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Thursday, October 4, 2007

Nclex Preparation Study Exam

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1. The client is advised by the physician to have mammography screening annually, measures to provide adherence with mammography screening include:

1. Making sure that the individual barriers to screening are minimized
2. Emphasizing that mammography screening can prevent breast cancer
3. Emphasizing that mammography screening is a low cost approach to cancer prevention
4. Informing the client that she is at high risk for breast cancer and needs to follow the physician's recommendation.

2. A client with hodgkins disease explains the monitoring that he will be doing at home between radiation treatments, which of the following statements would indicate that he knows how to detect a major complication?

1. I'll measure my neck circumference everyday
2. I'll take my temperature everyday
3. I'll monitor the loss of body hair every week
4. I'll check the circulation in my arms everyday

3. After mastectomy for breast cancer, the nurse teaches the client how to avoid the development of lymphedema. Which of the following instructions would be included?

1. Applying an elastic bandage to the affected extremity
2. Limiting range of motion exercises in the shoulder and elbow
3. Elevating the affected arm on the pillow
4. Taking diuretics as necessary to decrease sailing

4. Correct preparation of the client for a papanicolau smear would include which of the following measures?

1. The test should be scheduled while the client is menstruating
2. The client should not bathe on the morning before the examination
3. The woman should not douche on the morning before the examination
4. The woman should take laxative the night before the examination

5. Radiation therapy is institute for a client with hodgkins disease, after 1 week, the radiation site becomes red and irritated, which of the following statements would indicate that the client treated the area appropriately at home?

1. "I applied aloe vera lotion to the area"
2. "I applied nothing to the area; I just kept it dry"
3. "I applied moist cool soaks to the area"
4. "I applied a hot water bottle to the area"

6. A client is scheduled for radical neck surgery and total laryngectomy. During the preoperative teaching the nurse should prepare the client for which of the following postoperative possibilities?

1. Endotracheal intubation
2. Insertion of a laryngectomy tube
3. Immediate speech therapy
4. Gastronomy tube

7. Which of the following nursing interventions is most appropriate when caring for a client who has an acute case of stomatitis?

1. Using a soft toothbrush to provide oral hygiene
2. Rinsing mouth with commercial mouthwash before ans after each meal
3. Cleansing gums and oral mucosa with lemon-glycerin swabs every shift
4. Keeping dentures in place to decrease development of edema

8. After 2 weeks of radiotherapy, a client with hodgkins disease becomes discouraged, stating, 1m so tired that' can barely keep up with my studies" the nurse bases the response on which of the following statements about fatigue?

1. One of the most common problems associated with radiotherapy
2. A transient problem that typically will resolve as radiotherapy-continues
3. Further evaluation needed to determine another possible cause
4. An indication that the disease has been eradicated, maing additional radiotherapy

9. A client receiving chemotherapy experiences episodes of severe nausea and has vomited more than 1000ml of clear fluid in the past 4 hours, the nurse most appropriate action would be to:

1. Notify the physician
2. Maintain the client on a liquid diet
3. Continue to monitor the client for another 4hrs
4. Administer antiemetic medication as ordered

10. The development of laryngeal cancer is most clearly linked to which of the following factors?

1. High fat, low fiber diet
2. Alcohol and tobacco use
3. Low socioeconomic status
4. Overuse of artificial sweeteners

11. A client with testicular cancer is scheduled for a right orchiectomy. The day before surgery, the client tells the nurse that he is concerned about the effect of losing a testicle will have on his manhood, which of the following facts about orchiectomy should form the basis for the nurse's response?

1. Testosterone levels are decreased
2. Sexual drive and libido are unchanged
3. Sperm count increases in the remaining testicle
4. Secondary sexual characteristics change

12. The nurse understands that Hodgkin’s disease is suspected when a client presents with a painless swollen lymph node. Hodgkin’s disease typically affects people in which age group?

1. Children (6-12y/o)
2. Teenagers (13-20y/o)
3. Young adults (21-40y/o)
4. Older adults (41-50y/o)

13. On the third postoperative day after a radical mastectomy, the drainage tube is removed and the dressings are changed, the client appears shocked when she sees the operative area and exclaims," I look horrible, will it ever look better?" which of the following responses by the nurse would be most appropriate?

