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1. You are initiating a nursing care plan for a patient with osteoporosis.

All of these nursing interventions apply to the nursing diagnosis Risk for
Falls. Which intervention should you delegate to the nursing assistant?
a. Identify environmental factors that increase risk for falls
b. Monitor gait, balance, and fatigue level with ambulation
c. Collaborate with physical therapy to provide patient with walker
d. Assist the patient with ambulation to bathroom and in halls.

2. You are preparing to teach a newly diagnosed patient with osteoporosis


about strategies to prevent falls. Which of these points will you be sure to
include?
a. Wear a hip protector when ambulating
b. Remove throw rugs and other obstacles at home
c. Exercise will help build your strength
d. You should expect a few bumps and bruises when you go home
e. When you are tired, you should rest

3. You discover all of these assessment findings when admitting a patient


with Paget’s disease. Which finding indicates that the physician should be
notified.
a. The patient has bowing of both legs and the knees are asymmetric
b. The patient’s skull is soft, thick, and larger than normal
c. The patient is only 5 feet tall and weighs 120 pounds
d. The base of the patient’s skull is invaginated (platybasia).

4. As charge nurse you observe the LPN/LVN providing all of these


interventions for the patient with Paget’s disease. Which action requires
that you intervene.
a. Administers 600 mg of ibuprofen to the patient
b. Encourages the patient to perform PT recommended exercises
c. Reminds the patient to drink milk and eat cottage cheese
d. Applies ice and gentle massage to the patient’s lower extremities.

5. As charge nurse you are making assignments for the day shift. Which
patient would you assign to the nurse who has been pulled from the post-
anesthesia care unit (PACU) for the day.
a. A 35-year-old patient with osteomyelitis who needs teaching prior to
hyperbaric oxygen therapy
b. A 62-year-old patient with osteomalacia who is being discharged to a
long-term care facility
c. A 68-year-old patient with osteoporosis and a new orthotic device
whose knowledge of use of this device must be assessed
d. A 72-year-old patient with Paget’s disease who has just returned from
surgery for total knee replacement

6. You delegate taking vital signs to an experienced nursing assistant. The


patient has been diagnosed with osteomyelitis. Which vital sign do you
want the nursing assistant to report immediately
a. Temperature 99.90 F
b. Blood pressure 136/80
c. Heart rate 96/minute
d. Respiratory rate 24/minute

8. You are providing nursing care for a patient with carpal tunnel
syndrome (CTS) who is preparing for surgery. Which intervention should
you delegate to the nursing assistant?
a. Initiate placement of a splint for immobilization during the day
b. Assess the patient’s wrist and hand for discoloration and brittle nails
c. Assist the patient with daily self-care measures such as bathing and
eating.
d. Test the patient for painful tingling in the four digits of the hand

9. You deserve the nursing assistant performing all of these interventions


for the patient with CTS. Which action requires that you intervene
immediately?
a. Arrange the patient’s lunch tray and cut the meat.
b. Provide warm water and assist the patient with a bath
c. Replace the patient’s splint in hyperextension position.
d. Remind the patient not to lift very heavy objects

10.The patient is scheduled for endoscopic carpal tunnel release surgery


in the morning. What key point will you be sure to teach the patient
a. Pain and numbness will be experienced for several days to weeks
b. Immediately after surgery, the patient will no longer need assistance
c. After surgery, the dressing will be large with dots of drainage
d. After surgery, the pain and paresthesia will no longer be present

11.As charge nurse you assign the nursing care of a patient who has just
returned form open carpal tunnel release surgery to an experienced
LPN/LVN, who will perform under the supervision of an RN. Which of
the following instructions will you provide for the LPN/LVN? (Choose
all that apply.)
a. Check the patient’s vital signs every 15 minutes in the first hour.
b. Check the dressing for drainage and tightness
c. Elevate the patient’s hand above the heart
d. The patient will no longer need pain medication
e. Check the neurovascular status of the fingers every hour

12.You are preparing the post-operative CTS patient for discharge.


Which information is important to provide to this patient?
a. The surgical procedure is a cure for CTS
b. Hand movements will be restricted for 4 – 6 weeks after surgery.
c. Frequent pain medication dosages will no longer be necessary
d. Notify the physician immediately for any pain or discomfort

13.During discharge preparations, a patient with osteoporosis makes all


of these statements. Which statement indicates to you that the patient
needs additional teaching
a. “I take my ibuprofen every morning as soon as I get up.”.
b. “My daughter removed all of the throw rugs in my home.”
c. “My husband helps me every afternoon with range-of-motion
exercises.”
d. “I rest in my recliner chair every day for at least an hour.”

