note
on assessment of the client?
a) Rigid, board-like abdomen
b) Severe abdominal pain
c) Soft, relaxed, nontender uterus
d) Decreased fetal heart rate
Answer: c) Soft, relaxed, nontender uterus
112. A client with suspected HIV infection has positive results on enzyme-linked immunosorbent
assay (ELISA) and Western blot tests. The plasma HIV RNA level is assessed, and the result is
reported as 8000 copies/mL. The nurse interprets the results of the HIV RNA test as indicating
that the client:
Answer: Is at low risk for AIDS
113. A nurse provides dietary instruction to a hospitalized client with chronic obstructive
pulmonary disease (COPD). Which of the following menu selections by the client tells the nurse
that the client understands the instructions?
a) Spaghetti with marinara sauce

b) Cheeseburger
c) Fried chicken
d) Salad with vinaigrette dressing
Answer: b) Cheeseburger
114. A nurse is preparing medication instructions for a client who will be taking a daily oral dose
of digoxin (Lanoxin) 0.25 mg in the treatment of congestive heart failure (CHF). Which
instructions should the nurse include on the list? Select all that apply.
a) Take your pulse before taking each dose.
b) Take the digoxin at the same time each day.
c) Notify the physician if you experience loss of appetite, muscle weakness, or visual
disturbances.
d) Increase your potassium intake to prevent side effects.
e) Skip a dose if you forget and take two doses the next day.
Answer: a) Take your pulse before taking each dose.
b) Take the digoxin at the same time each day.
c) Notify the physician if you experience loss of appetite, muscle weakness, or visual
disturbances.
115. An emergency department nurse is caring for a client in hypovolemic shock, a result of
external hemorrhage caused by a gunshot wound. Which nursing interventions should the nurse
take? Select all that apply.
a) Ensuring that direct pressure is applied to the external hemorrhage site
b) Ensuring a patent airway and supplying oxygen to the client as prescribed
c) Inserting an intravenous (IV) catheter and administering fluids as prescribed
Answer: a) Ensuring that direct pressure is applied to the external hemorrhage site
b) Ensuring a patent airway and supplying oxygen to the client as prescribed
c) Inserting an intravenous (IV) catheter and administering fluids as prescribed
116. A client is brought to the emergency department after sustaining smoke inhalation.
Humidified oxygen is administered to the client by way of face mask, and arterial blood gases

(ABGs) are measured. ABG analysis indicates arterial oxygenation (PaO2) of less than 60 mm
Hg. On the basis of the ABG result, the nurse prepares to:
Answer: Assist in intubating the client and beginning mechanical ventilation
117. Fluticasone propionate (Advair) and albuterol (Ventolin HFA), administered by inhalation
twice daily, are prescribed for a client with asthma. The nurse, providing information to the client
about administration of the medication, tells the client to use the:
Answer: Albuterol several minutes before inhaling the fluticasone propionate
118. A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a
sinus infection, asks the client about medications that he is taking. The client tells the nurse that
he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse
determines that the client most likely has a history of:
Answer: Depression
119. A female client admitted to the mental health unit tells the nurse that she cannot leave the
house without checking to be sure that she has shut off the coffee maker and unplugged her
curling iron. The client states that she even leaves the house, gets into her car, and then has to go
back into the house to check these appliances again and that these behaviors are interfering with
her work and social commitments. With which of the following anxiety disorders does the nurse
associate this client's symptoms?
a) Generalized anxiety disorder
b) Panic disorder
c) Post-traumatic stress disorder
d) Obsessive-compulsive disorder
Answer: d) Obsessive-compulsive disorder
120. A client who is taking lithium carbonate (Lithobid) complains of mild nausea, voiding in
large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild
thirst. On the basis of these findings, the nurse should:
Answer: Document the findings

121. A nurse is teaching a client with angina pectoris who is being discharged from the hospital
about managing chest pain at home. Which statement by the client indicates a need for further
teaching?
Answer: "If I get chest pain, I should put 3 nitroglycerin tablets under my tongue and then go to
the emergency department if that doesn't work."
122. Although previously well controlled with glyburide (Diabeta), a client's fasting blood
glucose has been running 180 to 200 mg/dL. On reviewing the client's record, which medication,
recently added to the client's regimen, does the nurse recognize as a possible contributor to the
hyperglycemia?
Answer: Lithium carbonate (Lithobid)
123. Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides
information to the client about the medication. Which statement by the client indicates to the
nurse that the client understands the information?
Answer: "I need to stop the medication and call my doctor if I have severe diarrhea."
124. A postoperative client with deep-vein thrombosis is at risk for pulmonary embolism. For
which characteristic sign or symptom of this complication does the nurse monitor the client?
Answer: Pleuritic chest pain
125. A nurse provides dietary instructions to a client with osteoporosis who has sustained a
fracture about foods that will promote healing. The nurse tells the client that it is best to consume
foods that are high in:
Answer: Vitamin C
126. Methylergonovine (Methergine) is prescribed for a client to control postpartum bleeding.
Which action does the nurse take before administering the medication?
Answer: Checking the client's blood pressure

