NCLEX PN Medical Surgical Test Bank With Answers-200 Solved Questions

NCLEX-PN Test-Bank (200 Questions with Answers and Explanation)
1. The nurse is caring for a client scheduled for removal of a pituitary tumour using the
transsphenoidal approach. The nurse should be particularly alert for:
A. Nasal congestion
B. Abdominal tenderness
C. Muscle tetany
D. Oliguria
Answer: A
Rationale:
Removal of the pituitary gland is usually done by a transsphenoidal approach, through the nose.
Nasal congestion further interferes with the airway. Answers B, C, and D are not correct because
they are not directly associated with the pituitary gland.
2. A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC
6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is
experiencing which of the following?
A. Hypernatremia
B. Hypokalaemia
C. Myelosuppression
D. Leukocytosis
Answer: B
Rationale:
Hypokalemia is evident from the lab values listed. The other laboratory findings are within
normal limits, making answers A, C, and D incorrect.
3. A 24-year-old female client is scheduled for surgery in the morning. Which of the following is
the primary responsibility of the nurse?
A. Taking the vital signs
B. Obtaining the permit
C. Explaining the procedure

D. Checking the lab work
Answer: A
Rationale:
The primary responsibility of the nurse is to take the vital signs before any surgery. The actions
in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this
question.
4. The nurse is working in the emergency room when a client arrives with severe burns of the left
arm, hands, face, and neck. Which action should receive priority?
A. Starting an IV
B. Applying oxygen
C. Obtaining blood gases
D. Medicating the client for pain
Answer: B
Rationale:
The client with burns to the neck needs airway assessment and supplemental oxygen, so applying
oxygen is the priority. The next action should be to start an IV and medicate for pain, making
answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor.
5. The nurse is visiting a home health client with osteoporosis. The client has a new prescription
for alendronate (Fosamax). Which instruction should be given to the client?
A. Rest in bed after taking the medication for at least 30 minutes
B. Avoid rapid movements after taking the medication
C. Take the medication with water only
D. Allow at least 1 hour between taking the medicine and taking other medications
Answer: B
Rationale:
The client with burns to the neck needs airway assessment and supplemental oxygen, so applying
oxygen is the priority. The next action should be to start an IV and medicate for pain, making
answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor.

6. The nurse is making initial rounds on a client with a C5 fracture and Crutchfield tongs. Which
equipment should be kept at the bedside?
A. A pair of forceps
B. A torque wrench
C. A pair of wire cutters
D. A screwdriver
Answer: B
Rationale:
A torque wrench is kept at the bedside to tighten and loosen the screws of Crutchfield tongs. This
wrench controls the amount of pressure that is placed on the screws. A pair of forceps, wire
cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are incorrect.
7. An infant weighs 7 pounds at birth. The expected weight by 1 year should be:
A. 10 pounds
B. 12 pounds
C. 18 pounds
D. 21 pounds
Answer: D
Rationale:
A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth weight.
Answers A, B, and C therefore are incorrect.
8. A client is admitted with an Ewing’s sarcoma. Which symptoms would be expected due to this
tumour’s location?
A. Hemiplegia
B. Aphasia
C. Nausea
D. Bone pain
Answer: D
Rationale:

Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers A, B, and C
are not specific to this type of cancer and are incorrect.
9. The nurse is caring for a client with epilepsy who is being treated with carbamazepine
(Tegretol). Which laboratory value might indicate a serious side effect of this drug?
A. Uric acid of 5mg/dL
B. Haematocrit of 33%
C. WBC 2,000 per cubic millimetre
D. Platelets 150,000 per cubic millimetre
Answer: C
Rationale:
Tegretol can suppress the bone marrow and decrease the white blood cell count; thus, a lab value
of WBC 2,000 per cubic millimetre indicates side effects of the drug. Answers A and D are
within normal limits, and answer B is a lower limit of normal; therefore, answers A, B, and D are
incorrect.
10. A 6-month-old client is admitted with possible intussuception. Which question during the
nursing history is least helpful in obtaining information regarding this diagnosis?
A. “Tell me about his pain.”
B. “What does his vomit look like?”
C. “Describe his usual diet.”
D. “Have you noticed changes in his abdominal size?”
Answer: C
Rationale:
The least-helpful questions are those describing his usual diet. A, B, and D are useful in
determining the extent of disease process and, thus, are incorrect.
11. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food
should be avoided?
A. Bran
B. Fresh peaches

C. Cucumber salad
D. Yeast rolls
Answer: C
Rationale:
The client with diverticulitis should avoid foods with seeds. The foods in answers A, B, and D
are allowed; in fact, bran cereal and fruit will help prevent constipation.
12. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should
be the priority nursing care during the post-op period?
A. Teaching how to irrigate the ileostomy
B. Stopping electrolyte loss in the incisional area
C. Encouraging a high-fibre diet
D. Facilitating perineal wound drainage
Answer: D
Rationale:
The client with a perineal resection will have a perineal incision. Drains will be used to facilitate
wound drainage. This will help prevent infection of the surgical site. The client will not have an
ileostomy, as in answer A; he will have some electrolyte loss, but treatment is not focused on
preventing the loss, so answer B is incorrect. A high-fibre diet, in answer C, is not ordered at this
time.
13. The nurse is performing discharge teaching on a client with diverticulitis who has been
placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet?
A. Roasted chicken
B. Noodles
C. Cooked broccoli
D. Custard
Answer: C
Rationale:

The client with diverticulitis should avoid eating foods that are gas forming and that increase
abdominal discomfort, such as cooked broccoli. Foods such as those listed in answers A, B, and
D are allowed.
14. The nurse is caring for a new mother. The mother asks why her baby has lost weight since he
was born. The best explanation of the weight loss is:
A. The baby is dehydrated due to polyuria.
B. The baby is hypoglycaemic due to lack of glucose.
C. The baby is allergic to the formula the mother is giving him.
D. The baby can lose up to 10% of weight due to meconium stool, loss of extracellular fluid, and
initiation of breast-feeding.
Answer: D
Rationale:
After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding cause the
infant to lose body mass. There is no evidence to indicate dehydration, hypoglycaemia, or allergy
to the infant formula; thus, answers A, B, and C are incorrect.
15. The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health
history would not be common for this diagnosis?
A. Foul breath
B. Dysphagia
C. Diarrhoea
D. Chronic hiccups
Answer: C
Rationale:
Diarrhoea is not common in clients with mouth and throat cancer. All the findings in answers A,
B, and D are expected findings.
16. A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which
post-operative measure would usually be included in the plan?
A. Closed chest drainage

B. A tracheostomy
C. A mediastinal tube
D. Percussion vibration and drainage
Answer: A
Rationale:
The client with a lung resection will have chest tubes and a drainage-collection device. He
probably will not have a tracheostomy or mediastinal tube, and he will not have an order for
percussion, vibration, or drainage. Therefore, answers B, C, and D are incorrect.
17. Six hours after birth, the infant is found to have an area of swelling over the right parietal
area that does not cross the suture line. The nurse should chart this finding as:
A. A cephalohematoma
B. Molding
C. Subdural hematoma
D. Caput succedaneum
Answer: A
Rationale:
A swelling over the right parietal area is a cephalohematoma, an area of bleeding outside the
cranium. This type of hematoma does not cross the suture line because it is outside the cranium
but beneath the periosteum. Answer B, molding, is overlapping of the bones of the cranium and,
thus, incorrect. In answer C, a subdural hematoma, or intracranial bleeding, is ominous and can
be seen only on a CAT scan or x-ray. A caput succedaneum, in answer D, crosses the suture line
and is edema.
18. The nurse is assisting the RN with discharge instructions for a client with an implantable
defibrillator. What discharge instruction is essential?
A. “You cannot eat food prepared in a microwave.”
B. “You should avoid moving the shoulder on the side of the pacemaker site for 6 weeks.”
C. “You should use your cell phone on your right side.”
D. “You will not be able to fly on a commercial airliner with the defibrillator in place.”
Answer: C

Rationale:
The client with an internal defibrillator should learn to use any battery-operated machinery on
the opposite side. He should also take his pulse rate and report dizziness or fainting. Answers A,
B, and D are incorrect because the client can eat food prepared in the microwave, move his
shoulder on the affected side, and fly in an airplane.
19. A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The
nurse should be most careful to monitor the client for which dysrhythmia during this procedure?
A. Bradycardia
B. Tachycardia
C. Premature ventricular beats
D. Heart block
Answer: A:
Rationale:
Suctioning can cause a vagal response and bradycardia. Answer B is unlikely and, therefore, not
most important, although it can occur. Answers C and D can occur as well, but they are less
likely.
20. The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic
aneurysm. Which assessment is most crucial during the preoperative period?
A. Assessment of the client’s level of anxiety
B. Evaluation of the client’s exercise tolerance
C. Identification of peripheral pulses
D. Assessment of bowel sounds and activity
Answer: C
Rationale:
The assessment that is most crucial to the client is the identification of peripheral pulses because
the aorta is clamped during surgery. This decreases blood circulation to the kidneys and lower
extremities. The nurse must also assess for the return of circulation to the lower extremities.
Answer A is of lesser concern, answer B is not advised at this time, and answer D is of lesser
concern than answer A.

21. A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include
which statement in the teaching session?
A. “You will be sitting for the examination procedure.”
B. “Portions of the procedure will cause pain or discomfort.”
C. “You will be given some medication to anesthetize the area.”
D. “You will not be able to drink fluids for 24 hours before the study.”
Answer: B
Rationale:
Portions of the exam are painful, especially when the sample is being withdrawn, so this should
be included in the session with the client. Answer A is incorrect because the client will be
positioned prone, not in a sitting position, for the exam. Anaesthesia is not commonly given
before this test, making answer C incorrect. Answer D is incorrect because the client can eat and
drink following the test.
22. The nurse is performing an assessment on a client with possible pernicious anaemia. Which
data would support this diagnosis?
A. A weight loss of 10 pounds in 2 weeks
B. Complaints of numbness and tingling in the extremities
C. A red, beefy tongue
D. A haemoglobin level of 12.0gm/dL
Answer: C
Rationale:
A red, beefy tongue is characteristic of the client with pernicious anaemia. Answer A, a weight
loss of 10 pounds in 2 weeks, is abnormal but is not seen in pernicious anaemia. Numbness and
tingling, in answer B, can be associated with anaemia but are not particular to pernicious
anaemia. This is more likely associated with peripheral vascular diseases involving vasculature.
In answer D, the haemoglobin is low normal.
23. A client arrives in the emergency room with a possible fractured femur. The nurse should
anticipate an order for:

A. Trendelenburg position
B. Ice to the entire extremity
C. Buck’s traction
D. An abduction pillow
Answer: C
Rationale:
The client with a fractured femur will be placed in Buck’s traction to realign the leg and to
decrease spasms and pain. The Trendelenburg position is the wrong position for this client, so
answer A is incorrect. Ice might be ordered after repair, but not for the entire extremity, so
answer B is incorrect. An abduction pillow is ordered after a total hip replacement, not for a
fractured femur; therefore, answer D is incorrect.
24. A client with cancer is to undergo an intravenous pyelogram. The nurse should:
A. Force fluids 24 hours before the procedure
B. Ask the client to void immediately before the study
C. Hold medication that affects the central nervous system for 12 hours pre- and post-test
D. Cover the client’s reproductive organs with an x-ray shield
Answer: B
Rationale:
The client having an intravenous pyelogram will have orders for laxatives or enemas, so asking
the client to void before the test is in order. A full bladder or bowel can obscure the visualization
of the kidney ureters and urethra. In answers A, C, and D, there is no need to force fluids before
the procedure, to withhold medications, or to cover the reproductive organs.
25. The nurse is caring for a client with a malignancy. The classification of the primary tumour is
Tis. The nurse should plan care for a tumour:
A. That cannot be assessed
B. That is in situ
C. With increasing lymph node involvement
D. With distant metastasis
Answer: B

Rationale:
Cancer in situ means that the cancer is still localized to the primary site. Cancer is graded in
terms of tumour, grade, node involvement, and metastasis. Answer A is incorrect because it is an
untrue statement. Answer C is incorrect because T indicates tumour, not node involvement.
Answer D is incorrect because a tumour that is in situ is not metastasized.
26. A client is 2 days post-operative colon resection. After a coughing episode, the client’s wound
eviscerates. Which nursing action is most appropriate?
A. Reinsert the protruding organ and cover with 4×4s
B. Cover the wound with a sterile 4×4 and ABD dressing
C. Cover the wound with a sterile saline-soaked dressing
D. Apply an abdominal binder and manual pressure to the wound
Answer: C
Rationale:
If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked
dressing. Reinserting the content should not be the action and will require that the client return to
surgery; thus, answer A is incorrect. Answers B and D are incorrect because they are not
appropriate to this case.
27. The nurse is preparing a client for surgery. Which item is most important to remove before
sending the client to surgery?
A. Hearing aid
B. Contact lenses
C. Wedding ring
D. Artificial eye
Answer: B
Rationale:
It is most important to remove the contact lenses because leaving them in can lead to corneal
drying, particularly with contact lenses that are not extended-wear lenses. Leaving in the hearing
aid or artificial eye will not harm the client. Leaving the wedding ring on is also allowed;
usually, the ring is covered with tape. Therefore, answers A, C, and D are incorrect.