14.The patient suffered a fractured femur. Which of the following would


you tell the nursing assistant to report immediately
a. The patient appears confused
b. The patient complains of pain
c. The patient’s blood pressure is 136/88
d. The patient voided using the bedpan
15.After change-of-shift report, which patient should the nurse assess
first.
a. A 42-year-old patient with carpal tunnel syndrome complaining of pain
b. A 64-year-old patient with osteoporosis who is waiting for discharge
c. A 56-year-old patient with left leg amputation complaining of phantom
pain
d. A 28-year-old patient with fracture complaining that the cast is tight
16.A patient with a fractured fibula is receiving skeletal traction and has
skeletal pins in place. You instruct the nursing assistant to immediately
report which of the following?
a. The patient wants to change position in bed
b. There is a small amount of clear fluid on the pin sites
c. The traction weights are resting on the floor.
d. The patient is complaining of pain and muscle spasm
17.A patient with a fracture of the right ankle has a nursing diagnosis of
Impaired Physical Mobility. As charge nurse you observe a new graduate
RN perform all of these interventions. For which action should you
intervene?
a. Encourages the patient to go from lying to standing position.
b. Administers pain medication prior to beginning exercises
c. Explains to the patient and family the purpose of the exercise program
d. Reminds the patient about correct usage of crutches

18.The charge nurse assigns the nursing care of a patient who is 1 day
post-operative after a left below-the-knee amputation to an experienced
LPN/LVN, what will you describe as the major focus for care today?
a. To attain pain control for phantom pain
b. To monitor for signs of sufficient tissue perfusion.
c. To assist the patient to ambulate as soon as possible
d. To elevate the residual limb when the patient is supine

19.A patient with a right above-the-knee amputation has phantom limb


pain (PLP) and asks you why. What is your best response
a. “Phantom limb pain is not explained or predicted by any one theory.”
b. “Phantom limb pain occurs because your body thinks you leg is still
present.”
c. “Phantom limb pain will not interfere with your activities of daily
living.”
d. “Phantom limb pain is not real pain, but is remembered pain.”
20.During morning care, the patient with a below-the-knee amputation
asks the nursing assistant about prostheses. How should you instruct the
nursing assistant to respond.
a. “You should get a prosthesis so that you can walk again.”.
b. “Wait and ask your doctor that question next time he comes in.”
c. “It’s too soon to be worrying about getting a prosthesis.”
d. “I’ll ask the nurse to come in and discuss this with you.”

21.During assessment of a patient with fractures of the medial ulna and


radius, you find all of the following data. Which assessment finding
should you report to the physician immediately
a. The patient complains of pressure and pain
b. The cast is in place and is dry and intact
c. The skin is pink and warm to touch
d. The patient can move all fingers and thumb
1. Mrs. Chua a 78 year old client is admitted with the diagnosis of mild
chronic heart failure. The nurse expects to hear when listening to client’s
lungs indicative of chronic heart failure would be.
a. Stridor
b. Friction rubs
c. Wheezes
d. Crackles.

2. Patrick who is hospitalized following a myocardial infarction asks the


nurse why he is taking morphine. The nurse explains that morphine
a. Prevents shock and relieves pain
b. Decrease anxiety and restlessness
c. Dilates coronary blood vessels
d. Helps prevent fibrillation of the heart

3. Which of the following should the nurse teach the client about the
signs of digitalis toxicity.
a. Increased appetite
b. Elevated blood pressure
c. Skin rash over the chest and back
d. Visual disturbances such as seeing yellow spots

4. Nurse Trisha teaches a client with heart failure to take oral Furosemide
in the morning. The reason for this is to help.
a. Retard rapid drug absorption
b. Excrete excessive fluids accumulated at night
c. Prevention of electrolyte imbalance
d. Prevents sleep disturbances during night
5. What would be the primary goal of therapy for a client with pulmonary
edema and heart failure
a. Increase cardiac output
b. Enhance comfort
c. Improve respiratory status
d. Peripheral edema decreased

