1.

A client with HIV and AIDS confides that he is homosexual and his employer does not know his HIV status. The nurse's best response to him is a. "Would you like me to help you tell them?" b. "The information you confide in me is confidential." c. "I must share this information with your family." d. "I must share this information with your employer." 2. The mother of a child with bronchial asthma tells the nurse that the child wants a pet. Which of the following pets should the nurse tell the mother is most appropriate? a. Cat. b. Fish. c. Gerbil. d. Canary. 3. An elderly client is being admitted to same-day surgery for cataract extraction. The client has several diamond rings. The nurse should explain to the client that a. her rings will be taped before the surgery. b. she will sign a valuables envelope that will be placed in a safe. c. the rings will be locked in the narcotics box. d. the nursing supervisor will hold onto the rings during the surgery. 4. When an infant resumes taking oral feedings after surgery to correct intussusception, the parents comment that the child seems to suck on the pacifier more since the surgery. The nurse explains that sucking on a pacifier a. provides an outlet for emotional tension. b. indicates readiness to take solid foods. c. indicates intestinal motility. d. is an attempt to get attention from the parents. 5. A 22-year-old client is brought to the emergency department with his fiance after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7 and he demonstrates evidence of decorticate posturing. Which of the following would be appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring? a. The nurse will obtain a signed consent from the client's fiance because he is of legal age and they are engaged to be married. b. The physician will get a consultation from one other physician and proceed with placement of the ICP catheter until the family arrives to sign the consent. c. Two nurses will receive a verbal consent by telephone from the client's next of kin before inserting the catheter. d. The physician will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without a consent. 6. A 68-year-old client's daughter is asking about the follow-up evaluation for her father after his pneumonectomy for primary lung cancer. The nurse's best response is which of the following? a. "The usual follow-up is chest x-ray and liver function tests every 3 months." b. "The follow-up for your father will be a chest x-ray and a computed tomography (CT) scan of the abdomen every year." c. "No follow-up is needed at this time." d. "The follow-up for your father will be a chest x-ray every 6 months."

7. The nurse is preparing to administer blood to an otherwise healthy client who requires postoperative blood replacement. The nurse is aware that the blood administration set must include a. a micron mesh filter. b. anonfiltered administration blood set. c. a special leukocyte-poor filter. d. amicrodrip administration set. 8. Under which circumstance may a nurse communicate medical information without the client's consent? a. When certifying the client's absence from work. b. When requested by the client's family. c. When treating clients who have a sexually transmitted disease (STD). d. When ordered by another physician. 9. During the health history interview, which of the following strategies is the most effective for the nurse to use to help clients feel that they have an active role in their health care? a. Ask clients to complete a questionnaire. b. Provide clients with written instructions. c. Ask clients for their description of events and for their views concerning past medical care. d. Ask clients if they have any questions. 10. A client with severe major depression states, "My heart has stopped and my blood is black ash." The nurse interprets this statement to be evidence of which of the following? a. Hallucination. b. Illusion. c. Delusion. d. Paranoia. 11. When a client wants to read his chart, the nurse should a. call the doctor to obtain permission. b. give the client the chart and answer questions for him. c. tell the client that he can read the chart when the doctor makes rounds. d. ask the client what he wants to know and answer those questions without giving him the chart. 12. A client who has a fractured leg has been instructed to ambulate without weight bearing on the affected leg. The nurse evaluates that the client is ambulating correctly if she uses which of the following crutch-walking gaits? a. Two-point gait. b. Four-point gait. c. Three-point gait. d. Swing-to gait. 13. A client with major depression states, "Life isn't worth living anymore. Nothing matters." Which of the following responses by the nurse would be best? a. "Are you thinking about killing yourself?" b. "Things will get better, you know." c. "Why do you think that way?" d. "You shouldn't feel that way."