1. After it heals and you're dressed, you won't even know you had surgery
2. Don't worry, you know the tumor is gone, and the area will heal very soon
3. Would you like to meet Ms. Paul? She looks just great and she had mastectomy too
4. You're shocked by the sudden change in your appearance as a result of this surgery, aren’t you?

14. Which of the following statements indicates that the client needs further teaching about taking medication to control his cancer pain?

1. I should take my medication around the dock to control my pain
2. I should skip doses periodically so I don't get hooked on my drugs
3. It is okay to take my pain medication even if i am not having any pain.
4. I should contact the oncology nurse if my pain is not effectively controlled

15. Which of the following is an early sign of laryngeal cancer?

1. Difficulty swallowing
2. Persistent mild hoarseness
3. Chronic foul breath
4. Nagging unproductive cough

16. In providing discharge instruction for the client after a modified radical mastectomy, the nurse should instruct the client that she might need to modify or avoid which of the following activities?

1. Shampooing her dog
2. Caring for her tropical fish
3. Working in her rose garden
4. Taking a late evening swim

17. Risk factors for the development of breast cancer include

1. Early menopause (before age 40)
2. Early onset of menstruation
3. Having had more than two children
4. Breastfeeding

18. A priority nursing diagnosis for client receiving chemotherapy would be:

1. Excess fluid volume
2. Impaired physical mobility.
3. Risk for infection
4. Disturbed body Image

19. The nurse should plan care for the client with cancer based on the fact that an important principle of using medication to manage cancer pain is to:

1. Avoid giving the client addictive medications
2. Provide the medications as soon as the client requests them
3. Discontinue the medication periodically to discourage the development of drug tolerance
4. Individualize the medication therapy to the client

20. A middle aged woman with a malignant growth on the larynx is admitted to the hospital for a laryngectomy. The client would most likely state that the earliest symptom of her health problem was:

1. A sore throat
2. Chronic hoarseness
3. Pain radiating to the ear
4. Difficulty swallowing

21. The nurse is conducting an initial nursing history of a client who is experiencing pain related to bone cancer, the most important information to gather in this initial assessment is the:

1. Nurse's physical assessment of the client
2. Amount of pain medication the client is taking
3. Client's self reporting of her pain experience
4. Family's response to the client's Illness

22. The nurse plans to teach a client who is receiving radiation therapy how to care for his skin at home. The nurse's instructions should include:

1. Apply a heating pad to the area to relieve pain
2. You may use deodorant soap if you wish to cleanse the area
3. Put baby oil on the area after each treatment to keep it from getting dry
4. Keep the area covered when you go outdoors

23. the most common symptom of bladder cancer is:

1. Painless hematuria
2. Decreasing urine output
3. Burning on urination
4. Frequent infections

24. Which observation should the patient be taught to recognize when doing a self-examination for detection of breast cancer?

1. Pain on breast self examination
2. Dimpling of the breast tissue
3. Round wed defined lump
4. Tender, movable lump

25. The employee health nurse is discussing the risks and sequelae of breast cancer with a group of high risk female employees, which statement is incorrect about survival rate after the diagnosis of breast cancer?

1. The earlier the breast cancer is detected, the better the survival rate
2. The survival rate is considered better if there is no lymph node involvement
3. There is no risk of metastasis if the lymph nodes are negative
4. Younger women have a poorer survival rate

26. A client on chemotherapy has a WBC count of 1,200/mm 3. Which of the following nursing actions should the nurse take FIRST?

1. Check temperature q4h.
2. Monitor urine output.
3. Assess for bleeding gums.
4. Obtain an order for blood cultures.

27. Which of the following actions should the nurse instruct the client to complete FIRST to establish a normal urinary pattern?

1. Urinate every two hours.
2. Record each time you urinate.
3. Keep a record of your daily fluid intake.
4. Stay near a bathroom.

28. A 16-year-old young woman is brought by her parents to the outpatient clinic for treatment of pelvic inflammatory disease (PID). While the nurse obtains a history, the client says bitterly, "My parents are mean and don’t really care about me." Which of the following responses by the nurse is BEST?

1. "You feel your parents don't care about you?"
2. "Your parents brought you to the clinic, didn't they?"
3. "I am sure that your parents have your best interests at heart."
4. "Did you have a disagreement with your parents?"