28. The nurse on the 3–11 shift is assessing the chart of a client with an abdominal aneurysm
scheduled for surgery in the morning and finds that the consent form has been signed, but the
client is unclear about the surgery and possible complications. Which is the most appropriate
action?
A. Call the surgeon and ask him or her to see the client to clarify the information
B. Explain the procedure and complications to the client
C. Check in the physician’s progress notes to see if understanding has been documented
D. Check with the client’s family to see if they understand the procedure fully
Answer: A
Rationale:
It is the responsibility of the physician to explain and clarify the procedure to the client. Answers
B, C, and D are incorrect because they are not within the nurse’s purview.
29. When assessing a client for risk of hyperphosphatemia, which piece of information is most
important for the nurse to obtain?
A. A history of radiation treatment in the neck region
B. A history of recent orthopaedic surgery
C. A history of minimal physical activity
D. A history of the client’s food intake
Answer: A
Rationale:
Previous radiation to the neck might have damaged the parathyroid glands, which are located on
the thyroid gland, and interfered with calcium and phosphorus regulation. Answer B has no
significance to this case; answers C and D are more related to calcium only, not to phosphorus
regulation.
30. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of
170meq/L. What behavior changes would be most common for this client?
A. Anger
B. Mania

C. Depression
D. Psychosis
Answer: B
Rationale:
The client with serum sodium of 170meq/L has hypernatremia and might exhibit manic behavior.
Answers A, C, and D are not associated with hypernatremia and are, therefore, incorrect.
31. The nurse is obtaining a history of an 80-year-old client. Which statement made by the client
might indicate a possible fluid and electrolyte imbalance?
A. “My skin is always so dry.”
B. “I often use a laxative for constipation.”
C. “I have always liked to drink a lot of ice tea.”
D. “I sometimes have a problem with dribbling urine.”
Answer: B
Rationale:
Frequent use of laxatives can lead to diarrhoea and electrolyte loss. Answers A, C, and D are not
of particular significance in this case and, therefore, are incorrect.
32. A client visits the clinic after the death of a parent. Which statement made by the client’s
sister signifies abnormal grieving?
A. “My sister still has episodes of crying, and it’s been 3 months since Daddy died.”
B. “Sally seems to have forgotten the bad things that Daddy did in his lifetime.”
C. “She really had a hard time after Daddy’s funeral. She said that she had a sense of longing.”
D. “Sally has not been sad at all by Daddy’s death. She acts like nothing has happened.”
Answer: D
Rationale:
Abnormal grieving is exhibited by a lack of feeling sad; if the client’s sister appears not to
grieve, it might be abnormal grieving. This family member might be suppressing feelings of
grief. Answers A, B, and C are all normal expressions of grief and, therefore, incorrect.

33. The nurse recognizes that which of the following would be most appropriate to wear when
providing direct care to a client with a cough?
A. Mask
B. Gown
C. Gloves
D. Shoe covers
Answer: A
Rationale:
If the nurse is exposed to the client with a cough, the best item to wear is a mask. If the answer
had included a mask, gloves, and a gown, all would be appropriate, but in this case, only one
item is listed; therefore, answers B and C are incorrect. Shoe covers are not necessary, so answer
D is incorrect.
34. The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritic.
Which would be the most appropriate nursing intervention?
A. Suggest that the client take warm showers B.I.D.
B. Add baby oil to the client’s bath water
C. Apply powder to the client’s skin
D. Suggest a hot-water rinse after bathing
Answer: B
Rationale:
Oils can be applied to help with the dry skin and to decrease itching, so adding baby oil to bath
water is soothing to the skin. Answer A is incorrect because bathing twice a day is too frequent
and can cause more dryness. Answer C is incorrect because powder is also drying.
Rinsing with hot water, as stated in answer D, dries out the skin as well.
35. A client with pancreatitis has been transferred to the intensive care unit. Which order would
the nurse anticipate?
A. Blood pressure every 15 minutes
B. Insertion of a Levine tube
C. Cardiac monitoring

D. Dressing changes two times per day
Answer: B
Rationale:
The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to
decompress the stomach and rest the bowel, so the insertion of a Levine tube should be
anticipated. Answers A and C are incorrect because blood pressures are not required every 15
minutes, and cardiac monitoring might be needed, but this is individualized to the client. Answer
D is incorrect because there are no dressings to change on this client.
36. The client is admitted to the unit after a cholecystectomy. Montgomery straps are utilized
with this client. The nurse is aware that Montgomery straps are utilized on this client because:
A. The client is at risk for evisceration.
B. The client will require frequent dressing changes.
C. The straps provide support for drains that are inserted in the incision.
D. No sutures or clips are used to secure the incision.
Answer: B
Rationale:
Montgomery straps are used to secure dressings that require frequent dressing changes because
the client with a cholecystectomy usually has a large amount of drainage on the dressing.
Montgomery straps are also used for clients who are allergic to several types of tape. This client
is not at higher risk of evisceration than other clients, so answer A is incorrect.
Montgomery straps are not used to secure the drains, so answer C is incorrect. Sutures or clips
are used to secure the wound of the client who has had gallbladder surgery, so answer D is
incorrect.
37. The physician has ordered that the client’s medication be administered intrathecally. The
nurse is aware that medications will be administered by which method?
A. Intravenously
B. Rectally
C. Intramuscularly
D. Into the cerebrospinal fluid

Answer: D
Rationale:
Intrathecal medications are administered into the cerebrospinal fluid. This method of
administering medications is reserved for the client with metastases, the client with chronic pain,
or the client with cerebrospinal infections. Answers A, B, and C are incorrect because
intravenous, rectal, and intramuscular injections are entirely different procedures.
38. Which client can best be assigned to the newly licensed practical nurse?
A. The client receiving chemotherapy
B. The client post–coronary bypass
C. The client with a TURP
D. The client with diverticulitis
Answer: D
Rationale:
The best client to assign to the newly licensed nurse is the most stable client; in this case, it is the
client with diverticulitis. The client receiving chemotherapy and the client with a coronary
bypass both need nurses experienced in these areas, so answers A and B are incorrect. Answer D
is incorrect because the client with a transurethral prostatectomy might bleed, so this client
should be assigned to a nurse who knows how much bleeding is within normal limits.
39. The nurse notes the patient care assistant looking through the personal items of the client
with cancer. Which action should be taken by the registered nurse?
A. Notify the police department as a robbery
B. Report this behavior to the charge nurse
C. Monitor the situation and note whether any items are missing
D. Ignore the situation until items are reported missing
Answer: B
Rationale:
The best action at this time is to report the incident to the charge nurse. Further action might be
needed, but it should be determined by the charge nurse. Answers A, C, and D are incorrect

because notifying the police is overreacting at this time, and monitoring or ignoring the situation
is an inadequate response.
40. The nurse overhears the patient care assistant speaking harshly to the client with dementia.
The charge nurse should:
A. Change the nursing assistant’s assignment
B. Explore the interaction with the nursing assistant
C. Discuss the matter with the client’s family
D. Initiate a group session with the nursing assistant
Answer: B
Rationale:
The best action for the nurse to take is to explore the interaction with the nursing assistant. This
will allow for clarification of the situation. Changing the assignment in answer A might need to
be done, but talking to the nursing assistant is the first step. Answer C is incorrect because
discussing the incident with the family is not necessary at this time; it might cause more
problems. Answer C is not a first step, even though initiating a group session might be a plan for
the future.
41. A home health nurse is planning for her daily visits. Which client should the home health
nurse visit first?
A. A client with AIDS being treated with Foscarnet
B. A client with a fractured femur in a long leg cast
C. A client with laryngeal cancer with a laryngectomy
D. A client with diabetic ulcers to the left foot
Answer: C
Rationale:
The client with laryngeal cancer has a potential airway alteration and should be seen first. The
clients in answers A, B, and D are not in immediate danger and can be seen later in the day.
42. The nurse is assigned to care for an infant with physiologic jaundice. Which action by the
nurse would facilitate elimination of the bilirubin?

A. Increasing the infant’s fluid intake
B. Maintaining the infant’s body temperature at 98.6°F
C. Minimizing tactile stimulation
D. Decreasing caloric intake
Answer: A
Rationale:
Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the
body temperature is important but will not assist in eliminating bilirubin; therefore, answer B is
incorrect. Answers C and D are incorrect because they do not relate to the question.
43. The graduate licensed practical nurse is assigned to care for the client on ventilator support,
pending organ donation. Which goal should receive priority?
A. Maintain the client’s systolic blood pressure at 70mmHg or greater
B. Maintain the client’s urinary output greater than 300cc per hour
C. Maintain the client’s body temperature of greater than 33°F rectal
D. Maintain the client’s haematocrit less than 30%
Answer: A
Rationale:
When the cadaver client is being prepared to donate an organ, the systolic blood pressure should
be maintained at 70mmHg or greater to ensure a blood supply to the donor organ. Answers B, C,
and D are incorrect because they are unnecessary actions for organ donation.
44. Which action by the novice nurse indicates a need for further teaching?
A. The nurse fails to wear gloves to remove a dressing.
B. The nurse applies an oxygen saturation monitor to the ear lobe.
C. The nurse elevates the head of the bed to check the blood pressure.
D. The nurse places the extremity in a dependent position to acquire a peripheral blood sample.
Answer: A
Rationale:

The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction.
Answers B, C, and D are incorrect because they indicate an understanding of the correct method
of completing these tasks.
45. The nurse is preparing a client for mammography. To prepare the client for a mammogram,
the nurse should tell the client:
A. To restrict her fat intake for 1 week before the test
B. To omit creams, powders, or deodorants before the exam
C. That mammography replaces the need for self-breast exams
D. That mammography requires a higher dose of radiation than an x-ray
Answer: B
Rationale:
The client having a mammogram should be instructed to omit deodorants or powders beforehand
because powders and deodorants can be interpreted as abnormal. Answer A is incorrect because
there is no need for dietary restrictions before a mammogram. Answer C is incorrect because the
mammogram does not replace the need for self-breast exams. Answer D is incorrect because a
mammogram does not require higher doses of radiation than an x-ray.
46. Which of the following roommates would be best for the client newly admitted with gastric
resection?
A. A client with Crohn’s disease
B. A client with pneumonia
C. A client with gastritis
D. A client with phlebitis
Answer: D
Rationale:
The most suitable roommate for the client with gastric resection is the client with phlebitis
because phlebitis is an inflammation of the blood vessel and is not infectious. Crohn’s disease
clients, in answer A, have frequent stools that might spread infections to the surgical client. The
client in answer B with pneumonia is coughing and will disturb the gastric client. The client with
gastritis, in answer C, is vomiting and has diarrhoea, which also will disturb the gastric client.

47. The licensed practical nurse is working with a registered nurse and a patient care assistant.
Which of the following clients should be cared for by the registered nurse?
A. A client 2 days post-appendectomy
B. A client 1 week post-thyroidectomy
C. A client 3 days post-splenectomy
D. A client 2 days post-thoracotomy
Answer: D
Rationale:
The most critical client should be assigned to the registered nurse; in this case, that is the client 2
days post-thoracotomy. The clients in answers A and B are ready for discharge, and the client in
answer C who had a splenectomy 3 days ago is stable enough to be assigned to an
LPN.
48. The licensed practical nurse is observing a graduate nurse as she assesses the central venous
pressure. Which observation would indicate that the graduate needs further teaching?
A. The graduate places the client in a supine position to read the manometer.
B. The graduate turns the stop-cock to the off position from the IV fluid to the client.
C. The graduate instructs the client to perform the Valsalva maneuver during the CVP reading.
D. The graduate notes the level at the top of the meniscus.
Answer: C
Rationale:
The client should breathe normally during a central venous pressure monitor reading. Answer A
indicates understanding because the client should be placed supine if he can tolerate being in that
position. Answers B and D indicate understanding because the stop-cock should be turned off to
the IV fluid, and the reading should be done at the top of the meniscus.
49. Which of the following roommates would be most suitable for the client with myasthenia
gravis?
A. A client with hypothyroidism
B. A client with Crohn’s disease

C. A client with pyelonephritis
D. A client with bronchitis
Answer: A
Rationale:
The most suitable roommate for the client with myasthenia gravis is the client with
hypothyroidism because he is quiet. The client with Crohn’s disease in answer B will be up to the
bathroom frequently; the client with pyelonephritis in answer C has a kidney infection and will
be up to urinate frequently. The client in answer D with bronchitis will be coughing and will
disturb any roommate.
50. The nurse employed in the emergency room is responsible for triage of four clients injured in
a motor vehicle accident. Which of the following clients should receive priority in care?
A. A 10-year-old with lacerations of the face
B. A 15-year-old with sternal bruises
C. A 34-year-old with a fractured femur
D. A 50-year-old with dislocation of the elbow
Answer: B
Rationale:
The teenager with sternal bruising might be experiencing airway and oxygenation problems and,
thus, should be seen first. In answer A, the 10-year-old with lacerations might look bad but is not
in distress. The client in answer C with a fractured femur should be immobilized but can be seen
after the client with sternal bruising. The client in answer D with the dislocated elbow can be
seen later as well.
51. The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should:
A. Document the finding
B. Send a specimen to the lab
C. Strain the urine
D. Obtain a complete blood count
Answer: B
Rationale:

If the dialysate returns cloudy, infection might be present and must be evaluated. Documenting
the finding, as stated in answer A, is not enough; straining the urine, in answer C, is incorrect;
and dialysate, in answer D, is not urine at all. However, the physician might order a white blood
cell count.
52. The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the
rationale for the order for Lactulose is:
A. To lower the blood glucose level
B. To lower the uric acid level
C. To lower the ammonia level
D. To lower the creatinine level
Answer: C
Rationale:
Lactulose is administered to the client with cirrhosis to lower ammonia levels. Answers A, B,
and D are incorrect because this does not have an effect on the other lab values.
53. The client with diabetes is preparing for discharge. During discharge teaching, the nurse
assesses the client’s ability to care for himself. Which statement made by the client would
indicate a need for follow-up after discharge?
A. “I live by myself.”
B. “I have trouble seeing.”
C. “I have a cat in the house with me.”
D. “I usually drive myself to the doctor.”
Answer: B
Rationale:
A client with diabetes who has trouble seeing would require follow-up after discharge. The lack
of visual acuity for the client preparing and injecting insulin might require help. Answers A, C,
and D will not prevent the client from being able to care for himself and, thus, are incorrect.
54. The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated
while the client is receiving TPN?

