1001 NCLEX-RN Questions!

Congratulations on completing your initial nursing education. You are so close to becoming a
registered nurse. As you know, it was a tough road. There may have been days where you were
exhausted, overwhelmed, and unsure if you’d ever get this far. You persevered and you did it!

Now it's time to complete the next step which is preparing for the NCLEX-RN Exam. Don’t
worry, you’ve got this. You already know this stuff. Think of how many tests you have already
passed. You know more than you think you do, and after completing this course, you will do
just fine.

This course is going to make passing the exam more comfortable. We will cover all of the areas
you will be tested on. We highlight Key Takeaways which are critical points throughout the
program.

Some graduate nurses feel overwhelmed thinking about taking their boards. You don't have to.
By the time you complete this course you will be confident in your abilities to take, and pass,
the exam with flying colors.

This course is specially designed and balanced so you can identify areas you need to
concentrate your attention on. It contains the same proportions of topic questions as the
NCLEX-RN exam.

After completing this course, you will be well prepared and know what to expect when the day
comes for you take and pass your boards.

Let’s take a few minutes to discuss what you will be tested on.
TABLE OF CONTENTS

Introduction ............................................................................................................................ 1

Part 1 Safe and Effective Care Environment ............................................................................. 5

1.1 Standards of Nursing ............................................................................................................. 5

1.1a. Client Rights .................................................................................................................... 5
1.1b. Confidentiality ................................................................................................................ 8
1.1c. Advance Directives and Life Planning ........................................................................... 12
1.1d Organ Donation ............................................................................................................. 17
1.1e Ethics.............................................................................................................................. 19
1.1f Legal Issues, Responsibilities, and Consent ................................................................... 23
1.2 Delivery of Care ................................................................................................................... 27
1.2a The Care Team ............................................................................................................... 27
1.2b Leadership ..................................................................................................................... 32
1.2c Care Delivery Models ..................................................................................................... 38
1.2d Continuity of Care/ Case Management/ Advocacy/Referrals ....................................... 41
1.2e. Prioritizing care ............................................................................................................. 48
1.2f Documentation............................................................................................................... 59
1.2g Information technology and security ............................................................................ 60
1.2h Performance Improvement ........................................................................................... 61
1.3 Safety ................................................................................................................................... 65
1.3a Providing a Safe Environment ....................................................................................... 65
1.3b Equipment Safety .......................................................................................................... 68
1.3c Hazardous and Infectious Materials Management ....................................................... 70
1.3d Emergency Management, Response, and Security ....................................................... 71
1.3e Restraints and Safety ..................................................................................................... 73
 1.3f Untoward events ............................................................................................................ 75
1.3g Ergonomics .................................................................................................................... 78
1.4 Infection Control ................................................................................................................. 81
1.4a Hygiene .......................................................................................................................... 81
1.4 b. Precautions .................................................................................................................. 85
1.4c Asepsis ........................................................................................................................... 89
1.4d Perioperative care ......................................................................................................... 93
Part 2 Health Promotion and Maintenance ........................................................................... 97

2.1 Physical assessment ............................................................................................................ 97

2.1a Vital signs ....................................................................................................................... 97
2.1b Physical Examination ..................................................................................................... 98
2.2 Growth and Development though the Lifespan ............................................................... 101
2.2a Growth and Development Theory ............................................................................... 101
2.2b Prenatal Development ................................................................................................ 103
2.2c Pregnancy .................................................................................................................... 105
2.2d Newborns .................................................................................................................... 107
2.2e Children ....................................................................................................................... 108
2.2f Adults............................................................................................................................ 110
2.2g Older Adults ................................................................................................................. 111
2.3 Health Promotion .............................................................................................................. 114
2.3a Lifestyle ........................................................................................................................ 114
2.3b Health Promotion and illness prevention/Health Screening ...................................... 115
2.3c Self Care ....................................................................................................................... 119
2.3d High-Risk Behaviors ..................................................................................................... 120
Part 3 Psychological Integrity............................................................................................... 124

3.1 Mental Health Concepts .................................................................................................... 124

3.1a. Mental Health Concepts ............................................................................................. 124
 3.1b Therapeutic Communication ....................................................................................... 126
3.1c Stress Management ..................................................................................................... 128
3.1d Family Dynamics: ......................................................................................................... 130
3.1e Diversity and Cultural Awareness................................................................................ 132
3.1f Support systems ........................................................................................................... 134
3.1g Religion and Spirituality ............................................................................................... 136
3.1h Sensory Alterations ..................................................................................................... 138
3.1i Crisis Intervention......................................................................................................... 140
3.1j Crisis Intervention......................................................................................................... 142
3.1k Abuse and Neglect ....................................................................................................... 144
3.1l Behavioral Interventions .............................................................................................. 146
3.1m Addictions ................................................................................................................... 147
3.1n End of Life Care............................................................................................................ 149
3.1o Grief and Loss .............................................................................................................. 151
Part 4 Physiological Integrity ............................................................................................... 155

4.1 Basic Care and Comfort ..................................................................................................... 155

4.1a Mobility/ Immobility .................................................................................................... 155
4.8b Assistive Devices .......................................................................................................... 158
4.8c Elimination ................................................................................................................... 161
4.8d Non-Pharmacological Pain Interventions .................................................................... 165
4.8e Nutrition ...................................................................................................................... 168
4.8f Oral Fluids ..................................................................................................................... 178
4.8g Rest and Sleep ............................................................................................................. 180
4.2 Pharmacological and Parenteral Therapies ...................................................................... 182
4.2a Medication Administration.......................................................................................... 182
4.2b Outcomes and Actions of Medication ......................................................................... 192
4.2c Adverse Reactions and Side Effects ............................................................................. 201
 4.2d Dosage Calculation ...................................................................................................... 208
4.2e Pharmacological Pain Management ............................................................................ 214
4.2f Parenteral Therapies .................................................................................................... 217
4.2g Central Venous Access Devices ................................................................................... 222
4.2h Total Parenteral Nutrition ........................................................................................... 223
4.2i Blood and Blood products ............................................................................................ 224
4.3 Reduction of Risk Potential ............................................................................................... 227
4.3a Alterations in Health .................................................................................................... 227
4.3b Potential Alterations in Systems/ Abnormal Vital signs .............................................. 232
4.3c Diagnostic Tests/Potential Complications and Adverse Reactions to Tests and
Treatments .................................................................................................................. 235
4.3d Laboratory Values........................................................................................................ 239
4.3e Therapeutic Procedures/Enteral Nutrition/Oxygen Therapy...................................... 242
4.3f Potential Complications from Surgery ......................................................................... 248
4.4 Physiological Adaptation ................................................................................................... 252
4.4a Hemodynamics ............................................................................................................ 252
4.4b Altered Fluid Balance................................................................................................... 254
4.4d integumentary system................................................................................................. 256
4.4e Respiratory System ...................................................................................................... 258
4.4f Cardiovascular System ................................................................................................. 261
4.4g Nervous System/Mental Health .................................................................................. 265
4.4h Gastrointestinal System .............................................................................................. 268
4.4i Hepatic System ............................................................................................................. 272
4.4j Renal System ................................................................................................................ 273
4.4k Musculoskeletal System .............................................................................................. 275
4.4l Endocrine System ......................................................................................................... 277
4.4m Male Reproductive System ........................................................................................ 279
4.4n Female Reproductive System ...................................................................................... 280
 4.4o Immune system ........................................................................................................... 283
4.4p Hematological System and Oncology .......................................................................... 286
4.4q Illness Management .................................................................................................... 288
4.4r Unexpected Response to Treatment ........................................................................... 290
4.4s Medical Emergencies ................................................................................................... 292
Part Five Mixed Review ....................................................................................................... 298
INTRODUCTION

Content of the NCLEX-R

The entire test is based on client needs. There are four key areas.

• Safe and Effective Care Environment

• Health Promotion and Maintenance
• Psychosocial Integrity
• Physiological Integrity

Some of these areas are broken down into multiple focus topics. Here is the actual percentage
of questions you can expect during this review course and when you take the NCLEX-RN exam.

Safe and Effective Care Environment

• Management of Care 17-23%

• Safety and Infection Control 9-15%

Health Promotion and Maintenance 6-12%

Psychosocial Integrity 6-12%

Physiological Integrity

• Basic Care and Comfort 6-12%

• Pharmacological and Parenteral Therapies 12-18%
• Reduction of Risk Potential 9-15%
• Physiological Adaptation 11-17% (National Council of State Boards of Nursing., 2016)

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Here is what we will be covering in the course.

There are a total of 1001 review questions. We’ve got you covered so that there won’t be any
surprises during your exam. The following are the topics covered in the NCLEX-RN exam:

Topics:

Management of Care

Infection Control and Safety

Health Promotion and Maintenance

Psychosocial

Basic Care and Comfort

Pharmacological and Parenteral Therapies

Risk Reduction

Physiological Adaption

Your supplement shows how much of each topic is covered by approximate percentage in the
exam. It also lists the number of questions to expect in this course for each area.

These areas will be covered as we review professional standards, fundamentals, the human
lifespan, and body systems. We will initially address key areas and then incorporate them
throughout the course. This will prepare you well for your exam. The NCLEX-RN integrates
topics randomly during the test.

Here’s an example of what I am saying:

When we are reviewing the unit on cardiac health, there will be questions about management
of cardiac patient care. These may include ethical dilemmas, case management, or continuity of
care in relation to the care being provided to a patient with a cardiac problem. We may address
the safe use of AEDs and post-operative angioplasty care as part of infection control and safety.

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We may include a question about fear and coping to address psychosocial needs. There will be
additional questions focusing on the pharmacology of cardiac drugs, reducing the risk of post-
MI, and fluid balance in patients with congestive heart failure. By presenting problems within
the realm of human needs, you will have opportunities to think about real life questions that
arise as you care for your patients.

How to Use this Course

The beauty of this course is that you can use it anytime, anywhere. While we recommend
setting aside a block of time each day to review the materials, one of the benefits of the
program is you can set aside an hour to listen one day or answer just a few quick questions
while waiting to pick up children from a basketball game. Listen during your commute or at the
gym. Be sure to note the questions or areas that you should study more. This program is highly
flexible, so use it to meet your individual needs. By now you know how you study best, so
capitalize on the study skills you already possess.

It’s important to remember this is information you have already learned. There are bound to be
areas you are more and less confident about. Relax and view the course merely as a study tool.
Be sure to take care of your mind, body, and spirit in the weeks leading up to your exam. How
you approach the NCLEX-RN is as important as your knowledge base. You can relax, knowing
that we are covering all areas that will be addressed on the NCLEX-RN.

When you answer questions, assume you are providing acute care unless the question indicates
otherwise. Assume that the patient is an adult unless otherwise stated. Base your answers on
what you would do if you were in a top-notch facility with all the needed resources available.
Always choose the BEST answer to the question.

You will be asked a question a question followed by four multiple choice questions. Select the
best one. The answers will be presented next. Mark questions that are difficult or those that
remind you of other topics you want to review. The first 800 questions will be presented as
topics are reviewed. The final 201 will be presented after all of the material is covered. They
will be given randomly just like the NCLEX-RN.

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For a detailed outline of the course layout, please refer to the Table of Contents in your
supplement.

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PART 1 SAFE AND EFFECTIVE CARE ENVIRONMENT

Part one consists of information that you need regardless of the type of nursing that you do.
We will begin by covering standards. Next, we will review the delivery of care. We’ll then
proceed to safety, infection control, and surgery.

Let's start by reviewing standards of nursing.

1.1 STANDARDS OF NURSING

1.1A. CLIENT RIGHTS
1. The document which acknowledges a patient/client’s right to participate in their
health care and emphasizes autonomy is called the:

A. Client’s/Patient’s Bill of Rights

B. Good Samaritan Law
C. Mental Health System’s Act
D. Health Care Portability and Accountability Act

Correct answer: A

Rationale: Client’s /Patient’s Bill of Rights protects clients to participate in their health
care and health care decisions. The Good Samaritan Law protects health care providers
who provide emergency care while off duty. The Mental Health System’s Act protects
individuals who have mental health challenges. The Health Care Portability and
Accountability Notice (HIPAA) ensures the privacy of personal health information.

2. A sixteen-year-old presents to the Emergency Department in respiratory distress. Her

parents are unreachable. Which is the correct first action?

A. Keep trying to notify the parents. If they aren’t reachable, call the grandparents for
permission to treat.
B. Provide emergency care while attempts are made to contact the parents.
C. Ask the child to sign a temporary consent to treat since she is sixteen years of age.

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 D. Obtain telephone consent by having two staff members listen on the telephone
while verbal permission is given.

Correct answer: B

Rationale: Parental consent is not needed in emergency situations. The first priority is
relieving the respiratory distress. Teens under the age of eighteen may only sign
consents if they are emancipated minors.

3. The Americans with Disabilities Act protects:

A. individuals over the age of 65

B. people who are infected with HIV or have disabilities
C. only individuals who have developmental disabilities
D. children and elders over 65

Correct answer: B

Rationale: The Americans with Disabilities Act provides comprehensive protection for
workers, and other individuals infected with HIV. It protects all people who have
disabilities.

4. A homeless client arrives at the emergency department with a sprained ankle. He does
not have any money or insurance. What law requires that the client is treated?

A. the Americans with disabilities act

B. the patient self-determination act
C. no law requires the patient be treated
D. the emergency medical treatment and active labor act ( EMTALA)

Correct answer: D

Rationale: EMTALA, the Emergency Medical Treatment, and Active Labor Act requires
that hospitals provide an evaluation of a client. The facility may not discharge or transfer
the client in an emergency situation until the clients health status is stabilized.

5. What does the mental health parity act prohibit?

A. clients from being Baker acted without their consent

B. children under 18 from obtaining mental health services without parental consent

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 C. the arrest of clients who use medical marijuana while traveling in a state that has
not legalized medical marijuana providing they have written documentation of their
prescription
D. insurers from placing lower limits on policy amounts for mental health benefits than
other benefits

Correct answer: D

Rationale: The Mental Health Parity Act prohibits insurance companies from placing
lower limits on policy amounts for mental health than it does for other healthcare
issues.

6. The Health Insurance Portability and Accountability Act (HIPAA):

A. establishes privacy laws; and protects clients and employees

B. protects clients and ensures that they will be treated promptly
C. ensures portability of healthcare information and treatment regardless of financial
ability
D. provides financial assistance so that workers can keep their health plan after
terminating employment for up to 18 months

Correct answer: A

Rationale: HIPAA, the Health Insurance Portability and Accountability Act, protects
individuals from losing their health insurance when changing jobs. It establishes rules for
privacy and confidentiality.

7. A state statute that declares a competent individual with a terminal illness may legally
request medication to end their life humanely:

E. is called the Uniform Determination of Death Act

A. is known as patient self-determination
B. physician-assisted suicide statute
C. is the Uniform Anatomical Gift Act

Correct answer: C

Rationale: Physician-assisted suicide statutes allow clients of specific states to request

medication to end their own life if they are competent and diagnosed with a terminal
illness.

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Let’s move on to our next section.

1.1B. CONFIDENTIALITY
8. Disclosure of Personal Health Information (PHI) is acceptable for all of the following
except:

A. Health insurance reimbursement

B. Treatment
C. Health care operations
D. Family information

Correct answer: D

Rationale: Personal Health Information may be shared for healthcare reimbursement

and benefit decisions. It may be used to provide information about health care services
and operations. Personal Health Information may be shared for treatment purposes. It
may not be shared with friends, employers, or family members without client
permission.

9. Which of the following describes a violation of privacy?

A. Discussing a client’s care with a co-worker who is not assigned to that client.
B. Attending an interdisciplinary team meeting to discuss discharge plans for a
client.
C. Sharing a client’s Personal Health Information with the client’s physical
therapist.
D. Contacting Protective Services to report suspected elder abuse of a client
that you are providing care for.

Correct answer: D

Rationale: Personal Health Information may be shared with providers who are/or will be
involved in the care of the client. Providers may only access information needed to
perform their duties.

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10. A client is diagnosed with genital warts. She states that she is no longer sexually active
and does not want to tell her previous partner about her diagnosis. The nurse:

A. Calls the health department

B. Provides education to the client regarding the contagious disease
C. Obtains the ex- partner’s contact information and calls him without the client’s
consent
D. Provides care to the client and refers her to social services

Correct answer: B

Rationale: The nurse is bound by client confidentiality. Educating the client will help her
understand why it is vital she notify her former partner.

11. Safeguards to ensure confidentiality and the availability of Protected Health

Information are aspects of:

A. The Security Rule of the Health Insurance Portability and Accountability Act (HIPAA)
B. Case management
C. Performance improvement
D. Advance directives

Correct answer: A

Rationale: The Security Rule of the Health Insurance Portability and Accountability Act
(HIPAA) provides safeguards to ensure confidentiality and the availability of Protected
Health Information. The rule governs electronic and other forms of information.

12. The Health Insurance Portability and Accountability Act (HIPAA) protects all of the
following except:

A. Handwritten medical information

B. Oral medical Information
C. The right to die
D. Electronic medical information

Correct answer: C

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 Rationale: The Health Insurance Portability and Accountability Act (HIPAA) protects
confidential health information regardless of whether it is oral, handwritten, or
electronically stored.

13. A woman frantically calls the emergency department to see if her sister is there. The
woman’s sister is an emergency department client, but she is currently having an
ultrasound. The nurse:

A. Tells the caller that the sister is in the emergency department but can’t come to the
telephone right now
B. Asks the woman to call back in 20 minutes when the client is likely to be back from
getting the ultrasound
C. Reassures the woman that her sister is stable and having a test performed
D. Does not confirm or deny the presence of the client

Correct answer: D

Rationale: Healthcare workers are prohibited from disclosing information about clients
unless permission has been granted by the client.

14. A visitor enquires about a family member’s roommate. The roommate has been
moved to the intensive care unit. The nurse states that:

A. he cannot disclose information about clients

B. the client has been moved to the intensive care unit
C. the client had a severe health issue but is now stable
D. admits that the client had a CVA, is in ICU, and not expected to survive

Correct answer: A

Rationale: Healthcare workers are prohibited from disclosing information about clients
unless permission has been granted by the client.

15. The nurse is discussing a client’s health status in the hall with another staff member
who is also caring for the client. A therapist from another unit overhears and says that
she knows the client from previous admissions. The therapist asks for the room
number that the client is in. The nurse:

A. Tells the therapist the room number

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 B. Realizes that she has breached the law by disclosing a client’s Personal Health
Information
C. Asks the therapist for input about the client
D. Continues to discuss the client with the co-worker who needs information to provide
care

Correct answer: B

Rationale: Only health care providers involved in the clients care may discuss clients.
Health care workers are bound by law to avoid disclosing information intentionally or
inadvertently.

16. Who does not have the “right to know” about a client’s condition?

A. The billing department worker who is processing the client’s medical claim
B. The physician from another facility who is providing consultation services
C. A nursing student who is caring for the client’s roommate
D. The facility’s performance improvement nurse

Correct answer: B

Rationale: Direct and indirect providers have the right to know about a client’s
condition.

You are doing great! Let’s continue!

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1.1C. ADVANCE DIRECTIVES AND LIFE PLANNING
17. Documents competent individuals make which state their preferences regarding
medical care and decision made should they become incapacitated are collectively
called:

A. Living wills
B. Do Not Resuscitate Orders (DNR)
C. Durable Power of Attorney
D. Advanced Directives

Correct answer: D

Rationale: Advanced directives are documents created by competent individuals so that

they can state their preferences regarding care. They may identify a health care proxy or
surrogate. Medical interventions are reviewed. Living wills and durable powers of
attorney are components of advanced directives.

18. A client suffered a CVA and is not likely to survive without artificial feeding. He is
unresponsive. His living will indicates he does not want to receive tube feedings. The
client’s health care surrogate wants tube feedings administered. Which of the
following statements describes this situation correctly?

A. The surrogate is legally bound to respect the client’s living will and cannot insist that
tube feedings be administered.
B. The surrogate can choose to request that tube feedings be administered as a living
will is not legally binding.
C. Tube feedings may be provided legally for up to seventy-two hours only with the
approval of the hospital’s ethics committee.
D. It is illegal to order tube feedings for this patient so total parenteral nutrition may be
instituted instead.

Correct answer: B

Rationale: A living will is a document which states individual preferences that a person
has regarding care to be provided or withdrawn if the individual is unable to make their
needs/desires known. Surrogates/ proxies are not bound to honor the person’s
preferences.

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19. The law which states that clients/patients must be given information regarding their
rights to provide written instructions about the care that they wish to have if they are
unable to make their own health care decisions is called the:

A. Do Not Resuscitate/ DNR Comfort Care Order

B. Client/Patient Self - Determination Act
C. Health Care Proxy Law
D. Client’s Bill of Rights

Correct answer: B

Rationale: The Client/Patient Self-Determination Act is a law that ensures clients be

given information about their rights to provide written directions about the care that
they wish to have should they become incapacitated and unable to make their own
health care decisions.

20. Who needs to sign a “do not resuscitate/DNR” order for it to be valid?

A. The client, or their designee if the client is incapacitated, and the client’s primary
care provider
B. The client and their lawyer
C. A physician, and the client, or client’s next of kin or surrogate if the client is unable
to sign.
D. Two physicians

Correct answer: C

Rationale: Any physician who is caring for a client may sign a “do not resuscitate/DNR”
order. The client must sign. If the client can’t sign, the next of kin, health care proxy, or
health care surrogate may sign.

21. A client is admitted to a long-term care facility. He says that he has advanced
directives. What does the nurse do?

A. Flag the client’s chart so caregivers know that he has a Do Not Resuscitate Order
B. Call the physician and request a Do Not Resuscitate order
C. Make a copy of the advance directive and place it in the client’s medical record
D. Contact the nursing supervisor

Correct answer: C

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 Rationale: Upon admission to a facility, the client should be asked if they have executed
advanced directives. If there are advance directives, a copy needs to be made and
placed in the client’s medical record.

22. A client is admitted to the hospital. She does not have advance directives. What
should happen as a result?

A. A code status needs to be determined within twenty-four hours

B. A health care proxy is appointed
C. A healthcare surrogate is appointed
D. The client is asked where or not she would like to make out an advance directive. An
opportunity is provided to make out an advanced directive if she desires.

Correct answer: D

Rationale: Upon admission to a facility, the client should be asked if they have executed
advanced directives. If there are no advance directives, the client needs to be asked
whether or not they would like to create one. If the answer is yes, an opportunity needs
to be provided so that the client can create advance directives.

23. A 21-year-old overdosed and is ventilator dependent. The client has no advance
directives. There is no brain, respiratory, or cardiac function. The parents cannot agree
regarding whether or not he should be taken off of the ventilator and allowed to die.
What persons or groups of people may be best considered as supportive resources?

A. ethics committee and interdisciplinary team

B. chaplain and chief of staff
C. Vice president of nursing and a judge
D. Social worker and performance improvement specialist

Correct answer: A

Rationale: An interdisciplinary team meeting may help the family. If they don’t agree, a
referral to the ethics committee may be indicated.

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24. A client is going to be transferred to an inpatient hospice facility. The client is
unresponsive. He doesn’t have any family or known friends. The hospital ethics
committee has determined the client should have a do not resuscitate order. What
needs to happen?

A. The chief of staff and attending physician sign a do not resuscitate order
B. A notice is placed in local newspapers in an attempt to find the next of kin
C. A guardian is appointed by a judge
D. A do not resuscitate order cannot be written. The man needs to be resuscitated if he
goes into cardiac arrest

Correct answer: C

Rationale: The facility contacts the local court. A judge assigns a guardian. The guardian
can opt to sign or not sign a do not resuscitate order.

25. A client or their designee must provide _____________________ in order for a do not
resuscitate order to be valid.

A. An advanced directive witnessed by a lawyer

B. An advance directive that was witnessed by a notary
C. A notarized copy of a do not resuscitate order if the DNR was signed in a different
state
D. Informed consent

Correct answer: D

Rationale: A client or their designee must provide informed consent for a do not
resuscitate order to be valid.

26. An unresponsive terminally ill client goes into cardiac arrest at the clinic. The nurse:

A. Alerts emergency services, begins and continues cardiopulmonary resuscitation until

it can be determined whether or not the client has executed a do not resuscitate
order
B. Calls the family and lets the next of kin know that their loved one has died
C. Looks at the chart to see if there is a do not resuscitate order and finding none,
decides not to do cardiopulmonary resuscitation as the client was terminally ill
D. Administers epinephrine and 100% oxygen by non-rebreather mask

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 Correct answer: A

Rationale: If a do not resuscitate order is not available or if the code status is unknown,
health care personnel must begin cardiopulmonary resuscitation.

27. Public education regarding advance directives is mandated by

A. The Joint Commission

B. Each state's Department of Public Health
C. The Uniform Determination of Death Act
D. The Patient Self-Determination Act

Correct answer: D

Rationale: The Patient Self- Determination Act requires that public education regarding
advance directives be provided.

28. A true statement about a durable power of attorney is:

A. A person who has a durable power of attorney legally makes medical decisions on a
person’s behalf regardless of whether or not the person can make their desires
known or not.
B. A durable power of attorney for health care is the same as other types of durable
powers of attorney
C. A durable power of attorney for healthcare is distinct from a durable power of
attorney for financial purposes
D. A durable power of attorney is appointed by a judge

Correct answer: C

Rationale: A durable power of attorney for healthcare is distinct from a durable power
of attorney for financial purposes. It is only valid when a person cannot make their own
healthcare decisions.

29. A true statement regarding advance directives is:

A. Any responsible adult may create one

B. Advance directives need to be created and signed by lawyers

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 C. Married individuals are required by law to have their spouse represent them as their
health care surrogate unless they are legally separated, or the spouse agrees that
another individual may act as health the care surrogate
D. Advance directives are only valid for ten years in most jurisdictions of the US.

Correct answer: A

Rationale: Any responsible adult may create an advanced directive

1.1D ORGAN DONATION

30. All of the following are true statements about organ donation except:

A. Donation of organs does not delay funeral arrangements.

B. Donors must be free of cancer and infectious diseases.
C. Organs can only be harvested from persons kept on mechanical ventilation.
D. Individuals over the age of 18 may indicate on their driver’s licenses whether or not
they choose to be organ donors.

Correct answer: C

Rationale: Many organs can be harvested regardless of whether or not the body is kept
on mechanical ventilation. The other statements are true.

31. Which is a correct statement regarding generally accepted religious beliefs, organ
donation, and transplantation:

A. Orthodox Jews allow organ donation as long as family members agree.

Transplantation is not acceptable.
B. Islam prohibits organ donation
C. The Roman Catholic Church bans organ donation
D. Organ transplantation is acceptable by members of the Orthodox Church if the
organ is cleansed with a non-blood solution before transplantation.

Correct answer: B

Rationale: Islam prohibits organ donation. Orthodox Jews consider organ

transplantation acceptable with rabbi approval. Families may not make decisions
regarding organ donation. Roman Catholics may donate or receive organs. Members of
the Orthodox Church are discouraged from making organ donations. Jehovah's

17
 Witnesses may receive organ transplants only if the organs are cleansed with a non-
blood solution before transplantation.

32. One organ donor can save up to this many lives:

A. 2
B. 4
C. 8
D. 12

Correct answer: C

Rationale: One organ donor can save up to eight lives.

33. All of the following organs except _______________ may be harvested from donors
while they are living:

A. A kidney
B. Portions of a liver, and lung
C. Portions of a spleen
D. Portions of intestines

Correct answer: C

Rationale: Living donors may donate a kidney and portions of their liver, lungs, and
intestines. Other tissues such as skin and sometimes eyes may be given.

34. The following factors are considered when selecting a transplant recipient except:

A. Financial ability to pay for the cost of the transplant

B. Severity of illness
C. Blood type
D. Geographic location

Correct answer: A

Rationale: Factors weighed when determining who receives a transplant donation

include all of the above except financial ability. Organ donation and transplantation are
free. Medical status and time spent waiting for a transplant are considered.

35. What must occur first before organs may be harvested from a deceased donor?

18
 A. Blood type, cross, and screen
B. The Patient Self-Determination Act must be signed by the surviving next of kin or
guardian
C. Blood cultures must be obtained and found free from bacterial growth
D. Brain death

Correct answer: D

Rationale: Death of the entire brain including the brain stem must occur before organ
harvesting.

1.1E ETHICS
36. As you are receiving report at the beginning your shift, you notice a strong odor of
alcohol from the nurse giving you report. Her speech is slurred, and she appears to be
under the influence of alcohol. There is a vodka bottle next to her. What is the first
step that you should take?

A. Call security
B. Confront the nurse
C. Make out an incident report
D. Call your supervisor

Correct answer: D

Rationale: Notify your supervisor immediately. The supervisor will evaluate the
situation, report the incident to the board of nursing, and alert others as needed. The
board of nursing will review the incident and make recommendations regarding
treatment and supervision of the impaired nurse.

37. The nurse works in the medical-surgical nursing unit. Upon arrival at work, she's
instructed to work in the medical intensive care unit as that area is understaffed. The
nurses never worked in a medical intensive care unit. What is the best action that the
nurse can take?

A. Call her supervisor and tell her that she is sick and has to go home.
B. Refuse to float as she has never been oriented to the intensive care unit and does
not have the skills of an intensive care unit nurse.
C. Contact the vice president of nursing and the hospital's legal department.

19
 D. Accept and clarify the assignment, advise the nursing leader in the medical ICU of
her abilities and limitations, and request an assignment within her skill set.

Correct answer: D

Rationale: If the nurse has concerns about client safety and suitability of the assignment
she needs to follow the hospital chain of command and notify the nursing supervisor.
Nurses are routinely required to float unless union contracts guarantee that nurses
won't float or if a nurse can prove that they do not have the skills needed to carry out an
assignment. Clarifying the assignment and discussing the nurse’s abilities ensures that
care can be provided safely. Going home or refusing to float is not acceptable.

38. The concept that the best interest of the client is more important than that of a
caregiver is called:

A. Ethical behavior
B. Beneficence
C. Maleficence
D. Justice

Correct answer: B

Rationale: Beneficence is a concept that values the best interest of the client is more
important than that of a caregiver.

39. Taking measures to ensure that a client is not harmed is an example of:

A. Fidelity
B. Maleficence
C. Nonmaleficence
D. Justice

Correct answer: C

Rationale: The concept of avoiding harm is known as nonmaleficence.

20
40. A nurse is providing home health care services to a challenging client. The nurse
reassures the client that she always keeps her word and will not abandon him despite
his behavior. The nurse is demonstrating:

A. Justice
B. A judgmental attitude
C. Fidelity
D. Warranty

Correct answer: C

Rationale: Fidelity is demonstrated by keeping one's word and not abandoning clients.

41. What is not a valid statement about values formation? Values formation:

A. begins around the age of eighteen

B. is fluid and changes over time
C. is influenced by family and individual experiences
D. occurs as a result of internal perceptions and external experiences

Correct answer: A

Rationale: Values formation begins in childhood. It is influenced by the family and

individual experiences.

42. Ethics committees do all of the following except:

A. Make recommendations for care

B. Make recommendations regarding policies
C. Provide education
D. Create policies regarding infectious materials management

Correct answer: D

Rationale: Ethics committees do not make policies regarding infectious materials

management as that is not an ethical concern.

43. The nurse manages her time so that she can equitably distribute her attention to the
clients that are assigned to her. The nurse is demonstrating:

A. Ethics

21
 B. Accountability
C. Justice
D. Autonomy

Correct answer: C

Rationale: Nurses must distribute care justly, equitably, and fairly among those they
care for.

44. The mother of a child with complex medical needs asks that the nurse provide her
with details regarding the child’s condition. The nurse tells the truth and doesn’t
withhold information although it is painful for the mother to hear. The nurse’s action
is an example of:

A. A poor ethical decision

B. Veracity
C. Emotional abuse
D. Coercion

Correct answer: B

Rationale: Telling the entire truth is veracity. Nurses must tell the truth even when it
may cause clients and families emotional pain.

45. What are the most common issues that are brought before hospital ethics
committees?

A. Concerns about the distribution of resources and end of life issues

B. Contraception, and unplanned pregnancies
C. Homelessness and smoking
D. Drug addiction and elder abuse

Correct answer: A

Rationale: The most common issues brought before hospital ethics committees include
concerns about the distribution of limited resources and end of life decisions.

46. Ethical guidelines are provided b :

A. The American Nurses Association’s Code of Ethics

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 B. The American Nurses Association Standards of Care and Practice
C. The World Medicine Association Code of Ethics
D. All of the above

Correct answer: D

Rationale: All of the above organizations offer resources for resolving ethical dilemmas.
The American Medical Association Code of Ethics is an additional resource.

47. The ethical decision-making process regarding a specific client includes:

A. Contacting the facilities’ head of finance before the first meeting of an ethics
committee’s discussion
B. The use of ethical skills such as time management and delegation
C. A systematic method
D. An evaluation of staffing patterns throughout the facility

Correct answer: D

Rationale: The ethical decision-making process is a systematic method that involves

gathering information, analyzing data, selecting a solution and evaluating the outcome.

1.1F LEGAL ISSUES, RESPONSIBILITIES, AND CONSENT

48. A state’s Nurse Practice Act is an example of:

A. Statutory law
B. Administrative law
C. Civil law
D. Common Law

Correct answer: B

Rationale: A state’s Nurse Practice Act is an example of administrative law.

Administrative laws support statutory laws. They consist of rules and regulations.

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49. Violations related to client confidentiality, malpractice, and negligence are classified
as :

A. Slander
B. Torts
C. Assault
D. Defamation

Correct answer: B

Rationale: Violations related to client confidentiality, malpractice, and negligence are

classified as torts. Torts are civil laws that address client rights and caregiver
responsibilities.

50. A nurse failed to provide the recognized standard of care. The client did not suffer any
harm as a result. The nurse is guilty of:

A. A tort
B. Negligence
C. Malpractice
D. An intentional tort

Correct answer: B

Rationale: Negligence is a nonintentional tort that occurs when a nurse fails to meet an
established standard of care.

51. For an act to be deemed malpractice all of the following must occur except:

A. The nurse had a duty to a client

B. A breach of duty occurs
C. The nurse’s action doesn’t result in client harm
D. The act leads to client harm

Correct answer: C

Rationale: All of the above are components that must occur for a determination of
malpractice to be made except lack of client harm. An injury must occur.

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52. The nurse applies a Posey vest restraint to a wandering, confused client because he
has a history of recent falls. The nurse fails to obtain an order for the vest. The nurse
is:

A. committing an assault
B. Carrying out her duties according to established national Standards of Practice
C. guilty of false imprisonment
D. guilty of libel

Correct answer: C

Rationale: The use of a restraint without an order is false imprisonment.

53. A nineteen-year-old student comes into the college health center with a broken tooth
and split lip. The student states that her live-in partner struck her. The student is
embarrassed and doesn’t want anyone to know what happened. The nurse:

A. Is mandated to report abuse

B. Abides by the client’s desire for confidentiality
C. Refers the student to her college advisor
D. Calls the student’s parents

Correct answer: A

Rationale: Nurses are mandated reporters of abuse.

54. A client has signed a surgical consent. She is in the perioperative unit. As the nurse is
inserting the intravenous catheter, the client says: “I changed my mind. I do not want
to have the surgery.” What does the nurse reply to the client?

A. You are just nervous. I will give you some medicine to help you relax.
B. Everyone feels that way right before surgery. It’s a typical feeling.
C. What has made you change your mind now?
D. You have the right to refuse the surgery.

Correct answer: D

Rationale: Clients have the right to refuse any treatments and revoke consent at any
time.

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55. To provide informed consent, a client must:

A. Be legally able to give consent without coercion

B. Be provided with information needed to make a decision
C. Consult with his/her primary care provider
D. Be legally able to give consent without coercion, and be given information necessary
to make an informed decision

Correct answer: D

Rationale: A client must be legally able to give consent without coercion, and provided
with information needed to decide to provide informed consent.

This concludes the section regarding Standards of Nursing. Take a break if you need one. When
you are ready, we will proceed to section 2, Delivery of Care. We will explore the care team,
prioritizing care, and medical records.

26
1.2 DELIVERY OF CARE
1.2A THE CARE TEAM
56. Client care conferences are useful for:

A. weighing the pros and cons of unionization

B. developing a vision for a healthcare agency
C. solving complex patient care problems collaboratively
D. educating staff about new policies and procedures

Correct answer: C

Rationale: Multidisciplinary or interdisciplinary client care conferences provide

opportunities for workers from many disciplines to collaborate and create solutions for
complex patient problems.

57. A hospice client tells you that he feels guilty for some choices that he made in his life.
With the client's consent, you make a referral to the________________ as that person
is most likely to have the skills and training to help relieve the clients suffering.

A. primary care physician

B. advanced practice registered nurse
C. chaplain
D. a nursing supervisor

Correct answer: C

Rationale: The Chaplin has extensive education and experience helping people cope
with emotions and spiritual distress.

58. Who is likely to be most knowledgeable about how to meet the complex needs of
clients who have severe complications from diabetes?

A. clinical nurse specialist on the diabetes unit

B. licensed practical or vocational nurse on the diabetes unit
C. a nursing supervisor
D. charge nurse on the diabetes unit

Correct answer: A

27
 Rationale: The person most likely to have in-depth knowledge of a condition within
their specialty is the clinical nurse specialist. Clinical nurse specialists are masters
prepared advanced practice nurses who have specialized training in a specific area of
practice. Practical and vocational nurses have less training than registered nurses.
Nursing supervisors often possess knowledge about a wide range of health conditions
rather than in-depth knowledge of a specialty. The charge nurse is likely to be very
knowledgeable but is also responsible for managing staff and care on the unit.