14. A client with bipolar 1 disorder has been prescribed olanzapine (Zyprexa) 5 mg two times a day and lamotrigine (Lamictal) 25 mg two times a day. Which of the following adverse effects would the nurse report to the physician immediately? Select all that apply. a. Rash. b. Nausea. c. Hyperthemia. d. Muscle rigidity. 15. A client is prescribed atropine, 0.4 mg IM. The atropine vial is labeled 0.5 mg/mL. How many milliliters should the nurse plan to administer? a. 0.8. b. 0.4 c. 8 d. 0.5 16. A multiparous client tells the nurse that she is using medroxyprogesterone (Depo-Provera) for contraception. The nurse instructs the client to increase her intake of which of the following? a. Folic acid. b. Vitamin C. c. Magnesium d. Calcium. 17. Which of the following statements made by a woman in the first trimester are consistent with this stage of pregnancy? Select all that apply. a. "My husband told his friends we will have to give up the mustang for a minivan." b. "Oh my, how did this happen? I don't need this now." c. "I can't wait to see my baby. Do you think it will have my blond hair and blue eyes?" d. "I wonder how it will feel to buy maternity clothes and be fat." 18. The nurse is teaching a client about topical gentamicin sulfate (Garamycin). Which of the following comments by the client indicates the need for additional teaching? a. "I will avoid being out in the sun for long periods." b. "I should stop applying it once the infected area heals." c. "I'll call the physician if the condition worsens." d. "I should apply it to large open areas." 19. A client has been taking imipramine (Tofranil) for his depression for 2 days. His sister asks the nurse, "Why is he still so depressed?" Which of the following responses by the nurse would be most appropriate? a. "Your brother is experiencing a very serious depression." b. "I'll be sure to convey your concern to his physician." c. "It takes 2 to 4 weeks for the drug to reach its full effect." d. "Perhaps we'll need to change his medication." 20. Which interventions would the nurse use to assist the client with grandiose delusions? Select all that apply. a. Accepting the client while not arguing with the delusion. b. Focusing on the feelings or meaning of the delusion. c. Focusing on events and topics based in reality. d. Confronting the client's beliefs.

21. multigravid client visiting the prenatal clinic at 16 weeks' gestation exhibits facial swelling, a brownish vaginal discharge, and fundal height of 22 cm. The client's blood pressure is 160/90 mm Hg and her pulse is 80 bpm. The nurse interprets these findings as suggestive of which of the following? a. Placenta previa. b. Fetalanemia. c. Multifetal pregnancy. d. Gestational trophoblastic disease. 22. Which of the following responses would be most helpful for a client who is euphoric, intrusive, and interrupts other clients engaged in conversations to the point where they get up and leave or walk away? a. "When you interrupt others, they leave the area." b. You are being rude and uncaring." c. "You should remember to use your manners." d. "You know better than to interrupt someone." 23. The nurse coordinates with the laboratory staff to have the gentamicin trough serum level drawn. At what time should the blood be drawn in relation to the administration of the intravenous dose of gentamicin sulfate (Garamycin)? a. . 2 hours before the administration of the next intravenous dose. b. 3 hours before the administration of the next intravenous dose. c. 4 hours before the administration of the next intravenous dose. d. Just before the administration of the next intravenous dose. 24. Older adults with known cardiovascular disease must balance which of the following measures for optimum health? a. Diet, exercise, and medication. b. Stress, hypertension, and pain. c. Mental health, diet, and stress. d. Social events, diet, and smoking 25. A 4-year-old is brought to the emergency department with sudden onset of a temperature of 103F (39.5C), sore throat, and refusal to drink. The child will not lie down and prefers to lean forward while sitting up. Which of the following would the nurse do next? a. Give 600 mg acetaminophen (Tylenol) per rectum as ordered. b. Inspect the child's throat for redness and swelling. c. Have an appropriate-sized tracheostomy tube readily available. d. Obtain a specimen for a throat culture. 26. Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, which of the following would the nurse do next? a. Hold the lithium and obtain a stat lithium level to determine therapeutic effectiveness. b. Continue the lithium and immediately notify the physician about the assessment findings. c. Continue the lithium and reassure the client that these temporary side effects will subside. d. Hold the lithium and monitor the client for signs and symptoms of increasing toxicity. 27. A client asks the nurse how long she will have to take her medicine for hypothyroidism. The nurse's response is based on the knowledge that a. lifelong daily medicine is necessary. b. the medication is expensive, and the dose can be reduced in a few months. c. the medication can be gradually withdrawn in 1 to 2 years.