A. Haemoglobin
B. Creatinine
C. Blood glucose
D. White blood cell count
Answer: C
Rationale:
When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution
that contains large amounts of glucose. Answers A, B, and D are not directly related to the
question and are incorrect.
55. The client with a myocardial infarction comes to the nurse’s station stating that he is ready to
go home because there is nothing wrong with him. Which defense mechanism is the client using?
A. Rationalization
B. Denial
C. Projection
D. Conversion reaction
Answer: B
Rationale:
The client who says he has nothing wrong is in denial about his myocardial infarction.
Rationalization is making excuses for what happened, projection is projecting feeling or thoughts
onto others, and conversion reaction is converting a psychological trauma into a physical illness;
thus, answers A, C, and D are incorrect.
56. Which laboratory test would be the least effective in making the diagnosis of a myocardial
infarction?
A. AST
B. Troponin
C. CK-MB
D. Myoglobin
Answer: A
Rationale:

Answer A, AST, is not specific for myocardial infarction. Troponin, CK-MB, and myoglobin, in
answers B, C, and D, are more specific, although myoglobin is also elevated in burns and trauma
to muscles.
57. The licensed practical nurse assigned to the post-partal unit is preparing to administer
Rhogam to a postpartum client. Which woman is not a candidate for RhoGam?
A. A gravida IV para 3 that is Rh negative with a Rh-positive baby
B. A gravida I para 1 that is Rh negative with a Rh-positive baby
C. A gravida II para 0 that is Rh negative admitted after a stillbirth delivery
D. A gravida IV para 2 that is Rh negative with a Rh-negative baby
Answer: D
Rationale:
The mothers in answers A, B, and C all require RhoGam and, thus, are incorrect. The mother in
answer D is the only one who does not require a RhoGam injection.
58. The first exercise that should be performed by the client who had a mastectomy is:
A. Walking the hand up the wall
B. Sweeping the floor
C. Combing her hair
D. Squeezing a ball
Answer: D
Rationale:
The first exercise that should be done by the client with a mastectomy is squeezing the ball.
Answers A, B, and C are incorrect as the first step; they are implemented later.
59. The client is scheduled for a Tension test to check for Myasthenia Gravis. Which medication
should be kept available during the test?
A. Atropine sulphate
B. Furosemide
C. Prostigmin
D. Promethazine

Answer: A
Rationale:
Atropine sulphate is the antidote for Tensilon and is given to treat cholenergic crises. Furosemide
(answer B) is a diuretic, Prostigmin (answer C) is the treatment for myasthenia gravis, and
Promethazine (answer D) is an antiemetic, antianxiety medication. Thus, answers B, C, and D
are incorrect.
60. The client is scheduled for a pericentesis. Which instruction should be given to the client
before the exam?
A. “You will need to lay flat during the exam.”
B. “You need to empty your bladder before the procedure.”
C. “You will be asleep during the procedure.”
D. “The doctor will inject a medication to treat your illness during the procedure.”
Answer: B
Rationale:
The client scheduled for a pericentesis should be told to empty the bladder, to prevent the risk of
puncturing the bladder when the needle is inserted. A pericentesis is done to remove fluid from
the peritoneal cavity. The client will be positioned sitting up or leaning over a table, making
answer An incorrect. The client is usually awake during the procedure, and medications are not
commonly inserted into the peritoneal cavity during this procedure; thus, answers C and D are
incorrect (although this could depend on the circumstances).
61. To ensure safety while administering a nitro-glycerine patch, the nurse should:
A. Wear gloves
B. Shave the area where the patch will be applied
C. Wash the area thoroughly with soap and rinse with hot water
D. Apply the patch to the buttocks
Answer: A
Rationale:
To protect herself, the nurse should wear gloves when applying a nitro-glycerine patch or cream.
Answer B is incorrect because shaving the shin might abrade the area. Answer C is incorrect

because washing with hot water will vasodilate and increase absorption. The patches should be
applied to areas above the waist, making answer D incorrect.
62. A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which
action by the nurse is correct?
A. Use a magnet to remove the object.
B. Rinse the eye thoroughly with saline.
C. Cover both eyes with paper cups.
D. Patch the affected eye only.
Answer: C
Rationale:
Covering both eyes prevents consensual movement of the affected eye. The nurse should not
attempt to remove the object from the eye because this might cause trauma, as stated in answer
A. Rinsing the eye, as stated in answer B, might be ordered by the doctor, but this is not the first
step for the nurse. Answer D is not correct because often when one eye moves, the other also
does.
63. The physician has ordered sodium warfarin (Coumadin) for the client with thrombophlebitis.
The order should be entered to administer the medication at:
A. 0900
B. 1200
C. 1700
D. 2100
Answer: C
Rationale:
Sodium warfarin is administered in the late afternoon, at approximately 1700 hours. This allows
for accurate bleeding times to be drawn in the morning. Therefore, answers A, B, and D are
incorrect.
64. The schizophrenic client has become disruptive and requires seclusion. Which staff member
can institute seclusion?

A. The security guard
B. The registered nurse
C. The licensed practical nurse
D. The nursing assistant
Answer: B
Rationale:
The registered nurse is the only one of these who can legally put the client in seclusion. The only
other healthcare worker who is allowed to initiate seclusion is the doctor; therefore, answers A,
C, and D are incorrect.
65. The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal pH
7.36, CO2 45, O2 84, HCO3 28. The nurse would assess the client to be in:
A. Uncompensated acidosis
B. Compensated alkalosis
C. Compensated respiratory acidosis
D. Uncompensated metabolic acidosis
Answer: C
Rationale:
The client is experiencing compensated respiratory acidosis. The pH is within the normal range
but is lower than 7.40, so it is on the acidic side. The CO2 level is elevated, the oxygen level is
below normal, and the bicarb level is slightly elevated. In respiratory disorders, the pH will be
the inverse of the CO2 and bicarb levels. This means that if the pH is low, the CO2 and bicarb
levels will be elevated. Answers A, B, and D are incorrect because they do not fall into the range
of symptoms.
66. The nurse is assessing the client recently returned from surgery. The nurse is aware that the
best way to assess pain is to:
A. Take the blood pressure, pulse, and temperature
B. Ask the client to rate his pain on a scale of 0–5
C. Watch the client’s facial expression
D. Ask the client if he is in pain

Answer: B
Rationale:
The best way to evaluate pain levels is to ask the client to rate his pain on a scale. In answer A,
the blood pressure, pulse, and temperature can alter for other reasons than pain. Answers C and
D are not as effective in determining pain levels.
67. The nursing is participating in discharge teaching for the post-partial client. The nurse is
aware that an effective means of managing discomfort associated with an episiotomy after
discharge is:
A. Promethazine
B. Aspirin
C. Sitz baths
D. Ice packs
Answer: C
Rationale:
A sitz bath will help with swelling and improve healing. Ice packs, in answer D, can be used
immediately after delivery. Answers A and B are not used in this instance.
68. Which of the following post-operative diets is most appropriate for the client who has had a
haemorrhoidectomy?
A. High-fibre
B. Low-residue
C. Bland
D. Clear-liquid
Answer: D
Rationale:
After surgery, the client will be placed on a clear-liquid diet and progressed to a regular diet.
Stool softeners will be included in the plan of care, to avoid constipation. Later, a high-fibre diet,
in answer A, is encouraged, but this is not the first diet after surgery. Answers B and C are not
diets for this type of surgery.

69. The physician has ordered a culture for the client with suspected gonorrhoea. The nurse
should obtain which type of culture?
A. Blood
B. Nasopharyngeal secretions
C. Stool
D. Genital secretions
Answer: D
Rationale:
A culture for gonorrhoea is taken from the genital secretions. The culture is placed in a warm
environment, where it can grow Neisseria gonorrhoea. Answers A, B, and C are incorrect
because these cultures do not test for gonorrhoea.
70. The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest
periods because:
A. Grimacing and writhing movements decrease with relaxation and rest.
B. Hypoactive deep tendon reflexes become more active with rest.
C. Stretch reflexes are increased with rest.
D. Fine motor movements are improved.
Answer: A
Rationale:
Frequent rest periods help to relax tense muscles and preserve energy. Answers B, C, and D are
incorrect because they are untrue statements.
71. The nurse is making assignments for the day. Which client should be assigned to the nursing
assistant?
A. A client with Alzheimer’s disease
B. A client with pneumonia
C. A client with appendicitis
D. A client with thrombophlebitis
Answer: A
Rationale:

The client with Alzheimer’s disease is the most stable of these clients and can be assigned to the
nursing assistant, who can perform duties such as feeding and assisting the client with activities
of daily living. The clients in answers B, C, and D are less stable and should be attended by a
registered nurse.
72. A client with cancer develops xerostomia. The nurse can help alleviate the discomfort
associated with xerostomia by:
A. Offering hard candy
B. Administering analgesic medications
C. Splinting swollen joints
D. Providing saliva substitute
Answer: D
Rationale:
Xerostomia is dry mouth, and offering the client a saliva substitute will help the most. Eating
hard candy in answer A can further irritate the mucosa and cut the tongue and lips. Administering
an analgesic might not be necessary; thus, answer B is incorrect. Splinting swollen joints, in
answer C, is not associated with xerostomia.
73. A home health nurse is making preparations for morning visits. Which one of the following
clients should the nurse visit first?
A. A client with brain attack (stroke) with tube feedings
B. A client with congestive heart failure complaining of nighttime dyspnea
C. A client with a thoracotomy 6 months ago
D. A client with Parkinson’s disease
Answer: B
Rationale:
The client with congestive heart failure who is complaining of nighttime dyspnea should be seen
first because airway is number one in nursing care. In answers A, C, and D, the clients are more
stable.

74. A client with glomerulonephritis is placed on a low-sodium diet. Which of the following
snacks is suitable for the client with sodium restriction?
A. Peanut butter cookies
B. Grilled cheese sandwich
C. Cottage cheese and fruit
D. Fresh peach
Answer: D
Rationale:
The fresh peach is the lowest in sodium of these choices. Answers A, B, and C have much higher
amounts of sodium.
75. Due to a high census, it has been necessary for a number of clients to be transferred to other
units within the hospital. Which client should be transferred to the postpartum unit?
A. A 66-year-old female with a gastroenteritis
B. A 40-year-old female with a hysterectomy
C. A 27-year-old male with severe depression
D. A 28-year-old male with ulcerative colitis
Answer: B
Rationale:
The best client to transport to the postpartum unit is the 40-year- old female with a hysterectomy.
The nurses on the postpartum unit will be aware of normal amounts of bleeding and will be
equipped to care for this client. The clients in answers A and D will be best cared for on a
medical- surgical unit. The client with depression in answer C should be transported to the
psychiatric unit.
76. During the change of shift, the oncoming nurse notes a discrepancy in the number of
Percocet (Oxycodone) listed and the number present in the narcotic drawer. The nurse’s first
action should be to:
A. Notify the hospital pharmacist
B. Notify the nursing supervisor
C. Notify the Board of Nursing