59. Which of the following tasks may the nurse delegate to the certified/licensed nursing
assistant?

A. Obtain vital signs 15 minutes after the nurse hung a unit of packed red blood cells.
B. Observe a client who has a history of CVA while the client eats
C. Increase the rate of flow of oxygen from 2 to 4 liters per minute via nasal cannula.
D. Change a dressing over a stage II decubitus

Correct answer: B

Rationale: Nursing assistants may observe clients while they are eating. They may not
perform the other tasks.

60. The purpose of interdisciplinary care team meetings is to:

A. improve client outcomes

B. enhance union negotiations
C. reduce the frequency of falls on an inpatient unit
D. reduce the risk of malpractice claims in a facility

Correct answer: A

Rationale: Interdisciplinary or multidisciplinary care meetings are used to improve client

outcomes.

61. Roles of the registered nurse during interdisciplinary care conferences include all of
the following except:

A. client advocate
B. medical director
C. coordinator of care
D. collaborator

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 Correct answer: B

Rationale: Nurses serve as client advocates, collaborators, and care coordinators.

62. Skills needed to be an active collaborator in multidisciplinary care settings include:

A. being a good listener

B. problem-solving skills
C. decision-making skills
D. all of the above

Correct answer: C

Rationale: Nurses need to have excellent communication skills as well as problem-

solving and decision-making abilities to function well in an interdisciplinary care setting.

63. Unlicensed assistive personnel may perform all of the following tasks except:

A. clerical duties
B. collecting urine samples
C. changing sterile dressings
D. obtaining vital signs

Correct answer: C

Rationale: Unlicensed assistive personnel, including nursing assistants and patient care
technicians, may perform clerical duties, collect specific laboratory samples, and take
vital signs.

64. Unlicensed nursing personnel may do all of the following except:

A. measure the height and weight of clients

B. measure and record intake and output
C. assist clients as they do range of motion exercises
D. perform skin assessments in long-term care settings

Correct answer: D

Rationale: Only licensed personnel may assess clients. Unlicensed nursing personnel
may complete all of the other tasks.

29
65. Which is not a valid statement about licensed practical or vocational nurses?

A. licensed practical or vocational nurses may change sterile dressings

B. licensed practical or vocational nurses may only change non-sterile dressings
C. licensed practical nurses work under the supervision of registered nurses
D. while delegating care, the registered nurse should assign relatively stable clients to
the licensed practical nurse

Correct answer: B

Rationale: Licensed practical or vocational nurses may perform sterile and nonsterile
procedures, including dressing changes.

66. Which of the following is a correct statement?

A. nurse practitioners are independent practitioners, but physicians assistants are not
B. physicians assistants are independent practitioners however nurse practitioners are
not
C. physicians assistants and nurse practitioners are independent practitioners
D. neither physicians assistants or nurse practitioners are independent practitioners

Correct answer: A

Rationale: Physicians assistants are not independent practitioners. Nurse practitioners

are independent practitioners.

67. All of the following are true statements about Doctors of Osteopathy (DOs) except:

A. Doctors of Osteopathy may order medications

B. Doctors of Osteopathy can perform surgery
C. some Osteopaths are specialists
D. the educational preparation to become a doctor of osteopathy is the same as that of
medical doctors

Correct answer: D

Rationale: Educational training, licensing requirements, and scope of practice is

different for Doctors of Osteopathy then it is for Medical Doctors. Most Doctors of
Osteopathy serve as primary care providers. However, some are specialists. Doctors of

30
 Osteopathy may order medications and tests. Doctors of Osteopathy may perform
surgery.

68. All of the following are true statements about a Doctor of Chiropractic Medicine
except:

A. they are medical doctors who specialize in chiropractic medicine

B. their scope of practice is determined by the state licensing board
C. they use nonpharmacological methods to treat a wide array of conditions
D. most work primarily in community settings

Correct answer: A

Rationale: A Doctor of Chiropractic Medicine is not medical doctors who specialize in

chiropractic medicine. They follow a specific educational path and are licensed
healthcare professionals who treat a wide array of healthcare issues.

69. The nurse is working with a woman who is a primigravida that has high blood
pressure. A low-sodium diet was ordered. Who should she contact to provide
extensive teaching about the low-sodium diet?

A. the woman's midwife

B. the woman's obstetrician
C. a dietitian
D. a nurse practitioner

Correct answer: C

Rationale: While all of the healthcare workers, including the nurse, are knowledgeable
about low sodium diets, the expert is the dietitian who can provide the best education
for the woman.

70. A client has a limited range of motion, a gait disturbance, and weakness. The most
helpful consultation for the client is with a/an:

A. occupational therapist
B. recreational therapist
C. primary care provider
D. physical therapist

31
 Correct answer: D

Rationale: Physical therapists are licensed healthcare professionals who are specially
trained to address problems such as range of motion concerns, gait disturbances, and
weakness.

71. The nurse is working on a medical-surgical unit and cannot draw arterial blood gasses.
Who should she call to obtain the needed sample?

A. the pulmonologist
B. the occupational therapist
C. respiratory therapist
D. primary care physician

Correct answer: C

Rationale: Respiratory therapists know how to draw arterial blood gases and interpret
them.

1.2B LEADERSHIP
72. A laissez-faire style of leadership is most effective when:

A. an organization is looking for a new direction

B. workers are required to complete simple tasks without questioning the validity of
management decisions
C. workers with a wide array of skill levels are employed.
D. leading a group of skilled, responsible, experienced workers

Correct answer: D

Rationale: Laissez-faire leadership allows employees the freedom to work

independently with little guidance. Employees formulate decisions, goals, and strategies
independently. This leadership style works well with experienced, responsible
employees. It is not useful for unmotivated, unskilled, or inexperienced workers.

32
73. The most dominant traits of a transformational leader include:

A. autocratic decision-maker who rewards staff with monetary gains and punishes with
disciplinary measures
B. charisma, creativity, and innovation
C. visionary encourages others to work towards a common goal
D. sharing input and decision-making with staff members

Correct answer: B

Rationale: Transformational leaders are optimistic and charismatic. They believe

employees are motivated to perform well through positive incentives. Transformational
leaders encourage team building. Autocratic decision-makers who motivate through
reward and punishment are transactional leaders. Visionary leaders inspire others to
work towards a common goal. They provide tools for reaching that goal. Democratic
leaders encourage staff to participate in decision-making.

74. Which of the following is not necessary for a hospital to achieve Magnet recognition?

A. centralized management
B. clinical pathways for nurses to advance
C. evidence-based practices
D. autonomous nursing structure

Correct answer: A

Rationale: Nurses must have opportunities to practice autonomously for a hospital to

be awarded Magnet status. Clinical pathways for nurses to advance and evidence-based
practices must be in place.

75. When management decisions are made by a limited number of individuals, such as a
Board of Directors, an organization is using this type of management structure:

A. autocratic
B. centralized
C. decentralized
D. country club style

Correct answer: B

33
 Rationale: Limited numbers of individuals make management decisions when a
centralized structure of management is used.

76. Staff and managers participate in decision-making when this organizational structure
is used:

A. case management
B. centralized management
C. decentralized management
D. modular nursing

Correct answer: C

Rationale: Staff and managers participate in decision-making when a decentralized

model of governance is used.

77. Having the freedom to make decisions about care, and taking responsibility for those
decisions indicates:

A. authority
B. autonomy
C. accountability
D. accessibility

Correct answer: B

Rationale: Autonomy allows people make decisions and the responsibility of being held
accountable for those decisions.

78. Having legitimate power to make decisions and direct care within a specific role
defines:

A. accountability
B. authority
C. accessibility
D. autonomy

Correct answer: B

34
 Rationale: People with authority have legitimate power to give instructions and orders.
Intrinsic with authority is having the ability to make final decisions within the scope of a
specific role.

79. The five rights of delegation include all of the following except:

A. Right task
B. Right time
C. Right supervision
D. Right circumstance

Correct answer: B

Rationale: Right task, right supervision, and right circumstance are all aspects of the five
rights of delegation.

80. A registered nurse has just asked an unlicensed assistive personnel member of the
team to determine why an intravenous infusion pump is alarming. The nurse has
made an error of delegation regarding:

A. Right supervision
B. Right communication
C. Right circumstance
D. Right person

Correct answer: D

Rationale: The nurse made a mistake by delegating the wrong person to complete a
task. Unlicensed assistive personnel may not evaluate an intravenous pumps alarm.

81. The nurse advised her unit manager of an ongoing client care safety issue. The
manager told the nurse that she would look into the matter however he didn't. What
does the nurse do next?

A. call the board of nursing

B. notify the vice president of nursing
C. speak with the medical Chief of Staff
D. follow the chain of command and report the concern

Correct answer: D

35
 Rationale: Nurses must follow the chain of command to report concerns.

82. The person responsible 24 hours a day for making unit policies, supervising staff on a
particular unit, and evaluating the team on that unit is the:

A. a nursing supervisor
B. the charge nurse
C. unit manager
D. performance improvement nurse

Correct answer: C

Rationale: Unit managers create policies for that unit. They supervise and evaluate staff
on their particular unit. They have 24-hour responsibility for the unit.

83. The registered nurse assigns the licensed practical/vocational nurse the task of
suctioning oral secretions from a client’s mouth. What is the registered nurse doing?

A. asking the licensed practical nurse to perform a procedure that is not within her
scope of practice
B. delegating
C. demonstrating laissez-faire leadership
D. being democratic

Correct answer: B

Rationale: Delegation is the action of instructing another worker to perform a task.

84. The person responsible for ensuring safe staffing, making decisions during crises, and
overseeing personnel during a specific shift is the:

A. vice president of nursing

B. a nursing supervisor
C. the nurse manager
D. nurse preceptor

Correct answer: B

Rationale: The nursing supervisor is responsible for overseeing all aspects of care during
a particular shift. Nursing supervisors serve as resource people and administrators.

36
85. A nurse manager has identified an ongoing problem within the unit. He asks for input
regarding solutions from all staff members who work on the unit. The staff members
provide information. However, the nurse manager makes the final decision about
what solution to use. This is an example of what type of leadership style?

A. autocratic
B. participative
C. problem-oriented
D. visionary

Correct answer: B

Rationale: Leaders who employ a participative style of management ask for input from
team members. However, they make final decisions.

86. The graduate nurse organizes tasks that she needs to complete on a worksheet. She
estimates how long it will take her to perform a complicated dressing change. She
anticipates that there may be interruptions and admissions throughout the day. What
is the nurse attempting to do?

A. manage her time efficiently

B. work on core measures
C. be fiscally responsible
D. delegate tasks to other staff members

Correct answer: A

Rationale: Time management skills include evaluating what needs to be accomplished,

prioritizing tasks, and anticipating interruptions.

87. The registered nurse is a unit manager in a skilled nursing facility. A licensed
practical/vocational nurse on the unit makes an error which results in injury to a
client. Which of the following is an accurate statement?

A. only the licensed practical/vocational nurse is responsible for the mistake

B. the registered nurse is accountable for the error
C. the licensed nurse and the registered nurse are both held responsible for the error
D. the organization that owns the facility is not liable for damages

Correct answer: C

37
 Rationale: Both nurses and the facility are liable for the error. Malpractice claims may
be filed against all involved.

1.2C CARE DELIVERY MODELS

88. A nursing care delivery model:

A. ensures that adequate numbers of staff are available to provide quality care
B. identifies the level of complexity of patient needs, health, and level of care required
C. defines how work assignments, authority, and responsibilities are structured
D. states that nurses are responsible for performing all aspects of client care

Correct answer: C

Rationale: The nursing care delivery model, which is also known as a care or patient
care delivery model or system, spells out how to work, responsibility, and authority are
structured. It identifies the roles of caregivers. Staffing ensures that adequate numbers
of staff are available to provide quality care. Patient acuity determines the level of
complexity of client needs, health, and level of care. Functional nursing states that
nurses are responsible for performing all aspects of client care.

89. Care that is individualized, and respectful of individual client preferences in needs and
is guided by the patient's values in all clinical decisions is called:

A. primary nursing
B. the partnership model
C. case management
D. patient-centered care

Correct answer: D

Rationale: Patient-centered care is responsive and reflective of individual client needs,

values, and preferences. Primary nursing and the partnership model are care delivery
methods. Case management is a collaborative process. Case management coordinates
health services.

38
90. A registered nurse working in a rehabilitation facility conducts all nursing assessments
and administers intravenous medications. The licensed practical or vocational nurse
on that same unit administers oral drugs and performs dressing changes. Nursing
assistive personnel bathe and turn the clients. What nursing care delivery model is
being used?

A. primary nursing
B. total patient care
C. team nursing
D. functional nursing

Correct answer: D

Rationale: Staff members perform tasks for all clients based on their level of training
when a functional nursing model is employed. A registered nurse assumes 24-hour
responsibility for clients care when the primary nursing model is used. Nurses using the
total patient care model provide all aspects of care for clients assigned to them during
their shift. Registered nurses following the team nursing model serve as team leaders to
small groups of workers who work together and provide care for a small group of
clients.

91. This modification of the primary nursing model pairs a registered nurse with a licensed
practical or vocational nurse or nursing assistant to provide care to a group of clients.

A. team nursing
B. the partnership model
C. clinical pathway
D. total patient care

Correct answer: B

Rationale: The partnership model is based on the primary nursing model. However it is
designed to use the registered nurses, skills more efficiently by partnering the registered
nurse with a licensed practical/vocational nurse or a nursing assistant. The healthcare
providers work together consistently to ensure continuity of care.

39
92. Strategies used by the healthcare delivery system to reduce healthcare costs are
known as:

A. quality indicators
B. quality measures
C. case management
D. managed care

Correct answer: D

Rationale: Managed care is a general term that describes strategies used in healthcare
systems designed to reduce costs of care.

93. All of the following are emphasized by managed care systems except:

A. inpatient hospice services

B. disease prevention
C. early diagnosis
D. client education

Correct answer: A

Rationale: Managed-care promotes healthy behaviors, early identification of illnesses,

client education, self-care, and fiscally responsible use of healthcare resources.

94. A critical pathway is a:

A. client-centered plan for establishing care and monitoring the client’s progress over a
specific period
B. procedure used to identify positive variances promptly
C. method for managing critically ill clients efficiently
D. policy that mandates medical providers be notified immediately in the presence of
critically abnormal laboratory values

Correct answer: A

Rationale: Critical pathways are plans for client care. They include monitoring progress
over a specific length of time.

40
95. The process by which specific client outcomes are compared with expected outcomes
and critical pathways is called:

A. the nursing care plan

B. case management
C. an interdisciplinary care conference
D. variation analysis

Correct answer: D

Rationale: Variation analysis is an ongoing process that caregivers use when comparing
specific client outcomes with expected outcomes as defined on a critical pathway.

96. When nursing assignments within a unit are divided up geographically, this is known
as:

E. transactional nursing
F. functional nursing
G. client focused care
H. modular nursing

Correct answer: D

Rationale: Modular nursing takes into account the geography of the nursing unit.

1.2D CONTINUITY OF CARE/ CASE MANAGEMENT/ ADVOCACY/REFERRALS

97. Define continuity of care.

A. A smooth, timely, cohesive transition of a client from one level of care to another or
from one location to another
B. a multidisciplinary meeting to facilitate discharge plans
C. a means of obtaining reimbursement for uninsured clients
D. steps taken by a nurse to organize a political action committee to address issues
regarding accessibility and affordability of healthcare in the community

Correct answer: A

Rationale: Continuity of care is the timely cohesive transition of the client from one
level of care to another or from one location to another. Written and often verbal

41
 communication between the sending and receiving nurse is essential. Continuity of care
is required between transfers within a facility and post-discharge.

98. Define the triad model of case management.

A. Registered nurses serve as primary nurses and clinical case managers. Billing and
coding responsibilities are done by nonclinical personnel
B. The registered nurse serves as case manager for a specific care unit with a group of
clients that have the same medical diagnosis or DRGs
C. Case management is a collaborative effort between a social worker, nursing case
manager, and utilization review team
D. The registered nurse serves as case manager for a group of clients that have the
same medical diagnosis or DRGs throughout an entire facility

Correct answer: C

Rationale: The Triad model of case management is based on collaboration between a

social worker nurse case manager and the utilization review team. Registered nurses
work as case managers and primary nurses while billing and coding responsibilities are
done by nonclinical personnel when the professionally advanced care team also known
as the ProACT model is followed. The case manager model is being used when a nurse
serves as a case manager for a particular unit with a group of clients that have the same
medical diagnoses. The collaborative practice model uses nurses to coordinate care for
clients that have specific diagnoses or are members of a diagnostic related group
throughout an entire facility.

99. When the nurse discusses client needs, pros and cons of treatments and alternatives
with the client the nurse are said to be:

A. going beyond the scope and standards of her profession

B. advocating for the client
C. evaluating client needs
D. delegating tasks

Correct answer: B

Rationale: By discussing individual client needs and treatment options a nurse

advocates for the patient.

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100. To advocate for client successfully, the nurse needs to:

A. present information factually without bias

B. obtain permission from the nurse manager or supervisor
C. be an expert, such as a nurse practitioner or clinical nurse specialist
D. request a meeting with the physician and social worker

Correct answer: A

Rationale: Healthcare providers must present factual information. They must not be
coercive or biased.

101. A 15-year-old overdosed on heroin. The teen is on a ventilator in the intensive care
unit. He has been declared brain-dead. The family wants to keep him on the ventilator
for another day with the hope that a miracle will occur. The nurse knows that this is
unlikely. The nurse advocates for the family by:

A. explaining to them that a miracle will likely not happen

B. encouraging them to make funeral arrangements
C. letting the nurse manager know of the family's wishes
D. letting them know the child would have more dignity if they don't force him to linger

Correct answer: C

Rationale: The nurse advocate by acknowledging the family’s needs and discussing their
concerns and possible options with the nurse manager.

102. Nurses advocate for:

A. Individual clients
B. family members
C. groups of clients
D. all of the above

Correct answer: D

Rationale: Nurses may advocate for individual clients, family members, or groups of
clients.

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103. Where do nurses advocate for clients and health?

A. inpatient and outpatient facilities

B. state and local forums
C. nationally and internationally
D. all of the above

Correct answer: D

Rationale: Nurses advocate for individual clients and also for healthcare issues in a vast
array of settings. These can be one-on-one with clients, within healthcare organizations,
or on a global scale.

104. The nurse is working in the neonatal intensive care unit. He is providing care for an
infant that was born at 24 weeks of gestation. The child has multiple physical
abnormalities and is not expected to live. The child goes into cardiac arrest. What
does the nurse do?

A. Call the family and let them know that the child has died
B. begin cardiopulmonary resuscitation
C. notify the family and asked them what interventions they would like taken
D. notify the physician

Correct answer: B

Rationale: The nurse is required by law to perform cardiopulmonary resuscitation even

when it is likely to be unsuccessful unless the family has agreed to a do not resuscitate
order.

105. The nurse is a case manager in a tertiary medical center. The client needs to go to a
skilled nursing facility for rehabilitation. He has Medicaid. A discharge order has been
written. The family would like the client to stay in the medical center for four more
days. The case manager:

A. cancels the discharge order

B. advises the client and family that waiting longer is not possible due to regulations
and reimbursement.
C. agrees to let the client remain for four more days.
D. contacts the physician and requests that the discharge order be canceled

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 Correct answer: B

Rationale: While the case manager might like to accommodate the client and family, it
is not possible. The case manager has a primary responsibility to ensure that clients
receive services at the appropriate level of care or else reimbursement will not occur.

106. The use of critical pathways is mandated when this model of case management is
used:

A. Triad model of case management

B. proACT model
C. case manager model
D. client advocacy model

Correct answer: C

Rationale: The case manager model requires the use of critical pathways.

107. The Joint Commission on the Accreditation of Healthcare Organizations recommends

the use of handoff reports. Some standardized reports that they support include all of
the following except for the:

A. SBAR
B. BATON
C. SOAP
D. IPASS

Correct answer: C

Rationale: All of the above are approved handoff report forms except for the SOAP.
Other accepted forms include the ISBAR and 5P’s.

108. All of the following are true statements about the Joint Commission on the
Accreditation of Healthcare Organization's position regarding the use of abbreviations
except:

A. only specific abbreviations and terminology are acceptable to use in healthcare

settings
B. healthcare organizations are required to create and maintain a list of unacceptable
abbreviations

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 C. many abbreviations can be misinterpreted and potentially result in the client harm
D. abbreviations may not be used

Correct answer: D

Rationale: Healthcare organizations must not use abbreviations that are deemed
unacceptable. They are required to keep a list of unacceptable abbreviations.

109. Define continuity of care:

A. Seamless, appropriate, timely, coordinated transition of care when a client has a

change in acuity or location
B. a role of case managers that ensures clients receive proper care in a fiscally
responsible manner
C. Medicare's policy that holds discharging facilities financially accountable if clients
are hospitalized within 30 days after discharge
D. the Joint Commission on the Accreditation of Healthcare Organization’s requirement
for the use of standardized handoff report forms when clients are discharged from
acute care settings to skilled nursing facilities

Correct answer: A

Rationale: Continuity of care is a smooth transition of a client within a facility, whenever

changes in acuity occur, and when discharges to other organizations or home occur.

110. When obtaining a telephone order to increase the dose of a patient-controlled

intravenous narcotic analgesic, the nurse:

A. reminds the physician that narcotic orders may not be changed via telephone orders
B. asks another nurse to listen to the call so that the order can be verified
C. reads the order back, clarifies any questions, and writes the prescription
D. reminds the physician that intravenous patient-controlled analgesic orders may not
be changed over the phone

Correct answer: C

Rationale: it is acceptable to receive the order by phone. When accepting verbal or

telephone orders, nurses need to verify the client's name, room number, and diagnosis.
Nurses clarify questions with the prescribing practitioner. Orders need to be read back
and verified. Documentation of the order needs to be performed immediately.

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111. What information needs to be included and documented when the nurse is making a
telephone report in anticipation of a client being transferred to another unit within
the facility?

A. Information provided and received, and the names of the people on the call
B. fall risk, Braden scale, and diagnoses
C. level of elopement risk, and insurance information
D. date of birth, name, and when the last meal was eaten

Correct answer: A

Rationale: Nurses need to provide information about the client and receive information
as well about the planned discharge. Unresolved issues must be reported, and a plan
put in place to resolve them. The nurse needs to document that the call was made and
who he or she spoke to. The information provided by answers B, C, and D may be
relevant but not always necessary.

112. A client is being discharged from an urgent care center after treatment for a minor
upper respiratory infection. No follow-up appointment is needed unless the client’s
symptoms worsen. What is the nurse’s responsibility?

A. the nurse has no responsibility as the client was seen in an urgent care center
B. the nurse has no responsibility since no follow-up is needed
C. the nurse needs to provide discharge instructions and education
D. the nurse needs to ensure that the physician, physician's assistant, or nurse
practitioner offers a prescription for required medication

Correct answer: C

Rationale: The nurse needs to provide discharge instructions and education to the
client. The instructions need to be specific and related to the diagnosis. The client needs
to be provided with information regarding what to do if signs and symptoms worsen
and more care is required.

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113. When does discharge planning begin if a client is hospitalized?

A. 72 hours before the anticipated date of discharge

B. it varies, depending on the client’s specific needs
C. on admission
D. it depends on the client as discharge planning is not necessary for all clients

Correct answer: C

Rationale: Every client needs discharge planning. It begins upon admission.

114. Change of shift reports include:

A. background information and information about current health issues

B. significant information about family dynamics
C. education provided and needed
D. all of the above

Correct answer: D

Rationale: Change of shift reports should include concise background information,

diagnoses, observations, information about family dynamics if pertinent, the plan of
care, priorities of care and an evaluation of the client and treatments.

Let's practice prioritizing care.

1.2E. PRIORITIZING CARE

115. Whose theories of care are most important to consider when prioritizing care needs?

A. Sigmund Freud
B. Abraham Maslow
C. Eric Erickson
D. Martha Rogers

Correct answer: B

Rationale: Maslow's hierarchy of needs theory is essential to consider. Necessary

physiological requirements need to be addressed first. Freud theorized about the
personality and emotional needs. Erickson recognized developmental stages. Rogers
focused on energy fields.

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116. Which client needs to be cared for first?

A. The hospice patient who is expected to die within hours

B. The crying child with appendicitis
C. The man who has difficulty breathing
D. The woman in labor

Correct answer: C

Rationale: Use ABC's-airway, breathing, and circulation as your guide to provide care.
The man who has difficulty breathing is the highest priority.

117. A client comes into a clinic doubled over with abdominal pain. What is the first step
that you should take?

A. immediately notify the physician

B. contact the nurse practitioner and suggest that an abdominal ultrasound be ordered
C. conduct an assessment
D. tell the client not to eat or drink anything

Correct answer: C

Rationale: Perform an assessment first when prioritizing care needs if one has not
already been done.

118. The client is in cardiac arrest. What is your guideline for providing care?

A. airway, breathing, circulation,

B. compressions breathing, airway
C. airway, circulation, breathing
D. compressions, airway, breathing

Correct answer: D

Rationale: When cardiopulmonary resuscitation is needed use compressions, airway,

and breathing as the order to deliver care. This is a deviation from the normal process of
prioritization using airway, breathing, and circulation as a guideline.

119. A disaster has occurred. The client identified as needing emergent priority one care is:

A. A child who has an open fracture of his femur

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 B. A woman with a gunshot wound to her thumb
C. A comatose toddler who has massive open crush wounds to the head and chest and
Cheyne- Stokes respirations.
D. A seventy-year-old man who sustained chemical burns to the eyes

Correct answer: D

Rationale: Chemical burns to the eye must be treated immediately. The child who with
the open fracture and the woman with the gunshot wound is of urgent priority two
need. The toddler is unlikely to survive and is a low priority.

120. Essential time management steps include:

A. client assessment, multitasking, and establishing priorities

B. allowing planning time to develop priorities, completing highest priority tasks first,
working on one job at a time, and reprioritizing as needed
C. completing top priority tasks first, multitasking, and delegating
D. client assessment, responding to emergencies, documenting care at the end of the
shift

Correct answer: B

Rationale: Essential steps for effective time management include allowing time to plan
and prioritize. It is essential to perform the highest priority tasks first. Effective time
managers reprioritize depending on tasks and changes that occur throughout the day.

121. What impacts prioritization?

A. individual client acuity

B. acuity of all clients the nurse is responsible for
C. code status
D. A and B

Correct answer: D

Rationale: When setting priorities, individual client needs, as well as the acuity of all
clients, must be considered.

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122. Clients who have high-priority needs include:

A. individuals who have immediate threats to airway, breathing, and circulation

B. clients who at immediate risk for harm due to safety and security issues
C. infants and children
D. A and B

Correct answer: D

Rationale: Clients with immediate life-threatening health issues are the highest priority.
Clients who are in immediate physical danger are also of the highest priority.

123. Clients who are rated as having the second highest level of priority for care include all
of the following except:

A. people in acute pain

B. individuals are unable to urinate
C. clients who have mental status changes
D. clients who have stage III pressure ulcers

Correct answer: D

Rationale: Clients who have mental status changes, are unable to urinate, untreated
medical problems, or have a moderate risk of injury due to safety or security issues are
considered to be the second highest level of priority.

124. Which of the following clients is not a low-level priority client?

A. a client who needs education regarding insulin administration

B. a newborn scheduled for circumcision
C. a woman who is in the early stages of labor
D. a wandering client with Alzheimer's dementia

Correct answer: D

Rationale: All of the clients are a low priority except the wandering client. She is in
danger of harm due to safety concerns and mental status changes. The wandering client
is considered mid-level in need.

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125. Which client should be cared for first?

A. hospice client who is having grand mal seizures

B. man having chest pain
C. a woman who is pushing during delivery
D. a geriatric client who has a fractured hip that has not been treated

Correct answer: A

Rationale: The client having seizures is the highest priority due to the risk of airway
obstruction.

126. A team nursing model is being used to provide care. The team is comprised of a
registered nurse, licensed vocational nurse, and certified nursing assistant. Which
client should be assigned to the certified nursing assistant for care?

A. a toddler who is being evaluated for autism

B. a nine-year-old who is having severe abdominal pain
C. an infant who is being treated for bacterial meningitis
D. a teenager diagnosed with a minor traumatic brain injury after being in a car
accident earlier in the day

Correct answer: A

Rationale: The certified nursing assistant should be assigned the stable client who has a
chronic health concern. The toddler being evaluated for autism is the correct choice.

127. When determining care needs and delegating assignments, the nurse considers all of
the following except:

A. available resources
B. staff qualifications
C. funding sources
D. time needed to perform tasks

Correct answer: C

Rationale: While prioritizing care and delegating assignments, nurses consider what
resources are available, staff qualifications, and how long it takes to perform needed
tasks.

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128. What should the nurse do first?

A. change a complicated dressing that requires two staff members

B. administer an intravenous pain medication
C. obtain a urine sample
D. teach new parents how to bathe their baby

Correct answer: B

Rationale: Pain medication should be administered first to ensure client comfort. It is a

relatively fast procedure to perform. Procedures that take a short amount of time take
priority over those that require an extended amount of time and need coordination
between staff members.

129. Throughout the shift, the nurse anticipates that he

A. will complete all tasks in the order he planned when he received an assignment at
the beginning of the shift
B. must be flexible because priorities may be impacted by admissions, changes in client
acuity, and staffing changes
C. will spend an equal amount of time caring for each client assigned to him
D. will document all care at the end of his shift

Correct answer: B

Rationale: Assessing client needs, and prioritizing care is an ongoing process. The nurse
must be flexible as client needs and resources change.

130. The nurse is administering blood. Which reaction is the most severe and needs
attention first?

E. fever
F. swelling of the face and neck
G. generalized itching
H. infiltration at the intravenous site

Correct answer: B

Rationale: Swelling of the neck and face may lead to airway obstruction. Immediate
steps must be taken.

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131. A 45-year-old man has crushing chest pain and fever. The following interventions have
been ordered stat. Nitroglycerin 0.4 mg sublingually, chest x-ray, troponin level,
Tylenol 650 mg PO. What intervention is performed or administered first?

A. administer the nitroglycerin

B. notify the x-ray department of the stat x-ray order
C. contact the lab and alert them to the stat troponin order
D. give the Tylenol

Correct answer: A

Rationale: Nitroglycerin dilates the coronary blood vessels, improves circulation to the
heart, and prevents damage to cardiac tissues as it relieves pain.

132. Which of the following clients should be seen first in the emergency department?

A. an agitated 94-year-old who is yelling and disturbing other clients

B. a client who has a headache and has been waiting for 30 minutes for pain
medication
C. a child who is having an asthma attack
D. a client who arrived before the other clients and has nausea, vomiting, and diarrhea

Correct answer: C

Rationale: The child who is having an asthma attack is the highest priority due to
potential airway and breathing concerns.

133. Which client should be cared for by the registered nurse if the team consists of a
registered nurse, a licensed practical nurse, and a nursing assistant?

A. a client who has chronic back pain who is being treated with oral medication and
bedrest
B. a woman who had a hysterectomy three days ago
C. a man who sustained multiple injuries due to a workplace accident
D. an eight-year-old who has a fractured femur which was repaired two days ago

Correct answer: C

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 Rationale: The registered nurse cares for the man who sustained multiple injuries due
to a workplace accident as there is a potential for many body systems to be impacted
and the injuries occurred that day.

134. Which task should be delegated to the licensed practical or vocational nurse when a
registered nurse and licensed practical nurse are paired?

A. teaching a person how to use an insulin pen

B. administering packed red blood cells
C. changing a sterile dressing
D. administering morphine 2 mg IV push

Correct answer: C

Rationale: Licensed practical nurses can change sterile dressings. They may not teach,
administer IV push or medications. Most facilities do not allow licensed
practical/vocational nurses to administer blood products. A registered nurse should
administer blood when possible even in facilities that allow licensed practical/vocational
nurses to give blood.

135. Which need must be addressed first when all of the following are true about a client?

A. the client has 5 out of 10 abdominal pain

B. the client is a victim of spousal abuse
C. the client believes that she deserves the abuse
D. the client is unable to read discharge instructions

Correct answer: A

Rationale: Using Maslow's hierarchy of needs as a guide, pain is a physiological concern

which must be addressed first.

136. A medical-surgical nurse floats to the maternity unit. The charge nurse should assign
the following client(s) to the medical-surgical nurse:

A. The woman who is in transition

B. a woman who is pregnant with her first child has a blood pressure of 180/100 and is
edematous
C. the mother/baby pair. The child was born on the previous day.
D. the 16-year-old teen who needs a cesarean section to deliver twins

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 Correct answer: C

Rationale: The medical-surgical nurse should be assigned to the most stable patient(s).
In this case, it is the mother/ baby pair.

137. The 12-year-old is taken to surgery from the emergency room for repair of a ruptured
appendix. The boy is expected to be discharged within 48 hours. When should
discharge planning preparations begin?

A. on admission
B. after the surgery is performed
C. within 24 hours after the surgery
D. on the day of discharge as his follow-up is limited to just a post-op visit with the
surgeon

Correct answer: A

Rationale: Discharge planning begins on admission.

138. A 96-year-old female is admitted to a rehabilitation facility for care following a total
hip replacement. The woman has multiple comorbidities that make it difficult to
predict how long she will be in the facility and where she will reside after discharge. It
is unknown whether she will need placement in a long-term care facility, assisted-
living home, or live in her son's house with home health care services. When should
discharge planning services begin?

A. on admission
B. when she starts to stabilize
C. when the son decides where she will reside post discharge
D. one week before her anticipated discharge date

Correct answer: A

Rationale: Discharge planning begins on the day of admission regardless of client

circumstances.

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139. A child is being discharged from the emergency department following treatment for
an asthma attack. Which of the following is the most crucial information that the
nurse should provide to the parents?

A. How to recognize signs and symptoms of an asthma attack, including guidelines for
obtaining care
B. The child should be encouraged to drink plenty of fluids
C. The child should remain home from school for two days
D. The family must provide the child with emotional support should another asthma
attack occur

Correct answer: A

Rationale: It is essential that the parents be able to recognize signs and symptoms of an
asthma attack. They need to know what signs indicate the need for more care including
instructions about seeking emergency assistance. The other interventions are primarily
geared towards comfort which is a lower priority than obtaining safe and effective care
promptly.

140. The nurse is evaluating fall risk among her clients. Which client has the lowest risk of
falling?

A. The 25-year-old male who recently had back surgery and is using morphine via
patient-controlled analgesia
B. an 84-year-old female who just had a total hip replacement
C. a 12-year-old girl who is hospitalized for pneumonia
D. a 72-year-old male with glaucoma

Correct answer: C

Rationale: Clients most at risk for falling have cognitive or sensory impairments. Specific
conditions, such as muscle weakness or Parkinson's disease increase the risk of falls
occurring. Clients who take narcotics or medications which may cause drowsiness have
an elevated risk of falling.

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141. The nurse is evaluating her clients’ risk for skin breakdown. All of the following
increase the risk of skin breakdown except:

A. advanced age
B. sex
C. decreased level of serum albumin
D. shearing of skin during position changes

Correct answer: B

Rationale: advanced age, low levels of albumin, and shearing of skin all contribute to
skin breakdown.

142. The nurse is providing education to a client who has a diagnosis of thrombophlebitis in
the left leg. The client is being discharged home with a prescription for warfarin. What
is the most vital information to provide to the client?

A. elevate the legs whenever possible

B. seek immediate medical attention if shortness of breath or chest pain develops
C. have the INR checked according to the schedule provided
D. apply elastic compression stockings every morning before getting out of bed

Correct answer: B

Rationale: The most crucial information is to seek immediate medical attention should
shortness of breath or chest pain develop. These can be signs of a potentially life-
threatening pulmonary embolism. The other aspects of care are essential but not as
time sensitive.

143. The nurse is providing instructions to family members for visiting a client who has an
infection caused by Clostridium difficile. What is most important to tell the family
members about isolation precautions?

A. precautions are in place to prevent the spread of infection

B. do not use alcohol-based skin sanitizer, but use soap and water to wash hands
C. the disease spreads via spores
D. a mask is not necessary

Correct answer: B

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 Rationale: Comprehensive teaching about the use of personal protective equipment
and isolation precautions includes all four solutions. However, the most important
lesson is that soap and water should be used to wash hands as not doing so is likely to
result in the spread of infection.

Let’s look at documentation next.

1.2F DOCUMENTATION
144. You are charting on paper and make a mistake. What should you do?

A. Use whiteout to cover up the mistake

B. Draw a single line through the error and initial and date it.
C. Call the supervisor and make out an incident report
D. Erase the error

Correct answer: B

Rationale: Draw a single line through the error, initial, and date it. Do not erase or cover
it up. The supervisor does not need to be notified nor does an incident report need to
be created.

145. What does Medicare have to do with documentation of nurse’s notes?

A. Medicare reimbursement to facilities is based on nursing care which is documented

in the client chart.
B. Medicare uses documentation as a guideline for awarding certificates of need.
C. Medicare uses charting to evaluate salaries in a jurisdiction.
D. Medicare guides reimbursement by private health insurance companies based upon
how well nurses at a facility chart.

Correct answer: A

Rationale: Medicare bases reimbursement on care provided as documented in the

client’s medical record.

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146. Documentation standards required by the Joint Commission on the Accreditation of
Healthcare Organizations include:

A. Audits, a privacy statement, and the use of established nursing diagnoses.

B. The Norton and Braden scales.
C. Documentation of physical and emotional status and a living will.
D. Documentation within the context of a nursing process, patient and family
education, and discharge planning.

Correct answer: D

Rationale: The Joint Commission's standards for documentation include documentation

within the context of the nursing process, and evidence of patient and family education
as well as discharge planning.