the medication can be discontinued after the client's thyroid-stimulating hormone (TSH) level is normal. 28. Assessment of which of the following clients would lead the nurse to expect the physician to order an adjustment in lithium dosage? a. A client who continues work as a computer programmer. b. A client who attends college classes. c. A client who is now able to care for his or her children. d. A client who is beginning training for a tennis team. 29. A client admitted with a gastric ulcer has been vomiting bright red blood. His hemoglobin is 5.11 g/dL, and his blood pressure is 100/50 mm Hg. The client and the family state that their religious beliefs do not support the use of blood products and refuse blood transfusions as a treatment for the bleeding. The nurse would expect that the next step in the treatment plan would be to a. discontinue all measures. b. notify the hospital attorney. c. attempt to stabilize the client through the use of fluid replacement. d. give enough blood to keep the client from dying. 30. The parents of a child with cystic fibrosis express concern about how the disease was transmitted to their child. The nurse would explain that a. a disease carrier also has the disease. b. two parents who are carriers may produce a child who has the disease. c. a disease carrier and an affected person will never have children with the disease. d. a disease carrier and an affected person will have a child with the disease. 31. A client with angina shows the nurse her nitroglycerin (Nitrostat) that she is carrying in a plastic bag in her pocket. The nurse instructs the client that nitroglycerin should be kept a. in the refrigerator. b. in a cool, moist place. c. in a dark container to shield from light. d. in a plastic bag where it is readily available 32. The nurse caring for client on the telemetry unit is able to determine that the client is in sinus bradycardia by recognizing which characteristics? Select all that apply. a. P wave present. b. Ventricular rate of 50 beats per minute (bpm). c. Atrial rate of 120 bpm. d. PR interval ranging from 0.12 to 0.20. 33. When teaching a client with bipolar disorder, mania, who has started to take valproic acid (Depakene) about possible side effects of this medication, the nurse would include which of the following in the teaching plan? a. Increased urination. b. Slowed thinking. c. Sedation. d. Weight loss. 34. An infant is born with facial abnormalities, growth retardation, mental retardation, and vision abnormalities. These abnormalities are probably caused by maternal a. alcohol consumption b. vitamin B6 deficiency.

d.

c. vitamin A deficiency. d. folic acid deficiency. 35. Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used in the treatment of musculoskeletal conditions. It is important for the nurse to remind the client to a. take NSAIDs at least three times per day. b. exercise the joints at least 1 hour after taking the medication. c. take antacids 1 hour after taking NSAIDs. d. take NSAIDs with food. 36. The nurse would suspect that the client taking disulfiram (Antabuse) therapy has ingested alcohol when the client exhibits which of the following symptoms? a. Sore throat and muscle aches. b. Nausea and flushing of the face and neck. c. Fever and muscle soreness. d. Bradycardia and vertigo. 37. The nurse holds the gauze pledget against an intramuscular injection site while removing the needle from the muscle. This technique helps to a. seal off the track left by the needle in the tissue. b. speed the spread of the medication in the tissue. c. avoid the discomfort of the needle pulling on the skin. d. prevent organisms from entering the body through the skin puncture. 38. A client whose condition remains stable after a myocardial infarction gradually increases his activity. Which the following conditions should the nurse assess to determine whether the activity is appropriate for the client? a. Edema. b. Cyanosis. c. Dyspnea. d. Weight loss 39. When a client with alcohol dependency begins to talk about not having a problem with alcohol, the nurse would use which of the following approaches? a. Questioning the client about how much alcohol she drinks. b. Confronting the client with the fact that she was intoxicated 2 days ago c. Pointing out how alcohol has gotten her into trouble. d. Listening to what the client states and then asking her how she plans to stay sober. 40. Which of the following correctly describes Medicaid? a. A program designed to assist ill, low-income older adults. b. A federal insurance program for pregnant women. c. A joint federalstate program for low-income persons. d. A program administered by health maintenance organizations. 41. The nurse is preparing a teaching plan for a 45-year-old client recently diagnosed with type 2 diabetes mellitus. What is the first step in this process? a. Establish goals. b. Choose video materials and brochures. c. Assess the client's learning needs. d. Set priorities of learning needs.