D. Notify the director of nursing
Answer: B
Rationale:
The first action the nurse should take is to report the finding to the nurse supervisor and follow
the chain of command. If it is found that the pharmacy is in error, it should be notified, as stated
in answer A. Answers C and D, notifying the director of nursing and the Board of Nursing, might
be necessary if theft is found, but not as a first step; thus, these are incorrect answers.
77. The nurse is assigning staff for the day. Which assignment should be given to the nursing
assistant?
A. Taking the vital signs of the 5-month-old with bronchiolitis
B. Taking the vital signs of the 10-year-old with a 2-day post-appendectomy
C. Administering medication to the 2-year-old with periorbital cellulites
D. Adjusting the traction of the 1-year-old with a fractured tibia
Answer: B
Rationale: The client with the appendectomy is the most stable of these clients and can be
assigned to a nursing assistant. The client with bronchiolitis has an alteration in the airway, the
client with periorbital cellulitis has an infection, and the client with a fracture might be an abused
child. Therefore, answers A, C, and D are incorrect.
78. A new nursing graduate indicates in charting entries that he is a licensed practical nurse,
although he has not yet received the results of the licensing exam. The graduate’s action can
result in what type of charge:
A. Fraud
B. Tort
C. Malpractice
D. Negligence
Answer: A
Rationale:
Identifying oneself as a nurse without a license defrauds the public and can be prosecuted. A tort
is a wrongful act; malpractice is failing to act appropriately as a nurse or acting in a way that

harm comes to the client; and negligence is failing to perform care. Therefore, answers B, C, and
D are incorrect.
79. A client with acute leukaemia develops a low white blood cell count. In addition to the
institution of isolation, the nurse should:
A. Request that foods be served with disposable utensils
B. Ask the client to wear a mask when visitors are present
C. Prep IV sites with mild soap and water and alcohol
D. Provide foods in sealed single-serving packages
Answer: D
Rationale:
Because the client is immune-suppressed, foods should be served in sealed containers, to avoid
food contaminants. Answer B is incorrect because of possible infection from visitors. Answer A
is not necessary, but the utensils should be cleaned thoroughly and rinsed in hot water. Answer C
might be a good idea, but alcohol can be drying and can cause the skin to break down.
80. A 70-year-old male who is recovering from a strike exhibits signs of unilateral neglect.
Which behavior is suggestive of unilateral neglect?
A. The client is observed shaving only one side of his face.
B. The client is unable to distinguish between two tactile stimuli presented simultaneously.
C. The client is unable to complete a range of vision without turning his head side to side.
D. The client is unable to carry out cognitive and motor activity at the same time.
Answer: A
Rationale:
The client with unilateral neglect will neglect one side of the body. Answers B, C, and D are not
associated with unilateral neglect.
81. The nurse is providing discharge teaching for a client taking dissulfiram (Antabuse). The
nurse should instruct the client to avoid eating:
A. Peanuts, dates, raisins
B. Figs, chocolate, eggplant

C. Pickles, salad with vinaigrette dressing, beef
D. Milk, cottage cheese, ice cream
Answer: C
Rationale:
The client taking Antabuse should not eat or drink anything containing alcohol or vinegar. The
other foods in answers A, B, and D are allowed.
82. A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks. Which
laboratory finding indicates that the medication is having the desired effect?
A. Neutrophil count of 60%
B. Basophil count of 0.5%
C. Monocyte count of 2%
D. Reticulocyte count of 1%
Answer: D
Rationale:
Cyanocolamine is a B12 medication that is used for pernicious anaemia, and a reticulocyte count
of 1% indicates that it is having the desired effect. Answers A, B, and C are white blood cells and
have nothing to do with this medication.
83. The nurse has just received a change-of-shift report. Which client should the nurse assess
first?
A. A client 2 hours post-lobectomy with 150ccs drainage
B. A client 2 days post-gastrectomy with scant drainage
C. A client with pneumonia with an oral temperature of 102°F
D. A client with a fractured hip in Buck’s traction
Answer: A
Rationale:
The first client to be seen is the one who recently returned from surgery. The other clients in
answers B, C, and D are more stable and can be seen later.

84. Several clients are admitted to the emergency room following a three-car vehicle accident.
Which clients can be assigned to share a room in the emergency department during the disaster?
A. The schizophrenic client having visual and auditory hallucinations and the client with
ulcerative colitis
B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations
and a broken arm
C. A child whose pupils are fixed and dilated and his parents, and the client with a frontal head
injury
D. The client who arrives with a large puncture wound to the abdomen and the client with chest
pain
Answer: B
Rationale:
Out of all of these clients, it is best to hold the pregnant client and the client with a broken arm
and facial lacerations in the same room. The clients in answer A need to be placed in separate
rooms because these clients are disruptive or have infections. In the case of answer C, the child is
terminal and should be in a private room with his parents.
85. The home health nurse is planning for the day’s visits. Which client should be seen first?
A. The 78-year-old who had a gastrectomy 3 weeks ago with a PEG tube
B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with
amoxicillin liquid suspension
C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line
D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a
centrally placed venous catheter
Answer: D
Rationale:
The priority client is the one with multiple sclerosis who is being treated with cortisone via the
central line. This client is at highest risk for complications. MRSA, in answer C, is methicillinresistant staphylococcus aureas. Vancomycin is the drug of choice and can be administered later,
but its use must be scheduled at specific times of the day to maintain a therapeutic level. Answers
A and B are incorrect because these clients are more stable.

86. The nurse is found to be guilty of charting blood glucose results without actually performing
the procedure. After talking to the nurse, the charge nurse should:
A. Call the Board of Nursing
B. File a formal reprimand
C. Terminate the nurse
D. Charge the nurse with a tort
Answer: B
Rationale:
The action after discussing the problem with the nurse is to document the incident and file a
formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may
be terminated and reported to the Board of Nursing, but this is not the first step. A tort is a
wrongful act committed against a client or his belongings. Answers A, C, and D are incorrect.
87. Which information should be reported to the state Board of Nursing?
A. The facility fails to provide literature in both Spanish and English.
B. The narcotic count has been incorrect on the unit for the past 3 days.
C. The client fails to receive an itemized account of his bills and services received during his
hospital stay
D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the
bath.
Answer: B
Rationale:
The Joint Commission on Accreditation of Hospitals will probably be interested in the problems
in answers A and C. The failure of the nursing assistant to assist the client with hepatitis should
be reported to the charge nurse. If the behavior continues, termination may result. Answer D is
incorrect because failure to feed and bathe the client should be reported to the superior, not the
Board of Nursing.
88. Which nurse should be assigned to care for the postpartal client with preeclampsia?
A. The nurse with 2 weeks of experience on postpartum

B. The nurse with 3 years of experience in labor and delivery
C. The nurse with 10 years of experience in surgery
D. The nurse with 1 year of experience in the neonatal intensive care unit
Answer: B
Rationale:
The nurse in answer B has the most experience with possible complications involved with
preeclampsia. The nurse in answer A is a new nurse to this unit and should not be assigned to this
client; the nurses in answers C and D have no experience with the postpartal client and also
should not be assigned to this client.
89. The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132,
respirations 30. Which action by the nurse should receive priority?
A. Continue to monitor the vital signs
B. Contact the physician
C. Ask the client how he feels
D. Ask the LPN to continue the post-op care
Answer: B
Rationale:
The vital signs are abnormal and should be reported to the doctor immediately. Answer A,
continuing to monitor the vital signs, can result in deterioration of the client’s condition. Answer
C, asking the client how he feels, would supply only subjective data. Involving the LPN, in
answer D, is not the best solution to help this client because he is unstable.
90. Which assignment should not be performed by the licensed practical nurse?
A. Inserting a Foley catheter
B. Discontinuing a nasogastric tube
C. Obtaining a sputum specimen
D. Initiating a blood transfusion
Answer: D
Rationale:

A licensed practical nurse should not be assigned to initiate a blood transfusion. The LPN can
assist with the transfusion and check ID numbers for the RN. The licensed practical nurse can be
assigned to insert Foley and French urinary catheters, discontinue Levine and Gavage gastric
tubes, and obtain all types of specimens, so answers A, B, and C are incorrect.
91. The nurse witnesses the nursing assistant hitting the client in the long- term care facility. The
nursing assistant can be charged with:
A. Negligence
B. Tort
C. Assault
D. Malpractice
Answer: C
Rationale:
Assault is defined as striking or touching the client inappropriately, so a nurse assistant striking a
client could be charged with assault. Answer A, negligence, is failing to perform care for the
client. Answer B, a tort, is a wrongful act committed on the client or their belongings. Answer D,
malpractice, is failure to perform an act that the nursing assistant knows should be done, or the
act of doing something wrong that results in harm to the client.
92. The nurse is planning room assignments for the day. Which client should be assigned to a
private room if only one is available?
A. The client with Cushing’s disease
B. The client with diabetes
C. The client with acromegaly
D. The client with myxedema
Answer: A
Rationale:
The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of
cortisone causes the client to be immune suppressed. In answer B, the client with diabetes poses
no risk to other clients. The client in answer C has an increase in growth hormone and poses no

risk to himself or others. The client in answer D has hyperthyroidism or myxedema, and poses no
risk to others or himself.
93. The nurse is making assignments for the day. Which client should be assigned to the pregnant
nurse?
A. The client receiving linear accelerator radiation therapy for lung cancer
B. The client with a radium implant for cervical cancer
C. The client who has just been administered soluble brachytherapy for thyroid cancer
D. The client who returned from placement of iridium seeds for prostate cancer
Answer: A
Rationale:
The pregnant nurse should not be assigned to any client with radioactivity present. Therefore, the
client receiving linear accelerator therapy is correct because this client travels to the radium
department for therapy, and the radiation stays in the department; the client is not radioactive.
The client in answer B does pose a risk to the pregnant client. The client in answer C is
radioactive in very small doses. For approximately 72 hours, the client should dispose of urine
and feces in special containers and use plastic spoons and forks. The client in answer D is also
radioactive in small amounts, especially upon return from the procedure.
94. The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the
following drugs reverses the effects of heparin?
A. Cyanocobalamine
B. Protamine sulphate
C. Streptokinase
D. Sodium warfarin
Answer: B
Rationale:
The antidote for heparin is protamine sulphate. Cyanocobalamine is B12, Streptokinase is a
thrombolytic, and sodium warfarin is an anticoagulant. Therefore, answers A, C, and D are
incorrect.

95. The client is admitted with a BP of 210/120. Her doctor orders furosemide (Lasix) 40mg IV
stat. How should the nurse administer the prescribed furosemide to this client?
A. By giving it over 1–2 minutes
B. By hanging it IV piggyback
C. With normal saline only
D. By administering it through a venous access device
Answer: A
Rationale:
Lasix should be given approximately 1mL per minute to prevent hypotension. Answers B, C, and
D are incorrect because it is not necessary to be given in an IV piggyback, with saline, or through
a venous access device (VAD).
96. The physician prescribes captopril (Capoten) 25mg po tid for the client with hypertension.
Which of the following adverse reactions can occur with administration of Capoten?
A. Tinnitus
B. Persistent cough
C. Muscle weakness
D. Diarrhoea
Answer: B
Rationale:
A persistent cough might be related to an adverse reaction to Captoten. Answers A and D are
incorrect because tinnitus and diarrhoea are not associated with the medication. Muscle
weakness might occur when beginning the treatment but is not an adverse effect; thus, answer C
is incorrect.
97. The doctor orders 2% nitro-glycerine ointment in a 1-inch dose every 12 hours. Proper
application of nitro-glycerine ointment includes:
A. Rotating application sites
B. Limiting applications to the chest
C. Rubbing it into the skin
D. Covering it with a gauze dressing

Answer: A
Rationale:
Sites for the application of nitro-glycerine should be rotated, to prevent skin irritation. It can be
applied to the back and upper arms, not to the lower extremities, making answer B incorrect.
Answer C is contraindicated to the question, and answer D is incorrect because the medication
should be covered with a prepared dressing made of a thin paper substance, not gauze.
98. Lidocaine is a medication frequently ordered for the client experiencing:
A. Atrial tachycardia
B. Ventricular tachycardia
C. Heart block
D. Ventricular brachy cardia
Answer: B
Rationale:
Lidocaine is used to treat ventricular tachycardia. This medication slowly exerts an
antiarrhythmic effect by increasing the electric stimulation threshold of the ventricles without
depressing the force of ventricular contractions. It is not used for atrial arrhythmias; thus, answer
A is incorrect. Answers C and D are incorrect because it slows the heart rate, so it is not used for
heart block or brachy cardia.
99. The client is admitted to the emergency room with shortness of breath, anxiety, and
tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per
minute. The doctor orders quinidine sulphate. While he is receiving quinidine, the nurse should
monitor his ECG for:
A. Peaked P wave
B. Elevated ST segment
C. Inverted T wave
D. Prolonged QT interval
Answer: D
Rationale:

Quinidine can cause widened Q-T intervals and heart block. Other signs of myocardial toxicity
are notched P waves and widened QRS complexes. The most common side effects are diarrhoea,
nausea, and vomiting. The client might experience tinnitus, vertigo, headache, visual
disturbances, and confusion. Answers A, B, and C are not related to the use of quinidine.
100. The physician has prescribed tranylcypromine sulphate (Parnate) 10mg bid. The nurse
should teach the client to refrain from eating foods containing tyramine because it may cause:
A. Hypertension
B. Hyperthermia
C. Melanoma
D. Urinary retention
Answer: A
Rationale:
If the client eats foods high in tyramine, he might experience malignant hypertension. Tyramine
is found in cheese, sour cream, Chianti wine, sherry, beer, pickled herring, liver, canned figs,
raisins, bananas, avocados, chocolate, soy sauce, fava beans, and yeast. These episodes are
treated with Regitine, an alpha-adrenergic blocking agent. Answers B, C, and D are not related to
the question.
101. The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the
following statements by the patient’s mother indicates to the nurse that the patient is
experiencing a side effect of Dilantin therapy?
A. “She is very irritable lately.”
B. “She sleeps quite a bit of the time.”
C. “Her gums look too big for her teeth.”
D. “She has gained about 10 pounds in the last 6 months.”
Answer: C
Rationale:
Hyperplasia of the gums is associated with Dilantin therapy. Answer A is not related to the
therapy; answer B is a side effect, and answer D is not related to the question.