1.2G INFORMATION TECHNOLOGY AND SECURITY

147. The nurse is charting on a computer at the end of her shift. Another off-going nurse
informs her the completed a short assessment of his client and forgot to record an
observation. All of the other computer terminals are in use. The first nurse says:

A. I will log out, and you can use this computer for a moment.
B. Tell me your password, and I will record the information for you.
C. Tell me the patient's name and I will chart the observation for you.
D. Just chart the information as a late entry tomorrow.

Correct answer: A

Rationale: Only the person making an observation may chart the observation. It is a
security violation to share passwords. Documentation must be completed promptly.

148. Two acceptable patient identifiers include:

A. room number and name

B. physician and date of birth
C. diagnosis code and name
D. name and date of birth

Correct answer: D

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 Rationale: Acceptable patient identifiers include name and date of birth.

149. Problems with information technology may include:

A. Slow access to orders, inefficiency, and unethical practices

B. breaches of confidentiality, cost, and hacking
C. crashes that delete data, and illegible handwriting
D. time-consuming, repetitive record-keeping, and slow access to documents and
orders

Correct answer: B

Rationale: Problems with information technology may include breaches of

confidentiality, cost, exposure to hackers, and crashes the delete data.

150. Barcodes with unique patient identifiers are used to:

A. monitor the physical location of pediatric and clinic clients

B. increase costs of materials which are lost due to theft
C. prevent medical errors and keep track of billable supplies and equipment
D. rotate pharmaceutical stock and perform inventories of durable medical equipment

Correct answer: C

Rationale: Barcodes that contain unique patient identifiers are used to prevent
medication, treatment, and procedural errors which occur as a result of
misidentification. Barcodes are used to keep track of supplies and equipment and
ensure that related bills are accurate.

1.2H PERFORMANCE IMPROVEMENT

151. What are the comprehensive goals of performance improvement?

A. To improve the time management abilities of staff members so that they can
increase the number of clients that they provide care to
B. decreased liability within a healthcare organization
C. to improve care outcomes, enhance client safety, improve efficiency, reduce costs
and liability
D. To comply with regulations mandated by the National Institutes of Health.

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 Correct answer: C

Rationale: Performance improvement and performance improvement studies enhance

and improve care outcomes. They increase the efficiency of care and improve client
safety while reducing costs and lowering risks and liability.

152. What are core measures?

A. Standard measures of quality determined by the Joint Commission on the

Accreditation of Healthcare Organizations (JCAHO) that address specific populations,
diseases, and care units.
B. Risk management activities determined by the Joint Commission on the
Accreditation of Healthcare Organizations (JCAHO) which focus on a wide array of
medical errors.
C. Universal standards that all nurses must meet.
D. Quality standards that hospitals and healthcare organizations create in response to
needs assessments.

Correct answer: A

Rationale: Core measures are standardized quality indicators. The Joint Commission on
the Accreditation of Healthcare Organizations (JCAHO) identifies them. Core measures
address specific populations, diseases, and organizational units, such as emergency
departments.

153. Tools which decrease organizational liability and the likelihood of lawsuits include:

A. adequate staffing levels and establishing a positive rapport

B. primary nursing and standardized care plans
C. risk assessments for falls and skin breakdown
D. flexible scheduling and a low incidence of infection

Correct answer: C

Rationale: Risk assessments for falls and skin breakdown are used to decrease
organizational liability. The other answers may help reduce risk. However, they are not
specific tools.

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154. Performance improvement activities are mandated by:

A. the Joint Commission on the Accreditation of Healthcare Organizations

B. state health departments
C. the Centers for Medicare and Medicaid
D. all of the above

Correct answer: D

Rationale: Performance improvement activities are mandated by the Joint Commission

on the Accreditation of Healthcare Organizations, state health departments, and the
Centers for Medicare and Medicaid.

155. All of the following are performance improvement activities except:

A. identifying an area that needs improvement

B. collecting and analyzing data
C. putting punitive measures in place to ensure quality
D. exploring processes surrounding an area being investigated

Correct answer: C

Rationale: Performance improvement activities include identifying areas that need

improvement, creating a team to examine identified problems, collecting and analyzing
data. Processes surrounding an area being investigated are examined. Factors which
negatively impact the quality of care are reduced and eliminated.

156. Quality improvement activities should focus on all of the following areas except:

A. events that are costly to the organization

B. problems that affect the most people
C. employee benefit packages
D. activities which are high risk for client harm

Correct answer: C

Rationale: Effective quality improvement activities should focus on areas which are
high-risk for creating injury to clients, affect many people, occur often, and are costly.

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157. For healthcare organizations to have sufficient performance improvement activities in
place they must have:

A. a defined chain of command

B. a culture of safety and blame-free environment
C. well documented policies regarding absenteeism and related staffing issues
D. the designation of Magnet status

Correct answer: B

Rationale: For healthcare organizations to have effective performance improvement

activities they need to create a culture of safety and a blameless environment.

158. Outcome measures are used to:

A. create a culture of safety for employees

B. evaluate results of client care
C. identify sentinel events
D. developed root cause analyses

Correct answer: B

Rationale: Outcome measures are used to study and assess the outcomes of client care.
Two examples of outcome measures include screenings to identify clients who are at-
risk for skin breakdown and infection rates within the facility.

It’s time to take a break if you need one. This concludes our delivery of care module. When
you're ready, we will move on to our third module.

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1.3 SAFETY
In this section on safety, we will review strategies for keeping clients and staff safe and free of
injury. We will consider environmental safety and hazards including biomedical waste and
infectious materials. Equipment safety, ergonomics, and restraints will be discussed. We will
review emergency response plans and security. Let’s start by exploring environmental safety.

1.3A PROVIDING A SAFE ENVIRONMENT

159. At what age should screening for lead poisoning begin for most children?

A. Six months
B. Eighteen months
C. Three years
D. Six years

Correct answer: B

Rationale: Screening for lead poisoning should begin at 18 months for most children.
Repeat screenings should occur at 24, 30, and 36 months.

160. The leading cause of death among school-aged children is:

A. accidental poisoning
B. childhood leukemias and other cancers
C. meningitis
D. accidents

Correct answer: D

Rationale: Accidents are the primary cause of death among school-age children.

161. The group of people most likely to be injured from falls is:

A. infants
B. teens
C. young adults
D. older adults

Correct answer: D

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 Rationale: Falls are the leading cause of injury among older adults.

162. When anticipating home safety requirements of a frail older adult who is dialysis
dependent the nurse should:

A. Educate the family about the availability of Meals on Wheels.

B. Co-create an emergency evacuation plan with the family.
C. Ensure that medications are stored safely in a locked cupboard.
D. Instruct the client about the renal diet.

Correct answer: B

Rationale: The nurse needs to instruct the client and family about an emergency
evacuation plan, including plans to go to an emergency evacuation shelter should the
need arise. Meals on Wheels may be helpful for the client, but it is not a safety issue.
Nothing indicates that the medications should be kept out of the adult’s reach.

163. When evaluating a home for safety, which of the following commonly needs to be
assessed?

A. Food and meal preparation

B. The absence or presence of smoke and carbon monoxide detectors
C. The lack or presence of environmental hazards such as throw rugs or frayed
electrical cords.
D. All of the above

Correct answer: D

Rationale: All of the above need to be assessed. The home safety assessment needs to
be customized based on age and needs of the client and resources available.

164. Common security risks in the healthcare setting include all of the following except:

A. delivery of packages containing explosives

B. infant abduction
C. client elopement
D. violence

Correct answer: A

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 Rationale: Commonly occurring security risks in healthcare facilities include the
presence of violent people in the healthcare setting, infant abduction, client elopement,
and computer data breaches.

165. While making rounds, the nurse discovers a trashcan on fire in a client’s room. What
are the best actions that the nurse can take, and in the correct order?

A. Extinguish the fire, remove the client from the room, and close the door.
B. Obtain a fire extinguisher, pull the pin on the fire extinguisher, aim the fire
extinguisher at the base of the fire, squeeze the trigger, and sweep the fire
extinguisher contents back-and-forth at the base of the flame.
C. Remove the patient from the room, activate the alarm and alert other staff
members, close doors to confine or contain the fire, extinguish the fire if it's safe to
do so.
D. Cover the trashcan with a wet pillow, remove the patient, sound the alarm, evacuate
patients.

Correct answer: C

Rationale: Use the word RACE to remind you of what to do in case of fire. Remove the
client from the location of the fire. Activate the alarm and alert others. Contain the fire
by closing doors. Extinguish the fire only if it is safe to do so.

166. What is the first thing that you should do when confronted by an active shooter?

A. Evacuate patients nearby

B. Assess and treat victims
C. Call 911
D. Evacuate yourself immediately

Correct answer: D

Rationale: When an active shooter is present, evacuate yourself immediately if there is

an accessible escape path. Do not treat or move victims. Only call 911 when you are
safe.

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167. A three-year-old child consumed an unknown number of prenatal multivitamins.
What should you do before performing an intervention?

A. Induce vomiting
B. Call the Poison Control Center
C. Reassure the parents that vitamins are harmless except that the child might
experience gastrointestinal distress.
D. Prepare for gastric lavage

Correct answer: B

Rationale: Contact the Poison Control Center before attempting interventions. Inducing
vomiting or performing gastric lavage can be harmful in the presence of specific poisons.
Vitamins can be dangerous when not taken correctly.

168. Organisms which cause botulism, anthrax, and smallpox may be used for:

A. Relieving chronic migraine symptoms

B. Bioterrorism
C. Immunization
D. Pain management

Correct answer: B

Rationale: The use of botulinum toxin, anthrax, and the organism which causes
smallpox to create harm is called bioterrorism.

We will continue thinking about safety with the next section.

1.3B EQUIPMENT SAFETY

169. When teaching about oxygen safety in the home, you advise clients to:

A. Avoid smoking and open flames while using oxygen

B. Increase the oxygen flow rate while using a nasal cannula to maintain an oxygen
saturation level of at least 80 percent.
C. Be aware of the location of oxygen tubing when walking as a fall prevention
technique.
D. Both A and C.

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 Correct answer: D

Rationale: Avoid smoking and open flames when oxygen is in use. It is essential to be
aware of the location of oxygen tubing to avoid falls.

170. A blood glucose monitor should be calibrated:

A. Before each use

B. Before and after each use
C. According to the facility’s or manufacturer’s protocol.
D. Whenever a blood glucose reading of below 70 or greater than 350 is noted

Correct answer: C

Rationale: Calibrate blood glucose monitors according to the facility or manufacture’s

requirements. Calibration schedules are determined by rules for point of care testing.

171. To facilitate a safe transfer of a client from the stretcher to bed, you:

A. Keep the head of the stretcher elevated at a 30-degree angle

B. Lock the wheels of the stretcher and bed
C. Elevate the head of the bed 30 degrees
D. Always use a slide board

Correct answer: B

Rationale: Lock the wheels of equipment whenever transferring a client to ensure

safety. A slide board is helpful but not essential for all transfers.

172. While conducting a home evaluation for a three-year-old client, the nurse notices
dangling Venetian blind cords and plastic grocery bags on the floor. The nurse
identifies the following nursing diagnosis:

E. Risk for Impaired gas exchange

F. Risk of suffocation
G. Potential altered tissue perfusion
H. Altered thought processes

Correct answer: B

Rationale: The child is most at risk of suffocation due to airway obstruction.

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1.3C HAZARDOUS AND INFECTIOUS MATERIALS MANAGEMENT
173. Where is information about hazardous materials located?

A. On Materials Safety Data Sheets, as required by OSHA

B. In an employer’s Personnel Manual
C. Within a facility’s Disaster Plan
D. In the facility’s Pharmacy Policy and Procedure Manual

Correct answer: A

Rationale: OSHA mandates that readily available information about hazardous

materials, instructions for their safe handling and disposal be provided on MSDS,
Material Safety Data Sheets. Sheets must be provided for each potentially hazardous
material used by an organization. Treatment instructions are provided in case of misuse
or consumption.

174. Examples of biohazardous waste include all of the following except:

A. Soiled diapers
B. Used hypodermic needles
C. Packaged chemotherapy drugs
D. Used suction tubing

Correct answer: C

Rationale: Diapers, used hypodermic needles, and used suction tubing may contain
blood and body fluids which are biohazardous materials. Chemotherapy drugs can be
hazardous, but they are not considered biohazardous waste as they do not originate
from blood and body fluids.

175. Visitors to clients who are receiving brachytherapy, also known as internal radiation
therapy, are advised that:

A. they must wear a gown, mask, and gloves

B. the client is in a room that has a negative airflow for safety
C. women who are pregnant should not visit
D. no special safety measures are needed

Correct answer: C

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 Rationale: Women who are pregnant should not visit or care for clients receiving
brachytherapy due to the risk of radiation exposure.

176. Using disposable equipment, hand washing, needleless infusion systems, and red
sharps containers reduce the risk of:

A. exposure to radiation
B. exposure to biohazardous waste
C. needle stick injuries
D. combustion of hazardous materials

Correct answer: B

Rationale: The strategies reduce the likelihood of being exposed to potentially

hazardous blood and body fluids which are considered to be biohazardous wastes.

177. Prohibiting smoking, avoiding the use of acetone containing materials, and wearing
cotton clothing help reduce:

A. Air pollution
B. Water pollution
C. The risk of injury when oxygen is in use
D. The risk of injury due to toxins

Correct answer: C

Rationale: Avoiding open flames and sparks promote the safe use of oxygen. Cotton
fabric is less likely to cause static than other kinds of cloth. Acetone is very flammable.

1.3D EMERGENCY MANAGEMENT, RESPONSE, AND SECURITY

178. You receive a bomb threat via telephone while on duty at an inpatient facility. What
do you do first?

A. Notify your supervisor

B. Call the police
C. Attempt to keep the caller on the phone for as long as possible while simultaneously
notifying a coworker of the situation
D. Make evacuation plans

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 Correct answer: C

Rationale: Keep the caller on the telephone for as long as possible if you receive a bomb
threat by phone. Note qualities about the client’s words, voice, and background sounds.
Simultaneously notify a co-worker who can then take required next steps.

179. What type of fire extinguisher may be used on an electrical fire or a fire that began in
a client’s bed?

A. A
B. B
C. C
D. ABC

Correct answer: D

Rationale: ABC fire extinguishers may be used on all types of fires.

180. All of the following are examples of external disasters except a:

A. train crash
B. terrorist attack
C. staffing crisis due to absenteeism from influenza
D. Tornado or hurricane

Correct answer: C

Rationale: External disasters arise outside of a facility. They may be due to weather,
accidents, fire or terrorism. External disasters may result in mass casualties requiring
treatment.

181. Which of the following clients need to be treated first?

A. An adult male with a fractured humorous and a wound that is spurting blood from
the femur
B. A child who has loose stools, vomiting, and abdominal pain
C. A 26-year-old primigravida who went in to labor 2 hours ago
D. An older adult who is confused and wandering around the waiting room

Correct answer: A

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 Rationale: The spurting wound requires immediate attention. Use airway, breathing,
and circulation, the ABCs, as a guideline when triaging clients.

182. The nurse is working in a group home for medically fragile developmentally disabled
clients. There is a power outage due to an ice storm. In order to ensure quality care,
the nurse needs to do all of the following except:

A. Limit staff to essential personnel

B. Monitor clients visually by making frequent rounds
C. Provide alternative nurse call devices such as handbells or whistles
D. Document on paper

Correct answer: A

Rationale: During power outages, nurses must still provide quality care. This may
require creativity. Nurses should review policies and procedures in advance. They may
need to use alternative ways to record care, monitor patients, and provide nurse call
tools. Additional staff may be helpful.

1.3E RESTRAINTS AND SAFETY

183. Which of the following is the most comprehensive definition of a restraint?

A. A drug used for discipline or management of behaviors rather than for medical
treatment.
B. Protective devices that customarily and traditionally are used to limited movement
during a particular treatment.
C. Using sitters and distraction techniques to keep confused client’s safe.
D. A physical device or medication which restricts the client’s freedom. If a physical
device, it cannot be easily removed by the client.

Correct answer: D

Rationale: A restraint is a physical device or medication which is used to limit a client’s

freedom and ability to move about. If a physical device is used, it must not be readily
removable by the client. A drug used for discipline or management of behaviors rather
than for medical treatment is a chemical restraint. Intravenous arm boards are not
restraints. Sitters and the use of distraction techniques are preventative measures
which reduce the need for restraints.

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184. Select the best answer to the following question. Monitoring a client who is restrained
requires evaluating:

A. physical status
B. dignity and emotional state
C. the need for restraints, correct application, and use of the restraint
D. all of the above

Correct answer: D

Rationale: Ongoing monitoring of the patient in restraints includes the evaluation of

physical status. This includes nutrition, hydration, circulation, pain, elimination, and
comfort. Psychological condition and dignity must be evaluated. Safety must be
assessed. The evaluation considers whether or not restraints need to be continued,
discontinued, or modified.

185. The client is non-weight bearing, weak, and paralyzed. What will you use to transfer
the patient safely from bed to chair?

A. slide board
B. mechanical lift
C. gait belt
D. rolling walker

Correct answer: B

Rationale: The only safe tool to use for this client is a mechanical lift.

186. The acronym to recall when using a fire extinguisher is:

A. ABC
B. PASS
C. RACE
D. stop, drop, and roll

Correct answer: B

Rationale: PASS stands for: Pull the safety pin, Aim low. Squeeze the handle. Sweep
from side to side at the base of the fire until it is out.

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187. Steps which may be implemented to reduce falls include all of the following except:

A. employing a sitter
B. encouraging the use of bedroom slippers
C. using chair and bed alarms
D. placing the client in a place where he or she can be seen easily such as near a nurse’s
station

Correct answer: B

Rationale: All of the above are interventions that may be used to prevent falls except
encouraging the use of bathroom slippers. Bathroom slippers are often loose fitting and
contribute to falls. Well-fitting rubber-soled shoes or non-skid footwear is preferable.

1.3F UNTOWARD EVENTS

188. An incident is defined as:

A. an unforeseen event
B. a near miss that has the potential for patient harm
C. an assessment that determines client needs and identifies safety hazards
D. a group of activities that healthcare organization uses to reduce legal liability

Correct answer: A

Rationale: An incident is an unforeseen event. A near miss is an event that didn’t

happen; but had it occurred client harm may have resulted. Nursing assessments
evaluate client needs. Evaluation of safety hazards is part of a nursing assessment. Risk
management assessments and activities are performed to reduce facility legal liability
risk.

189. Define “sentinel event.”

A. An event, accident or near miss that leads to or has the potential to lead to client
harm
B. Incidents that result in death or severe injury to a client
C. A process used to identify flaws in processes within an organization
D. A deliberate action which results in the harm of a client

Correct answer: A

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 Rationale: A sentinel event is the occurrence of an accident, incident, or near miss that
leads to or potentially leads to client harm.

190. Define “root cause analysis.”

A. A process by which an organization investigates sentinel events to identify why

events occur.
B. A psychological assessment used to evaluate impaired health care providers.
C. A system for reducing fall risk and lawsuits.
D. A process designed to enhance performance and reduce financial liability

Correct answer: A

Rationale: Root cause analysis is a process that evaluates why sentinel events occur. It
emphasizes why they happened rather than who is at fault. This is done to identify
problems and prevent future issues.

191. A nurse fails to meet the standard of care while providing services to a patient. What
is the nurse guilty of?

A. Slander
B. Negligence
C. Libel
D. Assault

Correct answer: B

Rationale: When a healthcare provider fails to meet the standard of care, this is known
as negligence. Writing untruths that damage a person's reputation is called libel. Making
false verbal statements that hurts a person’s reputation is called slander. Assault is a
deliberate unsuccessful attempt to perform bodily harm to another individual.

192. The client developed anaphylaxis after the first dose of the new medication. What
type of event is this?

A. malpractice
B. medical error
C. adverse event
D. medical mistake

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 Correct answer: C

Rationale: Anaphylaxis is an example of an adverse event. Adverse events occur as a

result of an unexpected response to a medication or treatment. Sometimes adverse
events cannot be avoided. Other times, adverse events can be prevented. If they are
preventable, they may also be medical errors.

193. The client was found unharmed sitting on the floor beside her bed in the healthcare
facility. She stated that she tripped and fell. Which of the following is an example of
the documentation the nurse should provide?

A. “Client found sitting on the floor. Incident report made out.” This is documented in
the client’s chart
B. “Client fell” is documented in the client's chart. An incident report is completed but
not noted in the client's chart.
C. “Client found sitting on the floor” documented in the chart. An incident report is
completed but not noted in the client’s chart.
D. “Client states she fell. Incident report made out.” This is documented in the client's
chart.

Correct answer: C

Rationale: The nurse should chart what he sees. He should make out an incident report
but not record that he made out an incident report in the client's chart.

194. A facility limited the frequency that disposable diapers could be used as accost saving
measure. Clients had increases in redness of their perineal areas as a result. What type
of variance is this?

A. Practitioner
B. Client
C. Patient
D. System

Correct answer: D

Rationale: System variances arise when irregularities in care and service are present.
They may be due to faulty policies, inadequate education of staff or lack of equipment

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 and tools needed to provide optimal care. System variances are also known as
institutional variances.

1.3G ERGONOMICS
195. While lifting, how should the legs and feet be positioned?

A. With the left foot in front of the right if the person doing the lifting is right handed
B. Wide apart
C. The feet should be 12 inches apart
D. With the right foot in front of the left if the person doing the lifting is right handed

Correct answer: B

Rationale: While lifting stand with a wide stance to avoid injury and improve balance.

196. When moving an immobile client up in bed, it is best to:

A. Use a pull, draw sheet, or lift pad

B. Stand at the head of the bed and gently pull by grasping under the client’s shoulders
while supporting their head
C. Position the client in reverse Trendelenburg position
D. Ask the client to bend their knees while you move one side of the client’s body up
and then go around to the other side of the bed and lift the opposite side of their
body

Correct answer: A

Rationale: When possible, use a pull or draw sheet or draw pad when moving clients up
in bed. It is safer, efficient, and reduces shear on the client’s skin.

197. The correct way to turn a client who has a sustained a fractured spine is by employing
a procedure known as:

A. Applying halo traction

B. Placing the client in reverse Trendelenburg position
C. Logrolling
D. Applying direct pressure to support the injured area

Correct answer: C

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 Rationale: Roll the entire body while keeping the spine and extremities aligned. The
procedure is called log rolling. This enhances comfort and prevents client injury.

198. What is the best technique to use while ambulating a client who has a left sided
weakness?

A. Use a gait belt. Keep your hand on the gait belt at all times. Walk slightly behind the
client’s left side.
B. Use a gait belt. Keep your hand on the gait belt at all times. Walk slightly behind the
client’s right side.
C. Walk slightly behind the client’s right side. Only use a gait belt if the client is large or
unsteady.
D. Use a gait belt if the client agrees. Walk directly behind the client.

Correct answer: A

Rationale: Use a gait belt. Position yourself where you can support the client best
should he or she start to fall or lose balance.

199. Common signs and symptoms of repetitive stress injuries include:

A. fractures of the wrist and fingers

B. localized pain, stiffness, and muscle cramps
C. fever, redness, and inflammation
D. all of the above

Correct answer: A

Rationale: Repetitive stress injuries create pain, stiffness, and muscle cramps due to
overuse of muscles. Nerve and muscle pain results.

200. Which of the following activities helps to prevent injury to healthcare providers when
they are transferring clients from chair to bed?

A. keeping their feet in fixed positions

B. using the arms and leg muscles to lift
C. twisting at the waist
D. relying exclusively on back supporting devices

Correct answer: B

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 Rationale: Pivoting the feet in the direction of the move is essential. Twisting can cause
injuries. Back supporting devices can be useful. However, proper body mechanics must
be consistently employed to prevent injury. Use large muscles, such as those in the arms
and legs, to lift; not the muscles in the back.

Take a break if you need to, and then we will proceed to infection control.

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1.4 INFECTION CONTROL
In this section, we will review hygiene, standard precautions, and isolation.

1.4A HYGIENE
201. A client’s level of hygiene may be affected by:

A. cultural values
B. energy levels
C. environmental factors, such as room temperature and accessibility to hot water
D. all of the above

Correct answer: D

Rationale: Multiple factors impact client’s standards of hygiene.

202. What nursing theorist discussed the level of care clients need to perform activities of
daily living, such as bathing?

A. Florence Nightingale
B. Dorothea Orem
C. Margaret Rogers
D. Jean Watson

Correct answer: B

Rationale: Dorothea Orem's Self-care Theory discusses client needs relating to the level
of assistance needed to perform activities of daily living.

203. Bathing:

A. reduces odors and germs

B. removes dirt, sweat, and exfoliated skin
C. promotes comfort, and enhances circulation
D. all of the above

Correct answer: D

Rationale: Bathing improves client comfort and circulation. It removes sweat, thereby
reducing odors. Bathing helps rid the body of exfoliated skin, microorganisms, and dirt.

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204. What body structure provides the first level of defense against infection?

A. the small intestine

B. skin
C. nose
D. mouth

Correct answer: B

Rationale: The skin provides the body's first level of defense. The other body structures
are supportive but not primary.

205. A client needs a partial bed bath. What does the nurse expect to assist the client with?

A. washing body parts that the client cannot reach

B. gathering supplies necessary for the bath
C. ambulating to the shower
D. A and B are correct

Correct answer: D

Rationale: Clients who require partial bed baths can perform some tasks related to
bathing. They may need assistance getting supplies set up or bathing body parts that
they cannot reach, such as the feet or back.

206. Water used for bathing needs to be kept below:

A. 95°F
B. 100°F
C. 110°F
D. 120°F

Correct answer: C

Rationale: Water used for bathing needs to be kept at a temperature below 110°F to
prevent injury.

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207. Clients most at risk for burns while bathing due to scalds include those with:

A. hypertension
B. diabetes
C. COPD
D. Lyme disease

Correct answer: B

Rationale: Clients who have diabetes may have nerve damage and be unable to assess
water temperature accurately. They are therefore at risk for burns.

208. The unlicensed assistive personnel member of the team advises the nurse that the
client wants to take a shower. The client has generalized chronic weakness due to
advanced age. What does the nurse recommend that the unlicensed assistive
personnel member do to ensure client safety?

A. install grab bars in the shower

B. give the client a bed bath instead of a shower
C. use a shower chair
D. place a non-skid mat in the shower

Correct answer: C

Rationale: The client’s desire to have a shower can be respected and carried out safely
by using a shower chair. It is not the unlicensed assistive personnel's responsibility to
install grab bars. A non-skid mat can be helpful for fall prevention, but the shower chair
is essential for this client.

209. What is the correct procedure for giving a bed bath?

A. wash the entire body from head to toe and then dry the person's body
B. begin at the head and work downwards
C. wash the face and hands first and then do the back using soap and tepid water
D. keep all body parts covered below the head while washing with plain water

Correct answer: B

Rationale: Start at the top of the body and work downwards. Begin by cleaning around
the eyes and then the rest of the face. Use soap and warm water.

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210. An immobile, bedbound client wants her hair washed. What does the nurse say to the
client?

A. I'm sorry, the best I can do is wash your hair with a wet washcloth
B. I can use a hair washing tray, dry shampoo, or specially designed shampoo to wash
your hair
C. I am unable to wash your hair
D. you will have to contact a family member or hairdresser to wash your hair

Correct answer: B

Rationale: Clients need to have their hair cleaned for physical and emotional comfort.
Many tools are available to make hair washing possible.

211. What is the correct way to remove a full upper denture?

A. Use a gloved finger and reach between the denture and upper palate to break the
seal between the pallet and denture
B. apply firm pressure to each side of the denture and pull
C. wiggle the denture from side to side using a gloved hand
D. apply rapid, firm, downward pressure to the front of the denture

Correct answer: A

Rationale: Well-fitting dentures create a relatively airtight seal between the denture
and the upper palate. The easiest way to break the seal is to reach around to one side of
the denture and insert a finger between the denture and palate. The denture can easily
be removed once the seal is broken.

212. Bacteria thrive in the perineal area because it is:

A. warm
B. moist
C. comprised of mucosal tissue
D. A and B are correct

Correct answer: D

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 Rationale: Bacteria multiply quickly in the perineal area because it is frequently warm
and wet. Parts of the perineal area are comprised of mucosal tissue; however other
areas are covered with skin.

1.4 B. PRECAUTIONS
213. A client has died. Standard precautions were used for client care before his death.
While providing postmortem care for the client, the healthcare provider:

A. uses standard precautions

B. no longer needs to use precautions
C. places an identification tag on the client's wrist
D. leaves invasive lines and urinary catheters in the body unless the medical examiner
plans to review the death

Correct answer: A

Rationale: Standard precautions need to be maintained. Identification tags are placed

on the client's big toe. Invasive lines and urinary catheters are usually removed, except
when the medical examiner plans to review the death. Follow organizational procedures
for post-mortem care.

214. Mechanisms make organisms more resistant to antibiotics include all of the following
except:

A. producing enzymes that inhibit the effectiveness of antibiotics

B. changing their outside structure making it harder for the antibiotic to attack
C. creating new ways to manufacture toxins
D. reducing the rate that cells replicate

Correct answer: D

Rationale: Antibiotic-resistant bacteria may produce enzymes, change their external

structure, or create new ways to manufacture toxins. Each of these mechanisms
increases resistance to antibiotics.

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215. The most frequent cause of pneumonia is infection with:

A. Streptococcus pneumonia
B. group B streptococci
C. vancomycin-resistant enterococci
D. Klebsiella pneumonia

Correct answer: A

Rationale: Streptococcus pneumonia is the most common type. It is the leading cause of
life-threatening illness among children worldwide. In addition to pneumonia,
Streptococcus pneumonia causes septicemia, ear, and sinus infections.

216. All of the following facts are true except:

A. Staphylococcus aureus is rarely found on/in the tissues of healthy people

B. severely ill and elderly clients are most at risk of developing an MRSA infection
C. MRSA is often spread by healthcare workers after contact with an infected client or
surface that an infected individual has touched
D. when caring for clients to have MRSA, contact precautions are used

Correct answer: A

Rationale: Staphylococcus aureus is commonly found on the skin. It is usually harmless.

217. Clients most at risk of contracting an infection due to vancomycin-resistant

enterococci include all of the following except:

A. clients treated in intensive care units

B. people who are being treated with multiple antibiotics
C. individuals who recently had cardiovascular surgery
D. people who are recuperating from abdominal surgery

Correct answer: C

Rationale: Clients most at risk of contracting an infection caused by vancomycin-

resistant enterococci, or VRE, include people who are in intensive care, receiving
multiple antibiotics, or recuperating from abdominal surgery.

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218. People who have tuberculosis and are resistant to three or more drugs that are used
to treat the disease are said to have:

A. multidrug resistant tuberculosis MDR-TB

B. tuberculosis pneumonia
C. epithelioid cell tubercles
D. extensively drug-resistant tuberculosis XDR-TB

Correct answer: D

Rationale: People with tuberculosis which is resistant to three or more drugs known to
treat the disease are said to have extensively drug-resistant tuberculosis. It is rare.

219. What kind of precautions are used when caring for someone who has tuberculosis?

A. respiratory
B. airborne
C. contact
D. airborne and contact

Correct answer: D

Rationale: Airborne and contact precautions are utilized when care is provided for
clients who have tuberculosis.

220. While handwashing, most microorganisms are eliminated by:

A. the friction created by scrubbing

B. using antibacterial soaps
C. washing with hot water
D. none of the above

Correct answer: A

Rationale: Friction is responsible for reducing the presence of microorganisms and dirt
more than the use of antibacterial soaps or hot water.

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221. Which of the following is not true when caring for a client with a Clostridium difficile
(C-Diff) infection?

A. the client is likely to have nausea, abdominal pain, and profuse diarrhea
B. waterless hand cleaner is preferable to handwashing with soap and water
C. clients are at risk for nutritional deficits and fluid and electrolyte imbalances
D. the infection can be fatal

Correct answer: B

Rationale: Alcohol-based waterless hand cleaners are ineffective when Clostridium

difficile is present. Soap and water must be used. Dispensers that contain waterless
hand cleaners must be removed or labeled with a “do not use” sign in isolation rooms
which house clients who have C-Diff.

222. A client is immunosuppressed. What type of precautions should be used?

A. standard
B. protective/reverse
C. contact
D. airborne

Correct answer: B

Rationale: Reverse or protective isolation precautions are used when clients are
immunosuppressed. These precautions are sometimes referred to as neutropenic
precautions.

223. What type of precautions are used while treating a client who is hospitalized with
influenza?

A. airborne
B. standard
C. droplet
D. contact

Correct answer: C

Rationale: Droplet precautions are used to prevent the spread of influenza.

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224. What personal protective equipment and precautionary measures are used when
standard precautions are in place?

A. gown and gloves, proper handwashing

B. gloves and mask
C. eye protection when necessary, proper handwashing, gowns when necessary, gloves
D. gown, and eye protection when appropriate

Correct answer: C

Rationale: Proper handwashing is used regardless of the type of precautions

implemented. Eye protection, masks, and gowns are used if there is a chance that
contact may occur with blood and body fluids. Gloves are used when touching mucous
membranes, skin that is not intact, and when contact with blood and body fluids is
possible.

1.4C ASEPSIS
225. Inflammation is:

A. a protective response to infection, injury, or irritation.

B. a harmful reaction to infection or injury
C. the complete destruction of microorganisms
D. the time that it takes between exposure to a toxic organism and symptom
development

Correct answer: A

Rationale: Inflammation is the body's innate protective response to infection, injury or

irritation. White blood cells, fluid, nutrients, and other healing factors are delivered to
the affected area to protect the body.

226. When microorganisms from outside of the body infect an individual and cause
disease, this is known as:

A. impaired skin integrity

B. a mediated immunity decline
C. an exogenous infection
D. an endogenous infection

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 Correct answer: C

Rationale: Exogenous infections result from microorganisms which are not normally
found within a person's flora or body.

227. Disinfection:

A. destroys all microorganisms on an inanimate surface

B. kills all bacteria within the human intestine
C. destroys spores and fungi
D. reduces numbers of all types of microorganisms except spores

Correct answer: D

Rationale: Disinfection eliminates or reduces the number of microorganisms on an

object. It is ineffective against spores.

228. The client is being treated with multiple antibiotics. She has oral thrush. What type of
infection is the thrush?

A. viral
B. exogenous
C. endogenous
D. bacterial

Correct answer: C

Rationale: Thrush is an example of an endogenous infection. Endogenous infections

occur due to imbalances of client’s own flora.

229. What does sterilization destroy?

A. yeasts, bacteria, and spirochetes

B. all microorganisms including spores
C. all microorganisms except spores
D. enterococci and fungi

Correct answer: B

Rationale: Sterilization destroys all microorganisms including spores.

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230. The nurse is assisting with a sterile procedure. Using sterile gloves, the nurse holds a
sterile object below his waist. What is happening?

A. the nurse is inserting a Foley catheter

B. the object that the nurse is holding is no longer considered sterile
C. the nurse is following the correct protocol for aseptic technique
D. the nurse is distracted

Correct answer: B

Rationale: Objects held below the waist or out of the field of vision are not considered
sterile.

231. The time it takes from exposure to a microorganism to the onset of symptoms is
called:

A. the iatrogenic period

B. the incubation period
C. a route of transmission
D. the virulence of an organism

Correct answer: B

Rationale: The time it takes from exposure to a disease-producing organism to the

onset of symptoms is called the incubation period.

232. When organisms replicate inside the body without causing signs and symptoms of
infection this is known as:

A. transmission
B. colonization
C. creating a reservoir
D. an infectious disease

Correct answer: B

Rationale: Colonization occurs when microorganisms multiply inside the body without
causing signs and symptoms of illness.

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233. What creates bactericidal actions?

A. antibacterial hand soaps

B. high temperatures
C. chemicals
D. B and C are correct

Correct answer: D

Rationale: Heating objects to high temperatures such as placing them in an autoclave,

or using strong chemicals are bactericidal activities.

234. Diseases may be spread by all of the following except:

A. droplets
B. vehicles
C. vectors
D. virulence

Correct answer: D

Rationale: Droplets, vehicles, and vectors are modes of transmission. Virulence

describes an organism’s ability to survive within or outside of a host.

235. A client has septicemia. What kind of infection does he have?

A. systemic
B. localized
C. autoimmune
D. community acquired

Correct answer: A

Rationale: Systemic infections spread throughout the entire body.

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1.4D PERIOPERATIVE CARE
236. What type of surgery is optional and not always needed for health?

A. emergency
B. ablative
C. elective
D. major

Correct answer: C

Rationale: Elective surgery is optional.

237. A client has severe frostbite of the left great toe. The toe is being removed surgically.
What kind of surgery is this?

A. cosmetic
B. restorative
C. constructive
D. ablative

Correct answer: D

Rationale: When a damaged or diseased body part is excised or surgically removed that
procedure is called ablative surgery.

238. A client has a tumor pressing on nerves. He suffers from a high level of pain due to the
tumor. A surgical procedure is done to relieve his symptoms, but not cure the
problem. What kind of surgery is done?

A. diagnostic
B. restorative
C. minor
D. palliative

Correct answer: D

Rationale: Palliative surgery is done to enhance comfort and relieve symptoms. It is not
curative.

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239. When clients have a diagnosis of obstructive sleep apnea receive opioids and general
anesthesia they have an increased risk of developing:

A. reduced cardiac function

B. elevated blood glucose levels
C. airway obstruction
D. acid-base imbalances

Correct answer: C

Rationale: Clients with a diagnosis of obstructive sleep apnea are at risk for airway
obstruction and decreases in oxygen saturation levels when they receive opioids.

240. Individuals who abuse alcohol and other substances are at risk for developing
complications during and after surgery. Risks of developing all of the following
complications are elevated among these individuals except:

A. cross tolerance to anesthetic agents

B. increased viscosity and amount of respiratory secretions
C. delayed wound healing
D. adverse reactions to anesthesia

Correct answer: B

Rationale: Alcohol and substance abuse may result in poor wound healing secondary to
nutritional deficits. Adverse reactions and cross-tolerance to anesthetic agents may
occur.