127. A nurse is providing instruction in how to perform Kegel exercises to a client with stress
incontinence. The nurse tells the client to:
Answer: Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10
128. A nurse is providing information to a client with diabetes insipidus who will be taking
desmopressin acetate (DDAVP) by way of the nasal route. For which of the following
occurrences does the nurse tell the client to contact the physician?
a) Increased thirst
b) Headache and nausea
c) Mild nasal congestion
d) Slight dizziness
Answer: b) Headache and nausea
129. A nurse is assigned to conduct an admission assessment of a client with a diagnosis of
bipolar disorder. What does the nurse plan to do first?
Answer: Establish a trusting nurse-client relationship
130. A client has a physician's appointment to get a prescription for sildenafil (Viagra). The nurse
obtains the health history from the client. Which finding indicates that the medication is
contraindicated?
Answer: The client takes isosorbide dinitrate (Isordil).
131. The nurse notes the presence of drainage on the mustache dressing of a client who has
undergone transsphenoidal hypophysectomy. The initial nursing action is to:
Answer: Check the drainage for glucose
132. Calcium disodium edetate (EDTA) and British antilewisite (BAL, dimercaprol) is
prescribed for a child with lead poisoning. What does the nurse ask the child's mother before
administering the medications?
Answer: "Does your child have an allergy to peanuts?"

133. A nurse provides instructions to a client who is preparing for discharge after a radical
vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further
instruction?
Answer: "I need to contact my surgeon immediately if I feel any numbness in my genital area."
134. A nurse develops a list of home care instructions for a client who is wearing a halo fixation
device after sustaining a cervical fracture. Which instructions should the nurse include? Select all
that apply.
a) Use a straw to drink.
b) Use caution when leaning forward or backward.
c) Do not drive, because full range of vision is impaired with the device.
Answer: a) Use a straw to drink.
b) Use caution when leaning forward or backward.
c) Do not drive, because full range of vision is impaired with the device.
135. A nurse in a physician's office is conducting a 2-week postpartum assessment of a client.
During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding
would prompt the nurse to:
Answer: Document the findings
136. Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for
the treatment of a psychotic disorder. Which finding in the client's medical record would prompt
the nurse to contact the prescribing physician before administering the medication?
Answer: The client takes a prescribed antihypertensive.
137. A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor
tracing (see figure). Which of the following actions should the nurse take as a result of this
observation?
a) Increase intravenous fluid rate
b) Notify the physician immediately
c) Documenting the finding

d) Change the maternal position
Answer: c) Documenting the finding
138. Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to
take the medication with:
Answer: Tomato juice
139. A nurse is caring for a client undergoing skeletal traction of the left leg. The client
complains of severe pain in the leg. The nurse checks the client's alignment in bed and notes that
proper alignment is being maintained. Which of the following actions should the nurse take
next?
a) Applying heat to the affected leg
b) Notifying the physician
c) Administering pain medication
d) Reassessing the client's vital signs
Answer: b) Notifying the physician
140. A nurse is preparing to insert a nasogastric tube into a client. In which position does the
nurse place the client before inserting the tube?
Answer: Fowler's position
141. A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a
client with diabetes mellitus. The nurse tells the client that this blood test:
Answer: Helps predict the risk for the development of chronic complications of diabetes
mellitus
142. Levothyroxine (Synthroid) is prescribed to a client with hypothyroidism. One week after
beginning the medication, the client calls the physician's office and tells the nurse that the
medication has not helped. The nurse most appropriately tells the client that:
Answer: The full therapeutic effect may take 4 weeks

143. Calcium carbonate (Os-Cal 500) is prescribed for a client with mild hypocalcemia. What
food does the nurse instruct the client to avoid consuming while taking this medication?
Answer: Spinach
144. A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to relieve
joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is
causing nausea and indigestion. The nurse should tell the client to:
Answer: Take the medication with food
145. A nurse is monitoring a client with bronchogenic carcinoma for signs of superior vena cava
syndrome. For which early sign of this oncological emergency does the nurse assess the client?
Answer: Stokes sign
146. A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing
chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse
effect of the chemotherapy?
Answer: White blood cell count of 2500 cells/mm3
147. A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which
items of the following information elicited during the assessment indicate that the condition has
not yet resolved? Type the option number that is the correct answer.
1) Elevated blood pressure
2) Decreased urine output
3) Absence of headache
4) Decreased reflexes
Answer: 1
148. Captopril (Capoten) is prescribed for a hospitalized client with heart failure. Which action is
a priority once the nurse has administered the first dose?
Answer: Maintaining the client on bed rest for 3 hours