102. A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following
would indicate a complication of the surgery?
A. Decreased appetite
B. A low-grade fever
C. Chest congestion
D. Constant swallowing
Answer: D
Rationale:
A complication of a tonsillectomy is bleeding, and constant swallowing may indicate bleeding.
Decreased appetite is expected after a tonsillectomy, as is a low-grade temperature; thus, answers
A and B are incorrect. In answer C, chest congestion is not normal but is not associated with the
tonsillectomy.
103. A 6-year-old with cerebral palsy functions at the level of an 18-month- old. Which finding
would support that assessment?
A. She dresses herself.
B. She pulls a toy behind her.
C. She can build a tower of eight blocks.
D. She can copy a horizontal or vertical line.
Answer: B
Rationale:
Children at 18 months of age like push-pull toys. Children at approximately 3 years of age begin
to dress themselves and build a tower of eight blocks. At age four, children can copy a horizontal
or vertical line. Therefore, answers A, C, and D are incorrect.
104. Which information obtained from the mother of a child with cerebral palsy most likely
correlates to the diagnosis?
A. She was born at 42 weeks gestation.
B. She had meningitis when she was 6 months old.
C. She had physiologic jaundice after delivery.
D. She has frequent sore throats.

Answer: B
Rationale:
The diagnosis of meningitis at age 6 months correlates to a diagnosis of cerebral palsy. Cerebral
palsy, a neurological disorder, is often associated with birth trauma or infections of the brain or
spinal column. Answers A, C, and D are not related to the question.
105. A 10-year-old is being treated for asthma. Before administering Theodur, the nurse should
check the:
A. Urinary output
B. Blood pressure
C. Pulse
D. Temperature
Answer: C
Rationale:
Theodur is a bronchodilator, and a side effect of bronchodilators is tachycardia, so checking the
pulse is important. Extreme tachycardia should be reported to the doctor. Answers A, B, and D
are not necessary.
106. An elderly client is diagnosed with ovarian cancer. She has surgery followed by
chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals
and cloudiness in the IV medication?
A. Discard the solution and order a new bag
B. Warm the solution
C. Continue the infusion and document the finding
D. Discontinue the medication
Answer: A
Rationale:
Crystals in the solution are not normal and should not be administered to the client. Discard the
bad solution immediately. Answer B is incorrect because warming the solution will not help.
Answer C is incorrect, and answer D requires a doctor’s order.

107. The client is diagnosed with multiple myoloma. The doctor has ordered cyclophosphamide
(Cytoxan). Which instruction should be given to the client?
A. “Walk about a mile a day to prevent calcium loss.”
B. “Increase the fiber in your diet.”
C. “Report nausea to the doctor immediately.”
D. “Drink at least eight large glasses of water a day.”
Answer: D
Rationale:
Cytoxan can cause haemorrhagic cystitis, so the client should drink at least eight glasses of water
a day. Answers A and B are not necessary and, so, are incorrect. Nausea often occurs with
chemotherapy, so answer C is incorrect.
108. The client is taking rifampin 600mg po daily to treat his tuberculosis. Which action by the
nurse indicates understanding of the medication?
A. Telling the client that the medication will need to be taken with juice
B. Telling the client that the medication will change the color of the urine
C. Telling the client to take the medication before going to bed at night
D. Telling the client to take the medication if night sweats occur
Answer: B
Rationale:
Rifampin can change the color of the urine and body fluid. Teaching the client about these
changes is best because he might think this is a complication. Answer A is not necessary, answer
C is not true, and answer D is not true because this medication should be taken regularly during
the course of the treatment.
109. The client is taking prednisone 7.5mg po each morning to treat his systemic lupus
errythymatosis. Which statement best explains the reason for taking the prednisone in the
morning?
A. There is less chance of forgetting the medication if taken in the morning.
B. There will be less fluid retention if taken in the morning.
C. Prednisone is absorbed best with the breakfast meal.

D. Morning administration mimics the body’s natural secretion of corticosteroid.
Answer: D
Rationale:
Taking corticosteroids in the morning mimics the body’s natural release of cortisol. Answers A is
not necessarily true, and answers B and C are not true.
110. A 20-year-old female has a prescription for tetracycline. While teaching the client how to
take her medicine, the nurse learns that the client is also taking Ortho-Novum oral contraceptive
pills. Which instructions should be included in the teaching plan?
A. The oral contraceptives will decrease the effectiveness of the tetracycline.
B. Nausea often results from taking oral contraceptives and antibiotics.
C. Toxicity can result when taking these two medications together.
D. Antibiotics can decrease the effectiveness of oral contraceptives, so the client should use an
alternate method of birth control.
Answer: D
Rationale:
Taking antibiotics and oral contraceptives together decreases the effectiveness of the oral
contraceptives. Answers A, B, and C are not necessarily true.
111. A 60-year-old diabetic is taking glyburide (Diabetes) 1.25mg daily to treat Type II diabetes
mellitus. Which statement indicates the need for further teaching?
A. “I will keep candy with me just in case my blood sugar drops.”
B. “I need to stay out of the sun as much as possible.”
C. “I often skip dinner because I don’t feel hungry.”
D. “I always wear my medical identification.”
Answer: C
Rationale:
The client should be taught to eat his meals even if he is not hungry, to prevent a hypoglycaemic
reaction. Answers A, B, and D are incorrect because they indicate an understanding of the nurse’s
teaching.

112. The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to
exert an effect:
A. In 5–10 minutes
B. In 10–20 minutes
C. In 30–60 minutes
D. In 60–120 minutes
Answer: C
Rationale:
The time of onset for regular insulin is 30–60 minutes; therefore, answers A, B, and D are
incorrect.
113. The client is admitted from the emergency room with multiple injuries sustained from an
auto accident. His doctor prescribes a histamine blocker. The reason for this order is:
A. To treat general discomfort
B. To correct electrolyte imbalances
C. To prevent stress ulcers
D. To treat nausea
Answer: C
Rationale:
Histamine blockers are frequently ordered for clients who are hospitalized for prolonged periods
and who are in a stressful situation. They are not used to treat discomfort, correct electrolytes, or
treat nausea; therefore, answers A, B, and D are incorrect.
114. The client with a recent liver transplant asks the nurse how long he will have to take
cyclosporine (Sandimmune). Which response is correct?
A. 1 year
B. 5 years
C. 10 years
D. The rest of his life
Answer: D
Rationale:

Cyclosporin is an immunosuppressant, and the client with a liver transplant will be on
immunosuppressants for the rest of his life. Answers A, B, and C, therefore, are incorrect.
115. Shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia
rubra with large clots. The nurse should anticipate an order for:
A. Methergine
B. Stadol
C. Magnesium sulphate
D. Phenergan
Answer: A
Rationale:
Methergine is a drug that causes uterine contractions. It is used for postpartal bleeding that is not
controlled by Pitocin. Answers B, C, and D are incorrect: Stadol is an analgesic; magnesium
sulfate is used for preeclampsia; and phenergan is an antiemetic.
116. The client is scheduled to have an intravenous cholangiogram. Before the procedure, the
nurse should assess the patient for:
A. Shellfish allergies
B. Reactions to blood transfusions
C. Gallbladder disease
D. Egg allergies
Answer: A
Rationale:
Clients having dye procedures should be assessed for allergies to iodine or shellfish. Answers B
and D are incorrect because there is no need for the client to be assessed for reactions to blood or
eggs. Because an IV cholangiogram is done to detect gallbladder disease, there is no need to ask
about answer C.
117. A new diabetic is learning to administer his insulin. He receives 10U of NPH and 12U of
regular insulin each morning. Which of the following statements reflects understanding of the
nurse’s teaching?

A. “When drawing up my insulin, I should draw up the regular insulin first.”
B. “When drawing up my insulin, I should draw up the NPH insulin first.”
C. “It doesn’t matter which insulin I draw up first.”
D. “I cannot mix the insulin, so I will need two shots.”
Answer: A
Rationale:
Regular insulin should be drawn up before the NPH. They can be given together, so there is no
need for two injections, making answer D incorrect. Answer B is obviously incorrect, and answer
C is incorrect because it does matter which is drawn first: Contamination of NPH into regular
insulin will result in a hypoglycaemic reaction at unexpected times.
118. A client with osteomyelitis has an order for a trough level to be done because he is taking
Gentamycin. When should the nurse call the lab to obtain the trough level?
A. Before the first dose
B. 30 minutes before the fourth dose
C. 30 minutes after the first dose
D. 30 minutes after the fourth dose
Answer: B
Rationale:
Trough levels are the lowest blood levels and should be done 30 minutes before the third IV dose
or 30 minutes before the fourth IM dose. Answers A, C, and D are incorrect.
119. A 4-year-old with cystic fibrosis has a prescription for Viokase pancreatic enzymes to
prevent malabsorption. The correct time to give pancreatic enzyme is:
A. 1 hour before meals
B. 2 hours after meals
C. With each meal and snack
D. On an empty stomach
Answer: C
Rationale:

Viokase is a pancreatic enzyme that is used to facilitate digestion. It should be given with meals
and snacks, and it works well in foods such as applesauce. Answers A, B, and D are incorrect
times to administer this medication.
120. Isoniazid (INH) has been prescribed for a family member exposed to tuberculosis. The
nurse is aware that the length of time that the medication will be taken is:
A. 6 months
B. 3 months
C. 18 months
D. 24 months
Answer: A
Rationale:
The expected time for contact to tuberculosis is 1 year. Therefore, answers B, C, and D are
incorrect.
121. The client is admitted to the postpartum unit with an order to continue the infusion of
Pitocin. Which finding indicates that the Pitocin is having the desired effect?
A. The fundus is deviated to the left.
B. The fundus is firm and in the midline.
C. The fundus is boggy.
D. The fundus is two finger breadths below the umbilicus.
Answer: B
Rationale:
Pitocin is used to cause the uterus to contract and decrease bleeding. A uterus deviated to the left,
as stated in answer A, indicates a full bladder. It is not desirable to have a boggy uterus, making
answer C incorrect. This lack of muscle tone will increase bleeding. Answer D is incorrect
because the position of the uterus is not related to the use of Pitocin.
122. The nurse is teaching a group of new graduates about the safety needs of the client receiving
chemotherapy. Before administering chemotherapy, the nurse should:
A. Administer a bolus of IV fluid

B. Administer pain medication
C. Administer an antiemetic
D. Allow the patient a chance to eat
Answer: C
Rationale:
Before chemotherapy, an antiemetic should be given because most chemotherapy agents cause
nausea. It is not necessary to give a bolus of IV fluids, medicate for pain, or allow the client to
eat; therefore, answers A, B, and D are incorrect.
123. Before administering Methytrexate orally to the client with cancer, the nurse should check
the:
A. IV site
B. Electrolytes
C. Blood gases
D. Vital signs
Answer: D
Rationale:
The vital signs should be taken before any chemotherapy agent. If it is an IV infusion of
chemotherapy, the nurse should check the IV site as well. Answers B and C are incorrect because
it is not necessary to check the electrolytes or blood gases.
124. Vitamin K (aquamephyton) is administered to a newborn shortly after birth for which of the
following reasons?
A. To prevent dehydration
B. To treat infection
C. To replace electrolytes
D. To facilitate clotting
Answer: D
Rationale:
Vitamin K is given after delivery because the newborn’s intestinal tract is sterile and lacks
vitamin K needed for clotting. Answer A is incorrect because vitamin K is not directly given to

prevent dehydration, but will facilitate clotting. Answers B and C are incorrect because vitamin
K does not prevent infection or replace electrolytes.
125. The client with an ileostomy is being discharged. Which teaching should be included in the
plan of care?
A. Use Karaya powder to seal the bag.
B. Irrigate the ileostomy daily.
C. Stomahesive is the best skin protector.
D. Neosporin ointment can be used to protect the skin.
Answer: C
Rationale:
The best protector for the client with an ileostomy to use is stomahesive. Answer A is not correct
because the bag will not seal if the client uses Karaya powder. Answer B is incorrect because
there is no need to irrigate an ileostomy. Neosporin, answer D, is not used to protect the skin
because it is an antibiotic.
126. The client has an order for FeSo4 liquid. Which method of administration would be best?
A. Administer the medication with milk
B. Administer the medication with a meal
C. Administer the medication with orange juice
D. Administer the medication undiluted
Answer: C
Rationale:
FeSO4 or iron should be given with ascorbic acid (vitamin C). This helps with the absorption. It
should not be given with meals or milk because this decreases the absorption; thus, answers A
and B are incorrect. Giving it undiluted, as stated in answer D, is not good because it tastes bad.
127. The client arrives in the emergency room with a hyphema. Which action by the nurse would
be best?
A. Elevate the head of the bed and apply ice to the eye
B. Place the client in a supine position and apply heat to the knee

C. Insert a Foley catheter and measure the intake and output
D. Perform a vaginal exam and check for a discharge
Answer: A
Rationale:
Hyphema is blood in the anterior chamber of the eye and around the eye. The client should have
the head of the bed elevated and ice applied. Answers B, C, and D are incorrect and do not treat
the problem.
128. The nurse is making assignments for the day. Which client should be assigned to the nursing
assistant?
A. The 18-year-old with a fracture to two cervical vertebrae
B. The infant with meningitis
C. The elderly client with a thyroidectomy 4 days ago
D. The client with a thoracotomy 2 days ago
Answer: C
Rationale:
The most stable client is the client with the thyroidectomy 4 days ago. Answers A, B, and D are
incorrect because the other clients are less stable and require a registered nurse.
129. The client arrives in the emergency room with a “bull’s eye” rash. Which question would be
most appropriate for the nurse to ask the client?
A. “Have you found any ticks on your body?”
B. “Have you had any nausea in the last 24 hours?”
C. “Have you been outside the country in the last 6 months?”
D. “Have you had any fever for the past few days?”
Answer: A
Rationale:
The “bull’s eye” rash is indicative of Lyme’s disease, a disease spread by ticks. The signs and
symptoms include elevated temperature, headache, nausea, and the rash. Although answers B and
D are important, the question asks which would be best. Answer C has no significance.