6. Nurse Linda is caring for a client with head injury and monitoring the
client with decerebrate posturing. Which of the following is a
characteristic of this type of posturing.
a. Upper extremity flexion with lower extremity flexion
b. Upper extremity flexion with lower extremity extension
c. Flexion of the extremities after stimulus
d. Extension of the extremities after a stimulus
7. A female client is taking Cascara Sagrada. Nurse Betty informs the
client that the following maybe experienced as side effects of this
medication:
a. GI bleeding
b. Peptic ulcer disease
c. Abdominal cramps.
d. Partial bowel obstruction

8. Dr. Marquez orders a continuous intravenous nitroglycerin infusion for


the client suffering from myocardial infarction. Which of the following is
the most essential nursing action?
a. Monitoring urine output frequently
b. Monitoring blood pressure every 4 hours
c. Obtaining serum potassium levels daily
d. Obtaining infusion pump for the medication.

9. During the second day of hospitalization of the client after a


Myocardial Infarction. Which of the following is an expected outcome?
a. Able to perform self-care activities without pain.
b. Severe chest pain
c. Can recognize the risk factors of Myocardial Infarction
d. Can Participate in cardiac rehabilitation walking program

10. A 68 year old client is diagnosed with a right-sided brain attack and is
admitted to the hospital. In caring for this client, the nurse should plan to:
a. Application of elastic stockings to prevent flaccid by muscle
b. Use hand roll and extend the left upper extremity on a pillow to
prevent contractions.
c. Use a bed cradle to prevent dorsiflexion of feet
d. Do passive range of motion exercise

11. Nurse Liza is assigned to care for a client who has returned to the
nursing unit after left nephrectomy. Nurse Liza’s highest priority would
be
a. Hourly urine output
b. Temperature
c. Able to turn side to side
d. Able to sips clear liquid
12. A 64 year old male client with a long history of cardiovascular
problem including hypertension and angina is to be scheduled for cardiac
catheterization. During pre cardiac catheterization teaching, Nurse Cherry
should inform the client that the primary purpose of the procedure is…..
a. To determine the existence of CHD
b. To visualize the disease process in the coronary arteries.
c. To obtain the heart chambers pressure
d. To measure oxygen content of different heart chambers

13. During the first several hours after a cardiac catheterization, it would
be most essential for nurse Cherry to.
a. Elevate clients bed at 45°
b. Instruct the client to cough and deep breathe every 2 hours
c. Monitor clients temperature every hour
d. Frequently monitor client’s apical pulse and blood pressure
14. Kate who has undergone mitral valve replacement suddenly
experiences continuous bleeding from the surgical incision during
postoperative period. Which of the following pharmaceutical agents
should Nurse Aiza prepare to administer to Kate
a. Protamine Sulfate
b. Quinidine Sulfate
c. Vitamin C
d. Coumadin
15. In reducing the risk of endocarditis, good dental care is an important
measure. To promote good dental care in client with mitral stenosis in
teaching plan should include proper use of…
a. Dental floss
b. Electric toothbrush
c. Manual toothbrush.
d. Irrigation device
16. Among the following signs and symptoms, which would most likely
be present in a client with mitral gurgitation
a. Exceptional Dyspnea
b.Altered level of consciousness
c. Increase creatine phospholinase concentration
d. Chest pain

17. Kris with a history of chronic infection of the urinary system


complains of urinary frequency and burning sensation. To figure out
whether the current problem is in renal origin, the nurse should assess
whether the client has discomfort or pain in the.
a. Urinary meatus
b. Pain in the Labium
c. Suprapubic area
d. Right or left costovertebral angle
18. Nurse Perry is evaluating the renal function of a male client. After
documenting urine volume and characteristics, Nurse Perry assesses
which signs as the best indicator of renal function
a. Blood pressure
b. Consciousness
c. Distension of the bladder
d. Pulse rate

19. John suddenly experiences a seizure, and Nurse Gina notice that John
exhibits uncontrollable jerking movements. Nurse Gina documents that
John experienced which type of seizure.
a. Tonic seizure
b. Absence seizure
c. Clonic seizure
d. Myoclonic seizure.
A clonic seizure may sometimes be hard to distinguish from a myoclonic
seizure. The jerking is more regular and sustained during a clonic seizure.
Most often, clonic movements are seen as part of a tonic-clonic seizure.