241. Coagulation studies, including prothrombin time (PT), the international normalized
ratio (INR) and activated partial thromboplastin time (APTT) are commonly performed
before surgical procedures to evaluate potential risks. What do the tests provide
information about?

A. Ratios and total amounts of white blood cells

B. clot and bleeding risks
C. renal status
D. anemia

Correct answer: B

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 Rationale: Coagulation studies are done to evaluate clients’ risks for developing blood
clots and abnormal bleeding.

242. The nurse is teaching a client about a planned surgery, the need for the procedure,
anticipated benefits, potential risks, and alternatives to the operation. The nurse is:

A. providing preoperative teaching to prevent postoperative complications

B. providing information needed for the client to provide informed surgical consent
C. using adult learning principles
D. providing emotional support to reduce the client’s fear of the surgical procedure

Correct answer: B

Rationale: Informed surgical consent requires that clients be provided with education
about the planned procedure, indications for the surgery, and potential risks and
benefits. Clients must be given information about alternatives to the surgical procedure.

243. What are the three phases of general anesthesia?

A. preoperative, surgical, and postoperative

B. hypercarbia, tachypneic, and tachycardic
C. induction, maintenance, and emergence
D. induction, somnolence, arousal

Correct answer: C

Rationale: General anesthesia is administered over three phases. The phases are
induction, maintenance, and emergent.

244. A surgeon is concerned that an accident victim may lose a large volume of blood
during surgery. What nursing diagnosis is the highest priority for this client during
operation?

A. the risk for perioperative positioning injury

B. potential fluid volume deficit
C. the risk for trauma
D. post trauma syndrome, the risk for powerlessness

Correct answer: B

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 Rationale: The client is at risk for developing a fluid volume deficit related to blood loss.
The risk for fluid volume deficit during surgery is a higher priority than the other risks.
The risk for trauma is irrelevant.

245. During surgery, a client is noted to be tachypnea and tachycardic. His blood pressure is
fluctuating. The cardiac monitor shows he is having multiple premature ventricular
contractions, or PVCs. He is determined to be hypercarbic. The client has circumoral
cyanosis, and his extremities are mottling. His muscles are rigid. He is most likely
experiencing complications from:

A. an acute myocardial infarction

B. malignant hyperthermia
C. anaphylaxis
D. a pulmonary embolism

Correct answer: B

Rationale: Clients who experience complications from malignant hyperthermia are

hypecarbic, hypoxic, tachypneic, and tachycardic. They may have PVCs. Muscle rigidity
occurs. The blood pressure is labile.

246. What type of anesthesia is used when a decreased level of consciousness, but not
total anesthesia, is needed?

A. general anesthesia
B. conscious sedation
C. local anesthesia
D. regional anesthesia

Correct answer: B

Rationale: Conscious sedation is used when a decreased level of consciousness, but not
deep anesthesia, is needed. Conscious sedation is frequently used for short procedures.

This concludes Part 1, the Safe and Effective Care Environment. When you are ready, we will
begin with part two of the review.

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PART 2 HEALTH PROMOTION AND MAINTENANCE

Let's get started.

2.1 PHYSICAL ASSESSMENT

We will begin with a quick review of vital signs and then review the physical examination.

2.1A VITAL SIGNS

247. Which of the following pulse ranges is within normal limits for infants?

A. 60-80 beats per minute

B. 80-120 beats per minute
C. 100-140 beats per minute
D. 120-160 beats per minute

Correct answer: D

Rationale: Normal pulse rates for infants ranges from 120 to 160 beats per minute.

248. What do you measure when you are determining a pulse deficit?

A. differences in pulse rates of the radial pulses of the left and right arms
B. differences in pulse rates between apical and radial pulses
C. the difference between systolic and diastolic blood pressures
D. the difference in pulse rate at rest compared with during activity

Correct answer: B

Rationale: To obtain a pulse deficit, subtract the radial pulse rate from the apical pulse
rate. A pulse deficit occurs when contractions of the heart are ineffective.

249. Describe Kussmaul’s respiration:

A. agonal, shallow, noisy

B. ineffective, irregular, rapid
C. deep, regular, fast

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 D. prolonged, sonorous, labored

Correct answer: C

Rationale: Kussmaul’s respirations are very deep, regular, and rapid.

2.1B PHYSICAL EXAMINATION

250. All of the following are performed during a physical assessment except:

A. percussion
B. auscultation
C. inspection
D. reflection

Correct answer: D

Rationale: Techniques used to perform a physical examination include percussion,

auscultation, inspection, and palpation. The sense of smell may be utilized also.

251. When a nurse recognizes patterns within collected data, compares the information
with standards, and comes to a conclusion regarding a client’s response to a health
problem, this is known as:

A. formulating a nursing diagnosis

B. data validation
C. data analysis
D. conducting an assessment

Correct answer: C

Rationale: Data analysis involves recognizing trends and patterns within collected
information. The trends are compared with standards, and a conclusion is reached
regarding a client’s response to a health concern.

252. All of the following are examples of Gordon's 11 functional health patterns except:

A. value-belief system
B. nutritional-metabolic pattern
C. sexuality-relationship pattern
D. elimination pattern

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 Correct answer: C

Rationale: Gordon pairs sexuality with a reproductive pattern and role with relationship
pattern.

253. What tool may be used to graphically demonstrate relationships between multiple
health problems that a client has?

A. a concept map
B. a reflective journal
C. data validation
D. backchanneling

Correct answer: A

Rationale: Concept maps provide a visual tool for demonstrating relationships between
comorbidities that clients have.

254. A client is having mild difficulty breathing. Upon auscultation, the nurse hears
bibasilar rales. The neck veins are distended and ankles are swollen. Which of the
following is the correct nursing diagnosis?

A. fluid volume excess

B. fluid volume deficit
C. risk for fluid volume deficit
D. risk for fluid volume imbalance

Correct answer: A

Rationale: Shortness of breath, the presence of rales, neck vein distention, and edema
indicate a fluid volume excess.

255. Client-centered interviews provide the following benefits except:

A. creation of a caring, trusting nurse-client relationship

B. the client’s commitment to the plan of care increases
C. clients rely on nurses as experts about their health rather than themselves
D. treatment outcomes are positive

Correct answer: C

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 Rationale: Client-centered interviews create a caring, trusting relationship between
nurses and clients. Since clients are active participants, they are more likely to commit
to plans of care. With increased commitment, outcomes improve. Clients and nurses
work together rather than fostering a dependent relationship of the client upon the
nurse’s expertise and judgment.

256. The presence of Battle’s sign or raccoon eyes may indicate the presence of

A. heroin addiction
B. a skull fracture
C. liver failure
D. glaucoma

Correct answer: B

Rationale: Battle’s sign and raccoon eyes are evidence of skull fractures. Battle’s sign
may indicate a basilar skull fracture. Raccoon eyes indicate the presence of orbital
fractures.

Take a break if you need to when you are ready we will look at growth and development
throughout the lifespan.

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2.2 GROWTH AND DEVELOPMENT THOUGH THE LIFESPAN
2.2A GROWTH AND DEVELOPMENT THEORY
257. Gesell’s theory of development states:

A. growth follows a predictable series of developmental stages

B. every age has its own developmental tasks
C. although growth patterns vary, they are ultimately the results of genes
D. growth occurs along a continuum based upon internal and external influences

Correct answer: C

Rationale: Gesell’s theory of development emphasizes the impact of genes. Gesell’s

theory recognizes that individual differences occur.

258. What is the fifth stage of Freud's psychoanalytic model of personal development?

A. genital
B. phallic
C. latency
D. oral

Correct answer: A

Rationale: According to Freud’s psychoanalytic model of personal development earlier

sexual urges recur during the genital stage. They are directed toward a person outside
of the family group.

259. According to Erikson, what developmental tasks are teenagers struggling with as they
concentrate on their physical appearance?

A. autonomy versus shame and doubt

B. generativity versus stagnation
C. identity versus role confusion
D. intimacy versus isolation

Correct answer: C

Rationale: According to Erikson, teens accomplish the developmental task of identity

versus role confusion. This leads them to be focused on their appearance.

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260. According to Piaget’s theory of cognitive development, preschoolers are in the
following stage:

A. concrete operational
B. formal operational
C. sensorimotor
D. preoperational

Correct answer: D

Rationale: Between the ages of two and seven, children are in the preoperational stage
according to Piaget’s theory of cognitive development. This is also known as Period II.

261. What are Kohlberg’s three levels of moral development?

A. preconventional, conventional, postconventional

B. physical, safety, self-esteem
C. generativity, autonomy, independence
D. id, ego, superego

Correct answer: A

Rationale: Kohlberg identified preconventional, conventional, and postconventional

levels of moral development. Kohlberg subdivided each level into two stages.

262. What are the three main sources for developmental tasks according to Havinghurst’s
stage crisis theory?

A. pleasure, urges, restoration

B. survival, growth, maturation
C. inquisitiveness, creativity, satisfaction
D. physical maturity, personal values, societal pressures

Correct answer: D

Rationale: Havinghurst’s stage crisis theory identified physical maturation, personal

values, and societal pressures as being the primary sources for developmental tasks.

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2.2B PRENATAL DEVELOPMENT
263. The pre-embryonic stage of intrauterine development lasts:

A. from the first day of the last menstrual period until 15 days before the next expected
period
B. from implantation to day 28
C. from conception to day 14
D. for the first three months of the pregnancy

Correct answer: C

Rationale: The pre-embryonic stage, also known as the ovum, lasts from conception
until day 14.

264. The ectoderm, mesoderm, and endoderm give rise to:

A. the heart, lungs, liver

B. skin, brain, mucous membranes
C. bones, teeth, gastrointestinal system
D. all organs and tissues

Correct answer: D

Rationale: The three primary germ layers known as the ectoderm, mesoderm, and
endoderm form all body tissues and organs.

265. When does the embryonic stage of intrauterine development occur?

A. for the first 3 months of pregnancy

B. from conception to day 14
C. from day 15 to 8 weeks
D. from day 1 to day 30

Correct answer: C

Rationale: The second stage of intrauterine development called the embryonic stage,
lasts from Day 15 to 8 weeks

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266. Toxins are particularly dangerous during which stage of prenatal development?

A. embryonic disc
B. embryonic
C. pre-embryonic
D. weeks 36-38

Correct answer: B

Rationale: Toxins are very dangerous during all stages of prenatal development.
Harmful effects of toxins are especially dangerous during the embryonic stage because
cell division is rapid.

267. The sex of an unborn baby can be identified in utero via ultrasound at:

A. two weeks
B. four weeks
C. twelve weeks
D. four months

Correct answer: C

Rationale: Sex organs are identifiable by 12 weeks.

268. Monozygotic twins arise from:

A. one ovum
B. one embryo
C. one sperm
D. two zygotes

Correct answer: A

Rationale: Identical or monozygotic twins arise from one ovum.

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2.2C PREGNANCY
269. During pregnancy, the corpus luteum:

A. creates follicle stimulating hormone

B. balances progesterone levels
C. supplies estrogen
D. secretes luteinizing hormone

Correct answer: C

Rationale: The corpus luteum provides needed estrogen.

270. The fetal heartbeat heard with the aid of a Doppler at the age of:

A. 8 weeks
B. 14 weeks
C. 24 weeks
D. 32 weeks

Correct answer: A

Rationale: A Doppler can detect a fetal heartbeat at eight weeks.

271. A woman had genetic testing performed. An autosomal recessive disorder was
detected. What percentage of her children are likely to be affected by the disorder?

A. one out of two

B. one out of four
C. one out of five
D. none

Correct answer: B

Rationale: Autosomal recessive disorders, such as cystic fibrosis, may affect one out of
four children born to the woman.

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272. When is a glucose tolerance test customarily performed during pregnancy?

A. at the second prenatal visit

B. at 18 weeks to 24 weeks
C. at 24 to 28 weeks
D. at 32 to 34 weeks

Correct answer: C

Rationale: During pregnancy, a glucose tolerance test is normally performed between

the 24th and 28th weeks of pregnancy.

273. An alpha-fetoprotein level is drawn. It is low. What does this possibly indicate?

A. hydatiform mole
B. ectopic pregnancy
C. Down syndrome
D. Rh sensitivity

Correct answer: C

Rationale: A low alpha-fetoprotein level may indicate the presence of a child with Down
syndrome.

274. A pregnant woman states thinks her water broke. What test is performed to
determine the presence of amniotic fluid?

A. Fern
B. 24-hour urine
C. Antiphospholipid antibody
D. D-dimer

Correct answer: A

Rationale: A Fern test is used to confirm the presence of amniotic fluid.

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2.2D NEWBORNS
275. All of the following are normal vital signs for a newborn except:

A. temperature: 37.5
B. pulse: 120
C. respirations: 35
D. blood pressure: 88/54

Correct answer: D

Rationale: All of the vital signs are within normal limits except for the blood pressure
which is low. Normal blood pressure for a newborn is around 110/75.

276. Which of the following fetal heart rate tracings most likely indicates fetal distress?

A. variable decelerations
B. occasional late decelerations
C. occasional early decelerations
D. consistent late decelerations

Correct answer: D

Rationale: Consistent late decelerations often indicate fetal distress.

277. The most common hazards to a newborn when narcotics are administered during
labor include:

A. drowsiness and decreased respiratory drive

B. nausea and constipation
C. seizures and sedation
D. respiratory distress and vomiting

Correct answer: A

Rationale: Narcotics can be sedating and cause the respiratory drive to diminish.

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278. The Apgar score evaluates all of the following except:

A. weight
B. color
C. respiratory effort
D. muscle tone

Correct answer: A

Rationale: The Apgar score evaluates color, heart rate, muscle tone, respiratory effort,
and reflex irritability.

2.2E CHILDREN
279. At what age do infants seroconvert if they contract the human immunodeficiency
virus during pregnancy or delivery?

A. immediately upon birth

B. 6 months
C. 9 to 12 months
D. 15 to 18 months of age

Correct answer: D

Rationale: Babies who contract the human immunodeficiency virus during pregnancy or
birth seroconvert between the ages of 15 and 18 months.

280. How many times does an infant's weight multiply between birth and the age of one
year?

A. two
B. three
C. four
D. five

Correct answer: B

Rationale: Most infants triple their birth weight by the age of 12 months.

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281. A two-year-old’s vital signs are as follows: temperature 98.9, pulse 110, respirations
24, blood pressure 110/72. What do you tell the parents?

A. Your child's pulse is fast.

B. Your child's blood pressure is a little bit high.
C. All of your child's vital signs except for the temperature are elevated.
D. Your child's vital signs are within normal limits for two-year-old.

Correct answer: D

Rationale: The vital signs within normal limits for the two-year-old.

282. At what age is it safe to place a child in a forward-facing car seat?

A. three months
B. six months
C. one year
D. four years

Correct answer: C

Rationale: Children may be placed in a forward-facing car seat at the age of one year.

283. Most children who need glasses begin to experience visual difficulties during:

A. toddlerhood
B. the preschool years
C. the school-age years
D. the teen years

Correct answer: C

Rationale: Visual deficits often become apparent during the school-age years.

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284. The three leading causes of death among teenagers include the following except:

A. cancer
B. accidents
C. suicide
D. murder

Correct answer: A

Rationale: Sadly, the three leading causes of death among teenagers are accidents,
suicide, and homicide. All are preventable.

2.2F ADULTS
285. What type of biologic theories of aging hypothesize that changes are genetically
determined?

A. stochastic
B. transcription
C. nonstochastic
D. free radical

Correct answer: C

Rationale: Nonstochastic theories attribute changes to genes.

286. What is the primary developmental tasks of young adults according to Erikson?

A. intimacy versus isolation

B. generativity versus stagnation
C. ego identity versus despair
D. socializing versus sexualizing relationships

Correct answer: A

Rationale: According to Erikson, the major developmental task of young adults is to

develop intimacy rather than isolation.

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287. Peak sexual drive in women usually occurs between the ages of:

A. 18 and 25
B. 25 and 35
C. 30 to 45
D. 45 to 60

Correct answer: C

Rationale: Sexual drive in women typically peaks between the ages of 30 and 45.

288. All of the following usually improve during middle age except:

A. vocabulary and verbal reasoning skills

B. the ability to synthesize new information
C. crystallized intelligence
D. spatial perception

Correct answer: C

Rationale: The ability to synthesize new information often declines in middle age.

2.2G OLDER ADULTS

289. The theory about aging that states activities performed during middle age must
continue into old age for aging to be successful is this one:

A. conceptual
B. activity
C. continuity
D. disengagement

Correct answer: B

Rationale: Activity theory states that activities performed during middle-age must be
continued as a person grows older to age successfully.

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290. Hospitalized older adults have increased risks of developing:

A. dementia
B. delirium
C. depression
D. all of the above

Correct answer: B

Rationale: Delirium may develop in older adults who are hospitalized. This often occurs
due to sleep deprivation, illness, dehydration, drug interactions, and sensory
impairments.

291. What does the functional status of an older adult refer to?

A. ability to complete activities of daily living

B. safety
C. the relationship of the ability to perform activities of daily living and health status
D. all of the above

Correct answer: D

Rationale: An older adult’s functional status is an indicator of health. A person's ability

to perform ADLs safely is taken into account when evaluating functional status.

292. An 85-year-old male develops dehydration, a change in mental status, and

incontinence. What is the most likely cause of the symptoms?

A. gastrointestinal reflux disease

B. an acute illness
C. depression
D. delirium

Correct answer: B

Rationale: Older adults with an acute illness may present with a wide range of
symptoms that may initially appear unrelated to the disease. New onsets of changes in
mental status, dehydration, appetite, ADLs, incontinence, and dizziness may occur. A
client who has an acute illness may be weak and fall.

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293. Which of the following is/are correct regarding physiological changes in the older
adult?

A. Digestion may be impaired due to the reduction of secretions and pancreatic

enzymes
B. There is an increased risk of respiratory infections due to a decrease in vital capacity,
reduced airway resistance, and a diminished cough reflex
C. Nerve cells continue to generate at the same rate as they did earlier in life, but levels
of neurotransmitters decrease
D. A and B are correct

Correct answer: D

Rationale: Nerve cells degenerate with aging. All of the other facts are true.

294. What is validation therapy?

A. A communication technique which validates older adults’ beliefs regarding health,

relationships, and morality
B. an alternative communication method which is useful when working with confused
elders
C. a process use to review client’s life experiences through their perspective
D. a technique for customizing interventions for older clients with their beliefs about
health, wellness, and disease management

Correct answer: B

Rationale: Validation therapy is an alternative means of communication. It is used while

communicating with confused clients.

This is an opportunity for you to take a break. We have concluded the section on growth and
development through the lifespan. When you're ready, we will move on to the next part.

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2.3 HEALTH PROMOTION
We will examine lifestyle, self-care, and means for promoting health. We will review health
screening and high-risk behaviors.

2.3A LIFESTYLE
295. Focus areas of Healthy People 2020 include all of the following except:

A. promoting healthy behaviors

B. strategies for people to obtain longer healthy lives
C. reducing rates of influenza
D. achieving health equity throughout the population

Correct answer: C

Rationale: The focus areas of Healthy People 2020 include promoting healthy behaviors,
strategies to help people live longer, healthier lives. Health equity and reduction of
disparities in the provision of healthcare are goals. Another goal is the creation of
health-promoting environments.

296. What are aspects of the World Health Organization's definition of health?

A. the absence of disease

B. the presence of physical, emotional, and social wellness
C. vitality and emotional stability
D. optimal functioning and financial well-being throughout the lifespan

Correct answer: B

Rationale: Health is multifactorial. It relies on the welfare of mind-body, spirit,

environment, and community. Physical, emotional, and social wellness are essential
components of health.

297. Clients at risk for social isolation include those who:

A. have a chronic illness

B. are veterans with disfiguring injuries
C. have a diagnosis of schizophrenia
D. all of the above

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 Correct answer: D

Rationale: Social isolation may result from physical, emotional, and social factors.

298. The use of herbs, aromatherapy, guided imagery, and meditation are:

A. mind-body healing techniques

B. touch therapies
C. forms of complementary and alternative medicine
D. unsafe, ineffective treatment modalities

Correct answer: C

Rationale: Herbs, aromatherapy, guided imagery, and meditation are forms of

complementary and alternative medicine, commonly referred to as CAM. Nurses need
to be knowledgeable about complementary and alternative medicine because a vast
number of clients utilize these treatments.

2.3B HEALTH PROMOTION AND ILLNESS PREVENTION/HEALTH SCREENING

299. The process of enabling people to increase their control over their bodies and improve
their health is:

A. disease management
B. environmental awareness
C. the United States Centers for Disease Control's definition of health
D. the World Health Organization's definition of health promotion

Correct answer: D

Rationale: The World Health Organization defines health promotion as the process of
enabling people to increase their control over their bodies and improve their health.

300. A woman has a chronic health condition, but she continues to work full-time and care
for her children even though it is challenging to do so. She is considered to be healthy.
A man has a cold and stays home from work. He is deemed to be ill. What model of
health and wellness is demonstrated by these examples?

A. role performance model

B. the high-level wellness model

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 C. adaptation model
D. agent -host -environment model

Correct answer: A

Rationale: People are considered to be healthy when they can fulfill their
responsibilities related to their roles. They are considered to be ill if they cannot do so.

301. Who is most at risk for contracting a chlamydial infection?

A. a newborn baby
B. sexually active women in their late teens and early 20s
C. sexually active men in their 30s
D. sexually active women in their 30s

Correct answer: B

Women who are sexually active and under 25 years of age are most likely to contract chlamydia
infections.

302. Colorectal cancer screenings typically begin at age:

A. 50 for both sexes

B. 40 for both sexes
C. 35 for men and 40 for women
D. 35 for men and 50 for women

Correct answer: A

Rationale: Colorectal cancer screenings usually begin at age 50 for both sexes unless
there are other risk factors.

303. Depression screening:

A. is only conducted by psychiatrist and psychologists

B. is performed annually in high schools
C. is only performed when clients show signs and symptoms of possible depression
D. may be performed by nurses

Correct answer: D

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 Rationale: Depression is ubiquitous. Screening for depression is part of routine
preventative care. It is also implemented when signs and symptoms of depression are
present. Nurses screen for depression.

304. The United States Preventative Services Task Force recommends that women:

A. over 40 have a screening mammography every one to two years

B. over 50 have screening mammography annually
C. obtain baseline mammography at age 40 and baseline thermography by age 45
D. over the age of 62 only get mammograms if they have a previous history of cancer
or it runs their families

Correct answer: A

Rationale: Women over 40 are encouraged to have a screening mammogram every year
or two. The United States Preventative Services Task Force does not recommend
screening thermograms.

305. A 40-year-old man expresses his fear of early death. He says that all of the men in his
family die at an early age due to heart disease. What does the nurse teach the man?

A. your genetic makeup is likely to result in a shortened lifespan for you as well
B. new technology is helping people to live longer
C. they must've died because of unhealthy habits
D. genetics is one aspect that may affect the disease process, however you can make
healthy choices that will help you to live well and may promote a long lifespan

Correct answer: D

Rationale: Genes are important however lifestyle choices impact how genes are
expressed. A healthy lifestyle is essential regardless of a person's genetic makeup.

306. A diagnosis of sickle-cell anemia is most likely to be made for which of the following
people?

A. A person from Saudi Arabia or southern Europe

B. A northern European
C. A Native American
D. A Pacific Islander

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 Correct answer: A

Rationale: Sickle-cell anemia is most common among individuals of African-American or

Latin American descent. Individuals from some areas surrounding the Mediterranean
and people from Saudi Arabia also have a higher than average risk of developing sickle-
cell disease.

307. The client is a smoker. He is entering his final year of medical school. The client states
that he will stop smoking after graduation. What stage of health behavior change in
the client demonstrating?

A. pre-contemplative
B. contemplative
C. maintenance
D. preparation

Correct answer: A

Rationale: The client is in the pre-contemplative stage of health behavior change as he

is not planning on making any changes for at least six months.

308. Internal variables that influence health and health belief practices include all of the
following except:

A. spiritual beliefs
B. emotions
C. diet
D. developmental stage

Correct answer: C

Rationale: Internal variables that influence health and health belief practices include:
developmental stage, intellect, perceptional functioning, emotions, and spirit.

309. What type of risk factors do premature infants and 95-year-old men face?

A. psychological
B. spiritual
C. age-related
D. emotional

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 Correct answer: C

Rationale: People who are very young or very old have increased risk factors for
developing particular health problems.

310. Smoking and engaging in unprotected sex are examples of the following type of risk
factors:

A. environmental
B. lifestyle
C. physiological
D. mental

Correct answer: B

Rationale: A person's lifestyle choices and habits impact their risk for illness.

2.3C SELF CARE

311. Which of the following members of the multidisciplinary care team are most likely to
be able to provide input regarding a client’s self-care abilities?

A. nurse, social worker, occupational therapist

B. play therapist, physical therapist, chaplain
C. primary care provider, nursing assistant, psychiatrist
D. nurse, physical therapist, occupational therapist

Correct answer: D

Rationale: While all members of the multidisciplinary care team may have information
about the client self-care abilities the nurse, physical therapist, and occupational
therapist are likely to have the most valuable information.

312. Assessments of activities of daily living utilize:

A. screening scales
B. direct observation
C. screening scales and direct observation
D. the Norton scale

Correct answer: C

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 Rationale: Screening scales and direct observation are among the tools used to evaluate
a client’s ability to perform activities of daily living. The Norton scale evaluates a client’s
risk for falling. It may be part of an evaluation. However, it is not comprehensive enough
to assess all activities of daily living.

313. While evaluating a client’s home health needs which of the following requirements
should be considered?

A. the caregivers time availability and own needs

B. the cost of home care
C. how services will be coordinated
D. all of the above

Correct answer: D

Rationale: Many factors should be considered when clients are cared for in the home
setting. Caregiver needs and availability, financial resources, community services,
transportation for medical appointments and physical hazards in the home are just a
few considerations that need to be taken account when clients are provided with care in
the home setting.

314. A client has a manual wheelchair ad a diagnosis of paraplegia. All of the following will
help the client function independently except:

A. having a ramp built into the home

B. installing kitchen counters at a lower level than they are typically installed at
C. having modifications made so that the client's car can be operated with hand
controls
D. having new rugs installed in the client's bedroom

Correct answer: D

Rationale: It is easier to operate wheelchairs on hard surfaces. A rug will make mobility
more difficult.

2.3D HIGH-RISK BEHAVIORS

315. If a pregnant woman smokes marijuana, her child is at risk for:

A. developmental and behavioral abnormalities

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 B. withdrawal signs at birth
C. intrauterine growth restriction
D. all of the above

Correct answer: D

Rationale: Marijuana use during pregnancy may result in a restriction of fetal growth.
The child may experience withdrawal signs and symptoms at birth. Developmental and
behavioral challenges can arise as the child ages.

316. A child is born suffering from poor respiratory function, seizures, irritability, and signs
of drug withdrawal. What is the most likely cause of the child's distress?

A. nicotine
B. heroin
C. crack cocaine
D. ecstasy

Correct answer: B

Rationale: Babies exposed to or addicted to heroin may have difficulty breathing at

birth. They may have tremors and convulsions. Withdrawal symptoms and irritability
arise.

317. A pregnant woman is a former heroin addict. She is taking methadone throughout her
pregnancy. What risks are increased for her and her baby?

A. None. Methadone is safe to take during pregnancy

B. the child may have genetic abnormalities
C. the child may have seizures at birth and be of low birth weight
D. the woman may go into early labor or suffer from placenta abruptio. The baby may
aspirate meconium and develop withdrawal symptoms.

Correct answer: D

Rationale: Methadone is a potent narcotic. The woman may go into premature labor
which puts the child at risk. She may suffer from placenta abruptio which can be life-
threatening for mother and child. The baby is at risk for aspiration of meconium and
symptoms of drug withdrawal.

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318. The nursing student works and attends school full-time. She raises a family. The
student studies at night while the children are sleeping. She sleeps about four hours
per night. What is the student doing?

A. effectively balancing responsibilities

B. engaging in a high-risk behavior by not getting enough sleep
C. attaining generativity rather than stagnation
D. managing choices in accordance with Maslow's hierarchy of needs

Correct answer: B

Rationale: Sleep deprivation is high-risk behavior. It places the person at risk for
accidents, injury, and illness.

319. What strategies can a teenager implement to prevent bone loss later in life?

A. consume plenty of dark green vegetables such as broccoli

B. consume dairy products daily
C. engage in strength training exercises
D. all of the above

Correct answer: D

Rationale: It is vital to building strong healthy bones early in life to prevent bone loss
later on.

320. A teenage girl is brought into the emergency room after a minor car accident. She was
driving and found to have a blood-alcohol level of 0.05. The girl is surprised to learn
her alcohol is higher than her twin brother’s as she doesn’t think she drank much.
Which is the most important statement that the nurse can make to the teenager?

A. girls are usually smaller than males so that is probably why your alcohol level is
higher than you thought it would be
B. drinking while driving is a leading cause of death and permanent disability among
your age group. You can be incarcerated.
C. you are likely to develop liver disease at an earlier age than a man drinking a similar
amount of alcohol because you are female
D. drinking alcohol and driving is not safe

Correct answer: B

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 Rationale: The girl needs information which affects her life now. She likely already
knows that she shouldn't be drinking and driving. A forceful, clear statement regarding
consequences needs to be made.

321. An eight-year-old boy is cruel to animals and started a fire in his house. What
conclusion does the nurse draw?

A. the child may be a victim of abuse

B. the child's parents are poor disciplinarians
C. the child may be developmentally delayed
D. the boy may have Down syndrome

Correct answer: A

Rationale: Cruelty to animals and fire starting are often signs of child abuse.

This concludes part 2. Take a break if you need one. When you are ready we will begin Part 3 of
our review. You are doing great!

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PART 3 PSYCHOLOGICAL INTEGRITY

In part three we we will review mental health concepts and communication. Stress
management, families, and culture will be examined. We will address coping, senses, and
values. Our review includes diverse subjects including crises intervention, abuse, and end of life
care. Are you ready to start?

3.1 MENTAL HEALTH CONCEPTS

3.1A. MENTAL HEALTH CONCEPTS
322. A soldier is hospitalized after being injured. He sustained multiple traumatic wounds.
His right leg was amputated, and he has facial wounds that left permanent scarring.
The soldier says that he feels worthless, ugly, and useless. What is a potential nursing
diagnosis?

A. Denial
B. Altered self-image
C. Alteration in comfort
D. Role confusion

Correct answer: B

Rationale: The client has multiple diagnoses. The feelings that the soldier express
indicate he has an altered self-image. Self-image may be impacted by internal and
external forces and beliefs. They occur consciously and unconsciously.

323. A woman is struggling struggles to balance working, taking care of her young children,
and looking after her elderly mother who has a diagnosis of Alzheimer's dementia.
What type of stressor is the woman struggling with?

A. role confusion
B. identity
C. body image
D. role conflict

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 Correct answer: D

Rationale: The woman is likely suffering from role conflict as she is torn in multiple
directions.

324. Difficulty speaking and reading, disorientation, and poor short-term memory, may
indicate:

A. cognitive impairments
B. phobias
C. obsessive-compulsive disorder
D. personality disorders

Correct answer: A

Rationale: Cognitive impairments can lead to behavioral changes. Cognitive

impairments may originate from many sources. Cognitive mental health disorders
include dementia, organic brain syndrome, and delirium.

325. A client concentrates exclusively on her own needs. She believes that she is more
capable than anyone else. The client is devastated if she doesn't receive constant
praise. She likes to be the center of attention. The client is arrogant and lacks
empathy. What type of personality disorder may she be suffering from?

A. schizoid
B. paranoid
C. narcissistic
D. histrionic

Correct answer: C

Rationale: An individual who has a narcissistic personality disorder may experience

delusions of grandeur. The disorder is characterized by decreased empathy and the
need for constant praise by others.

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326. An 18-year-old female is hospitalized with a diagnosis of anorexia nervosa. Which of
the following systems may be affected?

A. renal
B. cardiovascular
C. musculoskeletal
D. all of the above

Correct answer: D

Rationale: Anorexia affects every cell of the body. People who have anorexia struggle
with mental health issues and obsession with weight. They are at risk for losing muscle
mass, fluid and electrolyte imbalances, nutritional deficits, amenorrhea, and
impairments throughout their entire bodies.

3.1B THERAPEUTIC COMMUNICATION

327. Age, level of consciousness, emotions, language, relationships, culture, values, and
medical treatments impact:

A. reflection
B. communication
C. stereotypes
D. receptive aphasia

Correct answer: B

Rationale: Communication is impacted by a person's age and developmental level. Level

of consciousness, stress, emotions, and values affect communication. Language, culture
and relationships between individuals are factors. Medical treatments and level of
wellness impact communication.

328. The nurse asks the client to describe his pain in detail. He encourages the client to
describe how the pain impacts his life. The nurse limits the use of questions that can
be answered with one-word answers or by responding with “yes” or “no”. What
communication technique is the nurse employing?

A. reflection
B. asking open-ended questions
C. focusing

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 D. clarification

Correct answer: B

Rationale: Asking open-ended questions gives opportunities for patients to fully

describe symptoms and how they are affected. Nurses are able to obtain detailed
information from clients by asking open-ended questions.

329. A client has been refusing to bathe for two days. This morning he said to the nurse: “I
am ready to bathe.” The nurse responds by asking, “did you just say you're ready to
bathe?” What therapeutic communication technique did the nurse use?

A. reflecting
B. paraphrasing
C. restating
D. exploring

Correct answer: C

Rationale: Restating means repeating the same words back to the client. It is done in
order to provide clarification of what the client is saying.

330. An elderly client is being sent to the hospice house for end-of-life care. Family
members ask the nursing staff to avoid using the words “hospice, dying, and end-of-
life” around the client. They request that the client is told that he is at the facility so
he can get well and resume his previous level of functioning. The nurse explains that it
is not fair to the client to provide false reassurances. The nurse knows that false
reassurances can lead to:

A. increased client anxiety

B. decreased trust between the nurse and the client
C. reluctance of the client to voice his true thoughts and feelings to the nurse
D. all of the above

Correct answer: D

Rationale: Nurses must gently speak the truth to clients and family members. Clients
have the right to know what is happening to their bodies. They need opportunities for
closure at end-of-life.

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331. The nurse works at an inpatient drug and alcohol abuse treatment center. She ensures
that clients do not have access to objects that they may use to harm themselves. The
building is well lit and decorated with simple, attractive furniture. Boundaries and
rules are clearly stated. Contracts are signed regarding behavioral expectations.
Clients have opportunities to engage in stress-relieving activities such as meditation
and listening to music. What is this setting known as?

A. a mandatory treatment center

B. a therapeutic environment
C. an inclusive milieu
D. an exclusive milieu

Correct answer: B

Rationale: Therapeutic environments provide physical and emotional safety. They are
used to facilitate clients’ abilities to cope and recover.

3.1C STRESS MANAGEMENT

332. According to Hans Selye’s General Adaptation Syndrome theory, there are three
stages of stress. The three stages, in order, are:

A. alarm, response, resolution

B. alarm, resistance, exhaustion
C. alarm, exhaustion, response
D. alarm, response, exhaustion

Correct answer: B

Rationale: The three stages of stress are alarm, resistance, and exhaustion, according to
Selye.

333. Which of the following occur in response to stress?

A. cardiac output decreases and adrenaline increases

B. cortisol increases the metabolic rate decreases
C. blood pressure decreases and glucose consumption increases
D. pupils dilate and cortisol increases

Correct answer: D

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 Rationale: The whole body is affected by stress. Gastrointestinal functioning slows,
pupils dilate, and the metabolic rate increases. Immune responses are less efficient.
Cortisol, adrenaline, and rates of glucose consumption increase. Cardiac output, blood
pressure, pulse, and respiratory rate also increases.

334. A client has diabetes. He has pain due to a back injury. His wife just died, and he is
responsible for caring for their three young children. The client is insulin dependent.
He verbalizes that he feels overwhelmed. What does the nurse anticipate?

A. the client may develop neuropathy in his feet within the next week
B. the client’s blood glucose level may suddenly drop due to stress
C. the client’s blood glucose level may increase, and he may need a higher dose of
insulin
D. the clients blood glucose level may be low, and his insulin dose will need to be
adjusted downwards

Correct answer: C

Rationale: Physical and emotional stress can cause blood sugar levels to rise. This client
may need additional insulin.

335. Food contaminated with salmonella, influenza, and head lice are examples of what
kind of environmental stressors?

A. chemical
B. gaseous
C. contaminated
D. biological

Correct answer: D

Rationale: Foods contaminated with salmonella, infectious diseases, and infestations

are examples of biological environmental stressors.

336. Improving water and air quality, reducing hazardous wastes and toxins, and working
towards improving the environment on a global scale are objectives of:

A. the Centers for Disease Control

B. Healthy People 2020 Environmental Health
C. the Environmental Protection Agency

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 D. the Occupational Safety and Health Administration

Correct answer: B

Rationale: The Healthy People 2020 Environmental Health Objectives include goals of
improving water and outdoor air quality. They are focused on reducing the presence of
toxic substances and hazardous waste. Goals include making healthier homes and
communities. The vision is global. It examines infrastructures and uses surveillance
activities.

337. The nurse is teaching a client a simple breathing technique to relieve stress because
the client is frightened before surgery. What does the nurse instruct the client to do?

A. open his eyes and breathe quickly through his nose

B. close his eyes, take slow deep breaths through the nose, and exhale gently through
the mouth
C. close his eyes, take forced abdominal breaths, and forcefully exhale after each one
D. close his eyes, take slow deep breaths through his open mouth, and exhale gently
through the nose

Correct answer: B

Rationale: Closing the eyes and taking slow deep breaths in through the nose and gently
exhaling through the mouth promotes relaxation and may distract the client from fear.