130. Which of the following is the best indicator of the diagnosis of HIV?
A. White blood cell count
B. ELISA
C. Western Blot
D. Complete blood count
Answer: C
Rationale:
The most definitive diagnostic tool for HIV is the Western Blot. The white blood cell count, as
stated in answer A, is not the best indicator, but a white blood cell count of less than 3,500
requires investigation. The ELISA test, answer B, is a screening exam. Answer D is not specific
enough.
131. The client has an order for gentamycin to be administered. Which lab results should be
reported to the doctor before beginning the medication?
A. Hematocrit
B. Creatinine
C. White blood cell count
D. Erythrocyte count
Answer: B
Rationale:
Gentamycin is a drug from the aminoglycoside classification. These drugs are toxic to the
auditory nerve and the kidneys. The haematocrit is not of significant consideration in this client;
therefore, answer A is incorrect. Answer C is incorrect because we would expect the white blood
cell count to be elevated in this client because gentamycin is an antibiotic. Answer D is incorrect
because the erythrocyte count is also particularly significant
132. The nurse is caring for the client with a mastectomy. Which action would be
contraindicated?
A. Taking the blood pressure in the side of the mastectomy
B. Elevating the arm on the side of the mastectomy
C. Positioning the client on the unaffected side

D. Performing a dextrostix on the unaffected side
Answer: A
Rationale:
The nurse should not take the blood pressure on the affected side. Also, venopunctures and IVs
should not be used in the affected area. Answers B, C, and D are all indicated for caring for the
client. The arm should be elevated to decrease edema. It is best to position the client on the
unaffected side and perform a dextrostix on the unaffected side.
133. The charge nurse is making assignments for the day. After accepting the assignment to a
client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which action
should the charge nurse take?
A. Change the nurse’s assignment to another client
B. Explain to the nurse that there is no risk to the client
C. Ask the nurse if the chickenpox have scabbed
D. Ask the nurse if she has ever had the chickenpox
Answer: D
Rationale:
The nurse who has had the chickenpox has immunity to the illness. Answer A is incorrect
because more information is needed to determine whether a change in assignment is necessary.
Answer B is incorrect because there could be a risk to the immune-suppressed client. Answer C
is incorrect because the client who is immune-suppressed could still be at risk from the nurse’s
exposure to the chickenpox, even if scabs are present.
134. The client with brain cancer refuses to care for herself. Which action by the nurse would be
best?
A. Alternate nurses caring for the client so that the staff will not get tired of caring for this client
B. Talk to the client and explain the need for self-care
C. Explore the reason for the lack of motivation seen in the client
D. Talk to the doctor about the client’s lack of motivation
Answer: C
Rationale:

The nurse should explore the cause for the lack of motivation. The client might be anaemic and
lack energy, might be in pain, or might be depressed. Alternating staff, as stated in answer A, will
prevent a bond from being formed with the nurse. Answer B is not enough, and answer D is not
necessary.
135. The nurse is caring for the client who has been in a coma for 2 months. He has signed a
donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle
the topic of organ donation with the wife?
A. Contact organ retrieval to come talk to the wife
B. Tell her that because her husband signed a donor card, the hospital has the right to take the
organs upon the death of her husband
C. Drop the subject until a later time
D. Refrain from talking about the subject until after the death of her husband
Answer: A
Rationale:
Contacting organ retrieval to talk to the family member is the best choice because a trained
specialist has the knowledge to assist the wife with making the decision to donate or not to
donate the client’s organs. The hospital will certainly honour the wishes of family members even
if the patient has signed a donor card. Answer B is incorrect; answer C might be done, but there
might not be time; and answer D is not good nursing etiquette and, therefore, is incorrect.
136. The nurse is assessing the abdomen. The nurse knows the best sequence to perform the
assessment is:
A. Inspection, auscultation, palpation
B. Auscultation, palpation, inspection
C. Palpation, inspection, auscultation
D. Inspection, palpation, auscultation
Answer: A
Rationale:
The nurse should inspect first, then auscultate, and finally palpate. If the nurse palpates first, the
assessment might be unreliable. Therefore, answers B, C, and D are incorrect.

137. The nurse is assisting in the assessment of the patient admitted with abdominal pain. Why
should the nurse ask about medications that the client is taking?
A. Interactions between medications can be identified.
B. Various medications taken by mouth can affect the alimentary tract.
C. This will provide an opportunity to educate the patient regarding the medications used.
D. The types of medications might be attributable to an abdominal pathology not already
identified.
Answer: B
Rationale:
Many medications can irritate the stomach and contribute to abdominal pain. For answer A, the
primary reason for asking about medications is not to identify interactions between medication.
Although this might provide an opportunity for teaching, this is not the best time to teach.
Therefore, answers C and D are incorrect.
138. The nurse is asked by the nurse aide, “Are peptic ulcers really caused by stress?” The nurse
would be correct in replying with which of the following:
A. “Peptic ulcers result from overeating fatty foods.”
B. “Peptic ulcers are always caused from exposure to continual stress.”
C. “Peptic ulcers are like all other ulcers, which all result from stress.”
D. “Peptic ulcers are associated with H. pylori, although there are other ulcers that are associated
with stress.”
Answer: D
Rationale:
H. pylori bacteria and stress are directly related to peptic ulcers. Answers A and B are incorrect
because peptic ulcers are not caused by overeating or always caused by continued stress. Answer
C is incorrect because peptic ulcers are related to but not directly caused by stress.
139. The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing
diagnoses is a priority?
A. Anxiety

B. Pain
C. Knowledge deficit
D. Altered thought process
Answer: C
Rationale:
The new diabetic has a knowledge deficit. Answers A, B, and D are not supported within the
stem and so are incorrect.
140. The nurse understands that the diagnosis of oral cancer is confirmed with:
A. Biopsy
B. Gram Stain
C. Scrape cytology
D. Oral washings for cytology
Answer: A
Rationale:
The best diagnostic tool for cancer is the biopsy. Other assessment includes checking the lymph
nodes. Answers B, C, and D will not confirm a diagnosis of oral cancer.
141. The nurse is assisting in the care of a patient who is 2 days post- operative from a
haemorrhoidectomy. The nurse would be correct in instructing the patient to:
A. Avoid a high-fibre diet because this can hasten the healing time
B. Continue to use ice packs until discharge and then when at home
C. Take 200mg of Colace bid to prevent constipation
D. Use a sitz bath after each bowel movement to promote cleanliness and comfort
Answer: D
Rationale:
The use of a sitz bath will help with the pain and swelling associated with a haemorrhoidectomy.
The client should eat foods high in fibre, so answer A is incorrect. Ice packs, as stated in answer
B, are ordered immediately after surgery only. Answer C, a stool softener, can be ordered, but
only by the doctor.

142. The nurse is caring for a patient with a colostomy. The patient asks, “Will I ever be able to
swim again?” The nurse’s best response would be:
A. “Yes, you should be able to swim again, even with the colostomy.”
B. “You should avoid immersing the colostomy in water.”
C. “No, you should avoid getting the colostomy wet.”
D. “Don’t worry about that. You will be able to live just like you did before.”
Answer: A
Rationale:
The client with a colostomy can swim and carry on activities as before the colostomy; therefore,
answers B and C are incorrect. Answer D shows a lack of empathy.
143. Which is true regarding the administration of antacids?
A. Antacids should be administered without regard to mealtimes.
B. Antacids should be administered with each meal and snack of the day.
C. Antacids should be administered within 1–2 hours of all other medications.
D. Antacids should be administered with all other medications, for maximal absorption.
Answer: C
Rationale:
Antacids should be administered within 1–2 hours of other medications. If antacids are taken
with many medications, they render the other medications inactive. All other answers are
incorrect.
144. The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would
perform which of the following before initiating the feeding?
A. Assess for tube placement by aspirating stomach content
B. Place the patient in a left-lying position
C. Administer feeding with 50% H20 concentration
D. Ensure that the feeding solution has been warmed in a microwave for 2 minutes
Answer: A
Rationale:

Before beginning feedings, an x-ray is often obtained to check for placement. Aspirating stomach
content and checking the pH for acidity is the best method of checking for placement. Other
methods include placing the end in water and checking for bubbling, and injecting air and
listening over the epigastric area. Answers B and C are not correct. Answer D is incorrect
because warming in the microwave is contraindicated.
145. The patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer.
When teaching about this medication, the nurse would say:
A. “This medication should be taken only until you begin to feel better.”
B. “This medication should be taken on an empty stomach to increase absorption.”
C. “While taking this medication, you do not have to be concerned about being in the sun.”
D. “While taking this medication, alcoholic beverages and products containing alcohol should be
avoided.”
Answer: D
Rationale:
Alcohol will cause extreme nausea if consumed with Flagyl. Answer A is incorrect because the
full course of treatment should be taken. The medication should be taken with a full 8oz. of
water, with meals, and the client should avoid direct sunlight because he will most likely be
photosensitive; therefore, answers A, B, and C are incorrect.
146. In planning care for the patient with ulcerative colitis, the nurse identifies which nursing
diagnoses as a priority?
A. Anxiety
B. Impaired skin integrity
C. Fluid volume deficit
D. Nutrition altered, less than body requirements
Answer: C
Rationale:
Fluid volume deficit can lead to metabolic acidosis and electrolyte loss. The other nursing
diagnoses in answers A, B, and D might be applicable but are of lesser priority.

147. The nurse is teaching about irritable bowel syndrome (IBS). Which of the following would
be most important?
A. Reinforcing the need for a balanced diet
B. Encouraging the client to drink 16 ounces of fluid with each meal
C. Telling the client to eat a diet low in fibre
D. Instructing the client to limit his intake of fruits and vegetables
Answer: A
Rationale:
The nurse should reinforce the need for a diet balanced in all nutrients and fibre. Foods that often
cause diarrhoea and bloating associated with irritable bowel syndrome include fried foods,
caffeinated beverages, alcohol, and spicy foods. Therefore, answers B, C, and D are incorrect.
148. The nurse is planning care for the patient with celiac disease. In teaching about the diet, the
nurse should instruct the patient to avoid which of the following for breakfast?
A. Cream of wheat
B. Banana
C. Puffed rice
D. Cornflakes
Answer: A
Rationale:
Clients with celiac disease should refrain from eating foods containing gluten. Foods with gluten
include wheat barley, oats, and rye. The other foods are allowed.
149. The nurse is caring for a patient with suspected diverticulitis. The nurse would be most
prudent in questioning which of the following diagnostic tests ordered?
A. Colonoscopy
B. Barium enema
C. Complete blood count
D. Computed tomography (CT) scan
Answer: B
Rationale:

A barium enema is contraindicated in the client with diverticulitis because it can cause bowel
perforation. Answers A, C, and D are appropriate diagnostic studies for the client with
diverticulitis.
150. When the nurse is gathering information for the assessment, the patient states, “My stomach
hurts about 2 hours after I eat.” Based upon this information, the nurse knows the patient likely
has a:
A. Gastric ulcer
B. Duodenal ulcer
C. Peptic ulcer
D. Curling’s ulcer
Answer: B
Rationale:
Individuals with ulcers within the duodenum typically complain of pain occurring 2– 3 hours
after a meal, as well as at night. The pain is usually relieved by eating. The pain associated with
gastric ulcers, answer A, occurs 30 minutes after eating. Answer C is too vague and does not
distinguish the type of ulcer. Answer D is associated with stress.
151. The registered nurse is conducting an in-service for colleagues about peptic ulcers. The
nurse would be correct in identifying which of the following as a causative factor?
A. N. gonorrhoea
B. H. influenza
C. H. pylori
D. E. coli
Answer: C
Rationale:
H. pylori bacteria has been linked to peptic ulcers. Answers A, B, and D are not typically
cultured within the stomach, duodenum, or esophagus, and are not related to the development of
peptic ulcers.