29. A 55-year-old woman with end-stage metastatic cancer of the breast is admitted to the hospital. It is MOST important for the nurse to

1. Suction the patient frequently.
2. Provide an air mattress.
3. Turn the patient every two hours.
4. Give the patient frequent baths.

30. A 32-year-old man comes to the clinic for a glycosylated hemoglobin assay (HbA 1c). The result is 6%. The nurse should;

1. Document the findings in the chart.
2. Call the physician about orders to adjust the insulin dosage.
3. Give him 15g of carbohydrates.
4. Ask him to list the foods he has eaten in the last 24 hours.

31. A shool-aged child informs the school nurse that his right knee "doesn't feel right." Which of the following actions should the nurse take FIRST?

1. Instruct the child to extend the right leg.
2. Put both of the child's legs through range-of-motion.
3. Advise the child to soak the right knee in warm water.
4. Compare the appearance of the right knee with the left knee.

32. The nurse in the newborn nursery receives report from the previous shift. Which of the following infants should the nurse see FIRST?

1. A two-day-old infant, lying quietly alert, heart rate of 185 bpm,
2. A one-day-old infant, crying, and the anterior fontanel are bulging.
3. A 12-hour-old infant, held by the mother, respirations 45 and irregular.
4. A five-hour-old infant, steeping, hands and feet are blue bilaterally.

33. The nurse plans care for a 36-year-old woman with Graves' disease. The nurse knows that which of the following foods or fluids should be restricted for this client?

1. Milk.
2. Apples.
3. Orange juice.
4. Tea.

34. After the anesthesiologist administers an epidural to a woman in labor, which of the following nursing actions has the HIGHEST priority?

1. Decrease IV fluids.
2. Assess the fetal heart monitor.
3. Place the mother on her right side.
4. Obtain the blood pressure.

35. The nurse is caring for clients in a rehabilitation facility. The nursing team reports that a client recovering from a hip fracture has repeatedly "transferred herself to the floor." Which of the following actions, if taken by the nurse, is BEST?

1. Place the call light within the client's reach.
2. Remove the footrests from the wheelchair.
3. Observe the client trying to rise from a sitting to a standing position.
4. Place a posey vest restraint on the client.

36. A client had a thoracotomy 3 hours ago. For the past 2 hours there has been 100 cc per hour bloody chest drainage. Which of the following actions should the nurse take FIRST?

1. Increase the IV fluid rate.
2. Administer oxygen at 5 L/min per oxygen mask.
3. Elevate the head of the bed.
4. Advise the physician of the amount of drainage.

37. While a client is receiving TPN, it is MOST important for the nurse to monitor

1. Vital signs and level of consciousness.
2. Arterial blood gases and liver enzymes.
3. Serum glucose and electrolytes.
4. Skin turgor and daily weight.

38. The nurse on postpartum is preparing four clients for discharge. It would be MOST important for the nurse to refer which of the following clients for homecare?

1. A 15-year-old who vaginally delivered a 7-lb male two days ago.
2. A 18-year-old multipara who delivered a 9-lb female by cesarean section two days ago.
3. A 20-year-old multipara who delivered 1 day ago and is complaining of cramping
4. A 22-year-old who delivered by cesarean section and is complaining of burning on urination.

39. A client has a cataract removed from the left eye. Which of the following is an important nursing intervention in the immediate postoperative period?

1. Position the client on the right side with the head slightly elevated.
2. Place the client on the left side to protect the eye.
3. Perform sensory neurological checks every two hours.
4. Maintain complete bedrest for the first 48 hours.

40. A 48-year-old woman is diagnosed with a tumor of the pituitary gland and has a transsphenoidal hypophysectomy. The nurse plans care for the patient two days after surgery, it is MOST important for the nurse to monitor the patient's

1. Complete blood count (CBC).
2. Temperature.
3. Specific gravity of urine.
4. Intracranial pressure.

41. The nurse is caring for a neonate with an infection. The nurse would be MOST concerned if which of the following was observed?

1. Heart rate of 150 bpm.
2. Axillary temperature of 96°F (35.5°C).
3. Weight increase of 4 oz.
4. Respiratory rate of 65 at rest.

42. A nursing student with a history of breast cancer reports that she has just developed shingle ""on her trunk. Which of the following actions by the nurse is BEST?

1. Suggest that the nursing student contact her physician.
2. Assign the nursing student to clients that are not high risk.
3. Inform the nursing student that she cannot care for clients.
4. Restrict the nursing student from performing invasive procedures.