3.1D FAMILY DYNAMICS:

338. Functions within a family are chronically disorganized. Family members experience
conflict, denial, and ineffective problem-solving skills. The family is resistant to
change. Crises perpetuate. The nurse makes a diagnosis of:

A. ineffective coping skills

B. family dysfunction
C. impaired communication
D. risk for injury

Correct answer: B

Rationale: The North American Nursing Diagnosis Association (NANDA) defines family
dysfunction as occurring when psychosocial, spiritual, and physiological functions of the

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 family unit are chronically disorganized. Disorganization leads to conflict, denial of
problems, resistance to change, ineffective problem-solving, and a series of self-
perpetuating crises.

339. The theorist who describes boundaries within family units as protective, defensive,
resistant, and flexible is:

A. Neumann
B. Newton
C. Lewin
D. Sissinghurst

Correct answer: A

Rationale: The systems model of Neumann defines family boundaries.

340. A family provides care for children who are in custody of the state. The length of time
that the children stay with the family varies from a few days to several years. What
type of family is this?

A. adoptive
B. communal
C. foster
D. binuclear

Correct answer: C

Rationale: Families which consists of adults and children who are not biologically related
are sometimes foster families. Children aren’t usually permanent members of the
household. Foster families sometimes adopt children in their care. They may also have
biologically related children in the home. Foster families may be arranged via the court,
informally, or they may consist of children living with family friends or relatives. Biologic
parents of the children may or may not be living, known, or involved with the children.

341. Family members are all involved in decision-making processes. Parents offer guidance
and support but encourage children to figure out how and when to accomplish tasks
autonomously. The leadership style of this family is:

A. matriarchal
B. democratic

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 C. laissez-faire
D. authoritarian

Correct answer: C

Rationale: All family members have responsibility and input regarding decisions and
how tasks are accomplished. Laissez-faire leadership is also known as delegative
leadership.

3.1E DIVERSITY AND CULTURAL AWARENESS

342. Culture is defined as:

A. a fixed set of beliefs and customs.

B. Individual differences within society.
C. a dynamic group of general beliefs, skills, and traditions.
D. a progressive, prosperous, artistic group of people.

Correct answer: C

Rationale: Culture is an ever-changing group of beliefs within a particular society. It is a

generalization of basic ideas, values, language, customs, and beliefs. Every culture
contains individual variances.

343. Cultural values may impact a client’s:

A. views regarding personal space, the meaning of illness, and diet.

B. likelihood of developing sickle-cell anemia.
C. intelligence and opinions about the roles of health care providers.
D. tolerance of ACE inhibitors.

Correct answer: A

Rationale: Cultural values affect internal beliefs and external behaviors. Culture affects
ideas about the roles of family members and healthcare workers. Punctuality, types of
accepted treatments, and the meaning of illness and death are influenced by cultural
values. Cultural values impact beliefs about counseling, diet, technology, and human
nature.

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344. Assuming that a blond haired, blue eyed woman from Norway wants herring with her
lunch is an example of:

A. cultural competency
B. treating all clients the same regardless of their cultural heritage
C. enculturation
D. stereotyping

Correct answer: D

Rationale: Every person within society is an individual. Culture is a generalization about

the beliefs and values of a group of people. Stereotyping occurs when a person believes
all individuals within a minority or other group are alike in their preferences, beliefs,
behaviors, and attitudes.

345. Cultural competency is defined as:

A. knowing that current nursing standards determine what is culturally acceptable

B. Treating everyone alike regardless of their cultural background
C. avoiding asking questions about a client’s heritage
D. actions, attitudes, and values that show respect for others irrespective of their
cultural backgrounds

Correct answer: D

Rationale: According to the National Center for Cultural Competence, cultural

competence is a set of values, practices, behaviors, and attitudes within a group that
enables the unit to work effectively cross-culturally. It is a fluid, continuous process.

346. What is the best practice to employ when teaching a non-English speaking client how
to prepare for a medical procedure?

A. Look at the client, speak slowly, and distinctly.

B. Provide the instructions to the English-speaking family members and encourage
them to instruct the client.
C. Go online and see if you can find instructions in the client's language.
D. Utilize interpreter services.

Correct answer: D

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 Rationale: Using an interpreter shows respect and enables the client to ask questions. It
is more likely that the client will feel valued and invested in the procedure when they
are provided information directly. There is a higher likelihood that instructions will be
comprehended when clients have opportunities to clarify directions and ask questions.

347. Tai chi, massage, herbal remedies, and therapeutic touch are examples of:

A. Folk remedies.
B. Orthomolecular medicine treatment modalities.
C. Mind-body medicine.
D. Complementary and alternative therapies.

Correct answer: D

Rationale: These are examples of Complementary and Alternative Therapies (CAM).

3.1F SUPPORT SYSTEMS

348. 65% of degenerative dementias are caused by:

A. Parkinson's disease
B. trauma to the brain
C. Alzheimer's disease
D. strokes

Correct answer: C

Rationale: Alzheimer's disease is the most common cause of degenerative dementia.

Other causes of dementia include vascular ills and injuries, Huntington's disease, AIDS,
tumors, trauma, an abnormal flow of spinal fluid, and multiple sclerosis.

349. Sedation, increased agitation, and confusion may occur among elders when:

A. psychotropic medications used to treat dementia are employed

B. clients who have dementia are incontinent
C. clients who have dementia show signs and symptoms of sundowner’s syndrome
D. nonsteroidal anti-inflammatory agents are used to treat pain among clients with a
diagnosis of Alzheimer's disease

Correct answer: A

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 Rationale: Psychotropic medications have many side effects. They may cause sedation,
agitation, and increased disorientation among the elderly with dementia.

350. The client is depressed. He worries because he keeps misplacing items and forgets the
names of friends at times. Family members notice the client’s forgetfulness. The
family members realize that the client is more disorganized than he used to be. What
stage of Alzheimer's disease is this client in?

A. early
B. middle
C. late
D. seventh

Correct answer: A

Rationale: Clients with early-stage Alzheimer's disease may feel frustrated and
depressed when they realize their memory is not as sharp as it used to be. Many
individuals with Alzheimer's disease suffer from depression, which is treatable. Family
members are often more aware of the person's limitations than the individual is.

351. Which of the following is a description related to a person with late stage Alzheimer's
disease?

A. he is entirely dependent on others for activities of daily living and unable to

communicate meaningfully
B. she requires assistance managing finances, and reminders to perform activities of
daily living
C. he benefits from writing reminders to himself and finds large social events
overwhelming
D. she is irritable, wanders, and has occasional incontinence

Correct answer: A

Rationale: Individuals with late-stage Alzheimer's disease have memory loss. They are
unable to communicate and perform any activities of daily living. People with late-stage
Alzheimer's disease do not recognize family members and cannot control the
elimination of stool and urine.

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352. A client has middle stage Alzheimer's disease. The client’s daughter says she has
difficulty getting her mother to shower. All of the following tips may make showering
easier except:

A. having a schedule
B. having an extensive discussion with the client about the importance of good hygiene
C. encouraging the daughter to help the client to prepare clothing and needed supplies
D. encouraging the daughter to matter-of-factly state, “it is time to take your shower
now” and then provide a reward for the client when the shower is completed

Correct answer: B

Rationale: Having a discussion with the client about the importance of good hygiene will
not motivate the client to shower. The best verbal approach is to say that it is time to
shower. It is essential to have a regular schedule and to speak in a positive manner.
Laying out needed supplies can reduce fatigue, confusion, and frustration.

3.1G RELIGION AND SPIRITUALITY

353. Client’s religious and spiritual beliefs:

A. are addressed by chaplains, social workers, and religious personnel, such as rabbis
and ministers
B. are private and not within a nurse’s scope of practice to address
C. impact attitudes towards healthcare, healing, self-worth, and death
D. have minimal impacts on health and healthcare

Correct answer: C

Rationale: Religion and spirituality impact the client’s view of health and sickness,
death, and meaning. Religion and spirituality may affect the choice of treatments and
treatments withheld. It is appropriate for nurses to conduct spiritual assessments.

354. The client practices the religion of Hinduism. He does not have a local spiritual
affiliation. He is experiencing spiritual distress. The chaplain is a Roman Catholic
priest. What does the nurse do to address the client’s spiritual distress?

A. looks online to see if there are any Hindu temples in the area to refer the client to
B. refers him to a Buddhist monk in the community
C. refers him to the chaplain

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 D. encourages the client to ask his family for support

Correct answer: C

Rationale: Chaplains provide spiritual support for people of all religions as well as
people who do not have any religious beliefs. They are aware of support in the
community for people practicing diverse religions.

355. An organized system of shared beliefs and practices, including worship, which
influences decisions, lifestyles, and healthcare practices is known as:

A. religion
B. spirituality
C. prayer
D. meditation

Correct answer: A

Rationale: Religion is an organized system of beliefs and practices among a group of

people. It guides worship practices and life choices. Religion may impact health care
decisions and views about the meaning of life, illness, suffering, and death.

356. Nurses may support a family’s spiritual needs when a newborn does not live by:

A. performing an emergency baptism

B. creating a memory pack, such as taking imprints of the child's footprint and placing a
picture of the child in it
C. encouraging the parents to hold the deceased child
D. all of the above

Correct answer: D

Rationale: Nurses have a critical role in supporting grieving parents when a child is born
dead or dies shortly after birth. Encouraging the parents to hold the deceased child,
making memory packs, and taking photos can ease the family’s spiritual pain. Any
person may perform an emergency baptism if it is not known whether a child will
survive. The person does not need to believe in infant baptism or be a member of a
particular religion.

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357. All of the following are true except:

A. it is possible to be spiritual without following a particular religion

B. when a member of the Islamic faith dies, the body is supposed to be wrapped in
white and positioned to face Mecca
C. no Jewish people eat pork
D. Jehovah's Witnesses usually do not receive blood transfusions

Correct answer: C

Rationale: It is important to remember that not all members of a religion follow the
tenants of that religion. It is essential to recognize that there are multiple belief systems
and divisions within most religions. For example, Roman Catholics, Eastern Orthodox
Catholics, Lutherans, evangelicals, and Episcopalians are all Christians; however, their
beliefs and practices are diverse.

Take a break if you need one. When you're ready, we will continue reviewing psychosocial
integrity.

3.1H SENSORY ALTERATIONS

358. Which is not a fact about cochlear implants?

A. cochlear implants are used to treat people who are hard of hearing
B. children must be six years old before they can get a cochlear implant
C. the external hardware requires frequent battery changes
D. when clients remove external cochlear implant hardware at night are unable to hear
in emergencies

Correct answer: A

Rationale: Cochlear implants are used to treat deafness. They are not hearing aids.
Babies can have cochlear implants. Nurses need to be aware that clients are unable to
hear when they aren’t wearing their external hardware.

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359. The family member of the critically ill client was told that the client might not survive.
The client was hospitalized in an intensive care unit. The family member states that no
one said to her that the client might not survive. What may explain the family
member’s lack of recall?

A. agitation
B. sensory deprivation
C. sensory overload
D. altered self-esteem

Correct answer: C

Rationale: The family member may be experiencing sensory overload. This is likely to
occur in busy settings, such as intensive care units and emergency departments. Sensory
overload is common during times of high stress.

360. Children who have little sensory stimulation may withdraw. Physical and mental
growth may be delayed. They may have difficulty trusting and forming relationships.
What is a possible nursing diagnosis for these children?

A. failure to thrive
B. adult failure to thrive
C. paranoid schizophrenia
D. trisomy 13

Correct answer: A

Rationale: Children need sensory stimulation, including touch to survive. Healthy

development and growth are impaired when they are affected by sensory deprivation.

361. The 49-year-old female has delirium tremens. She is having visual hallucinations. What
type of medication is indicated?

A. a narcotic
B. narcotic antagonist
C. benzodiazepine
D. tricyclic antidepressant

Correct answer: C

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 Rationale: Benzodiazepines are used to treat people who experience visual
hallucinations and agitation secondary to alcohol withdrawal.

362. An elderly client was transferred by ambulance to an emergency department after he

was found lying in the street. The nurse is attempting to assess the client. He stares
straight ahead and fails to answer her questions. There are no visible signs of injury.
What could be the cause of his behavior?

A. traumatic brain injury

B. he is unable to see or hear
C. he is severely depressed
D. all of the above

Correct answer D

Rationale: Behaviors may result from a wide range of causes. It is essential that nurses
consider sensory deprivation as contributing factors when assessing clients.

3.1I CRISIS INTERVENTION

363. Long-term stress causes wear-and-tear on the body. This is known as:

A. allostatic load
B. homeostasis
C. developmental crisis
D. appraisal

Correct answer: A

Rationale: Chronic stress results in wear-and-tear on the body. This is known as

allostatic load.

364. The fight or flight reaction occurs as a result of:

A. stimulation of the autonomic nervous system

B. depression of the sympathetic nervous system
C. stimulation of the sympathetic nervous system
D. activation of the parasympathetic nervous system

Correct answer: C

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 Rationale: The fight or flight reaction is a protective response which occurs when the
sympathetic nervous system is activated.

365. What is responsible for monitoring the body’s physiological status through connection
with sensory and motor tracts of the nervous system?

A. Medulla oblongata
B. cerebellum
C. reticular formation
D. General adaptation syndrome

Correct answer: C

Rationale: The reticular formation monitors physical status of the body through
connections with motor and sensory tracts.

366. Ego defense mechanisms are:

A. conscious choices that people make to help cope with stress

B. unconscious mechanisms which lower anxiety levels
C. paranoid responses to ordinary stimuli
D. the physiological basis for cognitive development throughout the lifespan

Correct answer: B

Rationale: Ego defense mechanisms are unconscious. They protect the ego when it
perceives threats. Anxiety and stress are lowered. Chronic activation of defense
mechanisms can be deleterious to the body and mind.

367. A woman has breast cancer. She will be treated with Cytoxan and Adriamycin. The
nurse explains to the woman that she will lose her hair and nails. The woman does not
believe the nurse. What defense mechanism is activated?

A. denial
B. repression
C. displacement
D. sublimation

Correct answer: A

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 Rationale: When denial occurs, a person does not believe what is being said or
happening even if logic and sensory information confirm that the event or statement is
real. Denial is not a lie. The body and mind unconsciously reject the situation.

3.1J CRISIS INTERVENTION

368. What type of crisis may occur when a person sustains a disfiguring injury?

A. adventitious
B. situational
C. maturational
D. primary

Correct answer: B

Rationale: A situational crisis may arise when a sudden injury occurs.

369. An example of a maturational crisis is:

A. a woman who is worried that she will no longer be attractive as she grows older
B. the teenager who is going into surgery due to appendicitis
C. a man who is scared in his home after a recent burglary to his house
D. children afraid to go to school in light of high school shootings

Correct answer: A

Rationale: Maturational crises occur in response to changes that occur along the
lifespan.

370. A client has a history of substance abuse. He is angry and clenching his fist. The client
is swearing at his visitors. He has a history of abusing his spouse. What is the most
likely nursing diagnosis for this client?

A. risk of violence directed towards others

B. risk of violence directed toward self
C. risk for self-mutilation
D. rape trauma syndrome

Correct answer: A

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 Rationale: The client’s history and demeanor indicate that he is more likely to be violent
towards others rather than to himself.

371. Which of the following clients has the highest risk of committing suicide?

A. the 16-year-old girl who yell, “I'll kill myself if I can't go to the dance.”
B. a 25-year-old male who wrote a suicide note, and purchased a gun with the
intention of killing himself
C. a 47-year-old female who has a terminal illness and plans to overdose on medication
when symptoms are unbearable
D. the 22-year-old male who is deciding whether he should take pills or drown himself

Correct answer: B

Rationale: Clients who write suicide notes and have specific plans of killing themselves
with weapons or via other violent means have a higher risk of committing suicide than
individuals without a clear plan or considering using less violent methods to take their
lives.

372. A client has been very depressed. He has been on suicide precautions. He says that he
feels better. His depressive symptoms have decreased. What can be said about his risk
of self-harm and/or his plan of care?

A. the suicide precautions should be discontinued

B. his risk for suicide is diminishing
C. his risk of death is likely unchanged
D. his risk for self-injury may be increasing

Correct answer: D

Rationale: Client’s whose symptoms of depression lift may be at higher risk of

committing suicide. They may feel relief when suicide plans are completed. When
depression lifts, clients have more energy to finish plans to kill themselves. The suicide
precautions need to stay in place until it can be determined whether the client is
improving or still plans to kill himself.

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3.1K ABUSE AND NEGLECT
373. An 87-year-old man is being treated for COPD. The client’s son comes to visit. The
nurse notices the client cowers when the son approaches. The son demands money
from the client. This describes:

A. elder abuse
B. neglect of an elder
C. sexual abuse
D. physical neglect

Correct answer: A

Rationale: Elder abuse consists of physical, emotional, sexual or financial threats or acts
against an older person.

374. A four-year-old child was brought to the emergency room for treatment of a fracture
of his forearm. The nurse notices multiple bruises in various stages of healing on the
child's knees and shins. The parent says that the child fell off of a slide at the park and
broke his arm. The child is crying and clinging to the parent. What is this likely an
example of?

A. a child who fell and fractured his arm

B. child abuse
C. neglect
D. psychological abuse of a child

Correct answer: A

Rationale: The child most likely fell and broke his arm. There is no indication that any
abuse or neglect has occurred. Four-year-olds fall and receive fractures of the forearm
at times. The child's response is reasonable. Four-year-olds often have bruises on their
knees and shins as a result of playing and falling.

375. Which of the following clients is at an elevated risk for abuse and neglect?

A. a pregnant woman
B. a developmentally delayed eight-year-old
C. a client who is blind
D. all of the above

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 Correct answer: D

Rationale: Predators and abusers select vulnerable individuals to prey upon. Women,
especially when pregnant or old, are at risk for abuse. Senior men, children, infants, and
disabled individuals are often victims of abuse. People who have cognitive or
developmental disabilities are at risk.

376. A client was struck in the face by his partner. During what phase of the cycle of
violence did the physical injury occur?

A. honeymoon
B. violence
C. tension building
D. reconciliation

Correct answer: B

Rationale: The violent stage of the cycle of abuse is when the bodily injury occurred.
The cycle of violence has four stages. They include honeymoon, tension building,
violence, and the reconciliation phases.

377. Characteristics of abusers include:

A. individuals from all walks of life

B. a history of being abused themselves
C. substance abusers
D. all the above

Correct answer: D

Rationale: Abusers come from all walks of life and cultural backgrounds. Abusers have
often been victims of abuse themselves. People who have substance abuse issues, poor
self-esteem, poor impulse control or mental health disorders are often abusers. Acute
crises and poor anger management skills are risk factors.

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3.1L BEHAVIORAL INTERVENTIONS
378. Observing the client’s facial expressions, movements, voice, and eye contact provides
information about the client’s:

A. nutritional status
B. risk for alterations in fluid and electrolyte balance
C. mood and affect
D. self-care deficits

Correct answer: B

Rationale: Verbal and nonverbal clues provide essential information about the client’s
mood and affect. Movements, facial expressions, the tone of voice, level of
distractibility, and eye contact give information on mood and affect.

379. Psychological data may be obtained via:

A. standardized testing, observations, and interviews

B. electroencephalogram, brain scans, and liver function tests
C. evaluating the client's response to treatment, and planning for future care
D. standardized testing

Correct answer: A

Rationale: Standardized tests, observations, and interviews all provide information

about a person's psychological status.

380. A client is unresponsive. His eyes open sometimes but they do not focus. The client
does not respond to painful or other stimuli. He shows no signs of recognition when
spoken to. What level of consciousness describes this client?

A. lethargic
B. obtunded
C. confused
D. persistent vegetative state

Correct answer: D

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 Rationale: Clients in a persistent vegetative state have no cognitive function. They may
have minimal movements such as opening the eyes or muscular contractions; however,
those movements are not purposeful.

381. A client is unable to move but can respond to questions by blinking. He seems to
recognize people and understand when care is provided. What describes the client’s
status?

A. locked in
B. comatose
C. stuporous
D. lethargic

Correct answer: A

Rationale: Clients with a diagnosis of locked-in syndrome have some level of cognitive
function. They are unable to move purposefully. They can communicate with eye
movements and are aware of people and activities around them.

3.1M ADDICTIONS
382. A client is faithfully following her weight reduction diet. Over the past two months,
she has lost 15 pounds. The woman consumes 1400 calories per day. She exercises
daily for one hour. She has not lost any weight in three weeks and is becoming
discouraged. The nurse:

A. explains to the client that the body is adjusting to the weight loss and that if she
continues doing what she is currently doing her body will change, and she will begin
to lose weight
B. instructs the client to reduce your caloric intake by 500 calories per day
C. tells the client to exercise for an additional hour each day
D. discusses other diets with the client

Correct answer: A

Rationale: The client is losing weight at an average rate. She is consuming a low-calorie
diet and getting regular exercise. People often reach a plateau while losing weight as the
body readjusts its set point. The woman needs to continue with her current program,
and she will begin to lose weight again.

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383. Which of the following is a correct statement?

A. people who are addicted to drugs may or may not have a physical dependency.
B. physical dependency indicates an addiction to a drug
C. even though a client takes more of a narcotic then prescribed; it is not substance
abuse
D. heroin causes psychological but not physical dependence

Correct answer: A

Rationale: A person may have a physical dependency on a drug but not be addicted to
it. A person can be addicted to a drug yet not have a physical dependency.

384. A client has a diagnosis of bipolar depression. He smokes crack cocaine daily. The
client:

A. has a dual diagnosis

B. is demonstrating drug-seeking behavior
C. has an average risk of developing cardiac illnesses, irritability, and euphoria
D. likely has constricted pupils, nausea, vomiting, and muscle spasms when he doesn't
smoke crack cocaine

Correct answer: A

Rationale: Clients who have a diagnosis of mental illness and are substance abusers are
said to have a dual diagnosis.

385. A client is brought into the emergency department. He is vomiting, and his speech is
slurred. The client is euphoric and walking with an impaired gait. He has tremors. He
complains of soreness around his nose. What type of substance is it likely that the
client is intoxicated with?

A. cocaine
B. an aerosol product
C. and opioid
D. alcohol

Correct answer: B

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 Rationale: Inhalants, including substances from aerosol cans, gasoline, paint thinner,
and glue lead to the symptoms that the client has.

386. Street drugs which are commonly referred to as bath salts are similar in effect to:

A. opioids
B. barbiturates
C. amphetamines
D. cannabinoids

Correct answer: C

Rationale: Bath salts, which are cathinones, produce effects resembling amphetamines,
including cocaine. Withdrawal symptoms are similar.

3.1N END OF LIFE CARE

387. A hospice referral is indicated for:

A. a woman with stage IV breast cancer and is receiving chemotherapy

B. a man with end-stage cardiac disease
C. a woman with end-stage Alzheimer's disease
D. B and C are correct

Correct answer: D

Rationale: Hospice is appropriate for people who are expected to live for less than six
months regardless of diagnosis. Hospice is not suitable for clients who are actively
receiving curative treatments.

388. Which of the following is a true statement?

A. geriatric clients tend to over report pain

B. clients who have a diagnosis of Alzheimer's disease do not feel pain
C. morphine relieves anxiety, dyspnea, and pain
D. clients who grimace and moan when turned but are otherwise unresponsive are
likely to be pain-free

Correct answer: C

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 Rationale: Older people generally underrate pain levels. Clients who are unresponsive
or have a diagnosis of dementia may have pain. Nurses need to be alert to nonverbal
signs of discomfort.

389. Which is the least desirable method for preventing and relieving excess secretions
when a client is dying?

A. frequent nasal suctioning

B. using anticholinergic medications
C. positioning to facilitate drainage of secretions
D. occasional oral suctioning

Correct answer: A

Rationale: Frequent nasal suctioning may cause an increase in secretions and

discomfort for the client.

390. Intravenous patient-controlled analgesia offers the following benefits:

A. rapid pain relief

B. client empowerment
C. elimination of peaks and valleys of pain levels when a continuous basal rate is
prescribed
D. all of the above

Correct answer: D

Rationale: Patient-controlled analgesia provides continuous pain relief when a

continuous basal rate is utilized. Rapid pain relief can be obtained if pain increases or
before turning clients or providing other forms of care. Clients experience a feeling of
empowerment which is especially important when clients are at end-of-life.

391. Palliative sedation is used to:

A. relieve pain when other methods are ineffective

B. hasten death in a comfortable manner
C. accomplish physician-assisted suicide
D. relieve pressure and pain that tumors cause by pressing on nerves

Correct answer: A

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 Rationale: Palliative sedation is used to alleviate suffering when other methods are
ineffective.

392. A client who is dying is experiencing delirium, agitation, and aggression. What is
another term for what the client is experiencing?

A. dementia
B. hypoxia
C. terminal agitation
D. terminal secretions

Correct answer: C

Rationale: Another name for delirium at end-of-life is terminal agitation. Delirium and
agitation are difficult symptoms to treat. Hypoxia may precipitate terminal agitation.

3.1O GRIEF AND LOSS

393. Family members of dying clients may experience stress due to:

A. anticipatory grief
B. financial pressures
C. altered family dynamics
D. all of the above

Correct answer: D

Rationale: Family members may experience stress due to a vast array of stressors.
Relationships within families may be strained when individuals disagree over the plan of
care.

394. A man died. He was an abusive father who used drugs, gambled, and was frequently
absent from the home. When he was home, he regularly played ball with his sons
when they were young. The sons are adults. What may his sons’ experience after the
man’s death?

A. a prolonged grieving process

B. a sense of relief
C. complicated grief
D. all of the above

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 Correct answer: D

Rationale: Grief is unpredictable. However, the sons are likely to experience

complicated grief. They may feel many emotions, including relief. The grieving process
may be prolonged because their relationships were complicated. The sons may
experience regret, anger, and sadness.

395. A child is terminally ill and cannot eat. The family wants to have a feeding tube
inserted to prolong the child's life. What does the nurse say to the family?

A. tube feeding does not extend life expectancy when a person is terminally ill
B. tube feeding will keep your child hydrated, comfortable, and extend his life
C. tube feeding will improve your child's quality of life and decrease the risk of
aspiration pneumonia
D. tube feedings will help to prevent bed sores and infections

Correct answer: A

Rationale: Tube feedings do not extend life expectancy when a person is terminally ill.
Hydration at end-of-life may increase suffering. Research shows that tube feeding does
not usually improve a person's quality of life at the end of life. Tube feedings increase
the risk of infections including aspiration pneumonia. Bedsores aren’t prevented and do
they heal better when tube feedings are used to treat terminally ill individuals.

396. The nurse is providing care for a client who has a terminal illness. The client requests
that his Rabbi is called. He says that he feels guilty because he didn't practice his faith
with vigor and commitment. The client promises to be a better Jew if God will spare
him. What stage of death and dying is the client in?

A. denial
B. bargaining
C. anger
D. depression

Correct answer: B

Rationale: The client is bargaining in an attempt to survive.

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397. Which of the following clients may experience grief?

A. a woman who is about to have a mastectomy

B. a man who is no longer able to indulge in sex
C. a child whose parent has a disabling mental illness
D. all of the above

Correct answer: D

Rationale: People grieve when they anticipate or experience loss. Grief is not always
related to death.

398. A client had multiple treatments for cancer over a period of 10 years. The treatment
he is now receiving is not working. He is rude, continually calling for the nurse, and
refusing to eat. What is a possible diagnosis?

A. anger related to grief

B. altered communication pattern
C. acceptance
D. loneliness

Correct answer: A

Rationale: The client is most likely angry. He is experiencing the first stage of the
grieving process.

399. A man is teary and sad. His wife of 30 years is terminally ill. What can the nurse do to
ease the man’s suffering?

A. sit with him in silence or encourage him to voice his emotions

B. help him to concentrate on his wife's needs and not his own
C. remind him that his wife is still alive and he should focus on her
D. ask him what kind of television programs he enjoys most and distract him by turning
on an appropriate program

Correct answer: A

Rationale: The man is likely experiencing the depression phase of grief. Sitting with him
or encouraging him to voice his feelings may help.

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400. A woman experienced a miscarriage when she was 14 weeks pregnant. What response
does the nurse anticipate?

A. grief
B. loss
C. sadness
D. all of the above

Correct answer: D

Rationale: When a pregnancy ends in miscarriage, it can be devastating for a woman.

Miscarriages that occur early in the pregnancy are often not acknowledged or only
acknowledged for a short time by the community and other family members. The
woman may benefit from counseling or a referral to a support group designed to ease
the suffering of individuals who have lost children to miscarriage or stillbirth.

Congratulations! You have just completed 400 questions of your NCLEX-RN review! Isn’t it
amazing how much you know? We are going to start a new unit. Are you ready? Let’s get
started!

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PART 4 PHYSIOLOGICAL INTEGRITY

4.1 BASIC CARE AND COMFORT

In this section, we will review hygiene, mobility, elimination, and non-pharmacological pain
management. We will examine nutrition and oral fluids. Our final topic for this section will focus
on sleep and rest. Here is our first topic:

4.1A MOBILITY/ IMMOBILITY

401. Jogging, walking, and swimming create:

A. Extensions of muscle length

B. Contractions and changes in muscle length
C. Minimal muscular movements and increased strength of the muscles being used
D. Shortening of muscle fibers

Correct answer: B

Rationale: Jogging, walking, and swimming are examples of isotonic exercises. Isotonic
exercises cause muscle contractions. The length of the muscle changes with activity.

402. What kind of joints are relatively immobile and fixed?

A. Cartilaginous
B. Fibrous
C. Synovial
D. Antagonistic

Correct answer: B

Rationale: Fibrous joints are fixed and close fitting.

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403. A client has torn the tissue that connects his muscles and bone of his forearm. What
type of tissue did he injure?

A. Muscle
B. Ligament
C. Tendon
D. Cartilage

Correct answer: C

Rationale: Tendons connect bones and muscles.

404. What kind of muscle stabilizes joints?

A. Antagonistic
B. Involuntary
C. Synergistic
D. Antigravity

Correct answer: D

Rationale: Antigravity muscles provide joint stability.

405. A client had a cerebrovascular accident. She is unaware of where her right leg is and
frequently bumps into objects. What is the client experiencing difficulty with?

A. Proprioception
B. Her antigravity muscles
C. Isometric contractions
D. Posture

Correct answer: A

Rationale: The client is having difficulty with proprioception. She is unaware of the
position of her body parts.

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406. Which of the following contribute to decreased bone mass in older adults?

A. Reduced activity of osteoclasts

B. Reduced physical activity
C. Increased activity of osteoclasts
D. B and C

Correct answer: D

Rationale: Bone mass decreases in older adults due to reduced physical activity,
increased activity of osteoclasts, and hormonal changes. Nutrition throughout the
lifespan and medications may also impact bone loss.

407. A male client is 60 years old. What is his target heart rate while he exercises?

A. 60-92 bpm
B. 84-120 bpm
C. 96-144 bpm
D. 110-152 bmp

Correct answer: C

Rationale: Here is how to obtain a target heart rate: Subtract the client’s age from 220.
Multiply by 60% to get the lower limit of his targeted heart rate. Multiply by 90 % to get
the upper limits of the targeted heart rate. The targeted heart rate is between the
upper and lower limits. The sex of the client is irrelevant.

408. A man is undergoing chemotherapy. He took a shower and stated that he feels
exhausted. He is so tired after the shower that he lies on the floor for a few minutes.
What is the nursing diagnosis?

A. Mental status change

B. Alteration in comfort
C. Activity intolerance
D. Alteration in mobility

Correct answer: C

Rationale: The client has activity intolerance related to his disease process and the
chemotherapy.

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409. Immobility contributes to the development of all of the following except:

A. Bone loss
B. Urinary stasis
C. Depression
D. Diarrhea

Correct answer: D

Rationale: Immobility impacts the entire body. People are more likely to develop
constipation, not diarrhea as a result of immobility.

4.1B ASSISTIVE DEVICES

410. A client weighs 450 pounds. He has poor trunk control and is non-weight bearing.
What do you use to get the client out of bed?

A. Three staff members

B. Gait belt
C. Mechanical lift
D. Both A and B

Correct answer: C

Rationale: Using a mechanical lift is safest for the client and staff. Use a mechanical lift
when clients are large, unable to support themselves, or unable to support their weight.

411. A client fell while using a broken walker. What does the nurse do first?

A. Remove the walker from service

B. Write an incident report
C. Notify the supervisor, physician and family
D. Assess the client and provide first aid if necessary

Correct answer: D

Rationale: Always provide care for the client first. If the client is in an unsafe situation,
remove the client from danger if necessary before providing care otherwise always
provide care before conducting other activities.

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412. A client had a cerebrovascular accident. The client has a weakness of his dominant
hand and failed a swallow evaluation. Which of the following are likely to be
employed to facilitate safer and easier oral intake?

A. A plate with built-up sides

B. A straw
C. Thickened liquids
D. A and C

Correct answer: D

Rationale: Adaptive plates and silverware can aid clients who have experienced
cerebrovascular accidents. Clients who have had strokes often have impaired
swallowing. Thickened liquids prevent choking. Straws are contraindicated when
swallowing problems are present.

413. You are teaching a client how to safely use a walker. What do you tell the client?

A. The walker handles need to be at the level of the abdomen when the arms are held
at the sides while standing upright
B. The walker handles need to be at the level of the wrists when the arms are held at
the sides while standing upright
C. It is important to lean the upper body weight backward with the arms outstretched
while holding the walker when changing from a sitting to standing position.
D. Non-wheeled walkers may not be used on uneven outdoor surfaces

Correct answer: B

Rationale: The walker handles need to be a wrist height. Leaning backward could result
in a fall. Wheeled and non-wheeled walkers may be used indoors and out.

414. A client has low vision bilaterally. What can the nurse do to support the client in the
home setting?

A. Ensure that glasses are clean and in good repair

B. Teach the client how to obtain large print reading materials and books on tape from
the local library
C. Instruct the client how to keep her ocular prosthesis clean
D. A and B are correct

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 Correct answer: D

Rationale: Basic actions including ensuring glasses are clean, within reach, and well
maintained are essential when caring for clients who have low vision. A wide array of
adaptive tools are available. These include, but are not limited to, reading materials,
magnifiers, and computer programs. An ocular prosthesis is an artificial eye. It is not
capable of providing vision.

415. The nurse is caring for a five-year-old who has a diagnosis of cerebral palsy. He will be
starting kindergarten soon. The child is unable to walk. He has a manual wheelchair.
The nurse suggests that the parent consider purchasing a mobility aid that resembles a
race car or decorating the wheelchair in bright colors. What nursing diagnosis is being
addressed?

A. Alteration in mobility
B. Potential impaired social interaction
C. Cognitive impairment
D. Delayed growth and development related to physical impairment

Correct answer: B

Rationale: All of the nursing diagnoses listed may be true for a child with a diagnosis of
cerebral palsy. However, the actions suggested by the nurse are intended to help the
child “fit in” when he attends kindergarten.

416. A child has spina bifida. She has a diaper rash. What kind of gloves are used while
providing care?

A. Latex gloves
B. Latex-free gloves
C. Rubber gloves
D. Cloth gloves

Correct answer: B

Rationale: Children who have spina bifida are at risk for a latex allergy response related
to repeated exposures to latex. Rubber gloves contain latex. Cloth gloves do not provide
adequate protection from microbes and may spread them.

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417. A deaf client lip reads. All of the following facilitate communication with the client
except:

A. Facing the client and speaking loudly

B. Using simple language while asking questions
C. Speaking slowly and using hand gestures
D. Provide written material for education

Correct answer: A

Rationale: Facing the client is essential. However, the client cannot hear regardless of
how loud the nurse speaks since he is deaf.

418. A woman had a mastectomy. She is considering whether to wear a breast prosthesis
or have reconstructive surgery performed. The woman is crying and sitting with her
arms crossed. She is wearing unattractive loose clothing. She states that she is worried
that her partner will find her undesirable. What is a possible nursing diagnosis?

A. Disturbed body image related to the loss of a sexually significant body part
B. Potential disturbed body image related to the loss of a sexually significant body part
C. Risk for powerlessness related to an unknown outcome of a procedure
D. Knowledge deficit related to self-care activities

Correct answer: A

Rationale: The woman is currently distressed about her body image. Her worry is about
her image and relationship, not the possible procedure. There is no evidence of a self-
care deficit.

4.1C ELIMINATION
419. A two-year-old needs his ears irrigated. What does the nurse do to perform the
procedure?

A. Place the child in a recumbent position

B. Encourage the person holding the child to hold him in a sitting position with his head
raised 90 degrees
C. Pull the pinna up and back
D. Pull the pinna forward and down

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 Correct answer: D

Rationale: While irrigating the ears of children who are less than three years old the
pinna must be pulled forward and down to straighten the ear canal. Pull the pinna up
and back while irrigating the ears of individuals who are aged three and up.

420. A client is constipated. The stool in her rectum is hard. What type of enema is
administered?

A. Oil retention
B. Cleansing
C. Carminative
D. Medicated

Correct answer: A

Rationale: Oil retention enemas lubricate the rectum. Stool absorbs the oil, making it
softer. These actions make defecating easier and more comfortable.

421. A client has a urinary catheter. She produced 2000 cc of urine in twenty-four hours.
Describe her urinary status:

A. Her output is within normal limits

B. She has dysuria
C. She is anuric
D. She has polyuria

Correct answer: A

Rationale: The average adult produces approximately two thousand ccs, two liters, of
urine per day.

422. An indwelling urinary catheter is clogged with mucus. The nurse determines that it
needs to be irrigated. Which of the following is a correct intervention to resolve the
problem?