42. A loading dose of digoxin (Lanoxin) is given to a client newly diagnosed with atrial fibrillation. The nurse begins instructing the client about the medication and the importance of monitoring the heart rate. An expected outcome of the education program will be a. a return demonstration of palpating the radial pulse. b. a return demonstration of how to take the medication. c. verbalization of why the client has atrial fibrillation. d. verbalization of the need for the medication. 43. A multigravid client is scheduled for a percutaneous umbilical blood sampling (PUBS) procedure. The nurse instructs the client that this procedure is useful for diagnosing which of the following? a. Twin pregnancies. b. Fetal lung maturation. c. Rh disease. d. Alpha-Fetoprotein level. 44. Which of the following is a side effect of vancomycin (Vancocin) and needs to be reported promptly? a. Vertigo. b. Tinnitus. c. Muscle stiffness. d. Ataxia. 45. Which of the following statements indicates that the client with a peptic ulcer understands the dietary modifications he will need to follow at home? a. "I should eat a bland, soft diet." b. "It is important to eat six small meals a day." c. "I should drink several glasses of milk a day." d. "I should avoid alcohol and caffeine." 46. The client with a nasogastric tube begins to complain of abdominal distention. Which of the following measures should the nurse implement first? a. Call the physician. b. Irrigate the nasogastric tube. c. Check the function of the suction equipment. d. Reposition the nasogastric tube. 47. A male client has been diagnosed as having a low sperm count during infertility studies. After instructions by the nurse about some causes of low sperm counts, the nurse determines that the client needs further instructions when he says low sperm counts may be caused by which of the following? a. Varicocele. b. Frequent use of saunas. c. Endocrine imbalances. d. Decreased body temperature. 48. The nurse assesses a client and notes puffy eyelids, swollen ankles, and crackles at both lung bases. The nurse understands that these clinical findings are most specifically associated with fluid excess in which of the following compartments? a. Interstitial compartment. b. Intravascular compartment. c. Extracellular compartment.

d. Intracellular compartment. 49. An expected physiologic response to a low potassium level is a. cardiac dysrhythmias. b. hyperglycemia. c. hypertension. d. increased energy. 50. When teaching unlicensed assistive personnel (UAP) about the importance of handwashing in preventing disease, the nurse makes which of the following statements? a. "It is not necessary to wash your hands as long as you use gloves." b. "Handwashing is the best method for preventing cross-contamination." c. "Waterless commercial products are not effective for killing organisms." d. "The hands do not serve as a source of infection." 51. The nurse is performing Leopold maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus at the symphysis pubis area. Which of the following maneuvers is the nurse performing? a. First maneuver. b. Second maneuver. c. Third maneuver. d. Fourth maneuver. 52. A client in a cardiac rehabilitation program states that he would like to make sure he is eating the right foods to ensure adequate endurance on the treadmill. Which of the following nutrients is most helpful for promoting endurance during sustained activity? a. Protein. b. Carbohydrate. c. Fat. d. Water 53. A client's chest tube is connected to a chest tube drainage system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that a. there is an obstruction in the chest tube. b. the client is developing subcutaneous emphysema. c. the chest tube system is functioning properly. d. there is a leak in the chest tube system. 54. A client with diabetes is explaining to the nurse how she will care for her feet at home. Which statement indicates that the client understands proper foot care? a. "When I injure my toe, I will plan to put iodine on it." b. "I should inspect my feet at least once a week." c. "I do not plan to wear shoes while I am in the house." d. "It is important to dry my feet carefully after my bath." 55. The nurse assesses a client with diverticulitis and suspects peritonitis when which of the following symptoms is noted? a. Hyperactive bowel sounds. b. Rigid abdominal wall. c. Explosive diarrhea. d. Excessive flatulence.

56. When assessing a client, which risk factors would lead the nurse to suspect that the client has pancreatitis? Select all that apply. a. Excessive alcohol use. b. Gallstones. c. Abdominal trauma. d. Hyperlipidemia with excessive triglycerides. 57. When performing chest percussion on a child, which of the following techniques would the nurse use? a. Firmly but gently striking the chest wall to make a popping sound. b. Gently striking the chest wall to make a slapping sound c. Percussing over an area from the umbilicus to the clavicle. d. Placing a blanket between the nurse's hand and the child's chest. 58. The nurse walks into the room of a client who has a "Do Not Resuscitate" order and finds the client without a pulse, respirations, or blood pressure. What is the most appropriate action? a. Stay in the room and notify the nursing team for assistance. b. Push the emergency alarm to call a code. c. Dial the hospital phone number for a code. d. Pull the curtain and leave the room. 59. A client is trying to lose weight at a moderate pace. If the client eliminates 1000 calories per day from his normal intake, how many pounds would he lose in 1 week? a. 1 pound b. 2 pounds. c. 3 pounds d. 4 pounds. 60. A nulliparous client calls the clinic and tells the nurse that she forgot to take her oral contraceptive this morning. Which of the following would the nurse instruct the client to do? a. Take the medication immediately. b. Restart the medication in the morning. c. Use another form of contraception for 2 weeks. d. Take two pills tonight before bedtime. 61. The nurse recognizes that a client with pain disorder is improving when the client states which of the following? a. "I need to have a good cry about all the pain I've been in and then not dwell on it." b. "I need to find another physician who can accurately diagnose my condition." c. "The pain medicine that you gave me helps me to relax." d. I'm angry with all of the doctors I've seen who don't know what they're doing." 62. A client admitted in an acute psychotic state says that she hears "terrible voices in the head" and thinks her neighbor is "out to get her." Which of the following would be the nurse's best response? a. "What has your neighbor been doing that bothers you?" b. "How long have you been hearing these 'terrible voices?"' c. "We won't let your neighbor visit, so you'll be safe." d. "What exactly are these 'terrible voices' saying to you?" 63. The nurse would assess the client with severe diarrhea for which acidbase imbalance? a. Respiratory acidosis. b. Respiratory alkalosis.