43. The nurse is caring for a patient following a right adrenalectomy. During the immediate postoperative period, it is MOST important for the nurse to observe for which of the following?

1. Fluid and electrolyte imbalance.
2. Temperature fluctuation.
3. Respiratory atelectasis.
4. Blood pressure alteration.

44. The nurse assesses the daily lab reports for a patient with a long history of cirrhosis with acute hepatic encephalopathy. Which of the following findings would indicate to the nurse that the patient is improving?

1. The patient's fasting blood sugar decreased from 100 to 90 mg/dL.
2. The patient's prothrombin time (PT) increased from 20 to 25 seconds.
3. The patient's ammonia level decreased from 160 to 120 mg/dL.
4. The patient's AST (SCOT) increased from 24 to 30 units.

45. The nursing team includes three RNs, one LPN/LVN, and one nursing assistant, me nurse should consider the assignments appropriate if the nursing assistant is assigned to which of the .following clients?

1. A client with an appendectomy.
2. A client with infectious meningitis.
3. An immunosuppressed client.
4. A client who had a radical mastectomy.

46. A 32-year-old male with acute lymphocytic leukemia is admitted with shortness of breath, anemia, and tachycardia. The MOST appropriately stated nursing diagnosis would be

1. Altered protection, immunosuppression: leukemia.
2. Impaired gas exchange related to decreased RBCs.
3. Risk for infection related to alter immune system.
4. Risk of injury related to decreased platelets.

47. A nursing team consists of an RN, an LPN/LVN, and a nursing assistant. The nurse should assign which of the following patients to the LPN/LVN?

1. A 72-year-old patient with diabetes who requires a dressing change for a stasis ulcer.
2. A 55-year-old patient with terminal cancer being transferred to hospice homecare.
3. A 42-year-old patient with cancer of the bone complaining of pain.
4. A 23-year-old patient with a fracture of the right leg who asks to use the urinal.

48. The nurse’s evaluating care given to clients by the home health aide. The nurse would intervene in which of the following situations?

1. The nursing assistant walks a client 15 feet with a walker.
2. The nursing assistant feeds a blind client using a spoon.
3. The nursing assistant administers a client's medication.
4. The nursing assistant performs catheter care for a client.

49. The nurse is caring for a patient who has been lethargic but responsive to verbal commands. The nurse now observes that the client is responding to noxious stimuli by withdrawing. The MOST appropriate nursing action is to

1. Reassess the client in one hour.
2. Notify the physician.
3. Place the client in Trendelenburg position.
4. Contact the family.

50. A 62-year-old man is undergoing peritoneal dialysis at a hemodialysis center. The nurse notices that the fluid outflow is inadequate. Which of the following activities, if performed by the nurse, would be best INITIALLY?

1. Place the man in low-Fowler's position
2. Position the drainage bag at the level of the man's heart.
3. Close the clamp to the drainage tubing for one-half hour, and then reopen.
4. Milk the drainage tubing firmly every 20 minutes.

51. The nursing team consists of an RN who has been practicing for 6 months, a LPN/LVN who has been practicing for 15 years, and a nursing assistant who has been caring for clients for 3 years. The RN should care for which of the following clients?

1. A client 1-day postoperative after an internal fixation of a fractured left femur.
2. A client receiving diltiazem (Cardizem) and phenytoin (Dilantin).
3. A client who is to receive 2 units of packed cells prior to an upper endoscopy procedure.
4. A client admitted yesterday with exhaustion and a diagnosis of acute bipolar disorder.

52. A man has undergone a total laryngectomy due to carcinoma. The nurse is teaching the man and his wife how to suction the laryngectomy tube. Which of the following actions would indicate that teaching was effective?

1. The man selects a Yankauer tonsillar tip catheter to suction the laryngectomy tube.
2. The man takes several deep breaths before the suction catheter is inserted.
3. The man applies suction as he introduces the sterile catheter into the stoma.
4. The wife suctions the man's mouth and then the laryngectomy tube.

53. The nurse is performing health screening at a shelter for the homeless. Which of the following nursing observations would most likely indicate the need for teaching about personal hygiene?

1. Fruity breath odor.
2. Foul-smelling stools.
3. Vaginal itching.
4. Red, swollen gums

54. The public health nurse is caring for a child with impetigo. The nurse would be MOST concerned if which of the following was observed?