A. Clamp the urinary catheter drainage tubing and raise the catheter drainage bag
above the client’s waist five to six times while the client is lying down.
B. Unclamp the urinary catheter drainage tubing and raise the catheter drainage bag
above the client’s waist five to six times while the client is lying down.

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 C. Clamp the urinary catheter drainage tubing and irrigate the catheter using a syringe
and irrigation port
D. Disconnect the catheter from the drainage tubing and irrigate the catheter with a 60
cc irrigation syringe

Correct answer: C

Rationale: Irrigate a clogged urinary catheter with a syringe. Use the irrigation port.
Clamp the tubing below the port before performing the procedure. Be sure to unclamp
the tubing post procedure.

423. A client had a surgical procedure. He is restless and complains of abdominal

discomfort. He has not urinated since his urinary catheter was removed six hours ago.
What does the nurse do?

A. Call the surgeon

B. Notify the nursing supervisor
C. Assess the client’s abdomen for signs of urinary retention
D. Encourage the client to turn, cough, and take a deep breath

Correct answer: C

Rationale: Evaluate the client’s abdomen as he is exhibiting signs of possible urinary

retention. His abdomen may be enlarged, uncomfortable and firm over the bladder.

424. A client had abdominal surgery three days ago. She has abdominal bloating and
discomfort. The client has a urinary catheter which is draining freely. She has not had
a bowel movement. Her bowel sounds are hypoactive. What does the nurse do?

A. Ambulate the client to increase peristalsis

B. Insert a rectal tube
C. Remove the urinary catheter
D. A and B are correct.

Correct answer: D

Rationale: The client’s bowel function has likely been impacted by the surgery,
anesthesia, and immobility. Walking stimulates peristalsis which will help the woman to
expel flatus and stool. The rectal tube relieves flatulence.

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425. A client has a continuous bladder irrigation post prostate surgery. 2000cc of irrigation
is solution infused during a shift. 2400 cc of liquid was emptied from the client’s
urinary drainage bag during the shift. What was the client’s urinary output during the
shift?

A. 4400 cc
B. 2400 cc
C. 2000 cc
D. 400 cc

Correct answer: D

Rationale: The client’s urinary output is 400 cc. Subtract the total irrigation fluid from
the total amount of liquid in the urinary drainage bag. The difference is the urinary
output.

426. A client has a catheter that was surgically implanted into the medial portion of his
pelvis, slightly above his symphysis pubis. A urinary drainage bag is attached to the
catheter. The device is called a:

A. Ileal-conduit
B. straight catheter
C. Suprapubic catheter
D. Condom catheter

Correct answer: C

Rationale: A suprapubic catheter is described. An ileal- conduit is a surgically created

diversion of urine. Straight catheters are used intermittently. Condom catheters are
applied over a male’s penis.

427. Bladder retraining is used to treat this type of incontinence:

A. Stress
B. Urge
C. Mixed
D. Functional

Correct answer: B

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 Rationale: Bladder retraining treats urge incontinence caused by an overactive bladder.

428. A client has an indwelling urinary catheter. What is the minimum frequency for
providing perineal care?

A. Daily and after each bowel movement

B. Twice daily and after each bowel movement
C. Three times per day and after each bowel movement
D. Four times per day and after each bowel movement

Correct answer: C

Rationale: When a client has an indwelling urinary catheter, perineal care is provided at
least three times daily and after each bowel movement.

4.1D NON-PHARMACOLOGICAL PAIN INTERVENTIONS

429. A woman is in labor. Her cervix is dilated 9 centimeters. She screams, swears, and
yells,

“Don’t touch me.” The woman demands that she be given a narcotic. She is most likely
showing these behaviors because:

A. she is an addict
B. she has a low tolerance for pain
C. the behaviors are typical of her cultural group
D. she is in the transition phase of labor.

Correct answer: D

Rationale: All of the behaviors are within a range of normal responses for a woman
during the transition stage of labor.

430. A client is resting quietly with her eyes closed. She states that her pain level is a 9/ 10
and requests that pain medication be given. The nurse concludes that the woman:

A. is drug seeking
B. doesn’t understand the pain scale
C. is experiencing a high leavel of pain
D. must have a low tolerance for pain

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 Correct answer: C

Rationale: No evidence is provided that indicates the woman is drug seeking or doesn’t
comprehend the pain scale. Whether or not the woman has a low pain tolerance is
irrelevant. The woman perceives that she is experiencing a great deal of pain. Not all
clients demonstrate high levels of pain outwardly.

431. Reassurance, touch, and simply sitting with a client are techniques which may reduce
a

client’s:

A. level of physical discomfort

B. level of emotional distress
C. knowledge deficit about a procedure
D. ability to learn

Correct answer: B

Rationale: Words, touch, and being present with a client may reduce emotional distress.
Reduced emotional or spiritual distress leads to enhanced physical comfort and a
greater capacity for learning. Ask clients for permission prior to touching them or sitting
with them as some individuals may feel increased distress when touched or in the
presence of healthcare providers.

432. A client sprained his ankle yesterday. He called the nurse support line as he is
experiencing 3/10 constant, achy pain in the ankle. What recommendations does the
nurse make to the client?

A. Rest, ice, apply a compression wrap, and elevate the ankle.

B. Apply heat to the ankle and take two ibuprofen
C. Go to urgent care or the emergency department immediately.
D. Rest, apply a hot pack alternating with an ice pack to the ankle, do not use any wrap
or bandage, and elevate the ankle

Correct answer: A

Rationale: Acute sprains are treated by RICE: Rest, Ice, Compress, and Elevation.

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433. A client has pain that has been occurring intermittently for two years. A definite cause
of the pain has not been identified. What type of pain does the client have?

A. nociceptive
B. visceral
C. idiopathic
D. neuropathic

Correct answer: B

Rationale: Idiopathic pain is chronic and occurs intermittently. The cause is not precisely
determined. Nociceptive pain is the normal processing of stimuli that are capable of
damaging tissue. Visceral pain is felt within internal organs. Neuropathic pain is a result
of nerve compression or damage.

434. What kind of nonpharmacological interventions for the prevention and treatment of
pain works by releasing endorphins blocking the transmission of painful stimuli?

A. cutaneous stimulation techniques

B. distraction
C. guided imagery
D. meditation

Correct answer: A

Rationale: Cutaneous stimulation techniques prevent the transmission of messages.

Types of techniques include acupressure, massage, and the use of transcutaneous nerve
stimulating devices.

435. Which of the following substances cause vasodilation and tissue swelling?

A. neuromodulators
B. substance P
C. serotonin
D. immunoglobulin

Correct answer: B

Rationale: The release of substance P causes vasodilation. This creates edema.

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4.1E NUTRITION
436. Which of the following nutrients is most difficult to obtain via the diet?

A. vitamin C
B. vitamin D
C. magnesium
D. iron

Correct answer: B

Rationale: Vitamin D is difficult to get from food sources. Cold deep-water fish and
mushrooms are among the few sources contain vitamin D. Vitamin D is primarily
obtained through exposure to sunlight. Supplementation is often necessary.

437. Which of the following groups of food are most likely to cause discomfort and
flatulence among postoperative clients?

A. whole-grain bread, fish, and bananas

B. broccoli, lentils, and coleslaw
C. whole milk cheese, corn, and potato chips
D. ice cream, chocolate chip cookies, and French fries

Correct answer: B

Rationale: Cruciferous vegetables, including broccoli and cabbage, are gas forming.
Lentils, dried peas, and beans are gas producing.

438. A client has a high-level of unhealthy LDL-cholesterol. What type of nutrient(s) will
lower his cholesterol level most efficiently?

A. water-soluble vitamins
B. fat-soluble vitamins
C. fiber
D. trace elements

Correct answer: C

Rationale: Fiber such as that which is contained in whole grains, legumes, fruit, and
vegetables helps to reduce unhealthy levels of LDL-cholesterol.

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439. The client is advised to eat liver three times a week. She's instructed to consume a
tablespoon of blackstrap molasses every day. The woman is encouraged to consume
plenty of legumes and dark green vegetables. What diagnosis are the recommended
foods used to treat?

A. gout
B. congestive heart failure
C. chronic kidney disease
D. anemia

Correct answer: D

Rationale: The foods listed are excellent sources of iron. People with anemia need iron.

440. Which of the following foods would vegans eat?

A. whole grains, maple syrup, and oranges

B. soy milk, tofu, and honey
C. fish, chicken, and eggs
D. eggs, tempeh, and brown rice

Correct answer: A

Rationale: Vegans do not eat foods which contain animal products.

441. 441. The client had a myocardial infarction and his blood pressure is elevated. He
needs to lose 60 pounds. What diet plan is best for him to follow?

A. Paleo
B. lacto Ovo vegetarian
C. DASH
D. Mediterranean

Correct answer: While all of the diets listed can be healthy, the best diet for this client
is the DASH Diet. It reduces hypertension and enhances cardiovascular health.

442. The client is being discharged. The nurse instructs the client to limit her intake of
spinach, broccoli, Brussels sprouts, and collards. Which of the following clients is most
likely to be given those instructions?

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 A. A 75-year-old woman who was treated for gastrointestinal hemorrhage and is being
discharged on pantoprazole
B. The 45-year-old female who had a pulmonary embolism and is being released on
warfarin
C. A 23-year-old woman who delivered twins via C-section and is being released with
multivitamins
D. The 87-year-old female who had an emergency appendectomy and is being
discharged on ciprofloxacin

Correct answer: B

Rationale: The 45-year-old woman who had a pulmonary embolism will require long-
term anticoagulant therapy. Dark green vegetables contain concentrated amounts of
vitamin K which are contraindicated.

443. A client is on aspiration precautions. What do you expect to find on the client's lunch
tray?

A. nectar thick liquids and hotdogs

B. honey thick liquids, baked macaroni, and cheese
C. a straw, milk, and a turkey sandwich
D. pasta, apple juice, and gelatin

Correct answer: B

Rationale: Thickened liquids, mechanically soft foods, and chopped ground meats are
indicated when a client is on aspiration precautions. Straws are contraindicated.

444. Clients with cirrhosis of the liver or advanced age are frequently prescribed the
following nutrient:

A. vitamin A
B. vitamin B12
C. vitamin E
D. CoQ10

Correct answer: B

Rationale: Sublingual forms or monthly injections of vitamin B-12 are commonly

prescribed for individuals who have cirrhosis of the liver or advanced age.

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445. Which of the following lipid profiles is most likely to contribute cardiovascular
disease?

A. elevated HDL, elevated LDL, low triglycerides

B. high HDL, low LDL, elevated triglycerides
C. low HDL, elevated LDL, elevated triglycerides
D. low HDL, low LDL, low triglycerides

Correct answer: C

Rationale: Low levels of HDL cholesterol combined with high levels of LDL-cholesterol
and triglycerides puts a person at risk for cardiovascular damage and illness.

446. Poor diet contributes to approximately this percentage of illness and death in the
United States:

A. 15%
B. 35%
C. 50%
D. 65%

Correct answer: D

Rationale: Over two-thirds of deaths in the United States are related to illnesses directly
impacted by dietary choices.

447. According to the US government’s “My Plate,” fruits and vegetables should comprise
this much of the plate:

A. one quarter
B. one third
C. one half
D. three quarters

Correct answer: C

Rationale: The United States Department of Agriculture's “My Plate” shows consumers
that half of their plates should be filled with fruits and vegetables.

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448. Vegans may need to take supplements of which of the following vitamins?

A. A
B. B6
C. B12
D. E

Correct answer: C

Rationale: Vegans may need supplements of vitamin B12.

449. All of the following statements are true regarding essential fatty acids except:

A. essential fatty acids are manufactured by the liver

B. diets rich in essential fatty acids reduce total cholesterol levels
C. essential fatty acids improve HDL to LDL levels
D. essential fatty acids must be obtained from food or supplements

Correct answer: D

Rationale: The body cannot manufacture essential fatty acids. Therefore, essential fatty
acids must be obtained via the diet or nutritional supplementation.

450. Compounds that decrease free radicals, slow the aging process, and protect against
cancer and cardiovascular disease are called:

A. antioxidants
B. lipids
C. polyunsaturated fats
D. amino acids

Correct answer: A

Rationale: Antioxidants help to remove free radicals from the body. Free radicals
contribute to disease and aging. Diets that contain high amounts of antioxidants have
been shown to reverse coronary artery disease and decrease the incidence of certain
cancers. Examples of antioxidants include vitamins A and E. Complex carbohydrates are
excellent sources of antioxidants.

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451. These substances help transport fats and fat-soluble vitamins throughout the body:

A. complex carbohydrates
B. lipoproteins
C. essential fatty acids
D. hemicelluloses

Correct answer: B

Rationale: Lipoprotein's aid the transport of fats and the fat-soluble vitamins; A, D, E,
and K; throughout the body.

452. An adult male client consumes between 25 and 35 g of fiber each day. When he asks
you about his fiber intake you state:

A. men need 25 g of soluble fiber and 10 g of insoluble fiber daily

B. keep doing what you're doing; you are consuming an adequate amount of fiber
C. you are consuming too much fiber and might experience diarrhea and gas
D. you need to consume more fiber, or you may become constipated

Correct answer: B

Rationale: The average adult needs to consume a minimum of 25 to 35 g of fiber each

day.

453. All of the following statements are true except:

A. beta-carotene converts to natural vitamin A

B. overdoses of vitamin A damage the kidneys
C. consuming excessive amounts of beta-carotene is harmless
D. clients who have hypothyroidism must use vitamin A instead of beta-carotene

Correct answer: B

Rationale: Overdoses of vitamin A are toxic to the liver, not the kidneys. Beta-carotene
is harmless. People who have hypothyroidism need to consume vitamin A as they
cannot convert beta-carotene to vitamin A.

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454. Folic acid deficiency is particularly harmful during the:

A. the second trimester of pregnancy

B. third trimester of pregnancy
C. first 12 months after birth
D. the first trimester of pregnancy

Correct answer: D

Rationale: Women who desire to become pregnant should consume folic acid
supplements before becoming pregnant. Consuming adequate amounts of folic acid
before pregnancy and during the first trimester prevents the majority of neural tube
defects such as anencephaly and spina bifida.

455. A client has a stage IV decubitus ulcer. What nutrients are critical for wound healing?

A. vitamin A and monounsaturated fats

B. vitamin E and complex carbohydrates
C. vitamin C and proteins
D. B complex vitamins and simple carbohydrates

Correct answer: C

Rationale: Protein is needed to rebuild tissue. Vitamin C promotes wound healing and
fights infection. Ensuring adequate protein and vitamin C is essential when treating a
client with a stage IV decubitus ulcer

456. All of the following statements regarding vitamin C are true except:

A. smoking depletes the body of vitamin C

B. vitamin C should be administered at the same time as sulfa drugs so that the effects
of both are potentiated
C. women who are pregnant should not take more than 5000 mg of vitamin C each day
while pregnant
D. signs of vitamin C deficiency include bleeding, weakness, and poor healing

Correct answer: B

Rationale: Vitamin C should not be taken simultaneously with medications used to treat
diabetes or with sulfa drugs. Vitamin C can decrease the effectiveness of these

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 medication. Women who take more than 5000 mg of vitamin C daily while pregnant are
at risk for delivering babies who develop scurvy after birth. Scurvy is a vitamin C
deficiency disease which is characterized by bleeding and weakness.

457. A nutrient aids nerve function, blood pressure regulation, and digestive health. It
provides structure for connective tissue, bones, and teeth. The nutrient helps to
prevent colon and breast cancers. What nutrient is it?

A. riboflavin
B. thiamine
C. calcium
D. potassium

Correct answer: C

Rationale: Calcium provides all of the listed benefits.

458. A client has a BMI of 25. What does the nurse recommend to the client?

A. get more exercise as you are at risk for bone loss

B. your BMI is in a healthy range
C. you need to increase your dietary intake as your BMI is low
D. begin a weight reduction diet and start walking 20 minutes per day

Correct answer: B

Rationale: According to the World Health Organization, a desirable body mass index is
between 18.9 and 24.9.

459. The World Health Organization recommends that pregnant women not consume more
than 300 mg of caffeine daily. Approximately how many cups of regular coffee is that?

A. one
B. two
C. three
D. four

Correct answer: B

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 Rationale: An 8-ounce cup of regular coffee contains about 140 mg of caffeine. The
March of Dimes recommends 200 mg of caffeine daily. Coffee from shops often contains
much higher amounts of caffeine per cup. Instant beverages usually contain less. Green
and black teas contain 40 to 50 mg of caffeine per cup. Cola drinks contain 30 mg per
cup as does one and a half ounces of dark chocolate.

460. A client has gout. Which of the following meal recommendations does the nurse
make?

A. milk, broccoli, steak

B. liver, coffee, onions
C. cherries, rice, vegetable soup
D. salmon, red wine, strawberry shortcake

Correct answer: C

Rationale: Cherries and their juice are beneficial for people who suffer from gout.
Cherries neutralize uric acid and prevent the formation of painful crystals. Pineapple,
strawberry, and blueberries are also helpful. People who have gout must limit or
eliminate foods which contain high amounts of purines. These include meat and oily
fishes. Organ meats contain extremely high amounts of purines and should not be
eaten. Alcohol, caffeine, legumes, and refined carbohydrates should be eliminated or
restricted.

461. An 87-year-old man has an albumin level of 3.0. What does this indicate?

A. malnutrition
B. renal disease
C. lymphoma
D. leukemia

Correct answer: A

Rationale: The normal serum albumin level is 3.5 to 5.5 g/dL. A level of less than 3.4
indicates protein loss and malnutrition. Malnutrition may occur as a result of kidney
disease or cancer. However further assessment is needed to make that determination.

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462. A child is diagnosed with rickets. What nutrient deficiency is responsible?

A. calcium
B. vitamin D
C. magnesium
D. zinc

Correct answer: B

Rationale: Rickets and osteomalacia are caused by a lack of vitamin D. Bones weaken,
and deformity arises.

463. A client has a diagnosis of Korsakoff's syndrome. What nutrient is needed?

A. riboflavin
B. pantothenic acid
C. niacin
D. thiamine

Correct answer: D

Rationale: Clients with Korsakoff’s syndrome have a deficiency of vitamin B1, thiamine.

464. Clients who have a diagnosis of COPD often have poor intake because:

A. eating is tiring
B. eating causes shortness of breath
C. they find food unpalatable
D. all of the above

Correct answer: D

Rationale: Many clients who have a diagnosis of COPD have poor intake due to fatigue
and shortness of breath. Medications and other factors may reduce the appetite and
cause food to seem less palatable.

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465. When women are breastfeeding, their caloric need:

A. remains the same as it was before they were pregnant

B. remains the same as it was during pregnancy
C. increases by 300 calories per day
D. increases by 500 calories per day

Correct answer: D

Rationale: Women need approximately 500 calories per day over their pre-pregnancy
requirements while breastfeeding.

466. The client is admitted to the inpatient hospice unit for end-of-life care. The family of
the client is concerned that he is not eating. What does the nurse do?

A. orders a puréed diet and teaches family members how to feed the client
B. offers liquid nutritional supplements four times per day
C. teaches the family it is normal for people to stop eating during the final days of life
D. contacts the physician to discuss nasogastric or peg tube placement

Correct answer: C

Rationale: Clients usually stop eating during the days leading up to death. Family
members often struggle with this. The nurse educates the family about signs and
symptoms of the dying process including cessation of eating.

4.1F ORAL FLUIDS

467. A client’s skin is dry and tenting. His eyes are sunken. He is listless. When the nurse
empties the client’s urinary drainage bag, the nurse finds that the client is producing
approximately 20 mL of urine per hour. Describe the client’s status:

A. retaining fluid
B. dehydrated
C. renal failure
D. experiencing urinary retention

Correct answer: B

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 Rationale: Dry, tented, cracked skin is a sign of dehydration. When people are
dehydrated, they have little energy. The eyes may be sunken. Urinary output decreases.

468. Older adults are prone to dehydration because:

A. they often don't drink enough

B. their bodies contain a lower percentage of water than younger adults
C. they don't ambulate frequently
D. A and B are correct

Correct answer: D

Rationale: Older adults often do not drink enough fluids. Their bodies contain a lower
percentage of water than younger adults. They may also take medications which
contribute to dehydration.

469. Where does the sensation of thirst originate?

A. adrenal glands
B. pancreas
C. hypothalamus
D. thymus gland

Correct answer: C

Rationale: The sensation of thirst originates in the hypothalamus. It is triggered by a

decrease in blood pressure and increased serum osmolality.

470. A nine-month-old infant has been diagnosed with mild dehydration secondary to
diarrhea. What method of rehydration is attempted first?

A. keep the child NPO until the diarrhea decreases

B. administer a hypotonic solution intravenously
C. administer a hypertonic solution intravenously
D. provide oral rehydration therapy

Correct answer: D

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 Rationale: When children, infants, or toddlers are dehydrated, oral rehydration therapy
is attempted before other measures are taken. Oral rehydration therapy is not invasive
or painful.

471. The nurse is caring for a client who was injured in a motor vehicle crash. The client
sustained a traumatic brain injury. He has difficulty swallowing. What does the nurse
use to facilitate adequate, safe oral fluid intake?

A. a sippy cup
B. thickened liquids
C. a large bore straw
D. a 50 mL syringe

Correct answer: B

Rationale: Thickened liquids prevent aspiration and are used when clients have
difficulty swallowing.

4.1G REST AND SLEEP

472. The nurse is showing new parents how to position their baby boy in a crib. The nurse
instructs the parents to:

A. place the child on his back or sides

B. position the child's head on a small pillow
C. position the child on his abdomen
D. place the child on his back or abdomen

Correct answer: A

Rationale: Babies should be positioned on their sides or back to prevent death due to
sudden infant death syndrome. Pillows should not be used for infants.

473. A client overdosed on a benzodiazepine medication. What medication should be

administered?

A. naloxone
B. dantrolene
C. flumazenil
D. amiodarone

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 Correct answer: C

Rationale: Flumazenil is used to treat people who overdose on benzodiazepines. The

drug reverses the sedative effects of benzodiazepines.

474. The client has a diagnosis of obstructive sleep apnea. Caution must be used when this
type of medication is administered:

A. NSAIDs
B. opioids
C. benzodiazepines
D. ACE inhibitors

Correct answer: B

Rationale: Clients who have a diagnosis of obstructive sleep apnea are at risk for
developing respiratory depression when opioids are administered.

475. The client has a diagnosis of narcolepsy. What may occur as a result?

A. seizure activity
B. night terrors
C. short periods of apnea at night
D. sudden onset of sleep during the daytime

Correct answer: D

Rationale: Clients who have narcolepsy may suddenly fall asleep at any time. They are
at risk of injuring themselves and others as a result.

476. Dreams which occur during REM sleep facilitate all of the following except:

A. learning
B. processing of memories
C. coping with stressors
D. regulation of blood pressure

Correct answer: D

Rationale: Experts believe that dreams which occur during REM sleep aid learning and
the processing of memories. It is understood that dreams help people cope with stress.

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Take a break if you desire. You have worked hard! We have just concluded unit 3.

When you are ready, please proceed to our next unit.

4.2 PHARMACOLOGICAL AND PARENTERAL THERAPIES

This unit is about medication. We will review administration, indications, and effects of drugs
and dosage calculations. Various routes of administration, including parenteral therapies, will
be covered. We will look at intravenous treatments, pain management, and central lines. The
final focus of the unit will be on total parenteral nutrition and the administration of blood
products. Let’s start out by reviewing guidelines for safe medication administration.

4.2A MEDICATION ADMINISTRATION

477. Which of the following is not a right of medication administration?

A. client education
B. dose
C. affordability
D. medication

Correct answer: C

Rationale: The ten rights of medication administration include correct time or

frequency, right drug, dose, client, route, education, documentation, assessment, and
evaluation. Clients have the right to refuse medication.

478. Which of the following are acceptable unique client identifiers?

A. age and last name

B. photograph of the client and room number
C. allergy band and complete name
D. complete name and personal barcode

Correct answer: D

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 Rationale: Healthcare organizations determine unique client identifiers. A complete
name or complete date of birth are usually acceptable identifiers. Some facilities
provide photographs or barcodes, which are also acceptable.

479. When medications are stored in a facility, all of the following must be in place except:

A. medication must be stored within easy reach of staff who are responsible for its
administration
B. drugs that need refrigeration must be kept cold
C. narcotics must be stored and locked
D. non-narcotic medications must be stored securely

Correct answer: A

Rationale: While storing medicines within easy reach of staff is desirable, it is not
mandated.

480. A medication is given via the buccal route. How is it administered?

A. by suppository within the vagina

B. using the Z track technique
C. it is placed between the teeth and gum
D. it is taken by mouth and chewed

Correct answer: C

Rationale: Buccal medications are placed inside of the cheek of the mouth.

481. Liquid medications are generally administered to children under the age of:

A. two
B. three
C. five
D. eight

Correct answer: C

Rationale: Liquid medications are usually prescribed for children under the age of five.
However, many children older than the age of five prefer liquid medicines as well.

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482. A client has a nasogastric tube. The nurse administers medication via the tube. All of
the following actions are necessary except:

A. turning off the suction before the medication is administered

B. changing the suction from intermittent to continuous before the drug is given
C. flushing the tubing with 30 mL of water after the medicine is given
D. ensuring that the client sits upright for 30 minutes after the drug is given

Correct answer: A

Rationale: The suction must be turned off or else the medication will be sucked out.

483. The nurse is going to administer an intramuscular injection to a two-year-old child.

Where does the nurse inject the medication?

A. deltoid muscle
B. vastus lateralis
C. gluteus medius
D. gluteus maximus

Correct answer: B

Rationale: The safest place to administer an IM injection to a two-year-old is the vastus

lateralis muscle.

484. A tuberculin syringe can hold up to this much fluid:

A. 0.5 mL
B. 1 mL
C. 2.5 mL
D. 3 mL

Correct answer: B

Rationale: A tuberculin syringe contains up to 1 mL of liquid.

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485. Choose the correct needle to use when administering an intramuscular injection to an
average -sized adult:

A. 22-gauge 5/8-inch
B. 22-gauge 1 ½-inch
C. 25-gauge 5/8-inch
D. 18-gauge 1-inch

Correct answer: B

Rationale: A 22-gauge 1 1/2-inch needle will deliver the medication to the right area.
The 5/8-inch needles are too short. The 18-gauge will cause increased resistance and
pain.

486. Choose the best needle to use when administering a subcutaneous injection to an
average -sized adult:

A. 22gauge 5/8-inch
B. 22gauge 1 ½-inch
C. 25gauge 5/8-inch
D. 18gauge 1-inch

Correct answer: C

Rationale: The 25-gauge 5/8-inch needle is sufficient to administer the medication. The
25-gauge needle will cause less discomfort than a 22-gauge needle. However, it may be
used if a 25-gauge needle isn’t available. The 1 and 1 ½ inch needles are too long.

487. A schedule one controlled substance:

A. is used to promote anesthesia

B. is not used medically
C. is available in stores without a prescription, but must be kept behind the pharmacy
counter
D. is used to promote sleep

Correct answer: B

Rationale: Schedule I controlled substances are not used in clinical settings because
they are dangerous.

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488. The nurse is teaching a client how to intranasally self-administer calcitonin. What does
the nurse tell the client to do?

A. bend forward while administering the medication

B. be aware of an increased tendency to bleed or bruise
C. tilt the head backward while administering the drug
D. hold one nostril closed while delivering the drug into the other nostril

Correct answer: C

Rationale: Tilting the head backward while administering the drug improves retention
and absorption of the medicine.

489. What is the most vital information to provide when instructing a client in the use of
eye drops?

A. do not allow the tip of the dropper to touch the eye, surrounding tissues, fingers, or
any object
B. shake the container before administering the drops
C. do not wipe the eyes with a tissue before or after administration of the medication
D. keep the eye drops refrigerated

Correct answer: A

Rationale: It is essential that the dropper tip not make contact with any object or body
part. This is done to prevent infection. If the dropper does make contact with the body
part or object, it should be disposed of and replaced. Shaking the container of eye drops
is not always necessary. Most drops do not need to be refrigerated. Clients shouldn't
wipe their eyes with tissues, particularly after medication administration. However,
preventing contamination of the drop dispenser is a higher priority.

490. Which of the following medications can be crushed?

A. enteric-coated aspirin
B. extended-release morphine sulfate
C. nitroglycerin sublingual tablet
D. hydrochlorothiazide

Correct answer: D

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 Rationale: Enteric-coated and extended release medications may not be crushed or
altered. Nitroglycerin sublingual tablets melt and are absorbed under the tongue.

491. The physician orders what appears to be 5 mg of furosemide. The nurse isn't sure
whether the order reads 5 mg or 15 mg. The client states that she usually takes 5 mg
and that's what the doctor told her he was going to order. What does the nurse do?

A. administer 5 mg of furosemide
B. administer 15 mg of furosemide
C. administer 5 mg of furosemide and then contact the doctor to see if an additional 10
mg should be given
D. contact the physician for clarification before administering any furosemide

Correct answer: D

Rationale: The nurse must contact the prescriber whenever an order is illegible.

492. A nurse received a telephone order for a medication. What does the nurse do?

A. nothing, telephone orders are not valid

B. request that the ordering party fax a copy immediately
C. read the order back to the prescriber and verify the order
D. administer the medication after transcribing the order

Correct answer: C

Rationale: Verbal and telephone orders must be read back and verified before they are
transcribed or carried out.

493. A client refused to take medicine this morning. What does the nurse do?

A. crush the drug and mix it in the client’s food

B. hold the medication and contact the prescriber
C. administer it with lunch
D. dispose of the medication down the toilet of the patient's room

Correct answer: B

Rationale: Clients have the right to refuse medication. The nurse holds medicine and
notifies the prescriber. Medication should not be disposed of down the toilet as it

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 contaminates water. The drug must be given within the healthcare organization’s time
frame for medication administration.

494. The nurse prepares to administer an oral suspension to an infant. What does the
nurse do?

A. shake the medication before pouring it

B. position the child on his left side
C. mix the medicine with infant formula and administer it via a baby bottle
D. warm the medication before giving it to the child

Correct answer: A

Rationale: Suspensions need to be shaken as the contents separate.

495. A client has a peg tube. You are about to administer medication. What do you do?

A. don sterile gloves

B. flush the tubing with saline before and after medication administration
C. combine multiple drugs and administer them
D. only administer liquid medications

Correct answer: D

Rationale: PEG, Keo- feeding, and jejunostomy tube have small bores. Only liquid
medications may be administered. When administering medication through PEG tubes,
nonsterile gloves are adequate. Tubing is flushed with water or sterile water, not saline.
Administer medications individually and flush with each drug.

496. The client went into cardiac arrest. The emergency response team is unable to secure
intravenous access quickly. The client has a nasogastric and endotracheal tube. The
emergency room physician orders epinephrine be given intravenously. What does the
nurse do first?

A. assist emergency room physician as she performs a cutdown procedure to obtain

intravenous access into the subclavian vein
B. request an order to administer the epinephrine via the nasogastric tube
C. seek an order to deliver the epinephrine via the endotracheal tube
D. seek an order to deliver the epinephrine intramuscularly

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 Correct answer: C

Rationale: The epinephrine must be administered immediately. When venous access is

not possible, epinephrine may be administered via an endotracheal tube.

497. The nurse may delegate all of the following tasks except:

A. instruct the licensed practical or licensed vocational nurse to administer 2 mg of

hydromorphone intravenously via the push method
B. tell the unlicensed assistive personnel member of the team to apply clotrimazole
cream topically to the client
C. tell the unlicensed assistive personnel member to teach a client how to instill eye
drops
D. none of the above

Correct answer: D

Rationale: Licensed practical or vocational nurses may not administer IV push narcotics.
Unlicensed assistive personnel may not apply medications. Unlicensed assistive
personnel may not teach the client how to administer medications.

498. A client is being discharged from the hospital. He has a new oral inhaler which is used
to deliver a steroid medication. The nurse instructs the client to rinse his mouth out
after using the inhaler. She explains that rinsing is essential because:

A. oral steroids leave a metallic taste in the mouth

B. food will taste better if the medicine is rinsed out of the mouth
C. oral steroid inhalers contribute to the development of thrush in the mouth
D. inhaled steroid medications cause a temporary burning sensation in the mouth and
throat

Correct answer: C

Rationale: Inhaled steroid medications increase the risk of developing a fungal infection
in the mouth. The infection is known as candidiasis or thrush.

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499. Category X medications are:

A. teratogenic and must not be taken during pregnancy

B. unregulated medicines that are not approved by the FDA
C. over-the-counter drugs that are generally recognized as safe
D. medicines which are only approved for phase one clinical trials

Correct answer: A

Rationale: Category X medications are teratogenic and must not be taken during
pregnancy.

Take a break!! Pat yourself on the back!!!! You are halfway through the review!!!!

500. Clients who take alendronate sodium:

A. self-administer the medication subcutaneously once a month

B. must sit up for at least 30 minutes after taking the medication
C. need to take the medication with orange juice
D. must take the medication with milk

Correct answer: B

Rationale: Alendronate sodium can cause esophageal erosion and bleeding. Clients
must sit up for at least a half of an hour after taking the medication.

501. A client is receiving an infusion of an antibiotic. The client complains of itchiness and a
scratchy throat. What does the nurse do first?

A. stop the infusion

B. obtain an order for diphenhydramine
C. administer oxygen 2 liters per minute via nasal cannula
D. notify the physician

Correct answer: A

Rationale: The client may be having an allergic reaction to the antibiotic. It is essential
to stop administering the medication immediately.

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502. Which of the following clients may not benefit from treatment with Streptokinase?

A. clients who are addicted to opiates

B. people with a history of alcohol addiction and abuse
C. clients who currently abuse alcohol
D. people who have a history of recurrent streptococcal infections

Correct answer: D

Rationale: Clients who have a history of recurrent streptococcal infections may have
developed antibodies which will interfere with Streptokinase.

503. The nurse instructs a client regarding the correct use of nitroglycerin sublingual tablets
before he is discharged home. The nurse tells the client:

A. Place one tablet under your tongue when you have chest pain. Wait five minutes. If
the pain persists, take another tablet. You may repeat this up to a maximum of three
tablets.
B. Place one tablet under your tongue when you're having chest pain. If the pain does
not subside within 10 or 15 minutes, call 911.
C. Place one tablet under your tongue when you're having chest pain. If the pain does
not subside within five minutes, place two tablets under your tongue.
D. Place one tablet under your tongue when you're having chest pain. Take 400 mg of
ibuprofen simultaneously as nitroglycerin may cause severe headaches.

Correct answer: B

Rationale: The American Heart Association now recommends that on one dose of
nitroglycerin be administered. They recommend calling 911 if relief is not obtained
within a few minutes.

504. All of the following are true regarding insulin administration except:

A. draw up NPH before regular insulin when combining into one syringe
B. regular and NPH insulin may be given in the same syringe
C. draw up regular insulin first when combining it with NPH in a syringe
D. do not massage the injection site after administering insulin

Correct answer: A

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 Rationale: Draw regular insulin into the syringe before the NPH. Remember clear before
cloudy.

505. The following are true regarding insulin administration except:

A. aspirate before injecting

B. use a small gauge needle
C. rotate sites
D. gently roll vials of NPH rather than vigorously shaking them before administering
insulin

Correct answer: A

Rationale: It is not necessary to aspirate before injecting when administering insulin.

506. A client is receiving warfarin. Which of the following laboratory tests should be
monitored?

A. digoxin level
B. INR
C. fasting blood sugar
D. CBC

Correct answer: B

Rationale: Warfarin is an anticoagulant agent. The INR needs to be monitored closely to

ensure safety. If an INR is too low, a thrombus may form. Bleeding risks increase as the
INR becomes higher.

4.2B OUTCOMES AND ACTIONS OF MEDICATION

507. The client presents with a diagnosis of liver failure. He has mental status changes due
to high ammonia levels. What medication is indicated?

A. magnesium sulfate
B. lactulose
C. metformin
D. glyburide

Correct answer: B

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 Rationale: Lactulose is a laxative that is used to eliminate excess ammonia from the
body. Ammonia levels rise when liver failure occurs. High ammonia levels are implicated
with hepatic encephalopathy. Early signs of hepatic encephalopathy include mental
status changes. Uncontrolled high ammonia levels result in coma and death.

508. A client has a high LDL-cholesterol reading and an unhealthy ratio of HDL to LDL
cholesterol. What supplement may be beneficial for the client?

A. thiamine
B. niacin
C. pantothenic acid
D. vitamin B12

Correct answer: B

Rationale: Niacin, vitamin B3, effectively treats hyperlipidemia. Advise the client that
niacin may cause harmless, transient flushing of the skin when administered. Flush-free
products are available over-the-counter.

509. A client received an antibiotic. He is wheezing, has hives, and swelling around the face
and throat. What medication is given first?

A. hydralazine
B. diphenhydramine
C. epinephrine
D. oxygen

Correct answer: C

Rationale: Administer epinephrine immediately. The client is having an anaphylactic

reaction. Hydralazine and diphenhydramine are not immediately indicated. Oxygen
should be administered, but epinephrine takes priority.

510. A client is taking a proton pump inhibitor and two antibiotics. What is likely occurring?

A. he is being treated for MRSA

B. the client has Clostridium difficile
C. he has a stomach ulcer caused by H. pylori
D. the client needs to have a cholecystectomy

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 Correct answer: C

Rationale: The treatment protocol described is used to treat H. pylori.

511. A client has neuropathic pain in the feet due to diabetes. What medication is likely to
be prescribed?

A. A nonsteroidal anti-inflammatory drug

B. acetaminophen with codeine
C. naproxen
D. gabapentin

Correct answer: D

Rationale: Gabapentin is commonly prescribed to treat neuropathic pain. It is a GABA

analog.

512. A client is three years old. He's hypotensive. His pulse is 42. He is cold and clammy.
What medications does the nurse anticipate administering?