20. Smoking cessation is critical strategy for the client with Burgher’s
disease, Nurse Jasmin anticipates that the male client will go home with a
prescription for which medication.
a. Paracetamol
b. Ibuprofen
c. Nitroglycerin
d. Nicotine (Nicotrol)
The exact cause of Buerger disease is unknown. The condition is strongly
linked to tobacco use. It's thought that chemicals in tobacco may hurt the
lining of the blood vessels
Buerger disease also called TAO.
21. Nurse Lilly has been assigned to a client with Raynaud’s disease.
Nurse Lilly realizes that the etiology of the disease is unknown but it is
characterized by.
a. Episodic vasospastic disorder of capillaries
b. Episodic vasospastic disorder of small veins
c. Episodic vasospastic disorder of the aorta
d. Episodic vasospastic disorder of the small arteries.
Experts don't fully understand the cause of Raynaud's attacks. But blood vessels in the
hands and feet appear to react too strongly to cold temperatures or stress.
22. Nurse Jamie should explain to male client with diabetes that self-
monitoring of blood glucose is preferred to urine glucose testing because
a. More accurate.
b. Can be done by the client
c. It is easy to perform
d. It is not influenced by drugs

23. Jessie weighed 210 pounds on admission to the hospital. After 2 days
of diuretic therapy, Jessie weighs 205.5 pounds. The nurse could estimate
the amount of fluid Jessie has lost
a. 2.0 L
b. 1.5 L
c. 0.3 L
d. 3.5 L
24. Nurse Donna is aware that the shift of body fluids associated with
Intravenous administration of albumin occurs in the process of
a. Osmosis
b. Diffusion
c. Active transport
d. Filtration

26. Which of the following statements should the nurse teach the
neutropenic client and his family to avoid?
a. Performing oral hygiene after every meal
b. Using suppositories or enemas.
c. Performing perineal hygiene after each bowel movement
d. Using a filter mask

27. A female client is experiencing painful and rigid abdomen and is


diagnosed with perforated peptic ulcer. A surgery has been scheduled and
a nasogastric tube is inserted. The nurse should place the client before
surgery in
a. Sims position
b. Supine position
c. Semi-fowlers position.
d. Dorsal recumbent position

28. Which nursing intervention ensures adequate ventilating exchange


after surgery?
a. Remove the airway only when client is fully conscious
b. Assess for hypoventilation by auscultating the lungs
c. Position client laterally with the neck extended.
d. Maintain humidified oxygen via nasal cannula
Positioning the client laterally with the neck extended does not obstruct
the airway so that drainage of secretions and oxygen and carbon dioxide
exchange can occur.
29. George who has undergone thoracic surgery has chest tube connected
to a water-seal drainage system attached to suction. Presence of excessive
bubbling is identified in water-seal chamber, the nurse should
a. Check the system for air leaks
b. “Strip” the chest tube catheter
c. Recognize the system is functioning correctly
d. Decrease the amount of suction pressure

30. A client who has been diagnosed of hypertension is being taught to


restrict intake of sodium. The nurse would know that the teachings are
effective if the client states that…
a. I can eat celery sticks and carrots
b. I can eat broiled scallops
c. I can eat shredded wheat cereal.
d. I can eat spaghetti on rye bread

31. A male client with a history of cirrhosis and alcoholism is admitted


with severe dyspnea resulted to ascites. The nurse should be aware that
the ascites is most likely the result of increased
a. Pressure in the portal vein
b. Production of serum albumin
c. Secretion of bile salts
d. Interstitial osmotic pressure
32. A newly admitted client is diagnosed with Hodgkin’s disease
undergoes an excisional cervical lymph node biopsy under local
anesthesia. What does the nurse assess first after the procedure?
a. Vital signs
b. Incision site
c. Airway.
d. Level of consciousness

33. A client has 15% blood loss. Which of the following nursing
assessment findings indicates hypovolemic shock
a. Systolic blood pressure less than 90mm Hg
b. Pupils unequally dilated
c. Respiratory rate of 4 breath/min
d. Pulse rate less than 60bpm

34. Nurse Lucy is planning to give pre operative teaching to a client who
will be undergoing rhinoplasty. Which of the following should be
included.
a. Results of the surgery will be immediately noticeable postoperatively
b. Normal saline nose drops will need to be administered preoperatively
c. After surgery, nasal packing will be in place 8 to 10 days
d. Aspirin containing medications should not be taken 14 days before
surgery.