152. The nurse is caring for the patient’s post-surgical removal of a 6mm oral cancerous lesion.
The priority nursing measure would be to:
A. Maintain a patent airway
B. Perform meticulous oral care every 2 hours
C. Ensure that the incisional area is kept as dry as possible
D. Assess the client frequently for pain using the visual analogue scale
Answer: A
Rationale:
Maintaining a patient’s airway is paramount in the post-operative period. This is the priority of
nursing care. Answers B, C, and D are applicable but are not the priority. The nurse should
instruct the client to perform mouth care using a soft sponge toothette or irrigate the mouth with
normal saline. The incision should be kept as dry as possible, and pain should be treated. Pain
medications should be administered PRN.
153. The nurse is assisting in the care of a patient with diverticulosis. Which of the following
assessment findings would necessitate a report to the doctor?
A. Bowel sounds of 5–20 seconds
B. Intermittent left lower-quadrant pain
C. Constipation alternating with diarrhoea
D. Haemoglobin 26% and haematocrit 32
Answer: D
Rationale:
Low haemoglobin and haematocrit might indicate intestinal bleeding. Answers A, B, and C are
normal lab values.
154. The nurse is assessing the client admitted for possible oral cancer. The nurse identifies
which of the following as a late-occurring symptom of oral cancer?
A. Warmth
B. Odor
C. Pain
D. Ulcer with flat edges

Answer: C
Rationale:
Pain is a late sign of oral cancer. Answers A, B, and D are incorrect because a feeling of warmth,
Odor, and a flat ulcer in the mouth are all early occurrences of oral cancer.
155. An obstetrical client decides to have an epidural anaesthetic to relieve pain during labor.
Following administration of the aesthesia, the nurse should:
A. Monitor the client for seizures
B. Monitor the client for orthostatic hypotension
C. Monitor the client for respiratory depression
D. Monitor the client for haematuria
Answer: C
Rationale:
Epidural anaesthesia involves injecting an anaesthetic into the epidural space. If the anaesthetic
rises above the respiratory centre, the client will have impaired breathing; thus, monitoring for
respiratory depression is necessary. Answer A, seizure activity, is not likely after an epidural.
Answer B, orthostatic hypotension, occurs when the client stands up but is not a monitoring
action. The client with an epidural anaesthesia must remain flat on her back and should not stand
up for 24 hours. Answer D, haematuria, is not related to epidural anaesthesia.
156. The nurse is performing an assessment of an elderly client with a total hip repair. Based on
this assessment, the nurse decides to medicate the client with an analgesic. Which finding most
likely prompted the nurse to decide to administer the analgesic?
A. The client’s blood pressure is 130/86.
B. The client is unable to concentrate.
C. The client’s pupils are dilated.
D. The client grimaces during care.
Answer: D
Rationale:

Facial grimace is an indication of pain. The blood pressure in answer A is within normal limits.
The client’s inability to concentrate, along with dilated pupils, as stated in answers B and C, may
be related to the anaesthesia that he received during surgery.
157. A client who has chosen to breastfeed complains to the nurse that her nipples became very
sore while she was breastfeeding her older child. Which measure will help her to avoid soreness
of the nipples?
A. Feeding the baby during the first 48 hours after delivery
B. Breaking suction by placing a finger between the baby’s mouth and the breast when she
terminates the feeding
C. Applying warm, moist soaks to the breast several times per day
D. Wearing a support bra
Answer: B
Rationale:
To decrease the potential for soreness of the nipples, the client should be taught to break the
suction before removing the baby from the breast. Answer A is incorrect because feeding the
baby during the first 48 hours after delivery will provide colostrum but will not help the soreness
of the nipples. Answers C and D are incorrect because applying warm, moist soaks and wearing a
support bra will help with engorgement but will not help the nipples.
158. The nurse asked the client if he has an advance directive. The reason for asking the client
this question is:
A. She is curious about his plans regarding funeral arrangements.
B. Much confusion can occur with the client’s family if he does not have an advanced directive.
C. An advanced directive allows the medical personnel to make all decisions for the client.
D. An advanced directive allows active euthanasia.
Answer: B
Rationale:
An advanced directive allows the client to make known his wishes regarding care if he becomes
unable to act on his own. Much confusion regarding life-saving measures can occur if the client
does not have an advanced directive. Answers A, C, and D are incorrect because the nurse

doesn’t need to know about funeral plans and cannot make decisions for the client, and active
euthanasia is illegal in most states in the United States.
159. The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the
client with chronic back pain. The nurse teaching the client with a TENS unit should tell the
client:
A. “You may be electrocuted if you use water with this unit.”
B. “Please report skin irritation to the doctor.”
C. “The unit may be used anywhere on the body without fear of adverse reactions.”
D. “A cream should be applied to the skin before applying the unit.”
Answer: B
Rationale:
Skin irritation can occur if the TENS unit is used for prolonged periods of time. To prevent skin
irritations, the client should change the location of the electrodes often.
Electrocution is not a risk because it uses a battery pack; thus, answer A is incorrect. Answer C is
incorrect because the unit should not be used on sensitive areas of the body. Answer D is
incorrect because no creams are to be used with the device.
160. The doctor has ordered a patient-controlled analgesia (PCA) pump for the client with
chronic pain. The client asks the nurse if he can become overdosed with pain medication using
this machine. The nurse demonstrates understanding of the PCA if she states:
A. “The machine will administer only the amount that you need to control your pain without
your taking any action.”
B. “The machine has a locking device that prevents overdosing to occur.”
C. “The machine will administer one large dose every 4 hours to relieve your pain.”
D. “The machine is set to deliver medication only if you need it.”
Answer: B
Rationale:
The client is concerned about overdosing himself. The machine will deliver a set amount as
ordered and allow the client to self-administer a small amount of medication. PCA pumps
usually are set to lock out the amount of medication that the client can give himself at 5- to 15-

minute intervals. Answer A does not address the client’s concerns, answer C is incorrect, and
answer D does not address the client’s concerns.
161. The 84-year-old male has returned from the recovery room following a total hip repair. He
complains of pain and is medicated by morphine sulphate and promethazine. Which medication
should be kept available for the client being treated with opioid analgesics?
A. Nalozone (Narcan)
B. Ketorolac (Toradol)
C. Acetylsalicylic acid (aspirin)
D. Atropine sulphate (Atropine)
Answer: A
Rationale:
Narcan is the antidote for the opoid analgesics. Toradol (answer B) is a nonopoid analgesic;
aspirin (answer C) is an analgesic, anticoagulant, and antipyretic; and atropine (answer D) is an
anticholengergic.
162. The nurse is taking the vital signs of the client admitted with cancer of the pancreas. The
nurse is aware that the fifth vital sign is:
A. Anorexia
B. Pain
C. Insomnia
D. Fatigue
Answer: B
Rationale:
The fifth vital sign is pain. Nurses should assess and record pain just as they would temperature,
respirations, pulse, and blood pressure. Answers A, C, and D are included in the charting but are
not considered to be the fifth vital sign and are, therefore, incorrect.
163. The client with AIDS tells the nurse that he has been using acupuncture to help with his
pain. The nurse should question the client regarding this treatment because acupuncture:
A. Uses pressure from the fingers and hands to stimulate the energy points in the body

B. Uses oils extracted from plants and herbs
C. Uses needles to stimulate certain points on the body to treat pain
D. Uses manipulation of the skeletal muscles to relieve stress and pain
Answer: C
Rationale:
Acupuncture uses needles, and because HIV is transmitted by blood and body fluids, the nurse
should question this treatment. Answer A describes acupressure, and answers B and D describe
massage therapy with the use of oils.
164. The client has an order for heparin to prevent post-surgical thrombi. Immediately following
a heparin injection, the nurse should:
A. Aspirate for blood
B. Check the pulse rate
C. Massage the site
D. Check the site for bleeding
Answer: D
Rationale:
After administering any subcutaneous anticoagulant, the nurse should check the site for bleeding.
Answers A and C are incorrect because aspirating and massaging the site are not done. Checking
the pulse is not necessary, as in answer B.
165. Which of the following lab studies should be done periodically if the client is taking sodium
warfarin (Coumadin)?
A. Stool specimen for occult blood
B. White blood cell count
C. Blood glucose
D. Erthyrocyte count
Answer: A
Rationale:
An occult blood test should be done periodically to detect any intestinal bleeding on the client
with coumadin therapy. Answers B, C, and D are not directly related to the question.

166. The doctor has ordered 80mg of furosemide (Lasix) two times per day. The nurse notes the
patient’s potassium level to be 2.5meq/L. The nurse should:
A. Administer the Lasix as ordered
B. Administer half the dose
C. Offer the patient a potassium-rich food
D. Withhold the drug and call the doctor
Answer: D
Rationale:
The potassium level of 2.5meq/L is extremely low. The normal is 3.5–5.5meq/L. Lasix
(furosemide) is a nonpotassium sparing diuretic, so answer A is incorrect. The nurse cannot alter
the doctor’s order, as stated in answer B, and answer C will not help with this situation.
167. The doctor is preparing to remove chest tubes from the client’s left chest. In preparation for
the removal, the nurse should instruct the client to:
A. Breathe normally
B. Hold his breath and bear down
C. Take a deep breath
D. Sneeze on command
Answer: B
Rationale:
The client should be asked to perform Valsalva maneuver while the chest tube is being removed.
This prevents changes in pressure until an occlusive dressing can be applied. Answers A and C
are not recommended, and sneezing is difficult to perform on command.
168. The nurse identifies ventricular tachycardia on the heart monitor. Which action should the
nurse prepare to take?
A. Administer atropine sulphate
B. Check the potassium level
C. Administer an antiarrhythmic medication such as Lidocaine
D. Defibrillate at 360 joules

Answer: C
Rationale:
The treatment for ventricular tachycardia is lidocaine. A precordial thump is sometimes
successful in slowing the rate, but this should be done only if a defibrillator is available. In
answer A, atropine sulphate will speed the rate further; in answer B, checking the potassium is
indicated but is not the priority; and in answer D, defibrillation is used for pulseless ventricular
tachycardia or ventricular fibrillation. Also, defibrillation should begin at 200 joules and be
increased to 360 joules.
169. A client is being monitored using a central venous pressure monitor. If the pressure is 2cm
of water, the nurse should:
A. Call the doctor immediately
B. Slow the intravenous infusion
C. Listen to the lungs for rales
D. Administer a diuretic
Answer: A
Rationale:
The normal central venous pressure is 5–10cm of water. A reading of 2cm is low and should be
reported. Answers B, C, and D indicate that the nurse believes that the reading is too high and is
incorrect.
170. The nurse is evaluating the client’s pulmonary artery pressure. The nurse is aware that this
test will evaluate:
A. Pressure in the left ventricle
B. The systolic, diastolic, and mean pressure of the pulmonary artery
C. The pressure in the pulmonary veins
D. The pressure in the right ventricle
Answer: B
Rationale:
The pulmonary artery pressure will measure the pressure during systole, diastole, and the mean
pressure in the pulmonary artery. It will not measure the pressure in the left ventricle, the

pressure in the pulmonary veins, or the pressure in the right ventricle. Therefore, answers A, C,
and D are incorrect.
171. The physician has ordered atropine sulphate 0.4mg IM before surgery. The medication is
supplied in 0.8mg per millilitre. The nurse should administer how many millilitres of the
medication?
A. 0.25mL
B. 0.5mL
C. 1mL
D. 1.25mL
Answer: B
Rationale:
If the doctor orders 0.4mgm IM and the drug is available in 0.8/1mL, the nurse should make the
calculation: ?mL = 1mL / 0.8mgm; × 0.4mg / 1 = 0.5m. Answers A, C, and D are incorrect.
172. If the nurse is unable to illicit the deep tendon reflexes of the patella, the nurse should ask
the client to:
A. Pull against the palms
B. Grimace the facial muscles
C. Cross the legs at the ankles
D. Perform Valsalva maneuver
Answer: A
Rationale:
If the nurse cannot elicit the patella reflex (knee jerk), the client should be asked to pull against
the palms. This helps the client to relax the legs and makes it easier to get an objective reading.
Answers B, C, and D will not help with the test.
173. A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which of
the following should be reported to the doctor?
A. An elevated white blood cell count
B. An abdominal bruit

C. A negative Babinski reflex
D. Pupils that are equal and reactive to light
Answer: A
Rationale:
The elevated white blood cell count should be reported because this indicates infection. A bruit
will be heard if the client has an aneurysm, and a negative Babinski is normal in the adult, as are
pupils that are equal and reactive to light and accommodation; thus, answers B, C, and D are
incorrect.
174. A 4-year-old male is admitted to the unit with nephrotic syndrome. He is extremely
edematous. To decrease the discomfort associated with scrotal edema, the nurse should:
A. Apply ice to the scrotum
B. Elevate the scrotum on a small pillow
C. Apply heat to the abdominal area
D. Administer a diuretic
Answer: B
Rationale:
The child with nephotic syndrome will exhibit extreme edema. Elevating the scrotum on a small
pillow will help with the edema. Applying ice is contraindicated; heat will increase the edema.
Administering a diuretic might be ordered, but it will not directly help the scrotal edema.
Therefore, answers A, C, and D are incorrect.
175. The nurse is taking the blood pressure of an obese client. If the blood pressure cuff is too
small, the results will be:
A. A false elevation
B. A false low reading
C. A blood pressure reading that is correct
D. A subnormal finding
Answer: A
Rationale:

If the blood pressure cuff is too small, the result will be a blood pressure that is a false elevation.
Answers B, C, and D are incorrect. If the blood pressure cuff is too large, a false low will result.
Answers C and D have basically the same meaning.
176. The client is admitted with thrombophlebitis and an order for heparin. The medication
should be administered using:
A. Buretrol
B. A tuberculin syringe
C. Intravenous controller
D. Three-way stop-cock
Answer: B
Rationale:
To safely administer heparin, the nurse should obtain an infusion controller. Too rapid infusion of
heparin can result in hemorrhage. Answers A, C, and D are incorrect. It is not necessary to have a
buretrol, an infusion filter, or a three-way stop-cock.
177. The client is admitted to the hospital in chronic renal failure. A diet low in protein is
ordered. The rationale for a low-protein diet is:
A. Protein breaks down into blood urea nitrogen and metabolic waste.
B. High protein increases the sodium and potassium levels.
C. A high-protein diet decreases albumin production.
D. A high-protein diet depletes calcium and phosphorous.
Answer: A
Rationale:
A low-protein diet is required because protein breaks down into nitrogenous waste and causes an
increased workload on the kidneys. Answers B, C, and D are incorrect.
178. The client is admitted to the unit after a motor vehicle accident with a temperature of 102°F
rectally. The nurse is aware that the most likely explanation for the elevated temperature is:
A. There was damage to the hypothalamus.
B. He has an infection from the abrasions to the head and face.