A. epinephrine and amiodarone

B. atropine and epinephrine
C. adenosine and amiodarone
D. lidocaine and procainamide

Correct answer: B

Rationale: The child's heart rate and the force of contraction of his cardiac muscle must
increase to resume adequate perfusion of tissue. Atropine and epinephrine create these
outcomes.

513. This type of medicine is used to treat clients who have glaucoma. It constricts the
pupils:

A. emollient
B. miotic
C. mydriatic
D. antipyretic

Correct answer: B

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 Rationale: Miotic medications constrict pupils. Therefore, they are used to treat
glaucoma. Emollients are moistening. Mydriatics dilate the pupils. Antipyretic drugs are
used to treat fevers.

514. What is amiodarone used to treat in an emergency situation?

A. bradycardia
B. asystole
C. ventricular fibrillation
D. choking

Correct answer: C

Rationale: Amiodarone is used to treat shock, recurrent ventricular tachycardia, and

ventricular fibrillation in emergency settings. It slows conduction through the ventricles.
Administer 5 mg per kilogram as a rapid bolus during cardiac arrest. That dose may be
repeated twice for refractory tachycardia or ventricular fibrillation.

515. A client overdosed on a tricyclic antidepressant. What medication is likely to be

administered?

A. naloxone
B. sodium bicarbonate
C. epinephrine
D. adenosine

Correct answer: B

Rationale: Sodium bicarbonate is used for the treatment of overdoses caused by

tricyclic antidepressants or calcium channel blockers.

516. A client experiences hypotensive shock after cardiac arrest. What medication may be
employed to treat post-arrest shock?

A. dopamine
B. regular insulin
C. heparin
D. digoxin

Correct answer: A

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 Rationale: Dopamine at an initial infusion rate of 10 to 20 µg per kilograms per minute is
used to treat post-arrest hypotensive shock. Epinephrine or norepinephrine are also
used to treat post-arrest hypotensive shock.

517. Acetylcysteine is used to treat:

A. individuals who overdose on acetaminophen

B. tachycardia
C. preeclampsia
D. cardiac tamponade

Correct answer: A

Rationale: Acetylcysteine helps create diversionary pathways for the metabolism of

acetaminophen. It restores glutathione levels in the liver and prevents future
hepatotoxicity.

518. A client sustained a closed head injury. Surgery is planned to relieve intracranial
pressure. What medication is administered while in the trauma bed?

A. atropine
B. amiodarone
C. dexamethasone
D. gabapentin

Correct answer: C

Rationale: Dexamethasone relieves cerebral edema. It is a corticosteroid that reduces

inflammation. Dexamethasone administration helps to relieve intracranial pressure.

519. Narcotics, barbiturates, and stimulants belong to this schedule of drugs:

A. I
B. II
C. V
D. X

Correct answer: B

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 Rationale: Schedule II drugs have a high potential for abuse. A new prescription is
required for each refill. Refills may not be provided over the telephone. Medications
used to treat pain, insomnia, and attention deficit hyperactivity disorder are usually
included in this class of drugs.

520. A client is scheduled for an elective surgical procedure next week. Which supplement
should be temporarily discontinued?

A. ginkgo
B. echinacea
C. cranberry
D. vitamin D

Correct answer: A

Rationale: Ginkgo can increase bleeding time particularly when used with valproic acid,
NSAIDs, and cephalosporins. The herb is used to treat poor circulation and memory.

521. A client is being discharged from the hospital with a new prescription for Carafate.
What information is essential that the nurse provide while providing instructions
regarding the medication?

A. take the medication with food

B. it is administered as a suppository
C. the medicine can cause an increase in blood pressure
D. do not take the drug within two hours of other medications

Correct answer: D

Rationale: Carafate can bind with other medicines. Therefore, it must not be taken at
the same time as other medications. Other medications may be ineffective when taken
within two hours of Carafate administration.

522. A woman who is addicted to heroin and actively using delivers a baby. Naloxone:

A. is not administered to the baby because the child may seize if the drug is
administered
B. is administered immediately upon the birth of the child
C. is administered 15 minutes after birth to mother and child
D. causes liver damage when administered to a newborn

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 Correct answer: A

Rationale: Administering naloxone to a heroin-addicted baby can result in seizures.

Naloxone can exacerbate symptoms of narcotic abstinence syndrome.

523. Oxytocin is administered to treat:

A. abruptio placenta
B. inadequate uterine contractions during labor
C. women who have an active genital herpes infection during labor and delivery
D. a prolapsed umbilical cord during labor

Correct answer: B

Rationale: Oxytocin treats inadequate uterine contractions during labor. It is used to

induce labor and shorten prolonged labor. Abruptio placenta, herpes, and a prolapsed
umbilical cord are contraindications for the use of oxytocin in most circumstances.

524. Lisinopril, captopril, and enalapril are examples of:

A. angiotensin receptor blockers (ARBs)

B. angiotensin-converting enzyme inhibitors (ACE inhibitors)
C. anticoagulants
D. beta-adrenergic blockers

Correct answer: B

Rationale: The suffix -pril generally indicates that the medication is an ACE inhibitor.
ACE inhibitors are used to treat primary and secondary hypertension. They convert
angiotensin I to angiotensin II. It is crucial to monitor vital signs, electrolytes, creatinine
levels, and the white blood cell counts when on ACE inhibitors.

525. The nurse expects to monitor peak and trough levels when this medication is in use:

A. gentamycin
B. metoprolol
C. ranitidine
D. pantoprazole

Correct answer: A

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 Rationale: Gentamycin is an aminoglycoside medication used to treat infection. It is
essential to monitor peak and trough levels of aminoglycosides to ensure that the levels
are within the therapeutic range.

526. This group of medications is used to treat digestive problems including GERD,
indigestion, and stomach ulcers:

A. cephalosporins
B. anticholinergics
C. proton pump inhibitors
D. angiotensin receptor blockers

Correct answer: C

Rationale: Proton pump inhibitors decrease gastric acid secretions.

527. The suffix -phylline often indicates that the medication is:

A. an anesthetic
B. a bronchodilator
C. a monoclonal antibody
D. a histamine 2 antagonist

Correct answer: B

Rationale: The suffix -phylline suggests the drug is a bronchodilator. Theophylline is an

example of a bronchodilator. Many anesthetics and with the suffix -caine. The suffix -
mab suggests a monoclonal antibody. Histamine 2 antagonists often end in - tidine.

528. The nurse prepares to administer promethazine intramuscularly. What does the nurse
need to know?

A. promethazine can cause tachycardia and irritability

B. the medication must be delivered via the Z track technique because it irritates the
tissues surrounding the injection site
C. promethazine must not be administered intramuscularly
D. the drug may not be administered to people who have a history of COPD

Correct answer: B

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 Rationale: Promethazine is a phenothiazine. Phenothiazines are irritating to tissues and
must be administered via the Z track technique. Phenothiazines are classified as anti-
emetics and antipsychotic drugs.

529. Mucomyst:

A. suppresses respirations
B. thins secretions
C. relieves bronchospasm
D. dries up secretions

Correct answer: B

Rationale: Mucomyst thins secretions making them easier to eliminate.

530. Nitroglycerin:

A. causes vasoconstriction
B. creates vasodilation
C. increases blood pressure
D. decreases the pulse rate

Correct answer: B

Rationale: Nitroglycerin causes vasodilation which reduces preload and relieves angina.

531. Novolog and Humalog are examples of:

A. sulfonylureas
B. rapid acting insulins
C. basal insulins
D. intermediate-acting insulins

Correct answer: B

Rationale: Novolog and Humalog are rapid-acting insulins. Sulfonylureas are not insulin.
They are oral anti-diabetic agents. Basal insulins are long-acting. Lantus is an example of
basal insulin. NPH is intermediate-acting insulin.

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4.2C ADVERSE REACTIONS AND SIDE EFFECTS
532. A client takes fluoxetine long term. His heart rate is 170 bpm. He is confused. His
blood pressure is 200/150. The client’s pupils are dilated. His muscles are rigid and
twitching. The client's temperature is 101°F. What is the most likely cause of his
distress?

A. serotonin syndrome
B. cocaine
C. methamphetamine
D. cardiovascular accident

Correct answer: A

Rationale: The most likely cause of the symptoms is serotonin syndrome. Fluoxetine
increases serotonin levels. It is a selective serotonin reuptake inhibitor.

533. The nurse just administered Humalog. When is the client most at risk for developing
hypoglycemia?

A. within 15 minutes
B. within 60 to 90 minutes
C. within 3 to 4 hours
D. within 6 to 8 hours

Correct answer: B

Rationale: Humalog, like Novolog, is rapid-acting insulin. Rapid-acting insulins have an

onset of 15 minutes. They peak within 60 to 90 minutes. The time of peak action is
when hypoglycemia is most likely to occur. Their duration of action is 3 to 4 hours.

534. A client is on doxorubicin for the treatment of cancer. She complains of pain when
eating or swallowing. The woman states that food tastes terrible. She has a white
coating in her mouth. What medication may relieve her distress?

A. nystatin
B. morphine
C. cephalexin
D. vitamin B12

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 Correct answer: A

Rationale: The woman has signs and symptoms of candidiasis, thrush. It is caused by
suppression of the immune system by doxorubicin and her illness. She has an infection.
Nystatin oral suspension is indicated. The woman should swish and swallow the
medicine.

535. Early signs of toxicity from local anesthesia include:

A. nausea and vomiting

B. ringing in the ears, tingling around the mouth, and blurred vision
C. respiratory depression and cardiac arrest
D. seizures

Correct answer: B

Rationale: Ringing in the ears, tingling around the mouth, and blurred vision are signs of
toxicity from local anesthesia. Nausea and vomiting are not usually signs of local
anesthesia toxicity. Respiratory depression, cardiac arrest, and seizures are late signs of
toxicity caused by local anesthesia.

536. The client takes warfarin. His INR is 3.4. He has hematuria, bruising, and bloodshot
eyes. What medication is administered?

A. Vitamin K
B. potassium
C. disulfiram
D. Heparin

Correct answer: A

Rationale: Vitamin K is the antidote for warfarin excess and toxicity. It promotes
synthesis of vitamin K dependant clotting factors.

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537. An 18-year-old female college student has a new prescription for tetracycline to treat
severe acne. What is the most critical question to ask the student before giving her
the prescription?

A. Do you have an eating disorder?

B. Are you sexually active?
C. Do you have a history of seizures?
D. Have you ever been diagnosed with attention deficit hyperactivity disorder?

Correct answer: B

Rationale: Tetracycline causes congenital disabilities. It is essential to know whether or

not the student is sexually active. If she is, the nurse needs to instruct the student to
consistently use a reliable birth control method.

538. The nurse is evaluating a pregnant client. The woman has a loss of patellar reflexes.
Her respiratory rate is six. She is forgetful and complains of feeling “spacey”. She has
had a minimal urinary output for 24 hours. What medication likely caused the
symptoms?

A. prenatal vitamins
B. vitamin K
C. potassium
D. magnesium

Correct answer: D

Rationale: Magnesium causes the described symptoms. Magnesium sulfate is the drug
of choice for the prevention of eclampsia. It is administered to pregnant women who
have preeclampsia to prevent seizures.

539. A woman is receiving magnesium sulfate during pregnancy. She displays symptoms of
magnesium toxicity. What medication is administered?

A. a saturated solution of potassium iodide (SSKI)

B. lisinopril
C. atropine
D. calcium gluconate

Correct answer: D

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 Rationale: Calcium gluconate is administered IV push over three minutes when
magnesium toxicity occurs. It is the antidote for magnesium toxicity.

540. Signs of digoxin toxicity include all of the following except:

A. tachycardia
B. vomiting
C. bradycardia
D. dysrhythmias

Correct answer: A

Rationale: Early signs of digoxin toxicity include lack of appetite and nausea. Vomiting
may occur as the toxicity worsens. Excess digoxin can cause bradycardia and
dysrhythmias.

541. The following medication can cause tardive dyskinesia:

A. phenobarbital
B. methotrexate
C. haloperidol
D. hydromorphone

Correct answer: C

Rationale: Haloperidol and related drugs may cause extrapyramidal symptoms and
tardive dyskinesia.

542. A man took Viagra two hours ago. He developed angina and self-administered 0.4 mg
of nitroglycerin sublingually. What is he at risk for?

A. A hypertensive crisis
B. severe hypotension
C. spasms of the coronary arteries
D. pulmonary edema

Correct answer: B

Rationale: When Viagra and nitroglycerin are in the body simultaneously, severe
hypotension may occur. They should not be used within 24 hours of each other.

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543. Children may develop Reye’s syndrome if they are given this medication when they
have a viral illness:

A. diphenhydramine
B. acetaminophen
C. aspirin
D. pseudoephedrine

Correct answer: C

Rationale: Children who have recently been infected with a viral disease, such as
chickenpox, cannot take aspirin because they may develop Reye’s syndrome. Reye’s
syndrome can result in brain damage or death. It causes swelling of the brain and liver.

544. A client takes lithium. When is a lithium level drawn?

A. immediately after a dose is given

B. immediately before a dose is given
C. before breakfast
D. after a meal

Correct answer: B

Rationale: Draw blood immediately before administering medicine when checking

medication levels such as lithium or phenytoin. Food has no impact on the medication
levels.

545. Caution must be exercised when administering cimetidine intravenously to clients

with a history of cardiovascular disease. This is because cimetidine may:

A. interact with drugs used to treat high blood pressure

B. interact with medications used to treat arrhythmias
C. cause a hypertensive crisis
D. cause low blood pressure and dysrhythmias

Correct answer: D

Rationale: Cimetidine may cause hypotension and dysrhythmias.

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546. A client has a new prescription for nitroglycerin patches. What is a typical side effect
that the nurse teaches the client about?

A. hypertensive crisis
B. an increased risk of bruising and bleeding
C. a dry cough
D. a headache

Correct answer: D

Rationale: Headaches are a common side effect of nitroglycerin.

547. A client has a prescription for a narcotic pain reliever. What does the nurse say to the
client?

A. This medication may cause constipation.

B. Monitor your blood pressure every day for two weeks.
C. Stay out of direct sunlight as much as possible.
D. You may develop cramping and diarrhea.

Correct answer: A

Rationale: Narcotics frequently cause constipation. Encourage the client to consume

plenty of fluids and eat high-fiber foods. Stool softeners and over-the-counter laxatives
may be useful. Medications that are specially designed to treat narcotic induced
constipation are sometimes needed.

548. Lidocaine, lorazepam, and sleeping medications may increase this among the elderly:

A. diarrhea
B. constipation
C. confusion
D. skin breakdown

Correct answer: C

Rationale: These medications may cause confusion when administered to older adults.
Careful monitoring is essential. The risk of falls increases when medicines that cause
confusion or drowsiness are ordered. Prescribers usually order smaller Initial doses than
they do for younger people.

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549. A client receives alprazolam. She becomes agitated, jittery, and fidgety. What is the
most likely cause of the woman's response to the medication?

A. it is an expected response to the stimulant

B. the woman is experiencing a paradoxical reaction
C. she is likely addicted to methamphetamine
D. the drug was administered simultaneously with a narcotic pain reliever

Correct answer: B

Rationale: The woman is most likely experiencing a paradoxical reaction to the

medicine. A paradoxical reaction is the opposite effect of the desired outcome. Children
and older adults are at risk for experiencing paradoxical reactions. Medications used to
calm people may have the opposite effect. Stimulants are administered to people who
have attention deficit hyperactivity disorder because they have a paradoxical effect on
those individuals and essentially slow them down.

550. Which of the following medications is least likely to cause gastrointestinal bleeding?

A. aspirin
B. acetaminophen
C. ibuprofen
D. enteric-coated aspirin

Correct answer: B

Rationale: Acetaminophen is less irritating to the gastrointestinal tract than aspirin or

ibuprofen. However, acetaminophen is more toxic to the liver.

551. A woman takes methotrexate due to rheumatoid arthritis. The medication has many
side effects. However, the drug places her at risk for:

A. developing infections
B. losing her hair
C. hypoglycemia
D. hypertension

Correct answer: A

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 Rationale: Methotrexate is a potent drug which impacts the entire body. It suppresses
immune function, therefore putting the client at risk for infection.

Take a break if you need one. When you are ready, please continue with:

4.2D DOSAGE CALCULATION

552. You need to give 1000 µg of medication. You know that this is the equivalent of:

A. 1000 mg
B. 1g
C. 1 mg
D. 100 mL

Correct answer: C

Rationale: µg is the symbol for microgram. Micrograms or a measure of weight. 1000 µg

equals 1 mg.

553. You need to administer 15 mL of cough syrup. What is the equivalent of that dose?

A. 1/2 teaspoon
B. 1 teaspoon
C. 1 tablespoon
D. 2 tablespoons

Correct answer: C

Rationale: 15 mL is a measure of volume. It is equivalent to 1 tablespoon.

554. A client has a prescription for 30 mL of lactulose. How much is an equivalent dose?

A. 1 teaspoon
B. 1 tablespoon
C. 2 teaspoons
D. 2 tablespoons

Correct answer: D

Rationale: 30 mL equals 2 tablespoons equals 1 ounce equals 8 drams

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555. 1 teaspoon is equivalent to:

A. 2.5 mL
B. 5 mL
C. 0.5 ounces
D. 4 drams

Correct answer: B

Rationale: 1 teaspoon is equivalent to 5 mL.

556. An order reads give 5 mg of Roxinal PO every four hours for pain. The nurse has a
container of morphine sulfate 20 mg/mL. How much medication does the nurse
administer?

A. Zero, the nurse, has morphine sulfate, not Roxinal.

B. 0.25 ML
C. 0.5 ML
D. 1 mL

Correct answer: B

Rationale: Roxinal is liquid morphine. It is designed for oral administration. 20 mg of

morphine is contained in 1 mL. 5 mg is one-fourth of a milliliter. This is the equivalent of
0.25 mL.

557. The medication order states, “morphine sulfate extended-release 45 mg PO BID”. The
client has chronic pain. The medication on hand is labeled morphine sulfate ER 30 mg.
What does the nurse do?

A. Contact the physician because the dose is high.

B. administer one, and a half tablets of the medication
C. administer one tablet
D. contact the physician because a different prescription is needed

Correct answer: D

Rationale: The medicine is in an extended release form. It cannot be divided or crushed.

The nurse should contact the physician and get an order for 15 mg tablets to be added

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 with the 30 mg tablets, unless 45 mg tablets are available. A new order needs to be
written.

558. You have lorazepam injectable 2 mg/mL on hand. You need to give 0.5 mg of
lorazepam. How much do you give?

A. 0.25 ML
B. 0.5 ML
C. 0.75 ML
D. 2 ML

Correct answer: A

Rationale: You have 2 milligrams per ML on hand. The desired dose is 0.5 mg of
medication. Set it up as a ratio and proportion. You need to give one-fourth of a
milliliter of medication.

559. The client has patient-controlled analgesia. He has a 500-milliliter bag of normal saline
hanging. It contains 1000 mg of hydromorphone. The order reads for the client to
receive 2 mg of hydromorphone every hour via continuous infusion. The client may
receive a bolus dose of 0.5 mg every 15 minutes as needed. What is the bolus dose?

A. 0.1 mL
B. 0.2 mL
C. 0.25 mL
D. 0.5 mL

Correct answer: C

Rationale: The concentration is 2 mg of hydromorphone per milliliter. The desired bolus

dose is 0.5 mg of hydromorphone. That is one-fourth of a milliliter.

560. A client is being discharged from the hospital. He takes 81 mg of aspirin daily. The
nurse instructs the client to buy:

A. regular aspirin and teaches him to take one half of a tablet daily
B. regular aspirin and tells him to take one pill daily
C. buffered aspirin and tells him to take one pill daily
D. baby aspirin and instructs him to take one tablet daily

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 Correct answer: D

Rationale: 81 mg of aspirin is contained in one baby aspirin tablet. Regular aspirin

contains 325 mg per tablet.

561. A client states that she takes 1000 mg of Tylenol daily. She says that she takes two
tablets of the medication. The nurse says:

A. You take two extra strength tablets of acetaminophen daily?

B. You take two regular Tylenol tablets each day?
C. You take more than the recommended maximum amount of acetaminophen each
day.
D. That much acetaminophen may cause stomach distress.

Correct answer: A

Rationale: 1000 mg of Tylenol equals 1000 mg of acetaminophen equals two extra-

strength acetaminophen tablets. 500 mg of acetaminophen is contained in one extra-
strength tablet. The dose does not exceed the daily recommended amount of
acetaminophen. Acetaminophen does not usually cause gastric distress.

562. A client has been instructed to take 200 mg of ibuprofen three times a day. She has
over-the-counter Motrin at home. How many tablets should she take each day?

A. one tablet
B. zero tablets since ibuprofen and Motrin are different medications
C. zero tablets of Motrin, however, she can take three Advil tablets daily
D. three tablets

Correct answer: D

Rationale: Motrin and Advil are trade names for ibuprofen. Regular ibuprofen over-the-
counter tablets contain 200 mg of medication. The woman will take one pill three times
a day for a total of three tablets of ibuprofen.

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563. A client weighs 100 kg. How many pounds does he weigh?

A. 45
B. 120
C. 200
D. 220

Correct answer: D

Rationale: Convert kilograms to pounds by multiplying by 2.2.

564. A six-year-old child weighs 44 pounds. A medication is ordered. 30 mg per kilogram of

body weight of the drug is to be administered. How much medicine does the child
receive?

A. 300 mg
B. 600 mg
C. 1200 mg
D. 2400 mg

Correct answer: B

Rationale: Divide the child's weight in pounds by 2.2 to get the weight in kilograms. A
child who weighs 44 pounds weighs 20 kg. 20 kg multiplied by 30 mg per kilogram of
medication equals 600 mg.

565. The medication order reads to administer 1200 mg of medication. How much medicine
is given?

A. 120 mL
B. 12 mL
C. 1.2 g
D. 2400 g

Correct answer: C

Rationale: 1000 mg equals 1 g. 1200 mg equals 1.2 g.

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566. An order reads to administer 0.125 mg of the medication. There are 0.25 mg tablets
on hand. What dose is administered?

A. one-fourth of a tablet
B. one half of a tablet
C. one tablet
D. two tablets

Correct answer: B

Rationale: 0.125 mg is one half of 0.25 mg, therefore, give one half of a tablet.

567. You have 0.25 mg tablets on hand. The dose to be administered is 0.75 mg. How many
tablets do you give?

A. 1 tablet
B. 1/2 tablet
C. 1 1/2 tablets
D. 3 tablets

Correct answer: D

Rationale: 0.75 mg is the equivalent of (3) 0.25 mg tablets.

568. The nurse is administering 15 units of NPH and four units of regular insulin. Describe
what this looks like.

A. There are two syringes. One contains 15 units of NPH, and the other contains four
units of regular insulin.
B. A tuberculin syringe is used. The nurse draws up 15 units of NPH and then four units
of regular insulin.
C. The nurse draws four units of regular insulin into an insulin syringe and then draws
up 15 units of NPH into the same syringe.
D. The nurse draws 15 units of NPH into an insulin syringe followed by four units of
regular insulin.

Correct answer: C

Rationale: Use an insulin syringe when administering insulin from multi-dose vials. Draw
up clear regular insulin before cloudy NPH insulin.

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569. An order reads to administer 0.25 g of a medication. How much medicine do you give?

A. 1/4 of a teaspoon
B. 250 mg
C. 25 drops
D. 250 mL

Correct answer: D

Rationale: Grams and milligrams are measures of weight. 1 g contains 1000 mg.
Therefore give 250 mg.

4.2E PHARMACOLOGICAL PAIN MANAGEMENT

570. The nurse hands the client his dose of oxycodone. The client says that his pain is mild
and that he does not want the oxycodone. What does the nurse do?

A. disposes of the medication

B. tells him that it was scheduled and he must take it
C. returns the medicines to the pharmacy
D. disposes the medication in the presence of another nurse

Correct answer: D

Rationale: The drug was handled by the client. He has the right to refuse. The drug must
be destroyed in the presence of a witness who signs according to organizational policy.
The medicine must be destroyed in compliance with regulatory and corporate rules.

571. Uncontrolled chronic pain can lead to:

A. depression
B. changes in vital signs
C. isolation
D. all of the above

Correct answer: D

Rationale: Uncontrolled chronic pain impacts every aspect of a person's life. It may
affect self-esteem, socialization, intimacy, ability to work, and health.

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572. The pain assessment tool which evaluates the quality of pain, location, precipitating
events, triggers, severity, and timing of pain is called:

A. FACES
B. McGill Pain Assessment
C. PQRST
D. Numerical

Correct answer: C

Rationale: The PQRST method considers precipitating events, quality, region, severity,
triggers, and timing of pain.

573. A client is nonverbal. He is alert and oriented. The client cannot write, but he can
gesture. What pain scale might be helpful for him?

A. Numerical
B. CRIES
C. FACES
D. PQRST

Correct answer: C

Rationale: The FACES scale is helpful. All he needs to do is point at a picture. He does
not need to provide detailed information about his pain.

574. How are doses of pain medication determined for neonates, infants, and young
children?

A. weight
B. body surface area
C. age
D. A and B are correct

Correct answer: D

Rationale: Weight and body surface area are used to determine doses of pain
medications for babies and young children.

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575. An 83-year-old man needs a narcotic for pain management. What does the nurse
anticipate?

A. A non-narcotic medication must be used

B. the client may need a larger dose than usual
C. the client will likely receive a dose based on his weight and body surface area
D. the client may need a smaller initial dose of medication

Correct answer: D

Rationale: Older adults may be sensitive to narcotics. The initial dose may be as little as
one half the average dose that is recommended for younger adults. Older adults are at
risk for complications when they take narcotics due to changes that occur with aging.

576. OxyContin, hydromorphone, and meperidine are classified as:

A. opioid agonists
B. opioid antagonists
C. opioids with mixed agonist-antagonist effects
D. centrally acting non-opioids

Correct answer: A

Rationale: Most commonly used narcotic pain relievers are opioid agonists. They may
produce a wide range of side effects and adverse effects.

577. A client states that he has a pain level of 6 out of 10. The nurse administers morphine
2 mg IV. What does the nurse need to do?

A. have naloxone in the client’s room

B. dilute the medication with 3 mL of normal saline before administration
C. check back with the client and see if the drug was effective after it's given
D. have another nurse checked the dose before the medication is administered

Correct answer: C

Rationale: It is essential that the nurse check with the patient after pain medication is
given so that the effectiveness can be determined. The nurse needs to document the
effect of the drug. If the remedy was not adequate, action must be taken.

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578. Naloxone:

A. is used to treat people who overdose on opioids

B. can cause liver damage and gastrointestinal distress
C. may cause joint pain, headaches, and anxiety
D. all of the above

Correct answer: D

Rationale: Naloxone is an opioid receptor antagonist which is used to reverse the

effects of opioids. The drug may cause nervousness, headaches, and joint pain. Insomnia
and gastrointestinal distress may result. Naloxone may damage the liver.

4.2F PARENTERAL THERAPIES

579. The main reasons why intravenous therapies are administered in the arms rather than
the legs when possible is:

A. because the veins are more abundant in the arms

B. to prevent phlebitis and emboli
C. because intravenous sites in the lower extremities are more painful
D. because lines in the lower extremities may make ambulation challenging

Correct answer: B

Rationale: The main reason why intravenous lines are started in the upper extremities
rather than lower is that the lower extremities are more prone to phlebitis and
thrombus formation. Having an intravenous line in the lower extremity of the
ambulatory patient can increase the risk for falls.

580. A client sustained multiple trauma in a motor vehicle accident. Which intravenous
catheter is best to use out of the following selection?

A. 16 gauge
B. 20 gauge
C. 22 gauge
D. 24 gauge

Correct answer: A

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 Rationale: Clients who sustain multiple trauma need the largest bore intravenous
catheter available. A 16 gauge is preferable. However, an 18 gauge is adequate if a 16
gauge cannot be inserted.

581. A client is going to receive two units of packed red blood cells. What size intravenous
catheter should be inserted?

A. 18 gauge
B. 21 gauge
C. 22 gauge
D. Any blood may be administered through any gauge intravenous catheter

Correct answer: A

Rationale: The client needs an 18 gauge catheter. Large bore catheters are preferable
when administering blood and blood products so that they don't clog or damage the
blood cells.

582. A 97-year-old woman has an intravenous catheter placed for intermittent medication
administration. What size intravenous catheter is used?

A. 18 gauge
B. 21 gauge
C. 22 gauge
D. 24 gauge

Correct answer: D

Rationale: Insert a small bore intravenous catheter when it is only going to be used
intermittently. The woman is likely to have frail veins at her age, so the small 24 gauge
catheter is adequate.

583. A nurse just inserted an intravenous line into a client. The line is connected to a pump.
It has a continuous infusion of lactated ringer's infusing at 80 mL per hour. What
instructions does the nurse provide to the client?

A. notify me if you experience pain and swelling at the IV site

B. call me if your pump alarms
C. do not drink more than 1000 mL of fluid this shift
D. A and B are correct

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 Correct answer: D

Rationale: The client needs to notify the nurse if pain or swelling occurs. Instruct the
client to call for the nurse if the pump alarms. There is no indication that this client is on
a fluid restriction.

584. A client is receiving a solution of 0.45% normal saline at 100 mL per hour. The drip
factor is 20 drops per milliliter. The IV bag holds 1000 mL. How many drops per minute
is administered?

A. 10
B. 33
C. 45
D. 66

Correct answer: B

Rationale: Drops per minute equals the volume to be infused times the drip factor,
divided by the number of minutes.

585. All of the following clients may have restricted access sites to choose from when
placing an intravenous line except for the client who has a diagnosis of:

A. CVA
B. MRSA
C. mastectomy
D. renal dialysis

Correct answer: C

Rationale: Do not insert an intravenous catheter into the arm of a client who has
paralysis or a mastectomy on that side. Do not insert an intravenous catheter into the
arm of a client who has a renal dialysis port in that arm.

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586. A nurse is caring for a client who has an IV of Ringer's lactate. The client states that
the intravenous site in the arm is sore. The nurse examines the site and finds that the
skin surrounding the site is cold and swollen. The intravenous pump keeps alarming.
The skin surrounding the insertion site is pale. What does the nurse do first?

A. stop the infusion and remove the intravenous catheter

B. flush the intravenous tubing with normal saline
C. flush the intravenous tubing with dilute heparin
D. apply warm compresses to the site

Correct answer: A

Rationale: Classic signs of infiltration are being described. The nurse immediately turns
off the IV and removes the catheter. After that, the nurse elevates the limb on a pillow
and applies warm compresses per facility policy.

587. A client experiences hypotensive shock after cardiac arrest. What medication may be
given intravenously to treat post-arrest shock?

A. dopamine
B. regular insulin
C. heparin
D. digoxin

Correct answer: A

Rationale: Dopamine at an initial infusion rate of 10 to 20 µg per kilograms per minute is

used to treat post arrest hypotensive shock. Epinephrine or norepinephrine are also
used to treat post-arrest hypotensive shock.

588. A client is in supraventricular tachycardia. The nurse obtains a medication which will
slow conduction through the AV node. The drug is given in the hope that the drug will
help reset the heart rhythm. The defibrillator is on standby. The client is positioned
supine. He is intubated and has a central line. Defibrillator pads are in place on the
client’s chest. What medication is going to be administered?

A. epinephrine
B. atropine
C. adenosine

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 D. lidocaine

Correct answer: C

Rationale: Adenosine is given to break the rapid heartbeat pattern. It is essential to

have emergency equipment ready. Defibrillator pads should be placed on the client
before administering the medication. Asystole may ensue. Adenosine has a very short
half-life and must be given directly into a large vein close to the heart.

589. A client is receiving a continuous infusion of heparin. What lab test is needed?

A. hemoglobin
B. hematocrit
C. aPTT
D. CBC

Correct answer: C

Rationale: The aPTT evaluates the client’s clotting status. It is essential to know what
the client’s aPTT is so that the right amount of heparin may be administered. Too much
heparin may cause bleeding. An adequate amount of heparin is needed to prevent the
formation of a thrombus

590. The client has patient-controlled analgesia. He has a 500-milliliter bag of normal saline
hanging. It contains 1000 mg of hydromorphone. The order reads for the client to
receive 0.5 mg of hydromorphone every hour via continuous infusion. What does the
nurse program into the infusion pump as a basal rate?

A. 0.25 mL per hour

B. 0.5 mL per hour
C. 1 mL per hour
D. 2 mL per hour

Correct answer: B

Rationale: Administer 0.25 ml per hour. The bag contains 1000 mg of hydromorphone in
a 500 mL bag of saline. That is a concentration of 2 mg per milliliter. The desired dose is
0.5 milligrams per hour. That dose is contained in 0.25 mL.

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591. An intravenous site is infiltrated. The nurse checks, and there is no blood return. The
skin surrounding the site is painful, hot, and blistered. What is this called?

A. phlebitis
B. embolus formation
C. hematoma
D. extravasation

Correct answer: D

Rationale: Extravasation occurs when a caustic medication or solution is infused, such as

chemotherapy. Signs include red, hot, painful, blistered skin. There may be swelling and
tingling. Severe pain, ulcers, and necrosis may result. Phlebitis, hematoma, and emboli
do not cause blistering.

4.2G CENTRAL VENOUS ACCESS DEVICES

592. How long can a midline catheter remain in place?

A. 72 hours
B. Ten days
C. four weeks
D. eight weeks

Correct answer: C

Rationale: Midline catheters can stay in place up to four weeks. Peripheral intravenous
catheters may remain in place for 72 hours.

593. Where are midline catheters usually placed or advanced to?

A. brachial vein
B. cephalic vein
C. basilic vein
D. all of the above are correct

Correct answer: D

Rationale: Midline catheters can be up to 8 inches in length. They are advanced into the
cephalic, basilic, or brachial veins. Nurses should monitor their position.

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594. A client has a peripherally inserted central venous catheter, PICC, line. How often are
occlusive transparent dressings changed over the insertion site?

A. Every three days or when soiled or loose

B. every seven days or when soiled or loose
C. every 14 days or when soiled or loose
D. daily

Correct answer: B

Rationale: Change clear, occlusive dressings which are located over central line insertion
sites every seven days or more frequently if the dressings are soiled or loose. Strict
sterile technique is crucial. The injection caps of the individual lumens are changed at
least every seven days.

595. Typical risks related to central venous catheters include all of the following except:

A. perforation of the heart during insertion

B. infection
C. pulmonary edema
D. pneumothorax

Correct answer: C

Rationale: Central venous catheters pose many life-threatening complications. The

heart may be perforated accidentally when the catheter is inserted. Pneumothorax and
hemothorax may occur. Thromboses and emboli may develop. The client is at risk for
infection.

4.2H TOTAL PARENTERAL NUTRITION

596. Compared with enteral feeding methods such as PEG and nasogastric tube feedings,
parenteral nutrition:

A. is less expensive
B. is more expensive
C. increases the risk of infection
D. B and C are correct

Correct answer: D

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 Rationale: Parenteral nutrition is costly and increases the chance of infection. Infection
risks rise because TPN requires an invasive procedure and the nutrient solution contains
a high level of dextrose.

597. The nurse is changing the tubing for a client who is receiving hyperalimentation. What
happens?

A. the client performs the Valsalva maneuver during the procedure

B. the client lies flat
C. the nurse changes the tubing every two weeks
D. the nurse monitors the CBC and liver function tests each shift for as long as the
client is receiving the therapy

Correct answer: A

Rationale: When containers or tubing are being changed the client performs the
Valsalva maneuver. The nurse rapidly conducts the procedure. This is done to prevent
emboli. Glucose levels are carefully monitored during TPN therapy.

4.2I BLOOD AND BLOOD PRODUCTS

598. Which of the following clients are unlikely to receive a blood transfusion?

A. Muslims
B. Jehovah's Witnesses
C. Christian scientists
D. B and C are correct

Correct answer: D

Rationale: Jehovah's Witnesses and Christian scientists do not usually accept blood
products. Plasma expanders may be used as substitutes.

599. A client has O negative blood. She can:

A. donate blood for all people

B. receive any blood type
C. receive O positive blood
D. receive packed red blood cells from any donor

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 Correct answer: A

Rationale: People with type O blood are considered to be universal donors. However,
they can only receive blood from people with type O blood. People who have Rh-
negative blood do not have the Rh factor. The client needs Rh-negative blood.

600. What blood product does not need to be typed and cross-matched before it is
administered?

A. whole blood
B. packed red blood cells
C. platelets
D. fresh frozen plasma

Correct answer: D

Rationale: Fresh frozen plasma doesn't have antigen containing red blood cells
therefore typing, and crossmatching is unnecessary.

601. A nurse gives a client a unit of packed red blood cells. She inserts an 18 gauge
intravenous catheter to administer the blood through. The nurse delivers the blood
through a special blood infusion set via a Y connector. She runs normal saline with the
blood. The nurse checks the identity of the client and the blood multiple times with
the certified nursing assistant. She frequently takes vital signs. What did the nurse do
wrong?

A. she used the wrong size intravenous catheter

B. she should not have used normal saline
C. she used the wrong connector
D. she checked the identity of the client in blood with the certified nursing assistant

Correct answer: D

Rationale: Only nurses can initiate and monitor blood transfusions. Nurses cannot
employ unlicensed assistive personnel to check the identity of the client or verify that
the correct blood product is being administered.

602. What is the maximum amount of time that a unit of blood should hang?

A. one hour

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 B. three hours
C. four hours
D. six hours

Correct answer: C

Rationale: Blood should not hang for more than four hours. Blood products must be
promptly administered when they are obtained from the blood bank.

This concludes the unit on pharmacological and parenteral therapies. Take a break if you need
one. When you are ready, we will move on to the next section of the review.