149. A nurse is planning to teach a crutch gait to a client who will be using wooden axillary
crutches. The nurse reviews the physician's instructions, understanding that the gait was selected
after assessment of the client's:
Answer: Physical and functional abilities
150. A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses
how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to
permit assessment of whether the infant is receiving an adequate amount of milk?
Answer: Count wet diapers to be sure that the infant is having at least six to 10 each day
151. A female client with rheumatoid arthritis is taking 3.6 g of acetylsalicylic acid (aspirin)
daily in a divided dose. At the physician's office, the client tells the nurse that she has been
experiencing ringing in the ears over the past few days. The nurse tells the client that:
Answer: The physician will probably withhold the aspirin until the symptoms have subsided,
then resume the aspirin at a lower dosage
152. The physician will probably withhold the aspirin until the symptoms have subsided, then
resume the aspirin at a lower dosage
Answer: Notifies the emergency department physician
153. A nurse reviews the medical record of a client with histoplasmosis. Which clinical
manifestation of this infection does the nurse expect to see documented?
Answer: Flulike pulmonary symptoms
154. A client who is scheduled to undergo chemotherapy asks the nurse, "Is my hair going to fall
out?" The nurse responds by telling the client that:
Answer: Her hair may fall out but will regrow after the chemotherapy is discontinued
155. A client who was involved in a high-speed motor vehicle crash is brought to the emergency
department. Which of the following findings indicates to the nurse that the client has sustained
flail chest?

a) Shallow breathing
b) Asymmetrical chest movement
c) Decreased breath sounds
d) Cyanosis of the lips
Answer: b) Asymmetrical chest movement
156. A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory
disease. What does the nurse ask the client during assessment for adverse effects of the
medication?
Answer: "Are you having any difficulty hearing?"
157. A client with advanced chronic renal failure (CRF) and oliguria has been taught about
sodium and potassium restriction between dialysis treatments. The nurse determines that the
client understands this restriction if the client states that it is acceptable to use:
Answer: Herbs and spices
158. A postpartum nurse provides information to a client who has delivered a healthy newborn
about normal and abnormal characteristics of lochia. Which of the following findings does the
nurse tells the client to report to the physician?
a) Reddish lochia on postpartum day 8
b) Foul-smelling lochia
c) Pinkish lochia during the first few days
d) Small clots in lochia
Answer: a) Reddish lochia on postpartum day 8
159. The nurse is performing a sterile change of an abdominal dressing. Once the dressing has
been removed and discarded in a waterproof bag, which action should the nurse take next?
Answer: Assessing the wound
160. NPO status is imposed 8 hours before the procedure on a client scheduled to undergo
electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the

client's record and notes that the client routinely takes an oral antihypertensive medication each
morning. The nurse should:
Answer: Administer the antihypertensive with a small sip of water
161. A nurse has provided nutrition instructions to a mother of an infant. Which statement by the
mother indicates to the nurse that the mother requires further instruction?
Answer: "It's best to use cow's milk, as long as it's whole milk and not skim."
162. Oral candidiasis (thrush) develops in a client infected with HIV, and the nurse provides
instruction to the client about measures to relieve the discomfort. Which statement by the client
indicates a need for further instruction?
Answer: "I should put ice in my drinks to help soothe the discomfort."
163. As a nurse prepares to administer medications to an assigned client, the client asks, "Why
don't you just leave me alone?" What is the best response by the nurse?
Answer: "I can see that you're upset. Would you like to talk about it?"
164. A nurse is caring for a client who sustained burn injuries on the anterior lower legs and
anterior thorax. What percentage of the client's body, according to the Rule of Nines, has been
affected?
Answer: 36%
165. A nurse in a physician's office is talking to a client who underwent mastectomy of the right
breast 2 weeks ago. The client says to the nurse, "I hate looking at this incision. I feel that I'm not
even myself anymore." The nurse interprets this statement to mean that the client is experiencing
which problem?
Answer: Distorted body image
166. A nurse provides instructions to a client who will be taking levothyroxine (Synthroid) for
hypothyroidism. The nurse tells the client that it is best to take the medication:
Answer: In the morning, before breakfast

167. Cyclobenzaprine (Flexeril) is prescribed to a client with multiple sclerosis for the treatment
of muscle spasms. For which common side effect of this medication does the nurse monitor the
client?
Answer: Drowsiness
168. A nurse admitting a newborn to the nursery notes that the physician has documented that the
newborn has a gastroschisis. The nurse performs an assessment, expecting to note that the
viscera are:
Answer: Outside the abdominal cavity, not covered with a sac
169. The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her child is a
member of the school soccer team and expresses concern about her child's participation in sports.
The nurse, after providing information to the mother about diet, exercise, insulin, and blood
glucose control, tells the mother:
Answer: That the child should eat a carbohydrate snack about a half-hour before each soccer
game
170. A child with a diagnosis of Wilms' tumor is being admitted to the pediatric unit. The nurse
prepares the room for the child and places a sign at the child's bedside that tells staff to avoid:
Answer: Palpating the abdomen
171. A nurse is performing an assessment of a newborn with a diagnosis of esophageal atresia
(EA) and tracheoesophageal fistula (TEF). Which findings does the nurse expect to note in the
infant? Select all that apply.
a) Drooling
b) Excessive oral secretions
c) Choking during feeding
d) Abdominal distention
e) Cyanosis during feeding
Answer: a) Drooling