1. White patches on the buccal mucosa.
2. Hearing loss.
3. Respiratory wheezes.
4. Periorbital edema.

55. The nurse overhears a conversation in the cafeteria between two nurses regarding a client's home situation. Which of the following actions is the MOST appropriate?

1. Report the incident to the nurse manager.
2. Join the conversation with the nurses.
3. Suggest that the nurses continue their conversation in private.
4. Ignore the incident since the nurse is not involved.

56. The nurse is caring for an eight-year-old child after a tonsillectomy. The nurse would be MOST concerned if which of the following was observed?

1. Heart rate of 88 beats per minute.
2. Expectorating bright red secretions.
3. 30 ml of dark brown secretions.
4. Infrequent swallowing.

57. The nurse is caring for a client in hypovolemic shock. Which of the following would indicate a therapeutic response to volume replacement?

1. Urine output increased to 40 cc per hour.
2. Blood glucose of 180 mg/dL, serum potassium of 4.0 mEq/L
3. CVP of 5 cm water, pupils equal and reactive.
4. Pulse rate of 110 with no dysrhythmias.

58. The nurse is preparing to examine the client's thyroid gland. Which of the following statements if made by the nurse is BEST?

1. "Would you like a band-aid?"
2. "Here is a glass of water"
3. "l will be using this tape measure."
4. "Please use this specimen cup."

59. The nurse is caring for a client with radium implant. It is MOST important for the nurse to take which of the following actions?

1. Evaluate the position of the applicator every two hours.
2. Place the client on a low-residue diet to decrease bowel movements.
3. Encourage the use of the bedside commode every one to two hours.
4. Decrease fluid intake to decrease radiation in the bladder.

60. The nurse is caring for clients in the outpatient clinic. The nurse returns to the desk and is given four phone messages. Which of the following phone messages should the nurse return FIRST?

1. A client who has an indwelling Foley catheter and is complaining of foul-smelling urine.
2. A client who had a 9 lbs infant 3 days ago and is complaining of painful breasts.
3. A client who had a cataract lens extraction 4 days ago and has not had a bowel movement in 3 days.
4. A client states that he had abdominal cramping and diarrhea after eating a large meal.


61. The nurse returns to the nurse's station after making client rounds and finds four phone messages. Which of the following messages should the nurse return FIRST?

1. A client with hepatitis A who states, "My arms and legs are itching."
2. A client with a cast on the right leg who states, "I have a funny feeling in my right leg."
3. A client with osteomyelitis of the spine who states, "I am so nauseous that I can't eat."
4. A client with arthritis who states, "I am having trouble steeping at night."

62. Following hip replacement surgery, an elderly client is ordered to begin ambulation with a walker. Which of the following statements by the nurse is BEST?

1. "Sit in a low chair for ease in getting up to use the walker."
2. "Make sure rubber caps are in place on all four legs of the walker."
3. "You will begin weight-bearing on the affected hip soon."
4. "Practice tying your own shoes before you begin ambulating."

63. The nurse is caring for a patient with hyperparathyroidism. Which symptom is MOST important for the nursed report to the next shift?

1. Abdominal discomfort.
2. Hematuria
3. Muscle weakness.
4. Diaphoresis.

64. The nurse is obtaining a history on a client just admitted to the unit. The client informs the nurse that any information shared with the nurse during the interview is to remain confidential. Which of the following responses by the nurse is BEST?

1. "I’ll share any information you give me with staff members only with your approval."
2. "If the information you share is important to your care, I'll need to share it with the staff."
3. "We can keep the information just between the two of us,"
4. "I have an obligation to maintain nurse/patient confidentiality about anything you tell me."

65. A client is diagnosed with lung cancer and undergoes a pneumonectomy. In the immediate postoperative period, which of the following nursing assessments is MOST important?

1. Presence of breath sounds bilaterally.
2. Position of the trachea in the sternal notch.
3. Amount and consistency of sputum.
4. Increase in the pulse pressure.

66. A client had a radical mastectomy for cancer in her right breast. After the client returns to the unit, which of the following actions, if performed by the nurse, would be MOST appropriate?

1. Position the client on her left side with her right arm protected in a sling.
2. Position the client on her right side with her right arm elevated.
3. Position the client in the semi-Fowler’s position with her right arm elevated.
4. Position the client in the prone position with her right arm elevated.