c. Metabolic acidosis. d. Metabolic alkalosis. 64. Which of the following outcome criteria would be appropriate for a client with excess fluid volume? a. A weight resolution of 10% will occur. b. Pain will be controlled effectively. c. Arterial blood gas values will be within normal limits. d. Serum osmolality value will be within normal limits. 65. A 7-year-old child is admitted to the hospital with the medical diagnosis of acute rheumatic fever. Which of the following laboratory blood findings would confirm that the child probably has had a streptococcal infection? a. High leukocyte count. b. Low hemoglobin count. c. Elevated antibody concentration. d. Low erythrocyte sedimentation rate. 66. A client is scheduled for hip replacement surgery and is interviewed by the nurse in the preadmission testing unit. The client states that he wishes to receive his own blood for the upcoming surgery. What is the nurse's most appropriate response? a. Document the client's request on the chart. b. Notify the hematology laboratory. c. Notify the surgeon's office. d. Call the blood bank. 67. A client needs surgery to relieve an intestinal obstruction. The day before the surgery, the nurse receives the following set of orders for the client. Which of the following orders should the nurse question before performing? a. Tapwater enemas until clear. b. Out of bed as tolerated. c. Neomycin sulfate 1 g PO every 4 hours. d. Betadine scrub to abdomen twice daily. 68. After teaching a client about collecting a stool sample for occult testing, which client statement indicates effective teaching? Select all that apply. a. "I will avoid eating meat for 1 to 3 days before getting a stool sample." b. "I need to eat foods low in fiber a few days prior to collecting the sample." c. "I'll take the sample from different areas of the stool that I have passed." d. "I need to send the stool sample to the lab in a covered container right away." 69. A client who is NPO is constantly asking for a drink. Which of the following would be the most appropriate nursing intervention? a. Reexplain to the client why she cannot drink. b. Offer ice chips every hour to decrease thirst. c. Offer the client frequent oral hygiene care. d. Divert the client's attention by turning on the television. 70. A female client is admitted with complaints of fatigue, cold intolerance, weight gain, and muscle weakness. The initial nursing assessment reveals brittle nails, dry hair, constipation, and possible goiter. The client is most likely experiencing signs and symptoms of a. Cushing's disease. b. hypothyroidism.

c. hyperthyroidism. d. a pituitary tumor. 71. A mother visiting the clinic for a routine visit with her 10-year-old daughter reports that her daughter has an increase in hair growth and breast enlargement. The nurse explains to the mother and daughter that after the symptoms of puberty are noticed, menstruation most typically occurs within which of the following time frames? a. 6 months. b. 12 months. c. 30 months. d. 36 months. 72. While a mother is feeding her full-term neonate 1 hour after birth, she asks the nurse, "What are these white dots in my baby's mouth? I tried to wash them out, but they're still there." After assessing the neonate's mouth, the nurse explains that these spots are which of the following? a. Koplik's spots. b. Epstein's pearls. c. Precocious teeth. d. Thrush curds. 73. The nurse would suspect esophageal atresia (EA) and tracheoesophageal fistula (TEF) in a newborn exhibiting which of the following initially? Select all that apply. a. Copious frothy mucus. b. Episodes of cyanosis. c. Several loose stools. d. Initial weight loss. 74. Which one of the following factors is most important for healing an infected decubitus ulcer? a. Adequate circulatory status. b. Scheduled periods of rest. c. Balanced nutritional diet. d. Fluid intake of 1,500 mL/day. 75. A client is receiving digoxin (Lanoxin). His pulse range is normally 70 to 76 bpm. After assessing the apical pulse for 1 minute and finding it to be 60 bpm, the nurse should initially a. call the physician for orders. b. withhold the digoxin. c. administer the digoxin. d. notify the charge nurse 76. While shopping at a local mall, the nurse hears a pregnant client yell "Oh my! The baby's coming!" After placing the client in a supine position and trying to maintain some privacy, the nurse sees that the neonate's head is delivering. Which of the following would the nurse do first? a. Suction the mouth with two fingertips. b. Check for presence of a cord around the neck. c. Tell the client to bear down with force. d. Advise the mother that help is on the way. 77. The nurse is preparing a discharge plan for a 16-year-old who has fractured her femur and ulna. The client asks the nurse how quickly her fractures will heal so she can return to her