b) Excessive oral secretions
172. A nurse provides information to a client with peripheral vascular disease about ways to limit
the disease's progression. Which of the following measures does the nurse tell the client to take?
Select all that apply.
a) Engaging in exercise such as walking on a daily basis
b) Washing the feet daily with a mild soap and drying them well
c) Avoiding smoking
d) Keeping the legs elevated when sitting
e) Wearing tight-fitting shoes
Answer: a) Engaging in exercise such as walking on a daily basis
b) Washing the feet daily with a mild soap and drying them well
173. A hospitalized client scheduled for surgery is told by the physician that she is extremely
anemic and will need a blood transfusion. The client, a Jehovah's Witness, tells the nurse that she
is refusing the transfusion. What is the most appropriate initial nursing action?
Answer: Supporting the client's decision to refuse the transfusion
174. A client experiencing delusions says to the nurse, "I am the only one who can save the
world from all of the terrorists." What is the appropriate response by the nurse?
Answer: "I don't think anyone can save the world from the terrorists by himself."
175. An intravenous dose of adenosine (Adenocard) is prescribed for a client to treat WolffParkinson-White syndrome. Which piece of equipment does the nurse make a priority of
obtaining before administering the medication?
Answer: Cardiac monitor
176. A nurse working the evening shift is helping clients get ready for sleep. A female client with
mania is hyperactive and pacing the hallway. The appropriate nursing action is to:
Answer: Take the client to the bathroom and provide her with a warm bath

177. A client living in a long-term care facility shouts at the nurse, "Get out of my room! I don't
need your help!" What is the appropriate way for the nurse to document this occurrence in the
client's record?
Answer: Writing down the client's words and placing them in quotation marks
178. An emergency department (ED) nurse is monitoring a client with suspected acute
myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The
nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor,
checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The
appropriate action by the nurse is:
Answer: Asking the ED physician to check the client
179. A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse
explains to the client that amniocentesis is often performed during the third trimester to
determine:
Answer: The degree of fetal lung maturity
180. Empyema develops in a client with an infected pleural effusion, and the nurse prepares the
client for thoracentesis. What characteristics of the fluid removed during thoracentesis should the
nurse, assisting the physician with the procedure, expect to note?
Answer: Thick and opaque
181. A client with depression is anorexic. Which measure does the nurse take to assist the client
in meeting nutritional needs?
Answer: Offering high-calorie and high-protein foods and fluids frequently throughout the day
182. Oral prednisone 10 mg/day is prescribed for a client with an acute exacerbation of
rheumatoid arthritis. The nurse, providing information to the client about the medication, tells the
client that it is best to take it:
Answer: In the morning, before 9:00 a.m.

183. A client who recently underwent coronary artery bypass graft surgery comes to the
physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling
depressed. Which response by the nurse is therapeutic?
Answer: "Tell me more about what you're feeling."
184. A nurse in the cardiac care unit is told that a client with a diagnosis of myocardial infarction
will be admitted from the emergency department. Which item does the nurse give priority to
placing at the client's bedside?
Answer: Oxygen cannula and flowmeter
185. A client being seen in the clinic complains of fatigue and weakness. Laboratory studies are
performed because the physician suspects iron-deficiency anemia. Which finding indicative of
this type of anemia does the nurse expect to find on reviewing the laboratory results?
Answer: Microcytic red blood cells (RBCs)
186. A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells
the client that:
Answer: Urine output must be measured and that the physician should be notified if output is
less than 500 mL in a 24-hour period
187. A nurse reviews the results of a total serum calcium determination in a client with renal
failure. The results indicate a level of 12.0 mg/dL. In light of this result, which finding does the
nurse expect to note during assessment?
Answer: Bounding, full peripheral pulses
188. A client on the mental health unit says to the nurse, "Everything is contaminated." The client
scrubs her hands if she is forced to touch any object.
While planning care, the nurse remembers that compulsive behavior:
Answer: Temporarily eases anxiety in the client

189. A client says to the nurse, "My doctor just left. He told me that my abdominal scan showed
a mass in my pancreas and that it's probably cancer. Does this mean I'm going to die?" The nurse
interprets the client's initial reaction as:
Answer: Fear
190. A client has been given a prescription for lovastatin (Mevacor). Which of the following
foods does the nurse instruct the client to limit consumption of while taking this medication?
a) Chicken
b) Whole grains
c) Steak
d) Salmon
Answer: c) Steak
191. A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+
(i.e., reflex present, hypoactive). On the basis of this finding, the nurse would:
Answer: Document the findings
192. A physician prescribes a dose of morphine sulfate 2.5 mg stat to be administered
intravenously to a client in pain. The nurse preparing the medication notes that the label on the
vial of morphine sulfate solution for injection reads "4 mg/mL." How many milliliters (mL) must
the nurse draw into a syringe for administration to the client? Type the answer in the space
provided.
Answer: 0.625mL
193. Vasopressin (Pitressin) is prescribed to a client with diabetes insipidus. For which sign,
indicative of an adverse effect of the medication, does the nurse monitor the client?
Answer: Chest pain
194. A nurse is preparing to provide information to a client who has been found to have stable
angina. The nurse plans to tell the client that this type of angina:

Answer: Is often managed medically with medications such as calcium channel blockers and
beta-blocking medications
195. A nurse is monitoring a child with intussusception for signs of peritonitis. For which of the
following findings, indicative of this complication, does the nurse notify the physician?
a) Increased heart rate
b) Decreased appetite
c) Mild abdominal tenderness
d) Intermittent vomiting
Answer: a) Increased heart rate
196. A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of
hypovolemic shock does the nurse closely monitor the client?
Select all that apply.
a) Tachycardia
b) Diminished peripheral pulses
c) Decreased blood pressure
d) Cool, clammy skin
e) Restlessness
Answer: a) Tachycardia
b) Diminished peripheral pulses
197. A nurse is caring for a client who has had a cast applied to the left leg and is at risk for acute
compartment syndrome. For which early sign of this complication does the nurse monitor the
client?
Answer: Paresthesia
198. An adult client with renal failure who is oliguric and undergoing hemodialysis is under a
fluid restriction of 700 mL/day. How many milliliters of fluid does the nurse allow the client to
have between 7 a.m. and 3 p.m.? Type your answer in the space provided.
Answer: 350 mL

199. A physician writes a prescription for 1000 mL of 0.9% normal saline solution to be
administered intravenously (IV) to a client over 10 hours. The drop factor for the infusion set is
15 gtt/mL. At what drip rate does the nurse set the infusion?
Answer: 25 gtt/min
200. A nurse is reviewing the medical record of an infant in whom hypertrophic pyloric stenosis
(HPS) is suspected. Which characteristics associated with the disorder does the nurse expects see
documented in the infant's medical record? Select all that apply.
a) Weight loss
b) Projectile vomiting
c) Distended upper abdomen
d) Frequent diarrhea
e) Excessive hunger
Answer: a) Weight loss
b) Projectile vomiting
c) Distended upper abdomen
201. A nurse in a physician's office is reviewing the medical record of a child with a diagnosis of
lactose intolerance. Which of the following findings does the nurse expect to see documented in
the child's record?
a) Episodes of cramping abdominal pain and excessive flatus
b) Frequent diarrhea without abdominal pain
c) Unexplained weight gain and lethargy
d) Persistent constipation and rectal bleeding
Answer: a) Episodes of cramping abdominal pain and excessive flatus
202. A client is found to have posttraumatic stress disorder (PTSD) after witnessing a terrorist
attack that caused the deaths of hundreds of people. The nurse, developing a plan of care for the
client, identifies post trauma syndrome as a concern and identifies a client outcome that states,

"The client will cope effectively with thoughts and feelings of the event." Which nursing
interventions will assist the client in achieving this outcome? Select all that apply.
a) Being honest, nonjudgmental, and empathetic
b) Assessing the immediate posttraumatic reaction
c) Encouraging the client to keep a journal focused on the trauma
d) Asking the client about the use of alcohol and drugs before and since the event
e) Teaching relaxation techniques
Answer: a) Being honest, nonjudgmental, and empathetic
b) Assessing the immediate posttraumatic reaction
c) Encouraging the client to keep a journal focused on the trauma
d) Asking the client about the use of alcohol and drugs before and since the event
203. A client who has been undergoing long-term therapy with an antipsychotic medication is
admitted to the inpatient mental health unit. Which of the following findings does the nurse,
knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor
in the client?
a) Tongue protrusion
b) Shuffling gait
c) Drowsiness
d) Hand tremors
Answer: a) Tongue protrusion
204. Chlorpromazine (Thorazine) has been prescribed to a client with Huntington's disease for
the relief of choreiform movements. Of which common side effect does the nurse warn the
client?
Answer: Drowsiness
205. A nurse assigns a nursing assistant to care for a client who is hearing impaired and provides
instructions to the nursing assistant about the effective methods for communicating with the
client. Which statement by the nursing assistant indicates that further instruction is needed?

Answer: "I should raise the volume of my voice and stand on the client's affected side when I'm
talking to him."
206. A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the
treatment of endometrial cancer. The nurse determines that the priority in the 24 hours after
surgery is:
Answer: Encouraging the client to deep-breathe, cough, and use an incentive spirometer
207. A client is found to have iron-deficiency anemia, and ferrous sulfate (Feosol) is prescribed.
The nurse tells the client that it is best to take the medication with:
Answer: Orange juice
208. A nurse is developing a plan of care for a client admitted to the nursing unit with a diagnosis
of paranoid personality disorder. On which characteristic of the disorder does the nurse base the
plan of care?
Answer: Projecting blame, possibly becoming hostile
209. A nurse has given a client with viral hepatitis instructions about home care. Which of the
following statements by the client indicates to the nurse that the client needs further teaching?
a) "I need to eat three meals a day with foods high in protein, fat, and carbs."
b) "I should rest as much as possible."
c) "I need to avoid alcohol and certain medications."
d) "I should stay hydrated by drinking plenty of fluids."
Answer: a) "I need to eat three meals a day with foods high in protein, fat, and carbs."
210. Oral prednisone 5 mg/day has been prescribed for a client with a chronic respiratory
disorder, and the nurse provides instructions to the client about the medication. The nurse tells
the client to:
Answer: Call the physician if a fever, sore throat, or muscle aches develop
211. The nurse, auscultating the breath sounds of a client, hears these sounds. What are they?