67. The nurse answers the psychiatric unit's desk phone. The caller identities himself as the Husband of a patient and inquires about her condition. Which of the following responses by the nurse is MOST appropriate?

1. "I may not deny or confirm any patient's presence in this hospital."
2. "Patients are not allowed to use his phone. Please call the patient's phone number directly."
3. "I cannot give information over the phone. If you come in we can discuss her condition."
4. "I will have to ask her if she wishes for me to give out that information."

68. A female client is diagnosed with human papillomavirus (HPV). Which of the following client statements, if made to the nurse, illustrates an understanding of the possible sequelae of this illness?

1. "I will need to take antibiotics for at least a week."
2. "I will use only prescribed douches to avoid a recurrence."
3. "I will return for a Pap smear in six months."
4. "I will avoid using tampons for eight weeks."

69. The nurse is caring for a client with internal radiation. Which of the following actions, if taken by the nurse, is MOST important?

1. Restrict visitors who may have an upper respiratory infection.
2. Assign only male caregivers to the client.
3. Plan nursing activities to decrease nurse exposure.
4. Wear a lead-lined apron whenever delivering client care.

70. A client has been diagnosed with metastatic cancer with a poor prognosis. Recently, the client has complained of increased pain and is less communicative, very irritable, and anorexic. Which of the following nursing goals should be a priority at this time?

1. Encourage client to talk about the possibility of dying.
2. Provide pain assessment and effective pain management.
3. Manage nutrition and hydration.
4. Verify that the physician has discussed the prognosis with the family.

71. The nurse is planning discharge for a group of clients. It is MOST important to refer which of the following clients for home care?

1. A postoperative appendectomy client who is complaining of incisional pain.
2. A diabetic client who had a cardiac catheterization in the early AM.
3. A postoperative cholecystectomy client who is complaining of incisional pain.
4. A client with congestive heart failure who underwent diuresis in the hospital.

72. A 57-year-old man admitted with metastatic cancer has been receiving chemotherapy for 3 months. His lab values include: RBC 3.8 million/mm 3, WBC 3,000/mm 3, Hgb 9.3 g/dL, platelets 50,000/mm 3. The nurse would expect the patient to exhibit which of the following symptoms?

1. BP 120/70, pulse 100, respirations 16.
2. Ankle edema and ascites.
3. Flushed face and light stools.
4. Nausea, anorexia, and vomiting.

73. The nurse is caring for a client after a bronchoscopy. The nurse would be MOST concerned if which of the following was observed?

1. Depressed gag reflex.
2. Sputum streaked with blood.
3. Tachypnea.
4. Complaints of a sore throat.

74. The homecare nurse is scheduling clients for the day. Which of the following clients should the nurse visit FIRST?

1. A primigravida client, 10-days postpartum, who is anxious about caring for her newborn.
2. A middle-aged client, 6-days postoperative, who is complaining of pain in his midsternal incision.
3. A client with AIDS who had a chest tube removed yesterday and is complaining of crackling under his skin.
4. A client who receives amiloride hydrochloride (Midamor) and states that she is dizzy when she gets up in the morning.

75. The nurse is caring for clients in the diabetic clinic. Which of the following clients should the nurse see FIRST?

1. A client with sunken eyeballs and a fruity breath odor.
2. A client who complains of pain in his calves when he exercises.
3. A client who states that she drinking liquids frequently and is always hungry.
4. A client says that she is having difficulty sleeping and cries frequently.

76. The nurse has just received report from the previous shift. Which of the following patients should the nurse see FIRST?

1. An elderly woman, 8-hours postoperative, following an open-reduction and internal fixation of the right hip.
2. An elderly man admitted 4 hours ago with status asthmaticus.
3. A middle-aged man admitted 2 days ago with pneumonia who has a temperature of 101.2°F (38.4°C).
4. A middle-aged woman who suffered a myocardial infarction (Ml) 3 days ago.

77. The nurse has just returned to the desk and has four phone messages to return. Which of the following messages should the nurse return FIRST?

1. A man with swelling of his left wrist following a fall from a ladder two hours ago.
2. A woman who had a cholecystectomy one week ago and now complains of redness and tenderness at the incision site.
3. A 40-year-old mother of a child reports that her son's lips are swollen following a fire ant bite.
4. A man with COPD reports he is coughing up large amounts of green-tinged sputum and has a temperature of 101 -2°F (38.4°C).