normal activities. Which of the following responses would be most appropriate for the nurse to make? a. "The healing of your leg will be delayed because you have had a skeletal traction." b. "It will take your arm about 12 weeks to heal completely, but it will take your leg about 24 weeks." c. "Because you are young and healthy, your bones should heal in less than 12 weeks." d. "You will require long-term rehabilitation and should expect it to take at least 8 months for your bones to heal." 78. A client with delirium becomes very anxious and says, "I can't stop what is happening to me. Make it stop, please!" Which of the following would be the nurse's most appropriate response? a. "I'll get you some medicines to help you relax. The more you worry, the worse it will get." b. "As soon as we know what's causing this, we can try to stop it. I'll get you some medicine to help you relax." c. "I wish I could do something to make it stop, but unfortunately I can't." d. "I'll sit with you until you calm down a little." 79. After teaching a primigravid client at 10 weeks' gestation about the recommendations for exercise during pregnancy, which of the following client statements indicates successful teaching? a. "While pregnant, I should avoid contact sports." b. "Even though I'm pregnant, I can learn to ski next month." c. "While we are on vacation next month, I can continue to scuba dive." d. "Sitting in a hot tub after exercise will help me to relax." 80. The nurse is caring for a client who has had a myocardial infarction involving a large section of the heart muscle. The nurse anticipates that the client is at risk for a. cardiogenic shock. b. hypovolemic shock. c. neurogenic shock. d. metabolic shock. 81. An obese 36-year-old multigravid client at 12 weeks' gestation has a history of chronic hypertension. She was treated with methyldopa (Aldomet) before becoming pregnant. When counseling the client about diet during pregnancy, the nurse realizes that the client needs additional instruction when she states which of the following? a. "I need to reduce my caloric intake to 1,200 calories a day." b. "A regular diet is recommended during pregnancy." c. "I should eat more frequent meals if I get heartburn." d. "I need to consume more fluids and fiber each day." 82. The physician has ordered a chemotherapy drug to be administered to a client every day for the next week. The client is on an adult medicalsurgical floor but the nurse assigned to the client has not been trained to handle chemotherapy agents. What is the nurse's most appropriate response? a. Send the client to the oncology floor for administration of the medication. b. Ask a nurse from the oncology floor to come to the client and administer the medication. c. Ask another nurse to help mix the chemotherapy agent. d. Ask the pharmacy to mix the chemotherapy agent and administer it.