Answer: Wheezes
212. Laboratory studies are performed on a client with suspected sickle cell disease, and
electrophoresis reveals a large percentage of hemoglobin S (HbS). Which additional laboratory
finding will the nurse expect to note that is a characteristic of this disease?
Answer: Increased white blood cell (WBC) count
213. A client is found to have hypoxemic respiratory failure. Which finding does the nurse
expect to note on review of the results of the client's arterial blood gas analysis?
Answer: PaO2 of 49 mm Hg, PacO2 of 32 mm Hg
214. A nurse is monitoring a client who was brought to the emergency department in an
unresponsive state and is now being treated for hyperglycemic hyperosmolar nonketotic
syndrome (HHNS). Which of the following findings indicates to the nurse that fluid replacement
is inadequate?
a) Level of consciousness remains unchanged
b) Urine output increases
c) Blood glucose levels decrease
d) Heart rate stabilizes
Answer: a) Level of consciousness remains unchanged
215. A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate
(Parnate). Which of the following foods does the nurse tell the client to avoid while she is taking
this medication? Select all that apply.
a) Beer
b) Yogurt
c) Pickled herring
Answer: a) Beer
b) Yogurt
c) Pickled herring

216. An emergency department nurse assessing a client with Bell's palsy collects subjective and
objective data. Which of the following findings does the nurse expect to note?
a. Complaints of inability to close the eye on the affected side
b. Unilateral facial drooping that improves with smiling
c. Increased tear production on the affected side
d. Tingling sensation around the mouth
Answer: a. Complaints of inability to close the eye on the affected side
217. A nurse provides information to a client with chronic obstructive pulmonary disease
(COPD) about methods of alleviating shortness of breath while the client is eating. Which
statement by the client indicates a need for further instruction?
Answer: "I should eat three meals a day, and the biggest meal should be at suppertime."
218. A nurse is providing morning care to a client in end-stage renal failure. The client is
reluctant to talk and shows little interest in participating in hygiene care. Which statement by the
nurse would be therapeutic?
Answer: "What are your feelings right now?"
219. A nurse provides information about activity and exercise to the wife of a client with
Parkinson's disease. Which statement by the spouse indicates a need for further instruction?
Answer: "I should encourage him to keep his hands hanging at his side when he walks."
220. A nurse is providing home care instructions to a client with coronary artery disease (CAD)
who will be discharged home and will be taking 1 aspirin daily. The nurse tells the client:
Answer: The answer for this question should be something relating to toxicity that may present
itself as tinnitus, ie., ringing in the ears.
221. A client who has undergone extensive gastrointestinal surgery is receiving intermittent
enteral tube feedings that will be continued after he is discharged home. When the nurse tells the
client that he will be taught how to administer the feedings, the client states, "I don't think I'll be
able to do these feedings by myself." Which response by the nurse is appropriate?

Answer: "Tell me more about your concerns regarding the tube feedings."
222. A nurse is providing information to a client with acute gout about home care. Which of the
following measures does the nurse tell the client to take? Select all that apply.
a. Drinking 2 to 3 L of fluid each day
b. Resting and immobilizing the affected area
c. Avoiding foods high in purines, such as red meat and shellfish
d. Taking nonsteroidal anti-inflammatory drugs (NSAIDs) as prescribed
Answer: a. Drinking 2 to 3 L of fluid each day
b. Resting and immobilizing the affected area
223. A nurse is caring for a client who has had a stroke and is experiencing hemianopsia. Which
of the following measures does the nurse take in the care of the client?
a. Teaching the client to move the head from side to side (scan) when eating
b. Positioning the client with the affected side toward the wall
c. Providing a bright light on the affected side during meals
d. Encouraging the client to close the unaffected eye while eating
Answer: a. Teaching the client to move the head from side to side (scan) when eating
224. A client undergoing therapy with carbidopa/levodopa (Sinemet) calls the nurse at the clinic
and reports that his urine has become darker since he started taking the medication. The nurse
should tell the client:
Answer: That this is an occasional side effect of the medication
225. A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of
sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory
finding would indicate to the nurse that DIC has developed in the client?
Answer: Positive result on d-dimer study
226. The nurse is the first responder at the scene of a bus crash. After a quick assessment of the
victims, which one does the nurse care for first?