35. Paul is admitted to the hospital due to metabolic acidosis caused by


Diabetic ketoacidosis (DKA). The nurse prepares which of the following
medications as an initial treatment for this problem
a. Regular insulin
b. Potassium
c. Sodium bicarbonate
d. Calcium gluconate

36. Dr. Marquez tells a client that an increase intake of foods that are rich
in Vitamin E and beta-carotene are important for healthier skin. The nurse
teaches the client that excellent food sources of both of these substances
are:
a. Fish and fruit jam
b. Oranges and grapefruit
c. Carrots and potatoes
d. Spinach and mangoes.

37. A client has Gastroesophageal Reflux Disease (GERD). The nurse


should teach the client that after every meals, the client should
a. Rest in sitting position
b. Take a short walk
c. Drink plenty of water
d. Lie down at least 30 minutes

38. After gastroscopy, an adaptation that indicates major complication


would be
a. Abdominal distention
b. Nausea and vomiting
c. Increased GI motility
d. Difficulty in swallowing

39. A client who has undergone a cholecystectomy asks the nurse


whether there are any dietary restrictions that must be followed. Nurse
Hilary would recognize that the dietary teaching was well understood
when the client tells a family member that.
a. “Most people need to eat a high protein diet for 12 months after
surgery”
b. “I should not eat those foods that upset me before the surgery”
c. “I should avoid fatty foods as long as I live”
d. “Most people can tolerate regular diet after this type of surgery”

40. Nurse Rachel teaches a client who has been recently diagnosed with
hepatitis A about untoward signs and symptoms related to Hepatitis that
may develop. The one that should be reported immediately to the
physician is.
a. Restlessness
b. Yellow urine
c. Nausea
d. Clay- colored stools

41. Which of the following antituberculosis drugs can damage the 8th
cranial nerve.
a. Isoniazid (INH)
b. Paraoaminosalicylic acid (PAS)
c. Ethambutol hydrochloride (myambutol)
d. Streptomycin.

42. The client asks Nurse Annie the causes of peptic ulcer. Nurse Annie
responds that recent research indicates that peptic ulcers are the result of
which of the following.
a. Genetic defect in gastric mucosa
b. Stress
c. Diet high in fat
d. Helicobacter pylori infection.

43. Ryan has undergone subtotal gastrectomy. The nurse should expect
that nasogastric tube drainage will be what color for about 12 to 24 hours
after surgery.
a. Bile green
b. Bright red
c. Cloudy white
d. Dark brown

44. Nurse Joan is assigned to come for client who has just undergone eye
surgery. Nurse Joan plans to teach the client activities that are permitted
during the post operative period. Which of the following is best
recommended for the client?
a. Watching circus
b. Bending over
c. Watching TV.
d. Lifting objects
most patients are able to watch some television or look at a computer
screen for a short period of time.

45. A client suffered from a lower leg injury and seeks treatment in the
emergency room. There is a prominent deformity to the lower aspect of
the leg, and the injured leg appears shorter that the other leg. The affected
leg is painful, swollen and beginning to become ecchymotic. The nurse
interprets that the client is experiencing:
a. Fracture.
b. Strain
c. Sprain
d. Contusion

46. Nurse Jenny is instilling an otic solution into an adult male client left
ear. Nurse Jenny avoids doing which of the following as part of the
procedure
a. Pulling the auricle backward and upward
b. Warming the solution to room temperature
c. Pacing the tip of the dropper on the edge of ear canal.
d. Placing client in side lying position

47. Nurse Bea should instruct the male client with an ileostomy to report
immediately which of the following symptom
a. Absence of drainage from the ileostomy for 6 or more hours
b. Passage of liquid stool in the stoma
c. Occasional presence of undigested food
d. A temperature of 37.6 °C

48. Jerry has diagnosed with appendicitis. He develops a fever,


hypotension and tachycardia. The nurse suspects which of the following
complications
a. Peritonitis
b. Intestinal obstruction
c. Bowel ischemia
d. Deficient fluid volume
49. Which of the following compilations should the nurse carefully
monitors a client with acute pancreatitis.
a. Myocardial Infarction
b. Cirrhosis
c. Peptic ulcer
d. Pneumonia.
With severe pancreatitis there are a lot of inflammatory chemicals that are
secreted into the blood stream. These chemicals create inflammation
throughout the body, including the lungs. As a result, a person may
experience an inflammatory type of reaction in the lungs called ARDS

Acute pancreatitis has been associated with atypical bacterial


pneumonia since 1973
50. Which of the following symptoms during the icteric phase of viral
hepatitis should the nurse expect the client to inhibit?
a. Watery stool
b. Yellow sclera.
c. Tarry stool
d. Shortness of breath
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