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1. A two-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly?

• The infant no longer complains of pain.
• The buttocks are 15° off the bed.
• The legs are suspended in the traction.
• The pins are secured within the pulley.

2. The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to:

• Administer the medications together in one syringe
• Administer the medication separately
• Administer the Valium, wait five minutes, and then inject the Phenergan
• Question the order because they cannot be given at the same time

3. The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the:

• Phlebostatic axis
• PMI
• Erb’s point
• Tail of Spence

4. The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:

• Likes to play football
• Drinks carbonated drinks
• Has two sisters
• Is taking acetaminophen for pain

5. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:

• Question the order.
• Administer the medications.
• Administer separately.
• Contact the pharmacy.

6. A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for:

• Allergies to pineapples and bananas
• A history of streptococcal infections
• Prior therapy with phenytoin
• A history of alcohol abuse

7. The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client taking rosuvastatin (Crestor)?

• Report muscle weakness to the physician.
• Allow six months for the drug to take effect.
• Take the medication with fruit juice.
• Report difficulty sleeping.

8. A client with leukemia is receiving Trimetrexate. After reviewing the client’s chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:

• Treat iron-deficiency anemia caused by chemotherapeutic agents
• Create a synergistic effect that shortens treatment time
• Increase the number of circulating neutrophils
• Reverse drug toxicity and prevent tissue damage

9. The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse’s action should be to:

• Place the client in Trendelenburg position.
• Increase the infusion of normal saline.
• Administer atropine intravenously.
• Move the emergency cart to the beds

10. A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?

• Assess for signs of abnormal bleeding.
• Anticipate an increase in the Coumadin dosage.
• Instruct the client regarding the drug therapy.
• Increase the frequency of neurological assessments.

11. The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?

• The client with HIV
• The client with a radium implant for cervical cancer
• The client with RSV (respiratory synctial virus)
• The client with cytomegalovirus

12. Which information should be reported to the state Board of Nursing?

• The facility fails to provide literature in both Spanish and English.
• The narcotic count has been incorrect on the unit for the past three days.
• The client fails to receive an itemized account of his bills and services received during his hospital stay.
• The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.

13. A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood tinged hemoptysis, fatigue, and night sweats. The client’s symptoms are consistent with a Diagnosis of:

• Pneumonia
• Reaction to antiviral medication
• Tuberculosis
• Superinfection due to low CD4 count

14. A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:

• Venereal Disease Research Lab (VDRL)
• Rapid plasma reagin (RPR)
• Florescent treponemal antibody (FTA)
• Thayer-Martin culture (TMC)

15. The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig’s sign is charted if the nurse notes:

• Pain on flexion of the hip and knee
• Nuchal rigidity on flexion of the neck
• Pain when the head is turned to the left side
• Dizziness when changing positions

16. One of your health care assistants came to you saying that she could not continue with her rounds due to a bad back. What will you do first?

• Document the incident and report to the manager.
• Ring for agency staff to cover the shift.
• Assess your colleague’s back and administer pain killers.
• Send her home and cover her work yourself to help the team.

17. The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:

• Replenish his supply every three months.
• Take one every 15 minutes if pain occurs.
• Leave the medication in the brown bottle.
• Crush the medication and take with water.

18. A client with vaginal cancer is being treated with a radioactive vaginal implant. The client’s husband asks the nurse if he can spend the night with his wife. The nurse should explain that:

• Overnight stays by family members is against hospital policy.
• There is no need for him to stay because staffing is adequate.
• His wife will rest much better knowing that he is at home.
• Visitation is limited to 30 minutes when the implant is in place.

19. The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to:

• Turning the client to the left side
• Milking the tube to ensure patency
• Slowing the intravenous infusion
• Notifying the physician

20. The infant is admitted to the unit with tetralogy of Fallot. The nurse would anticipate and order for which medication?

• Digoxin
• Epinephrine
• Aminophyline
• Atropine

21. A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:

• Altered nutrition
• Impaired communication
• Risk for injury/aspiration
• Altered urinary elimination

22. A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor’s order should the nurse question?

• Magnesium sulfate 4gm (25%) IV
• Brethine 10mcg IV
• Stadol 1mg IV push every 4 hours as needed prn for pain
• Ancef 2gm IVPB every 6 hours

23. The nurse is caring for a client with uremic frost. The nurse is aware that uremic frost is often seen in clients with:

• Severe anemia
• Arteriosclerosis
• Liver failure
• Parathyroid disorder

24. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses’ next action be?

• Obtain a crash cart.
• Check the calcium level.
• Assess the dressing for drainage.
• Assess the blood pressure for hypertension.

25. A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?

• Alteration in nutrition
• Alteration in bowel elimination
• Alteration in skin integrity
• Ineffective individual coping

26. Nurses who seek to enhance their cultural-competency skills and apply sensitivity towards are committed to which professional nursing value?

