#1.
A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?
A
Increase the dosage, because the level is lower than normal.
B
Stop the I.V. infusion of heparin and notify the physician.
C
Expect the warfarin to increase the PTT.
D
Continue treatment as ordered.
Answer: Continue treatment as ordered.
#2.
Nurse Michelle should know that the drainage is normal 4 days after a sigmoid colostomy when the stool is _____________________.
A
Solid formed
B
Green liquid
C
Semiformed
D
Loose, bloody
Answer: Loose, bloody
#3.
Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia?
A
Where the client like
B
On the client’s left side
C
On the client’s right side
D
Directly in front of the client
Answer: On the client’s right side
#4.
A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse?
A
Align the spine, check pupils, and check for hemorrhage.
B
Check respiration, circulation, neurological response.
C
Assess level of consciousness and circulation.
D
Check respirations, stabilize spine, and check circulation.
Answer: Check respirations, stabilize spine, and check circulation.
#5.
In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by:
A
Increasing AV conduction and heart rate.
B
Increasing contractility and slowing heart rate.
C
Decreasing venous return through vasodilation.
D
Decreasing contractility and oxygen consumption.
Answer: Decreasing venous return through vasodilation.
#6.
Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action?
A
Administer two quick blows.
B
Give two sharp thumps to the precordium, and check the pulse.
C
Clear the airway
D
Call for help and note the time.
Answer: Call for help and note the time.
#7.
Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should:
A
Monitor vital signs every 2 hours.
B
Plan care so the client can receive 8 hours of uninterrupted sleep each night.
C
Provide milk every 2 to 3 hours.
D
Make sure that the client takes food and medications at prescribed intervals.
Answer: Make sure that the client takes food and medications at prescribed intervals.
#8.
A client undergone ileostomy, when should the drainage appliance be applied to the stoma?
A
24 hours later, when edema has subsided.
B
When the client is able to begin self-care procedures.
C
After the ileostomy begin to function.
D
In the operating room.
Answer: In the operating room.
#9.
A client undergone spinal anesthetic, it will be important that the nurse immediately position the client in:
A
On the back, with knees flexed 15 degrees.
B
On the side, to prevent obstruction of airway by tongue.
C
Flat on back.
D
Flat on the stomach, with the head turned to the side.
Answer: Flat on back.
#10.
While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?
A
Pulse is increased from 87 to 95, with an occasional skipped beat.
B
Blood pressure is decreased from 160/90 to 110/70.
C
The client refuses dinner because of anorexia.
D
The client is oriented when aroused from sleep, and goes back to sleep immediately.
Answer: The client is oriented when aroused from sleep, and goes back to sleep immediately.
#11.
Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first?
A
Pleuritic chest pain and cough
B
Hemoptysis and Dyspnea
C
Fever and chills
D
Altered mental status and dehydration
Answer: Altered mental status and dehydration
#12.
A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit?
A
Headache and photophobia
B
Chest and lower back pain
C
Chills, fever, night sweats, and hemoptysis
D
Fever of more than 104°F (40°C) and nausea
Answer: Chills, fever, night sweats, and hemoptysis
#13.
Mark, a 7-year-old client is brought to the emergency department. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He recently had a cold. Form this history; the client may have which of the following conditions?
A
Bronchial pneumonia
B
Chronic obstructive pulmonary disease (COPD)
C
Emphysema
D
Acute asthma
Answer: Acute asthma
#14.
Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have which of the following reactions?
A
Wake up on his own
B
Asthma attack
C
Respiratory arrest
D
Seizure
Answer: Respiratory arrest
#15.
A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging?
A
Decreased vital capacity
B
Decreased residual volume
C
Increased number of functional capillaries in the alveoli
D
Increased elastic recoil of the lungs
Answer: Decreased vital capacity
#16.
Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to administration of this medication?
A
Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter.
B
Presence of premature ventricular contractions (PVCs) on a cardiac monitor.
C
Increase in intracranial pressure (ICP).
D
Increase in systemic blood pressure.
Answer: Presence of premature ventricular contractions (PVCs) on a cardiac monitor.
#17.
Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to:
A
Take aspirin to pain relief.
B
Report incidents of diarrhea.
C
Avoid foods high in vitamin K
D
Use a straight razor when shaving.
Answer: Avoid foods high in vitamin K
#18.
Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by:
A
Clipping the hair in the area
B
Removing the hair with a depilatory.
C
Shaving the area
D
Leaving the hair intact
Answer: Clipping the hair in the area
#19.
Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication:
A
Negative calcium balance
B
Dowager’s hump
C
Bone fracture
D
Loss of estrogen
Answer: Bone fracture
#20.
Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover:
A
Cancerous lumps
B
Fibrocystic masses
C
Areas of thickness or fullness
D
Changes from previous examinations.
Answer: Changes from previous examinations.
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