83. Which of the following nursing diagnoses would the nurse identify as a priority after surgical repair of a cleft lip? a. Pain. b. Risk for Infection. c. Impaired Physical Mobility. d. Impaired Parenting. 84. Which of the following would be an appropriate outcome for a client with rheumatoid arthritis? The client will a. manage joint pain and fatigue to perform activities of daily living. b. maintain full range-of-motion (ROM) in joints. c. prevent the development of further pain and joint deformity d. take anti-inflammatory medications as indicated by the presence of disease symptoms. 85. A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. Which of the following interventions should be included in the plan of care before a hydrotherapy treatment is initiated? a. Limit food and fluids 45 minutes before therapy to prevent nausea and vomiting. b. Increase the intravenous flow rate to offset fluids lost through the therapy. c. Apply a topical antibiotic cream to burns to prevent infection. d. Administer pain medication 30 minutes before therapy to help manage pain. 86. A health care provider has been exposed to hepatitis B through a needlestick. Which of the following drugs would the nurse anticipate administering as postexposure prophylaxis? a. Hepatitis B immune globulin. b. Interferon. c. Hepatitis B surface antigen. d. Amphotericin B. 87. When performing an otoscopic examination of the tympanic membrane of a 2-year-old child, the nurse would pull the pinna in which of the following directions? a. Down and back. b. Down and slightly forward. c. Up and back. d. Up and forward. 88. Which of the following findings would the nurse most likely note in the client who is in the compensatory stage of shock? a. Decreased urinary output. b. Significant hypotension. c. Tachycardia. d. Mental confusion. 89. A client has been prescribed hydrochlorothiazide (HydroDIURIL) for treatment of heart failure. For which of the following symptoms should the nurse monitor the client? a. Urinary retention. b. Muscle weakness. c. Confusion. d. Diaphoresis. 90. The son of a client with Alzheimer's disease excitedly tells the nurse, "Mom was singing one of her favorite old songs. I think she's getting her memory back!" Which of the following responses by the nurse is most appropriate?

a. "She still has long-term memory, but her short-term memory will not return." b. "I'm so happy to hear that. Maybe she is getting better." c. "Don't get your hopes up. This is only a temporary improvement." d. "I'm glad she can sing even if she can't talk to you." 91. The nurse collects a urine specimen from a client for a culture and sensitivity analysis. Which of the following is the correct care of the specimen? a. Promptly send the specimen to the laboratory. b. Send the specimen with the next pickup. c. Send the specimen the next time a nursing assistant is available. d. Store the specimen in the refrigerator until it can be sent to the laboratory. 92. A 16-year-old client is in the emergency department for treatment of minor injuries from a car accident. A crisis nurse is with her because she became hysterical and was saying, "It's my fault. My Mom is going to kill me. I don't even have a way home." Which of the following would be the nurse's initial intervention? a. "Hold her hands and say, "Slow down. Take a deep breath." b. "Calm down. The police can take you home." c. "Put a hand on her shoulder and say, 'It wasn't your fault."' d. "Your mother is not going to kill you. Stop worrying." 93. The nurse is developing a community health education program about STDs. Which information about women who acquire gonorrhea should be included? a. Women are more reluctant than men to seek medical treatment. b. Gonorrhea is not easily transmitted to women who are menopausal. c. Women with gonorrhea are usually asymptomatic. d. Gonorrhea is usually a mild disease for women. 94. A client has his leg immobilized in a long leg cast. Which of the following assessments would indicate the early beginning of circulatory impairment? a. Inability to move toes. b. Cyanosis of toes. c. Complaints of cast tightness. d. Tingling of toes. 95. While feeding a term neonate at 2 hours of age, the nurse observes that the neonate has a drooping appearance on the left side of the face. The nurse notifies the physician based on the understanding that this is associated with which of the following? a. Craniotabes. b. Meningitis. c. Facial nerve damage. d. Skull fracture. 96. A client tells the nurse that she has had sexual contact with someone whom she suspects has genital herpes. Which of the following instructions should the nurse give the client in response to this information? a. Anticipate lesions within 25 to 30 days. b. Continue sexual activity unless lesions are present. c. Report any difficulty urinating. d. Force fluids to prevent lesions from forming.

97. The nurse is assigned to a client with irreversible shock. The nurse realizes that the negative outcomes of irreversible shock include severe hypoperfusion to all vital organs and failure of vital functions. Therefore, the nurse will monitor the client for a. increased alertness. b. circulatory collapse. c. hypertension. d. diuresis. 98. The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiration rate of 46 breaths/minute and a blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action? a. Notify the physician. b. Administer a sedative. c. Try to elicit a positive Homan's sign. d. Increase the flow rate of intravenous fluids. 99. The charge nurse should give a new graduate nurse who made an insulin medication error the following advice: a. "Trust your judgment; don't listen to your client." b. "Compare the insulin doses that other clients are receiving." c. "Large doses must always be double-checked." d. "Use 'U' as an abbreviation for 'Unit."' 100. A client who has Mnire's disease is trying to cope with the chronic tinnitus that she is experiencing. Which of the following interventions would be most appropriate for the nurse to suggest for coping with the tinnitus? a. Maintain a quiet environment. b. Play background music. c. Avoid caffeine and nicotine. d. Take a mild sedative.