Answer: A victim with an open fracture of the arm that is bleeding profusely
227. A client with depression is being encouraged to attend art therapy as part of the treatment
plan. The client refuses, stating, "I can't draw or paint." Which of the following responses by the
nurse is therapeutic?
a. "Art therapy is not about being a good artist; it’s about expressing yourself."
b. "You should give it a try; you might be surprised at what you can do."
c. "Many people feel that way at first, but it gets easier with practice."
d. "It's important to try new things to improve your mood."
Answer: a. "Art therapy is not about being a good artist; it’s about expressing yourself."
228. Propylthiouracil (PTU) has been prescribed for a client with Graves disease, and the nurse
provides instructions to the client about the medication. For which of the following occurrences
does the nurse tells the client to contact the physician?
a. Sore throat
b. Mild nausea
c. Increased appetite
d. Dizziness
Answer: a. Sore throat
229. A pediatric nurse is caring for a hospitalized toddler. Which of the following activities does
the nurse deem the most appropriate for the toddler?
a. Large building blocks
b. Puzzle games with small pieces
c. Board games with complex rules
d. Reading a book with detailed illustrations
Answer: a. Large building blocks
230. A registered nurse is planning client assignments for the day. There is a licensed practical
nurse and a nursing assistant on the team. Which client is the appropriate choice for the nursing
assistant?

Answer: A client with rheumatoid arthritis who needs assistance with feeding and ambulation
231. Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which
interventions does the nurse implement? Select all that apply.
a. Keeping the room slightly darkened
b. Monitoring the client for changes in alertness or mental status
c. Restricting visits to close family members and significant others and keeping visits short
d. Encouraging the client to engage in physical activity as tolerated
e. Providing education about the importance of medication adherence
Answer: a. Keeping the room slightly darkened
b. Monitoring the client for changes in alertness or mental status
c. Restricting visits to close family members and significant others and keeping visits short
232. A nurse is monitoring a client receiving terbutaline (Brethine) by intravenous infusion to
stop preterm labor. The nurse notes that the client's heart rate is 120 beats/min and that the fetal
heart rate is 170 beats/min. The appropriate action by the nurse is:
Answer: Contacting the physician
233. Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a
client for the management of anxiety. The nurse prepares the medication as prescribed and
administers the medication over a period of:
Answer: 3 minutes
234. A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled
for a mastectomy. Which of the following findings would cause the nurse to conclude that the
client is at risk for poor sexual adjustment after the mastectomy?
a. The client reports a history of sexual abuse by her father
b. The client expresses concern about the appearance of her body after surgery
c. The client has a supportive partner who is aware of the surgery
d. The client is actively participating in support groups for breast cancer
Answer: a. The client reports a history of sexual abuse by her father

235. A child who has just been found to have scoliosis will need to wear a thoracolumbosacral
orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which
statement by the mother indicates a need for further information?
Answer: "Wearing the brace is really important in curing the scoliosis."
236. A nurse is monitoring a client with pheochromocytoma who is receiving an intravenous (IV)
infusion of phentolamine. Which vital sign does the nurse monitor most closely during the
infusion?
Answer: Blood pressure
237. A nurse is preparing to care for a client who was admitted to the antepartum unit at 34
weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In
report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140
beats/min with a reassuring pattern, and that both the client and her husband are anxious about
the condition of the fetus. On reviewing the client's plan of care, which client concern does the
nurse identify as the priority at this time?
Answer: Anxiety
238. A client is admitted to the nursing unit with a diagnosis of avoidant personality disorder.
Which of the following behaviors is a characteristic of the disorder?
a. Hypersensitivity to negative evaluation
b. Excessive attention-seeking behavior
c. A pattern of grandiosity and need for admiration
d. Lack of remorse for harmful actions
Answer: a. Hypersensitivity to negative evaluation
239. Disulfiram (Antabuse) is prescribed to a client with an alcohol abuse problem.
The nurse provides information about the medication and tells the client:
Answer: That the medication cannot be started until at least 12 hours has elapsed since the
client's last ingestion of alcohol

240. A nurse is reviewing the laboratory results of a client in the emergency department with
diabetic ketoacidosis (DKA). Which laboratory result would the nurse expect to note?
Answer: Serum bicarbonate of 12 mEq/L
241. A client with multiple sclerosis has been started on baclofen (Lioresal) for muscle spasms.
The client calls the physician's office 1 week after beginning the medication and tells the nurse
that she feels extremely drowsy. The nurse most appropriately tells the client:
Answer: That drowsiness usually diminishes with continued therapy
242. A nurse transcribing the prescriptions of a client admitted to the nursing unit notes that
metformin (Glucophage) 850 mg/day has been prescribed. The nurse makes a note in the client's
medication record that the medication should be administered:
Answer: With the morning meal
243. The mother of a newborn found to have a congenital diaphragmatic hernia asks the nurse to
explain the diagnosis. The nurse tells the mother that in this condition:
Answer: Abdominal contents herniate through an opening of the diaphragm
244. A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12
hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the
basis of this finding, the nurse would:
Answer: Recheck the temperature in 4 hours
245. Desmopressin (DDAVP) is prescribed to a client with diabetes insipidus. Which parameter
does the nurse tell the client that it is important to monitor while she is taking the medication?
Answer: Intake and output
246. A nurse is transcribing a physician's prescription for oral prednisone 5 mg/day that was
written in the chart of a client with type 2 diabetes mellitus who is already taking an oral