78. The nurse is assigned a team with another registered nurse and an LPN. Which of the following patients should the nurse assign to the LPN?

1. A 67-year-old man who is NPO and scheduled for a transurethral resection of the prostate (TURP) in 3 hours.
2. A 53-year-old woman with an IV of 0.9% NaCI at 100 cc/h who had a lumbar laminectomy two days ago.
3. A 40-year-old woman with a Hemovac drain and a large surgical dressing from a mastectomy 2 days ago who is showing signs of depression.
4. A 27-year-old woman scheduled for discharge later today after receiving chemotherapy through a portacath for treatment of leukemia.

79. The nurse is caring for clients in the outpatient clinic. The nurse returns to the desk and finds four phone messages. Which of the following messages should the nurse return FIRST?

1. A client with cold symptoms has an oral temperature of 103°F (39.4°C).
2. A client with stage II decubitus ulcer reports that the dressing has come off.
3. A client is nauseated and has vomited 6 times in the previous 24 hours.
4. A client is complaining of leg pain after walking half a mile.

80. The nurse is caring for a client with Gushing s syndrome. Which of the following nursing actions would be of HIGHEST priority?

1. Implement measures to prevent skin breakdown.
2. Plan measures to prevent infections.
3. Teach the client signs and symptoms of hyperglycemia.
4. Instigate measures to prevent fluid overload.

81. The nurse has just received report from the previous shift. Which of the following clients should the nurse see FIRST?

1. A client with chronic renal failure complaining of swollen fingers and ankle edema.
2. A client one-day postoperative after abdominal surgery who has dried blood on the abdominal dressing.
3. A client with type I diabetes mellitus who states, "I have this quivering feeling in my abdomen."
4. A client on high doses of antibiotics for a resistant infection who complains of diarrhea.

82. A 57-year-old man admitted with metastatic cancer has been receiving chemotherapy for 3 months. His lab values include: RBC 3.8 million/mm 3, WBC 2,000/mm 3, Hgb 9.3 g/dL, platelets 50,000/mm 3. Which of the following nursing diagnoses is MOST appropriate for this patient?

1. Decreased cardiac output.
2. Ineffective thermoregulation.
3. Risk for injury.
4. Ineffective airway clearance.

83. A charge nurse is developing the assignment for the evening shift. In a semiprivate room, Client A has neutropenia. Client B has a tracheostomy with purulent drainage and a pending culture and sensitivity (C&S). Which of the following indicates the MOST appropriate assignment?

1. Assign an experienced nurse to care for both clients in the same room.
2. Assign two nurses: one nurse for Client A and another nurse for Client B, in the same room.
3. Place Client A in a private room and assign the same nurse to care for Client A and Client B.
4. Place Client A in a private room and assign different nurses to care for Client A and Client B.

84. A 72-year-old client has an order for digoxin (Lanoxin) 25 mg PO daily. The nurse reviews the following information: apical pulse 68/min, respirations 16/min, plasma digoxin level 2 ng/ml. Based on this assessment, which of the following nursing actions is appropriate?

1. Give the medication on time.
2. Withhold the medication; notify the physician.
3. Administer epinephrine 1:1,000 stat.
4. Check the client's blood pressure.

85. The nurse is changing the dressing on a woman who had a mastectomy two days ago. After the nurse removes the old dressing, the client turns her head away. Which of the following is the BEST response by the nurse?

1. "I notice that you turn your head away as if you don't want to look at your incision."
2. "It's good that you turn your head away while I am doing this sterile procedure."
3. "Your incision looks like it's healing nicely."
4. "Why don't you look at the incision while I have the old dressing off?"

86. The nurse team consists of an RN, two LPN/LVNs, and a nursing assistant. The RN should care for which of the following clients?

1. An infant who is two-days postoperative after repair of deft lip that requires a tube feeding.
2. A preschool child who is three-days postoperative after surgical removal of Wilms' tumor that requires a bath.
3. A school-aged child with osteomyelitis that requires a dressing change.
4. A teenager with a head injury, has a Glasgow coma scale of 5, and requires personal care.

87. The nurse is making patient assignments on a medical/surgical unit. The staff includes one RN, one RN pulled from the pediatric floor, an LPN/LVN, and a nursing assistant. Which of the following patients should be assigned to the RN from the pediatric floor?