• Autonomy
• Strong commitment to service
• Belief in the dignity and worth of each person
• Commitment to education

27. The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?

• The client with methicillin resistant-staphylococcus aureas (MRSA)
• The client with diabetes
• The client with pancreatitis
• The client with Addison’s disease

28. The nurse is caring fora client hospitalized with a facial stroke. Which diet selection would be suited to the client?

• Roast beef sandwich, potato chips, pickle spear, iced tea
• Split pea soup, mashed potatoes, pudding, milk
• Tomato soup, cheese toast, Jello, coffee
• Hamburger, baked beans, fruit cup, iced tea

29. Which action by the healthcare worker indicates a need for further teaching?

• The nursing assistant ambulates the elderly client using a gait belt.
• The nurse wears goggles while performing a venopuncture.
• The nurse washes his hands after changing a dressing.
• The nurse wears gloves to monitor the IV infusion rate.

30. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis?

• Alteration in cerebral tissue perfusion
• Fluid volume deficit
• Ineffective airway clearance
• Alteration in sensory perception

31. The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

• “I will make sure I eat breakfast within 10 minutes of taking my insulin.”
• “I will need to carry candy or some form of sugar with me all the time.”
• “I will eat a snack around three o’clock each afternoon.”
• “I can save my dessert from supper for a bedtime snack.”

32. One of your residents in the nursing home has requested for a glass of whiskey before she goes to bed. What would you do?

• Refuse to give it / ignore the request
• Explain that the whiskey will cause her harm
• Give her a shot of whiskey, as requested
• Give her a glass of apple juice and tell her it is whiskey

33. The client has recently been diagnosed with diabetes. Which of the following indicates understanding of the management of diabetes?

• The client selects a balanced diet from the menu.
• The client can tell the nurse the normal blood glucose level.
• The client asks for brochures on the subject of diabetes.
• The client demonstrates correct insulin injection technique.

34. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in four months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

• Impaired physical mobility related to decreased endurance
• Hypothermia r/t decreased metabolic rate
• Disturbed thought processes r/t interstitial edema
• Decreased cardiac output r/t bradycardia

35. A client with a diagnosis of HPV is at risk for which of the following?

• Hodgkin’s lymphoma
• Cervical cancer
• Multiple myeloma
• Ovarian cancer

36. The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:

• 30 minutes before a meal
• With each meal
• In a single dose at bedtime
• 30 minutes after meals

37. The client with confusion says to the nurse, “I haven’t had anything to eat all day long. When are they going to bring breakfast?” The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?

• “You know you had breakfast 30 minutes ago.”
• “I am so sorry that they didn’t get you breakfast. I’ll report it to the charge nurse.”
• “I’ll get you some juice and toast. Would you like something else?”
• “You will have to wait a while; lunch will be here in a little while.”

38. Which nurse should not be assigned to care for the client with a radium implant for vaginal cancer?

• The LPN who is six months postpartum
• The RN who is pregnant
• The RN who is allergic to iodine
• The RN with a three-year-old at home

39. The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer’s disease. Which side effect is most often associated with this drug?

• Urinary incontinence
• Headaches
• Confusion
• Nausea

40. The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?

• Allow the client to keep the fruit.
• Place the fruit next to the bed for easy access by the client.
• Offer to wash the fruit for the client.
• Ask the family members to take the fruit home.

41. A mother calls the home care nurse & tells the nurse that her 3 year old child has ingested liquid furniture polish, the home care nurse would direct the mother immediately to

• Induce vomiting
• Bring the child to the ER
• Call an ambulance
• Call the poison control centre

42. The best method of evaluating the amount of peripheral edema is:

• Weighing the client daily
• Measuring the extremity
• Measuring the intake and output
• Checking for pitting

43. The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:

• Using oil- or cream-based soaps
• Flossing between the teeth
• The intake of salt
• Using an electric razor

44. During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:

• Syphilis
• Herpes
• Gonorrhea
• Condylomata

45. The client with clotting disorder has an order to continue Lovenox (Enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:

• Be injected into the deltoid muscle
• Be injected into the abdomen
• Aspirate after the injection
• Clear the air from the syringe before injections

46. The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?

• Macaroni and cheese
• Shrimp with rice
• Turkey breast
• Spaghetti with meat sauce

47. The client admitted two days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?

• Order a chest x-ray.
• Reinsert the tube.
• Cover the insertion site with a Vaseline gauze.
• Call the doctor.

48. The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client’s history should be reported to the doctor?

• Diabetes
• Prinzmetal’s angina
• Cancer
• Cluster headaches

49. The client has elected to have epidural anaesthesia to relieve labour pain. If the client experiences hypotension, the nurse would:

• Place her in Trendelenburg position.
• Decrease the rate of IV infusion.
• Administer oxygen per nasal cannula.
• Increase the rate of the IV infusion.

50. The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:

• Utilize an infusion pump.
• Check the blood glucose level.
• Place the client in Trendelenburg position.
• Cover the solution with foil.