hypoglycemic medication. The nurse contacts the physician to ask about the prescription
because:
Answer: Prednisone can increase the blood glucose level
247. A nurse is caring for a client who is immobilized in skeletal traction after sustaining a leg
fracture in a motor vehicle crash. The nurse notes that the client is restless, and the client
complains of being bored. Which problem does the nurse identify on the basis of this
information?
Answer: Lack of adequate diversional activity
248. Testing of the plasma theophylline level in a client who is receiving a continuous
intravenous infusion of theophylline reveals a level of 20 mcg/mL. The nurse interprets this
result as:
Answer: At the top of the therapeutic range
249. A nurse notes documentation in the client's medical record indicating that the client has a
stage II pressure ulcer. On the basis of this information, which of the following findings does the
nurse expect to note?
a. A diagram of ulcers; stage II ulcer is characterized by nonintact skin. There is partial thickness
skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister.
b. A diagram of ulcers; stage II ulcer is characterized by full thickness skin loss involving the
epidermis and dermis.
c. A diagram of ulcers; stage II ulcer is characterized by non-blanchable erythema of intact skin.
d. A diagram of ulcers; stage II ulcer is characterized by necrosis of subcutaneous tissue.
Answer: a. A diagram of ulcers; stage II ulcer is characterized by nonintact skin. There is partial
thickness skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister.
250. A client in labor experiences spontaneous rupture of the membranes. The nurse immediately
counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse
notes that the fluid is yellow and has a strong odor. Which of the following actions should be the
nurse's priority?

a. Contacting the physician
b. Documenting the findings in the client's chart
c. Assessing the fetal heart rate again after 5 minutes
d. Preparing the client for a cesarean delivery
Answer: a. Contacting the physician
251. A nurse is assessing a client with hepatitis for signs of jaundice. Which area does the nurse
check, knowing that it will provide the best data regarding the presence of jaundice?
Answer: Mucous membranes
252. A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides
instructions to the client about the test. Which statement by the client indicates a need for further
instruction?
Answer: "I need to drink citrate of magnesia the night before the test and give myself a Fleet
enema on the morning of the test."
253. A Tensilon test is performed on a client with suspected myasthenia gravis. Which finding
constitutes a positive result?
Answer: An increase in muscle strength
254. A nurse provides skin care instructions to a client with acne vulgaris. Which statement by
the client indicates a need for further instruction?
Answer: "I should use oil-based cosmetics."
255. A client with type 1 diabetes mellitus is instructed by the physician to obtain glucagon
hydrochloride (Glucagon) for emergency home use. The nurse provides information to the
client's wife about the medication. Which statement by the client's wife indicates that she
understands the information?
Answer: "I need to give this if he has signs of low blood sugar and goes into a coma."

256. A nurse has assisted a physician in inserting a central venous access device into a client with
a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion
of the catheter, the nurse immediately plans to:
Answer: Call the radiography department to obtain a chest x-ray
257. A client with post-traumatic stress disorder tells the nurse that he has stopped taking his
prescribed medication because he didn't like how the medication was making him feel. Which of
the following initial responses by the nurse is appropriate?
a. "Tell me more about how the medication was making you feel."
b. "You should consider taking the medication again; it’s important for your treatment."
c. "Many patients experience side effects; it’s normal."
d. "Have you talked to your doctor about stopping the medication?"
Answer: a. "Tell me more about how the medication was making you feel."
258. A nurse assisting with a delivery is monitoring the client for placental separation after the
delivery of a viable newborn. Which of the following observations indicates to the nurse that
placental separation has occurred?
a. A sudden gush of dark blood from the introitus
b. The umbilical cord lengthens significantly
c. The client reports a feeling of fullness in the vagina
d. The uterus becomes firmer and rises in the abdomen
Answer: a. A sudden gush of dark blood from the introitus
259. A nurse caring for a client 24 hours after a radical neck dissection notes the presence of
serosanguineous drainage in the portable wound suction device attached to the surgical site. On
the basis of this finding, the nurse should:
Answer: Document the findings
260. Alprazolam (Xanax) is prescribed for a client to treat an anxiety disorder. Which side effect
does the nurse warn the client of?
Answer: Light-headedness

261. A nurse is caring for a client who has undergone transsphenoidal hypophysectomy to
remove a microadenoma of the pituitary gland. Which of these findings would be of greatest
concern to the nurse?
Answer: Urinary specific gravity is low
262. A nurse is teaching a client with left-side weakness how to walk with the use of a quadcane. The nurse ensures that:
Answer: 30-degree flexion of the client's elbow is maintained when the client is holding the cane
263. A client is brought to the emergency department after sustaining smoke inhalation injury
during a fire in the client's home. The nurse plans to first:
Answer: Provide the client with 100% oxygen by mask
264. A nurse is providing dietary instructions to the mother of a child with celiac disease. The
nurse tells the mother that it is acceptable to give the child:
Answer: Boiled rice
265. A nurse discovers that a client receiving heparin sodium by way of continuous intravenous
(IV) infusion has removed the IV tubing from the infusion pump to change his hospital gown.
After assessing the client and placing the tubing back in the infusion pump, which medication
does the nurse check for in the medication room in case a heparin overdose has occurred?
Answer: Protamine sulfate