1. A client one-day postoperative after an appended.
2. A client who had a detached retina surgically repaired 4 hours ago.
3. A client with a Sengstaken-Blakemore tube in place.
4. A client two-days postoperative after a laminectomy with spinal fusion.

88. A 20-year-old woman calls the outpatient clinic to schedule her first Papanicolaou's smear. The nurse should instruct the client to

1. Avoid intercourse for 48 hours before the examination.
2. Avoid douching for 24 hours prior to her appointment.
3. Withhold all foods and fluids 12 hours before the appointment.
4. Save her first voided urine specimen the morning of her appointment.

89. After receiving report, which of the following patients should the nurse see FIRST?

1. A patient in sickle-cell crisis with an infiltrated.
2. A patient with leukemia who has received one-half unit of packed cells.
3. A patient scheduled for a bronchoscopy.
4. A patient complaining of a leaky colostomy bag.

90. The nurse has just returned to the desk and has four phone messages to return. Which of the following messages should the nurse return FIRST?

1. A woman in her first trimester of pregnancy complaining of heartburn.
2. A man complaining of heartburn that radiates to his jaw.
3. A woman complaining of hot flashes and difficulty sleeping.
4. A boy complaining of knee pain after playing basketball.

91. A 38-year-old woman, mother of two, has a mastectomy for breast cancer. When she returns to the physician's office a month later for a routine check-up, the nurse asks the client how she has been. Which of the following responses, if made by the client to the nurse, indicates that the client is experiencing a normal reaction to the surgery?

1. "I have been helping my family deal with their feelings about the surgery."
2. "I have been having difficulty coping with the surgery and cry frequently."
3. "I have been unable to have the house or talk to my friends about the surgery."
4. "I am doing just great since the surgery and have gone back to work at my job."

92. A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall.
Which of the following is the BEST indication that the patient's nutritional status has improved after 4 days?

1. The patient eats most of the food served to her.
2. The patient has gained 1 pound since admission.
3. The patient's albumin level is 4.0mg/dL.
4. The patient's hemoglobin is 8.5g/dL

93. The nurse is caring for clients on a medical/surgical unit and determines that several 'situations need to be addressed. Which of the following situations should the nurse attend to FIRST?

1. An angry daughter is threatening to sue the hospital because her confused mother fell out of bed during the previous shift.
2. The nursing assistant is 30 minutes overdue from a dinner break in the cafeteria for the third time this week.
3. The physician calls the unit to ask the nurse to obtain a client's latest serum electrolyte results from the lab.
4. The husband of a client reports to the nurse that his wife's nose began bleeding after she returned from radiation therapy.

94. A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority?

1. Administer oxygen.
2. Turn her to the right side.
3. Provide adequate hydration.
4. Start Antibiotics.

95. A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following?

1. Sit up for at least 30 minutes after eating.
2. Avoid fluids between meals.
3. Increase the intake of high-carbohydrate foods.
4. Avoid eating large meals that are high in simple sugars and liquids.

96. When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse's actions during this intervention?

1. The restraints/seclusion policies set forth by the institution.
2. The patient's competence.
3. The patient's voluntary/involuntary status.
4. The patient's nursing care plan.

97. The nurse's INITIAL priority when managing a physically assaultive client is to

1. Restrict the client to the room.
2. Place the client under one-to-one supervision.
3. Restore the client's self-control and prevent further loss of control.
4. Clear the immediate area of other clients to prevent harm.

98. The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignments appropriate if the nursing assistant is assigned to care for

1. A client with Alzheimer's requiring assistance with feeding.
2. A client with osteoporosis complaining of burning on urination.
3. Client with scleroderma receiving a tube feeding.
4. A client with cancer who has Cheyne-Stokes respirations.

99. The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST?

1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a rusty metal can.
2. A 19-year-old with a fever of 103.8T (39.8°C) who is able to identify her sister but not the place and time.
3. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain.
4. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL.

100. When assisting with a bone marrow aspiration, the nurse should

1. Drop additional sterile supplies onto a sterile tray.
2. Have alt sterile packs unwrapped for the procedure in case they are needed.
3. Reach over the tray and remove contaminated supplies.
4. Place the bottle of sterile liquid on the sterile field so it does not splash.



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