C. He will require a cooling blanket to decrease the temperature.
D. There was damage to the frontal lobe of the brain.
Answer: A
Rationale:
Damage to the hypothalamus can result in an elevated temperature because this portion of the
brain helps to regulate body temperature. Answers B, C, and D are incorrect because there is no
data to support the possibility of an infection, a cooling blanket might not be required, and the
frontal lobe is not responsible for regulation of the body temperature.
179. The nurse is caring for the client following a cerebral vascular accident. Which portion of
the brain is responsible for taste, smell, and hearing?
A. Occipital
B. Frontal
C. Temporal
D. Parietal
Answer: C
Rationale:
The temporal lobe is responsible for taste, smell, and hearing. The occipital lobe is responsible
for vision. The frontal lobe is responsible for judgment, foresight, and behavior. The parietal lobe
is responsible for ideation, sensory functions, and language. Therefore, answers A, B, and D are
incorrect.
180. A 20-year-old is admitted to the rehabilitation unit following a motorcycle accident. Which
would be the appropriate method for measuring the client for crutches?
A. Measuring five finger breaths under the axilla
B. Measuring 3 inches under the axilla
C. Measuring the client with the elbows flexed 10°
D. Measuring the client with the crutches 20 inches from the side of the foot
Answer: B
Rationale:

To correctly measure the client for crutches, the nurse should measure approximately 3 inches
under the axilla. Answer A allows for too much distance under the arm. The elbows should be
flexed approximately 35°, not 10°, as stated in answer C. The crutches should be approximately
6 inches from the side of the foot, not 20 inches, as stated in answer D.
181. The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the
following is not a factor for the nurse to consider?
A. Dietary patterns
B. Mobility
C. Fluid intake
D. Sexual function
Answer: D
Rationale:
When assisting the client with bowel and bladder training, the least helpful factor is the sexual
function. Dietary history, mobility, and fluid intake are important factors; these must be taken
into consideration because they relate to constipation, urinary function, and the ability to use the
urinal or bedpan. Therefore, answers A, B, and C are incorrect.
182. The client returns to the recovery room following repair of an intrathoracic aneurysm.
Which finding would require further investigation?
A. Pedal pulses bounding and regular
B. Urinary output 20mL in the past hour
C. Blood pressure 108/50
D. Oxygen saturation 97%
Answer: B
Rationale:
Because the aorta is clamped during surgery, the blood supply to the kidneys is impaired. This
can result in renal damage. A urinary output of 20mL is oliguria. In answer A, the pedal pulses
that are thready and regular are within normal limits. For answer C, it is desirable for the client’s
blood pressure to be slightly low after surgical repair of an aneurysm. The oxygen saturation of
97% in answer D is within normal limits and, therefore, incorrect.

183. The nurse is teaching the client regarding use of sodium warfarin. Which statement made by
the client would require further teaching?
A. “I will have blood drawn every month.”
B. “I will assess my skin for a rash.”
C. “I take aspirin for a headache.”
D. “I will use an electric razor to shave.”
Answer: C
Rationale:
The client taking an anticoagulant should not take aspirin because it will further thin the blood.
He should return to have a Protime drawn for bleeding time, report a rash, and use an electric
razor. Therefore, answers A, B, and D are incorrect.
184. A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most
suitable roommate for this client is the client with:
A. Hypothyroidism
B. Diabetic ulcers
C. Ulcerative colitis
D. Pneumonia
Answer: A
Rationale:
The best roommate for the post-surgical client is the client with hypothyroidism. This client is
sleepy and has no infectious process. Answers B, C, and D are incorrect because the client with a
diabetic ulcer, ulcerative colitis, or pneumonia can transmit infection to the postsurgical client.
185. The nurse has just received shift report and is preparing to make rounds. Which client
should be seen first?
A. The client who has a history of a cerebral aneurysm with an oxygen saturation rate of 99%
B. The client who is three days post–coronary artery bypass graft with a temperature of 100.2°F
C. The client who was admitted 1 hour ago with shortness of breath
D. The client who is being prepared for discharge following a femoral popliteal bypass graft

Answer: C
Rationale:
The client admitted 1 hour ago with shortness of breath should be seen first because this client
might require oxygen therapy. The client in answer A with a low-grade temperature can be
assessed after the client with shortness of breath. The client in answer B can also be seen later.
This client will have some inflammatory process after surgery, so a temperature of 100.2°F is not
unusual. The low-grade temperature should be re-evaluated in 1 hour. The client in answer D can
be reserved for later.
186. The doctor has ordered antithrombolic stockings to be applied to the legs of the client with
peripheral vascular disease. The nurse knows that the proper method of applying the stockings is:
A. Before rising in the morning
B. With the client in a standing position
C. After bathing and applying powder
D. Before retiring in the evening
Answer: A
Rationale:
The best time to apply antithrombolytic stockings is in the morning before rising. If the doctor
orders them later in the day, the client should return to bed, wait 30 minutes, and apply the
stockings. Answers B, C, and D are incorrect because there is likely to be more peripheral edema
if the client is standing or has just taken a bath; before retiring in the evening is wrong because,
late in the evening, more peripheral edema will be present.
187. The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The client
should be taught to avoid:
A. Using a recliner to rest
B. Resting in supine position
C. Sitting in a straight chair
D. Sleeping in right Sim’s position
Answer: C
Rationale:

The client with a femoral popliteal bypass graft should avoid activities that can occlude the
femoral artery graft. Sitting in the straight chair and wearing tight clothes are prohibited for this
reason. Resting in a supine position, resting in a recliner, or sleeping in right Sim’s are allowed,
as stated in answers A, B, and D.
188. While caring for a client with hypertension, the nurse notes the following vital signs: BP of
140/20, pulse 120, respirations 36, temperature 100.8°F. The nurse’s initial action should be to:
A. Call the doctor
B. Recheck the vital signs
C. Obtain arterial blood gases
D. Obtain an ECG
Answer: A
Rationale:
The client is exhibiting a widened pulse pressure, tachycardia, and tachypnea. The next action
after obtaining these vital signs is to notify the doctor for additional orders.
Rechecking the vital signs, as in answer B, is wasting time. It is the doctor’s call to order arterial
blood gases and an ECG.
189. The nurse is caring for a client with peripheral vascular disease. To correctly assess the
oxygen saturation level, the monitor may be placed on the:
A. Abdomen
B. Ankle
C. Earlobe
D. Chin
Answer: C
Rationale:
If the finger cannot be used, the next best place to apply the oxygen monitor is to the earlobe. It
can also be placed on the forehead, but the choices in answers A, B, and D are incorrect.
190. Dalteparin (Fragmin) has been ordered for a client with pulmonary embolis. Which
statement made by the graduate nurse indicates inadequate understanding of the medication?

A. “I will administer the medication before meals.”
B. “I will administer the medication in the abdomen.”
C. “I will check the PTT before administering the medication.”
D. “I will not need to aspirate when I give Dalteparin.”
Answer: C
Rationale:
Giving the medication in the abdomen provides for the best absorption. A is incorrect because
there is no need to give this medication prior to meals. B is incorrect because checking the
glucose level is unnecessary. D is incorrect because the nurse should not aspirate when
administering any heparin derivative subcutaneously.
191. The client has a prescription for a calcium carbonate compound to neutralize stomach acid.
The nurse should assess the client for:
A. Constipation
B. Hyperphosphatemia
C. Hypomagnesemia
D. Diarrhea
Answer: A
Rationale:
The client taking calcium preparations will frequently develop constipation so the client should
be assessed for any problems related to bowel elimination. Answers B, C, and D are not
problems related to the use of calcium carbonate.
192. A client who has been receiving urokinase has a large bloody bowel movement. What
nursing action would be best for the nurse to take immediately?
A. Administer vitamin K IM
B. Discontinue the urokinase
C. Reduce the urokinase and administer heparin
D. Stop the urokinase, notify the physician, and prepare to administer amicar
Answer: D
Rationale:

Urokinase is a thrombolytic used to destroy a clot following a myocardial infraction. If the client
exhibits overt signs of bleeding, the nurse should stop the medication, call the doctor
immediately, and prepare the antidote, which is Amicar. Answer B is not correct because simply
stopping the urokinase is not enough. In answer A, vitamin K is not the antidote for urokinase,
and reducing the urokinase, as stated in answer B, is not enough.
193. Which of the following best describes the language of a 24-month-old?
A. Doesn’t understand yes and no
B. Understands the meaning of words
C. Able to verbalize needs
D. Continually asks “Why?” to most topics
Answer: C
Rationale:
Children at age 2 can reach for objects that they desire and use simple words such as cookie to
express what they want. They already understand “yes” and “no,” so answer A is incorrect.
Simple language patterns begin to develop after this age, even though children at this age might
understand some words; therefore, answer B is not a good choice. Later, at about age 3 or 4, they
begin to ask “Why?” making answer D incorrect.
194. In terms of cognitive development, a 2-year-old would be expected to:
A. Think abstractly
B. Use magical thinking
C. Understand conservation of matter
D. See things from the perspective of others
Answer: B
Rationale:
A 2-year-old is expected only to use magical thinking, such as believing that a toy bear is a real
bear. Answers A, C, and D are not expected until the child is much older. Abstract thinking,
conservation of matter, and the ability to look at things from the perspective of others are not
skills for small children.

195. The nurse is ready to begin an exam on a 9-month-old infant. The child is sitting in his
mother’s lap. What should the nurse do first?
A. Check the Babinski reflex
B. Listen to the heart and lung sounds
C. Palpate the abdomen
D. Check tympanic membranes
Answer: B
Rationale:
The first action that the nurse should take when beginning to examine the infant is to listen to the
heart and lungs. If the nurse elicits the Babinski reflex, palpates the abdomen, or looks in the
child’s ear first, the child will begin to cry and it will be difficult to obtain an objective finding
while listening to the heart and lungs. Therefore, answers A, C, and D are incorrect.
196. Which of the following examples represents parallel play?
A. Jenny and Tommy share their toys.
B. Jimmy plays with his car beside Mary, who is playing with her doll.
C. Kevin plays a game of Scrabble with Kathy and Sue.
D. Mary plays with a handheld game while sitting in her mother’s lap.
Answer: B
Rationale:
Parallel play is play that is demonstrated by two children playing side by side but not together.
The play in answers A and C is participative play because the children are playing together. The
play in answer D is solitary play because the mother is not playing with Mary.
197. Assuming that all have achieved normal cognitive and emotional development, which of the
following children is at greatest risk for accidental poisoning?
A. A 6-month-old
B. A 4-year-old
C. A 10-year-old
D. A 13-year-old
Answer: B

Rationale:
The 4-year-old is more prone to accidental poisoning because children at this age are much more
mobile and this makes them more likely to ingest poisons than the other children. Answers A, C,
and D are incorrect because the 6-monthold is still too small to be extremely mobile, the 10year-old has begun to understand risk, and the 13-year-old is also aware of the risks of poisoning
and is less likely to ingest poisons than the 4-year-old.
198. An important intervention in monitoring the dietary compliance of a client with bulimia is:
A. Allowing the client privacy during mealtimes
B. Praising her for eating all her meals
C. Observing her for 1–2 hours after meals
D. Encouraging her to choose foods she likes and to eat in moderation
Answer: C
Rationale:
To prevent the client from inducing vomiting after eating, the client should be observed for 1–2
hours after meals. Allowing privacy as stated in answer A will only give the client time to vomit.
Praising the client for eating all of a meal does not correct the psychological aspects of the
disease; thus, answer B is incorrect. Encouraging the client to choose favourite foods might
increase stress and the chance of choosing foods that are low in calories and fats.
199. The client is admitted for evaluation of aggressive behavior and diagnosed with antisocial
personality disorder. A key part of the care of such a client is:
A. Setting realistic limits
B. Encouraging the client to express remorse for behavior
C. Minimizing interactions with other clients
D. Encouraging the client to act out feelings of rage
Answer: A
Rationale:
Clients with antisocial personality disorder must have limits set on their behavior because they
are artful in manipulating others. Answer B is not correct because they do express feelings and

remorse. Answers C and D are incorrect because it is unnecessary to minimize interactions with
others or encourage them to act out rage more than they already do.
200. A client with a diagnosis of passive-aggressive personality disorder is seen at the local
mental health clinic. A common characteristic of persons with passive-aggressive personality
disorder is:
A. Superior intelligence
B. Underlying hostility
C. Dependence on others
D. Ability to share feelings
Answer: B
Rationale:
The client with passive-aggressive personality disorder often has underlying hostility that is
exhibited as acting-out behavior. Answers A, C, and D are incorrect. Although these individuals
might have a high IQ, it cannot be said that they have superior intelligence. They also do not
necessarily have dependence on others or an inability to share feelings.