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4.3 REDUCTION OF RISK POTENTIAL
We will examine alterations in health and methods to reduce risks. A review of alterations in
health and diagnostic tests will start us off. We will review procedures, enteral nutrition, and
oxygen delivery. We’ll wrap up the unit by discussing surgical complications. Let's get started.

4.3A ALTERATIONS IN HEALTH

603. A client is given materials to collect a stool sample to screen for colon cancer. What
kind of up preventative activity is this?

A. alternative
B. primary
C. secondary
D. tertiary

Correct answer: C

Rationale: Secondary prevention includes methods such as screenings to detect illness

early so that treatment may begin at the first stages of disease. Primary prevention
activities are those that decrease the likelihood of diseases occurring. Rehabilitation is a
tertiary preventative step which is used when illness or injury is already present.

604. Older adults have increased risks of:

A. malnutrition
B. depression
C. pneumonia
D. all of the above

Correct answer: D

Rationale: Older adults are susceptible to many health problems. They include but are
not limited to respiratory, circulatory, and gastrointestinal problems. As people grow
older, their skin becomes vulnerable to break down. Falls may occur. Sensory changes
create risks. Emotional and mental status changes may arise. Malnutrition, fluid, and
electrolyte balances may occur.

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605. All of the following indicates that a client may be depressed except:

A. poor self-esteem
B. outgoing behavior
C. anorexia
D. excess sleep

Correct answer: B

Rationale: Depression manifests in a wide variety of ways. Most depressed individuals

are not outgoing but inwardly focused. Signs of depression include withdrawal, a lack of
expression, low energy, crying, difficulty concentrating, and fatigue. People may sleep a
lot or be unable to sleep. Eating may increase or decrease.

606. A client is admitted to the hospital following a motor vehicle crash. He has a history of
alcohol abuse. When is the client most likely to develop delirium tremens?

A. within six hours after cessation of heavy drinking

B. within 24 hours after termination of heavy drinking
C. within 72 hours after suspension of heavy alcohol intake
D. within one week after ending heavy drinking

Correct answer: C

Rationale: Delirium tremens is most likely to occur within three days of termination of
heavy drinking. Signs and symptoms include tremors, mental status changes, irritability,
sensitivity to stimuli, and tonic-clonic seizures.

607. A 23-year-old female athlete has type I diabetes. Which of the following statements
indicates that the client may need further teaching?

A. “I try to exercise when my insulin peaks”

B. “I consume 15 to 30 g of carbohydrate for each hour that I exercise”
C. “I don't inject insulin into my arm when I am lifting weights a lot that day”
D. “I'm careful to monitor my blood glucose levels before exercise, while I'm exercising,
and when I'm through”

Correct answer: A

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 Rationale: Exercise should be avoided when insulin peaks as the risk of hypoglycemia
increases.

608. The nurse is screening clients for tuberculosis. She provides education to the clients.
Which of the following is not a sign of tuberculosis?

A. fatigue
B. constant thirst
C. a cough
D. lack of appetite

Correct answer: B

Rationale: Night sweats and low-grade fevers in the afternoon are a sign of tuberculosis.
Malaise, fatigue, weight loss, productive cough, and a lack of appetite are other signs.
Hemoptysis occurs with advanced disease.

609. All of the following are goals of healthy people 2020 initiative except:

A. promote longer healthier lives

B. eliminate disparities and establish health equity among all people
C. encourage activities that concentrate on improving health for infants and children
D. create positive physical and social environments

Correct answer: C

Rationale: The goal is to promote the health of people across the lifespan. Other goals
of healthy people 2020 include helping people live longer healthier lives, establishing
health equity, and creating healthy environments.

610. Pender’s health promotion model includes all the following variables which impact
health except:

A. behavioral outcomes
B. behavior specific thoughts and affect
C. individual experiences and characteristics
D. personal history of diseases

Correct answer: D

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 Rationale: Pender's health promotion model lists three variables that impact health
behavior. They include individual’s experiences and characteristics; cognition and effect
as they relate to behavior, and outcomes of behavior.

611. The trans-theoretical model of change identifies each of the following stages except

A. pre-contemplative
B. contemplative
C. action
D. maintenance

Correct answer: A

Rationale: The trans-theoretical model of change identifies four stages. They are
contemplation, determination, action, and maintenance.

612. The following health promotion activities are appropriate for people age 65 and over:

A. immunizations
B. nutrition
C. depression screening
D. All of the above

Correct answer: D

Rationale: immunizations, nutrition, and depression screening are appropriate for

people age 65 and over. All age groups benefit from screening and health promotion
activities which address diet, exercise, safety, lifestyles, and immunizations.

613. Health screenings are conducted to:

A. detect disease early

B. enable early treatment
C. limit the impact that a disease has on a person's quality of life
D. all of the above

Correct answer: D

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 Rationale: Health screenings detect disease at early stages. This enables prompt
treatment. Early detection and treatment limits the impact a disease has on a person's
quality of life and can favorably improve outcomes.

614. People with limited access to healthcare, high-quality food, and safe, affordable
housing in a community. Adults drink heavily and smoke cigarettes. Children are often
unsupervised. What kind of population is this?

A. immigrant
B. uneducated
C. uncaring
D. vulnerable

Correct answer: D

Rationale: Community members at an increased risk for health problems are considered
to be a vulnerable population.

615. What is the Omaha classification system used for?

A. creating national healthcare goals for the year 2030

B. establishing national patient safety guidelines
C. creating care plans for communities or individuals in a community setting
D. assessing risk for drug and alcohol abuse

Correct answer: C

Rationale: The Omaha classification system is used to create care plans for communities
or care plans for individuals in their specific community environment.

616. A home health nurse is establishing care for a 90-year-old woman who just returned
to her home after being discharged from a skilled nursing facility where she was
receiving rehabilitation services following a total hip replacement. The nurse
evaluates all of the following when making a safety assessment of the woman's home
except:

A. accessibility to public transportation

B. the presence of clutter in the house
C. the presence of throw rugs on the floor
D. lighting

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 Correct answer: A

Rationale: Safety assessment of the home is multifactorial and based on a client's

individual needs. The client may or may not need to use public transportation. It is not a
safety issue.

617. A worker splashes a cleaning product in her eyes. Her eyes are red. She says that they
are tearing and burning. What does the nurse first help the worker to do?

A. rinse out her eyes at the eye rinse station

B. go to the emergency room
C. contact her ophthalmologist
D. apply over-the-counter eye drops

Correct answer: A

Rationale: When a substance is splashed into the eyes, the priority is to rinse the eyes
thoroughly. This is done to prevent tissue damage.

4.3B POTENTIAL ALTERATIONS IN SYSTEMS/ ABNORMAL VITAL SIGNS

618. 618. The nurse is assessing a client’s lungs. The client has COPD. When the nurse
percusses the client’s lungs, he won't be surprised to hear:

A. hyper-resonance
B. tympany
C. dullness
D. flatness

Correct answer: A

Rationale: Overly inflated alveoli and rigid structures can create a loud sound known as
hyper-resonance. Tympany is heard over the stomach when it is percussed. Dullness is
heard when a solid organ is percussed. Musculoskeletal tissues sound flat. Healthy lungs
have a hollow sound known as resonance.

619. A client injured his ankle. The ankle is assessed by physical examination. Information
is obtained regarding the origin of the injury. An x-ray of the ankle is taken. A
diagnosis and treatment plan is formulated. What kind of health assessment is
conducted?

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 A. incomplete
B. comprehensive
C. focused
D. health history

Correct answer: C

Rationale: A focused assessment was conducted. Focused assessments address a

specific health concern. A comprehensive health assessment includes a general survey,
complete physical assessment, and complete history.

620. A client is going to surgery. The nurse obtains a set of baseline vital signs immediately
before anesthesia is given. Why?

A. baseline vital signs provide information which allows practitioners to evaluate the
impact of procedures
B. a lack of baseline vital signs may directly create complications for the client
C. the baseline vital signs are only useful to meet documentation requirements
D. the baseline vital signs are only needed to meet industry standards

Correct answer: A

Rationale: Baseline vital signs are obtained before many procedures. Knowing what a
person's baseline vital signs help practitioners to identify deviations quickly. Having
baseline vital signs allows providers to accurately assess the impact of a procedure or
medication on a client.

621. Rectal temperatures are contraindicated for all of the following clients except the
person who has:

A. epilepsy
B. heart disease
C. a recent hemorrhoidectomy
D. dementia

Correct answer: D

Rationale: A rectal temperature is contraindicated among people who have a seizure

disorder, heart disease, or an injury or illness to the rectum.

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622. Which of the following clients should the nurse evaluate first?

A. A neonate who has a respiratory rate of 58

B. an infant who is respiratory rate is 32
C. a toddler who is respiratory rate is 14
D. a preschool child with a respiratory rate of 30

Correct answer: C

Rationale: The toddler who is respiratory rate is 14 needs to be evaluated first. The
normal respiratory rate for toddlers is between 20 and 40 breaths per minute. All of the
other children have respiratory rates which are within normal limits for their ages.

623. Which of the following clients should the nurse evaluate first?

A. A newborn whose heart rate is 62

B. an infant who has a heart of 160 bpm
C. an adolescent who has a pulse of 80 bpm
D. an adult who has a pulse of 90 bpm

Correct answer: A

Rationale: The newborn should be assessed first. All of the other people have pulse
rates which are within normal limits for their age. A newborn’s pulse rate should be
between 80-180 bpm.

624. Which of the following clients should the nurse evaluate first?

A. a newborn with a blood pressure of 60/40

B. an infant with a blood pressure of 92/52
C. a toddler with a blood pressure of 124/84
D. a school-age child with a blood pressure of 116/58

Correct answer: C

Rationale: All of the children have blood pressures within normal limits for their age
except for the toddler. The normal blood pressure range for toddlers is from 80 to 112
mm Hg systolic and 50 to 80 mm Hg diastolic.

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625. What is the normal range of intracranial pressure measured in millimeters of mercury?

A. 1-5
B. 3 -12
C. 5-15
D. 10 -20

Correct answer: C

Rationale: The normal range of intracranial pressure is between 5 to 15 mmHg.

626. The following are signs and symptoms of increased intracranial pressure except:

A. decorticate posturing
B. narrowing pulse pressure
C. seizures
D. a headache

Correct answer: B

Rationale: Increased intracranial pressure is characterized by widening pulse pressure.

Other signs of increased intracranial pressure include decorticate or decerebrate
posturing, seizures, headache, nausea, and vomiting. Pupils dilate and react sluggishly to
light. Sensorimotor losses including visual disturbances may arise. Cheyne-Stokes
respirations may develop.

4.3C DIAGNOSTIC TESTS/POTENTIAL COMPLICATIONS AND ADVERSE REACTIONS

TO TESTS AND TREATMENTS

627. The client has a bronchoscopy. The nurse does all of the following except:

A. insert an intravenous catheter to be used for injection of dye

B. observes for signs and symptoms of bronchospasm after the procedure
C. encourages the client to gargle afterward for comfort
D. administers lozenges, if ordered, to relieve a sore throat after the procedure

Correct answer: A

Rationale: Dye is not necessary when bronchoscopy is performed. The nurse carries out
the other activities to ensure the client safety and comfort following the bronchoscopy.

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628. A fetal heart rate that is less than the baseline is called a

A. deceleration
B. acceleration
C. variable
D. nadir

Correct answer: A

Rationale: A fetal heart rate that is less than the baseline is called deceleration.
Decelerations may occur at various times. They may be episodic or prolonged. The
baseline fetal heart rate is the average rate measured over a 10-minute period that does
not have significant variability.

629. A normal fetal heart rate is between:

A. 80 to 100 bpm
B. 90 to 120 bpm
C. 110 to 160 bpm
D. 120 to 180 bpm

Correct answer: C

Rationale: The normal fetal heart rate is between 110 and 160 bpm excluding
accelerations, decelerations, or variability measured over a 10-minute period.

630. Clients who undergo cardiac catheterization are at risk for:

A. arrhythmias
B. pneumonia
C. compartment syndrome
D. disseminated intravascular coagulation, DIC

Correct answer: A

Rationale: Cardiac catheterization may precipitate arrhythmias. Cardiac monitoring and

careful cardiovascular assessment are needed.

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631. A client had a spinal tap. The nurse instructs the unlicensed assistive personnel to
position the client:

A. prone
B. flat
C. on the left side
D. with the head of the bed elevated 30°

Correct answer: B

Rationale: Clients must be kept flat after a spinal tap. They can develop a spinal
headache or complications otherwise.

632. A nurse prepares to insert a nasogastric tube. How does she measure the length of
tube to be inserted?

A. from the nose to the base of the sternum

B. from the earlobe tip to the nose and then to the base of the xiphoid process
C. from the axilla to the wrist
D. from the mouth to the area over the stomach

Correct answer: B

Rationale: Measure from the earlobe to the nose to the base of the xiphoid process
when inserting a nasogastric tube. Mark the length before inserting the tube. Secure the
tube after determining it is placed correctly.

633. This is used to aid assessment of peripheral pulses:

A. pulse oximeter
B. glucometer
C. central venous pressure monitor
D. Doppler

Correct answer: D

Rationale: Use a Doppler when peripheral pulses are difficult or impossible to palpate.

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634. Which of the following tests is used to evaluate blood flow and the health of blood
vessels?

A. MRI
B. MRA
C. CT
D. Skull x-ray

Correct answer: B

Rationale: MRA stands for magnetic resonance angiography. It is used to assess blood
flow and the health of blood vessels. It can be used instead of conventional
angiography. The test does not require contrast medium, so it may be used for
individuals who cannot receive a conventional angiogram.

635. An MRI can be performed on which of the following clients?

A. a veteran who has shrapnel in his body

B. a client who has a pacemaker
C. a woman who has metal hardware in her back
D. a trauma victim

Correct answer: D

Rationale: None of the clients can have an MRI except for the trauma victim because
the others have metal objects in their bodies.

636. Which of the following clients should not receive nuclear contrast agents for tests?

A. a three-year-old with pneumonia

B. 47-year-old with stage III chronic kidney disease
C. an 84-year-old with an artificial left hip
D. an 84-year-old who had a myocardial infarction 48 hours ago

Correct answer: B

Rationale: People who have acute or chronic severe kidney disease should not be given
nuclear contrast agents for tests.

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637. Exercise stress tests are useful for identifying:

A. cardiac changes that arise with activity

B. pulmonary emboli
C. coping skills
D. microvascular changes in the brain

Correct answer: A

Rationale: Many cardiac symptoms only occur during periods of activity. Exercise stress
tests can precipitate symptoms. Clients are closely monitored. A continuous EKG
measurement occurs while the client exercises on a treadmill or stationary bicycle.
Clients who are unable to exercise may be given a chemical stress test instead.

Take a break if you need one.

4.3D LABORATORY VALUES

638. Each of the following represents the normal blood glucose level except:

A. a fasting blood glucose level of 74

B. a random blood glucose level of 130
C. hemoglobin A1C test equal to seven
D. a two-hour oral glucose tolerance test of 180

Correct answer: C

Rationale: A hemoglobin A1C test equal to or greater than 6.5% is indicative of diabetes.
The normal range for a fasting blood sugar is between 70 and 99. Random blood sugars
less than 140 are within normal limits. A two-hour oral glucose tolerance test over 200
indicates diabetes.

639. Measured in seconds, a normal PT range is:

A. 2-4
B. 5 to 10
C. 10 to 13.5
D. 12 to 18.5

Correct answer: C

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 Rationale: The normal PT range is 10 to 13.5. The prothrombin time, PT, is used to
evaluate clotting and bleeding.

640. A client takes warfarin. What is the normal INR range for people who take
anticoagulants?

A. 0.8-1.2
B. 1-3.5
C. 2-4
D. 3-5.5

Correct answer: C

Rationale: The normal INR range for people who take anticoagulants is usually 2 to 4.
People who do not receive anticoagulants have a normal INR range of 0.8 to 1.2.

641. Triglyceride levels should be below:

A. 50
B. 100
C. 150
D. 200

Correct answer: C

Rationale: Triglycerides are fats. Levels should be less than 150.

642. Which is of the following indicates a healthy HDL level?

A. less than 35
B. less than 50
C. greater than 50
D. none of the above

Correct answer: C

Rationale: HDL cholesterol levels should be above 50. HDL-cholesterol levels below 35
are very unhealthy. Very low-density cholesterol levels should be below 35. LDL levels
should be below 130. The proportion of HDL to LDL is important.

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643. What is the normal range for pH in arterial blood?

A. 0.25-1.45
B. 6.45-7.48
C. 7.38-7.42
D. 22 -28

Correct answer: C

Rationale: The normal range for pH in arterial blood is 7.38 to 7.42. Lower levels
indicate acidosis. Higher levels indicate alkalosis.

644. A normal blood urea nitrogen level (BUN) is between:

A. 0.8-1.3
B. 1.5-2
C. 135-145
D. 8-21

Correct answer: D

Rationale: A normal BUN is between 8 and 21 mg/dL. Normal chloride is between 95 to

105. Glucose should be between 65 and 110 mg/dL. Magnesium should be between 1.5
and 2 mEq per liter. Normal potassium levels are between 3.5 and 5. Sodium levels
should be between 135 and 145. Total calcium should be between 2 and 2.6

645. Normal hemoglobin for a woman is between:

A. 8 to 12 g/dL
B. 12 to 15 g/dL
C. 13 to 17 g/dL
D. 14 to 19 g/dL

Correct answer: B

Rationale: Hemoglobin levels for women should be between 12 and 15. Hemoglobin
levels for men should be between 13 and 17. A normal hematocrit for women is
between 36 and 47%. The normal hematocrit for men is between 40 and 52%.

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646. A nurse draws blood from a central line. All of the following steps are correct except:

A. clean the port before obtaining the sample

B. use the first blood collected for the sample
C. flush the central line with 20 mL of sterile saline after collecting the sample
D. label specimens completely

Correct answer: B

Rationale: Discard a small amount of blood before obtaining the blood that will be used
for the sample when drawing blood from a central line.

647. All of the following clients are likely to be at high risk for low albumin levels except
the person who has this diagnosis:

A. malnutrition
B. burns
C. fractured femur
D. stage IV kidney disease

Correct answer: C

Rationale: Clients with kidney disease, severe burns, or are malnourished likely to have
low levels of albumin. Serum albumin is a valuable test for evaluating those conditions.

4.3E THERAPEUTIC PROCEDURES/ENTERAL NUTRITION/OXYGEN THERAPY

648. Each of the following methods may be used to check for proper endotracheal tube
placement except:

A. capnography
B. x-ray
C. aspiration with a bulb syringe
D. auscultating bilateral lung sounds

Correct answer: C

Rationale: Capnography measures the presence of carbon dioxide when a person

exhales. It is an excellent method for checking endotracheal tube placement. A chest x-
ray can visually confirm placement. Hearing lung sounds bilaterally ensures that the

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 tube is placed correctly. The chest should rise and fall symmetrically when an ET tube is
placed correctly.

649. A nurse attempts to suction a client with a tracheostomy. It is a cuffed tracheostomy

device. The nurse encounters resistance when inserting the catheter. She deflates the
cuff and unsuccessfully tries to insert the catheter. What does the nurse do next?

A. call the emergency response team

B. administer epinephrine into the tracheostomy
C. remove the inner cannula
D. remove the outer cannula

Correct answer: C

Rationale: It is likely the client has a mucous plug obstructing the inner cannula. The
nurse removes the inner cannula of the tube. She removes the mucous plug.

650. A client is receiving intermittent nasogastric tube feedings. Before administering the
next feeding, the nurse does all of the following except:

A. aspirate and monitor residual stomach contents

B. observe the client’s abdomen for distention
C. elevate the head of the bed 30°
D. turn the client on the left side

Correct answer: D

Rationale: It is essential the nurse aspirate and measure residual stomach contents
before administering a tube feeding. The abdomen should be assessed for distention.
The head of the bed must be elevated at least 30° to prevent aspiration. The head of the
bed should remain elevated after the feeding concludes.

651. The nurse is providing discharge instructions to the parent of an eight-year-old boy.
The boy's arm has a new cast on it due to a fracture of the radius and ulna. The nurse
instructs the parent to follow all of these instructions except:

A. make sure the cast isn't too tight by slipping one finger between the cast and skin
B. keep the cast out of water
C. use a sling and swath for comfort if the child desires them
D. evaluate circulation by checking for mobility of the child's fingers

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 Correct answer: A

Rationale: The parent should be able to insert two or three fingers between the cast
and the child’s skin. If the parent cannot do that, the cast may be too tight.

652. A client had a cast on his upper arm. It was too tight. The arm sustained severe
damage. This is likely due to:

A. A blood clot
B. compartment syndrome
C. frozen shoulder
D. infection

Correct answer: B

Rationale: Compartment syndrome may occur after a fracture. Untreated compartment

syndrome may result in the loss of a limb. Compartment syndrome arises when swelling
is present, and there is no room for expansion. Circulation is impaired. People with a
tight cast or burns are at risk for developing compartment syndrome.

653. Chest tubes do all of the following except:

A. provide negative pressure

B. drain air or fluid
C. enhance lung expansion
D. reduce the likelihood of infection

Correct answer: D

Rationale: Whenever an invasive procedure or indwelling tube is placed in the body, the
possibility of infection increases. Sometimes chest tubes drain purulent secretions from
the pleural cavity, but that is not their primary purpose.

654. A client is receiving peritoneal dialysis. The nurse must monitor all of the following
laboratory results due to effects from the dialysate used except:

A. protein
B. lipids
C. glucose
D. iron

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 Correct answer: D

Rationale: The dialysate may remove protein from the blood. Glucose and lipid levels
may rise.

655. A client has a chest tube. The nurse notes that the water in the water seal chamber is
fluctuating. What does the nurse do?

A. cover the chest tube insertion site with an airtight dressing and apply pressure
B. clamp the tubing
C. increase the amount of suction
D. documents the findings

Correct answer: D

Rationale: The nurse documents the findings. The wave-like action indicates the chest
tube and drainage system are functioning correctly.

656. All of the following actions are correct when nasally suctioning a person, except:

A. insert the catheter to a depth which measures the length from the client’s earlobe
to the tip of his nose
B. apply suction only when withdrawing the catheter
C. suction while inserting the catheter in the nostrils
D. hyper oxygenate the client before, during, and after the procedure

Correct answer: C

Rationale: Apply suction when the catheter is being withdrawn. The maximum amount
of time that each active suction occurs is limited to 10 or 15 seconds.

657. A client is anxious and claustrophobic. She has a diagnosis of COPD. What is the best
oxygen delivery device to use for this client?

A. nasal cannula
B. non-rebreather mask
C. simple face mask
D. Half face mask

Correct answer: A

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 Rationale: Clients with COPD use low flow oxygen which is efficiently delivered via the
nasal cannula. Masks may increase claustrophobia and anxiety.

658. The client is on a ventilator. He is in a deep coma. The high-pressure alarm keeps going
off. Which of the following is unlikely to be causing the warning?

A. The comatose state

B. kinking of the tube
C. thick secretions
D. water in the line

Correct answer: A

Rationale: The client in a deep coma is unlikely to have resistance or restlessness. It is

more likely that the ventilator is alarming due to excessive, thick secretions or problems
with the tubing.

659. A client’s chest tube is being pulled. The nurse does all of the following except:

A. administer a narcotic 30 minutes before the procedure

B. instruct the client to breathe normally during the process
C. provide emotional support before, during, and after the procedure
D. apply an occlusive dressing to the chest tube site after the tube is removed

Correct answer: B

Rationale: Pain medication is administered before chest tube removal because the
procedure can be painful or uncomfortable. The narcotic may also help the client to
relax. A dressing should be applied after the chest tube is removed. The nurse provides
emotional support and education throughout the process. The nurse instructs the client
to perform the Valsalva maneuver or hold a deep breath in while the tube is being
removed. This is done to prevent an air embolism.

660. A client is having a paracentesis performed because of ascites. The nurse expects the
client will experience all the following after the procedure except:

A. increased comfort
B. further lung expansion
C. decreased girth
D. chest discomfort

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 Correct answer: D

Rationale: Paracentesis is used to relieve ascites. Clients feel less bloated and more
comfortable after the procedure. They can breathe easier. Abdominal girth decreases.
Paracentesis is helpful but is not curative. Some experts believe that it is not beneficial
at the end of life.

661. A client has a tracheostomy. What does the nurse keep readily available?

A. Crash cart
B. Ambu bag
C. spare tracheostomy tube
D. telemetry

Correct answer: C

Rationale: A spare tracheostomy tube, including an obturator, should be kept at the

bedside in case emergency replacement is needed.

662. The client has a fracture. It is being treated with skeletal traction and external fixation.
The nurse is providing pin site care. The nurse observes that the skin around the pin is
swollen, drainage is present, and a pin is loose. The nurse continues to assess the
client. She contacts the physician because the client is demonstrating signs of:

A. compartment syndrome
B. infection
C. pressure ulcer formation
D. poor alignment of the fracture

Correct answer: B

Rationale: The client has signs of infection. The physician must be contacted for further
orders.

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4.3F POTENTIAL COMPLICATIONS FROM SURGERY
663. What is the most common cause of postoperative hypoxemia?

A. infection
B. atelectasis
C. aspiration
D. bronchospasm

Correct answer: B

Rationale: Atelectasis is the most common cause of postoperative hypoxemia.

Atelectasis occurs when alveoli collapse. Alveoli collapse due to obstruction of the
bronchioles from secretions or reduced respiratory effort. General anesthesia and high
concentrations of supplemental oxygen contribute to atelectasis.

664. What is the proper position to place an unconscious client in while they are recovering
from general anesthesia?

A. Semi-Fowler’s
B. Trendelenburg
C. Lateral
D. High Fowler’s

Correct answer: C

Rationale: Client should be positioned laterally. They should lie on their sides in case
they vomit. This is known as the recovery position.

665. The most common cardiovascular problems which arise in the PACU are all of the
following except:

A. hypertension
B. hypotension
C. pulmonary emboli
D. dysrhythmias

Correct answer: C

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 Rationale: The most common cardiovascular problems encountered in the PACU are
hypertension, hypotension, and dysrhythmias.

666. Which of the following clients is most likely to develop postoperative cognitive
dysfunction?

A. a two-week-old baby
B. a three-year-old
C. a 45-year-old
D. an 87-year-old

Correct answer: D

Rationale: Postoperative cognitive dysfunction almost always occurs in older adults. The
client's age, a presence of infection, comorbidities, surgical complications, and duration
exposed to anesthesia contribute to the development of postoperative cognitive
dysfunction.

667. A nurse is caring for a client who had abdominal surgery three days ago. The nurse
notes a substantial increase in the amount of drainage while changing the dressing.
The wound edges that were approximated yesterday are separated. What is
occurring?

A. dehiscence
B. the normal progression of wound healing
C. infection
D. evisceration

Correct answer: A

Rationale: Wound dehiscence occurs when previously approximated or healed surgical

wounds reopen. The nurse needs to cover the incision and notify the surgeon.

668. A client had prostate surgery. He has continuous bladder irrigation running. The
urinary drainage bag contains bright red fluid and small clots. The nurse determines
the clots are not obstructing the drainage. What does the nurse do?

A. increase the rate of the continuous bladder irrigation

B. stop the bladder irrigation
C. notify the surgeon

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 D. disconnect and flush the tubing

Correct answer: A

Rationale: The nurse increases the rate of the continuous bladder irrigation. There is no
reason to stop the irrigation or notify the surgeon. The nurse will irrigate the system if
an obstruction occurs due to a clot. The nurse should inform the surgeon when
obstructions don’t clear with irrigation.

669. A client received bupivacaine, Marcaine, during surgery. The nurse monitors the client
postoperatively for:

A. a metallic taste in the mouth, tinnitus, and seizures

B. a headache
C. inability to move the lower extremities after three hours
D. numbness around the mouth, nausea, and vomiting

Correct answer: A

Rationale: Bupivacaine and Marcaine are used for regional nerve blocks. Side effects
include seizures, a metallic taste in the mouth, ringing in the ears, and numbness around
the mouth.

670. Describe evisceration:

A. it occurs when the edges of the surgical wound are no longer intact
B. swelling of the surgical site
C. abdominal organs protrude through a surgical wound that is no longer intact
D. prolonged vomiting

Correct answer: C

Rationale: Wound dehiscence occurs when a surgical incision reopens, and the
abdominal organs protrude through it. The nurse obtains immediate assistance and
covers the wound with a sterile dressing which is saturated with normal saline. The
surgeon is notified. The client is monitored continuously and placed supine. Position a
pillow under the client’s hips and knees to relieve pressure on the abdomen and
enhance comfort. Do not reinsert the organs back into the abdominal cavity.

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671. Signs of postoperative infection include all of the following except:

A. fever
B. elevated white blood count
C. decreased hemoglobin and hematocrit
D. pain

Correct answer: C

Rationale: Postoperative signs of infection include fever, elevated white blood count,
increased pain, increased drainage, the presence of pus along the incision, redness in
the area of the incision, puffiness of the wound, and a foul odor.

You worked very hard. Take a break if you need one.

When you're ready, we are going to begin the final unit of review questions. The only task left
after we complete this unit is to do the 200 mixed questions. So let’s get started on the last
review unit.

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4.4 PHYSIOLOGICAL ADAPTATION
We will begin by reviewing hemodynamics and fluid balance. Most of our time will be spent
discussing specific body systems. We will talk about managing illness and unexpected responses
to treatment. The final topic will be medical emergencies.

4.4A HEMODYNAMICS
672. All of the following are signs of decreased cardiac output except:

A. polyuria
B. dyspnea
C. hypotension
D. decreased central venous pressure

Correct answer: A

Rationale: Decreased cardiac output is characterized by low or no urinary output. Other

signs of decreased cardiac output include low blood pressure, changes in pulse rate,
decreased peripheral pulses, dyspnea, fatigue, palpitations, and dysrhythmias. S3 and S4
heart sounds may be present. Central venous and pulmonary artery pressures decrease.

673. Normal sinus rhythm:

A. originates from the sinoatrial node of the heart

B. has a rate of 60 to 100 bpm
C. has a PR interval from 0.12 to 0.2 seconds
D. all of the above are correct

Correct answer: D

Rationale: Normal sinus rhythm has a rate of 60 to 100 bpm. It originates from the
sinoatrial node of the heart. There is a regular rhythm of the atria and ventricles. P
waves are seen on an EKG strip before each QRS complex. The PR interval is from 0.12
to 0.2 seconds. QRS complexes last from 0.06 to 0.12 seconds.

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674. Pain, cocaine, and hyperthyroidism are most likely to precipitate:

A. sinus bradycardia
B. sinus tachycardia
C. 3rd° heart block
D. first-degree atrioventricular heart block

Correct answer: B

Rationale: Hypertension, fever, stress, and pain may precipitate the onset of sinus
tachycardia. Cardiovascular disease, electrolyte imbalances, cocaine, nicotine, caffeine,
and alcohol can cause sinus tachycardia. Sinus tachycardia looks like sinus rhythm on an
EKG strip except that it has a rate of over 100 per minute. Clients may be asymptomatic.
Oxygen should be administered if they are symptomatic due to increased demands on
the heart.

675. All of the following are used to treat atrial fibrillation except:

A. epinephrine
B. cardioversion
C. calcium channel blockers
D. digoxin

Correct answer: A

Rationale: Atrial fibrillation is treated with beta blockers, calcium channel blockers, and
oxygen. Digoxin and verapamil are also employed. Cardioversion may be needed. Anti-
thrombolytic medications may be administered due to the risk of clot formation.

676. A client has an agonal rhythm. How is it treated?

A. administer CPR
B. initiate ACLS protocols
C. administer lidocaine
D. A and B are correct

Correct answer: D

Rationale: The presence of an agonal rhythm is a grave sign. Most clients do not recover
when agonal rhythm occurs. CPR and ACLS protocols are initiated.

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677. A rhythm strip shows downward and upward deflections of wide QRS complexes. The
QT interval is prolonged. The rate is between 150 and 250 bpm. The PR interval is not
measurable. What is the rhythm?

A. 3rd degree heart block

B. ventricular fibrillation
C. ventricular tachycardia
D. Torsades de Pointes

Correct answer: D

Rationale: A rhythm strip with long QT intervals and upward and downward deflections
of the QRS complexes is characteristic of Torsades de Pointes. QRS complexes are wide.
The QT interval is prolonged. The rate is between 150 and 250 bpm. The PR interval is
not measurable. The rhythm may be regular or irregular. Torsades de Pointes may occur
as a result of hypokalemia, tricyclic antidepressant overdose, or hypomagnesemia. The
rhythm may correct itself. However, it can lead to ventricular fibrillation. Signs and
symptoms include shortness of breath, nausea, chest pain, and loss of consciousness.
Treatment includes BLS and ACLS protocols. Magnesium sulfate and cardioversion may
be implemented. The underlying cause must be treated.

4.4B ALTERED FLUID BALANCE

678. Signs of hypernatremia include:

A. thirst and agitation

B. muscle weakness and nausea
C. fatigue
D. B and C are correct

Correct answer: A

Rationale: Hypernatremia is characterized by dry mucous membranes, thirst, agitation,

edema, confusion, seizures, and coma.

679. Hyperkalemia occurs most often among individuals who have the following diagnoses:

A. renal disease
B. congestive heart failure
C. C. difficile infection

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 D. ketoacidosis

Correct answer: A

Rationale: The clients most at risk for developing hyperkalemia have renal disease. Mild
hyperkalemia is treated with restricting the intake of foods that contain potassium.
Severe hyperkalemia can be life-threatening. It is treated with medications that reduce
potassium levels. Dialysis may be necessary.

680. Low levels of calcium are associated with:

A. vitamin D deficiency
B. hyperparathyroidism
C. corticosteroids
D. all of the above

Correct answer: D

Rationale: Hypocalcemia results from kidney disease, vitamin D deficiency, calcium

deficiency in the diet, reduce levels of magnesium, and medications. Medications which
may lower levels of calcium include anticonvulsants, some biphosphonates, and
corticosteroids.

681. All of the following clients have a risk of developing hypomagnesemia except the
person who has a diagnosis of:

A. Addison's disease
B. burns
C. congestive heart failure
D. Crohn's disease

Correct answer: A

Rationale: Clients who lose fluids due to medication or illnesses are at risk of losing
magnesium. People who have burns, chronic diarrhea, prolonged vomiting risk fluid and
magnesium depletion. Clients who take diuretics, cyclosporines, proton pump inhibitors,
and aminoglycosides are also at risk.

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682. Signs of hypervolemia include:

A. distended jugular veins and peripheral edema

B. vomiting and dehydration
C. hemorrhage and headache
D. severe back pain and dehydration

Correct answer: A

Rationale: Hypervolemia occurs as a result of too much fluid in the blood. Hypervolemia
is also known as fluid overload or fluid volume excess. Signs of hypervolemia include
high blood pressure, shortness of breath, rales, crackles, ascites, distended neck veins,
peripheral edema, and tachycardia.

4.4D INTEGUMENTARY SYSTEM

683. The client has many wheals. What is the likely reason for their occurrence?

A. allergic reaction
B. scabies
C. shingles
D. acne

Correct answer: A

Rationale: Wheals are characteristic of urticaria due to exposure to an allergen.

684. The most serious form of skin cancer is:

A. melanoma
B. squamous cell
C. basal cell
D. keratosis

Correct answer: A

Rationale: The most serious type of skin cancer is melanoma. Its precise cause is not
known. Genetics and sun exposure are contributing factors. Lesions are most commonly
found on the lower legs and backs of women and the head, neck, and trunk of men.

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685. The client presents to the emergency room. His left lower leg is hot, tender, and
swollen. The client has a fever of 101°F. He has chills and fatigue. What is a likely
cause of the client’s distress?

A. folliculitis
B. candidiasis
C. cellulitis
D. carbuncles

Correct answer: C

Rationale: Cellulitis is characterized by hot, painful, edematous tissues. Fever is likely to

be present. Cellulitis is an infection of subcutaneous tissues. Streptococci and staph
aureus are usually causative agents. The client needs to have warm, moist compresses
applied to the extremity. The extremity needs to be elevated. Antibiotics need to be
administered.

686. The head nurse is creating assignments. A client has a herpes zoster infection. Which
of the following staff members should not care for the client?

A. The nurse who never had measles

B. a pregnant nurse in her first trimester
C. a male nurse
D. a nurse who is preparing to retire

Correct answer: B

Rationale: Herpes zoster infections, shingles, are highly contagious. People who have
never had chickenpox or been vaccinated against chickenpox or shingles should not care
for clients who have shingles. Pregnant women cannot care for clients who have herpes
zoster infections.

687. A pediatric client has scabies. Which of the following instructions are given?

A. observe for signs and symptoms of an anaphylactic reaction

B. a bulls-eye like rash may develop
C. wash the child's hair with the medicated shampoo and carefully comb out the nits
D. apply permethrin lotion. Repeat the application in one week

Correct answer: D

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 Rationale: Scabies is treated with 5% permethrin lotion. It needs to be reapplied after
one week. Lesions are very itchy, particularly at night. Burrows may be present. Scabies
are not usually found on the face. The entire household must be treated. Linens must be
washed carefully.

4.4E RESPIRATORY SYSTEM

688. A client has a large pneumothorax. Which of the following interventions is crucial?

A. the client is placed on a ventilator

B. a chest tube is inserted
C. high flow oxygen is administered
D. antibiotics are administered

Correct answer: B

Rationale: A client with a large pneumothorax needs a chest tube inserted.

Pneumothorax occurs when air gets into the pleural space.

689. What is the highest priority emergency treatment for tension pneumothorax?

A. chest tube insertion

B. artificial airway placement
C. needle decompression
D. administer oxygen by Ambu bag

Correct answer: C

Rationale: Immediate needle decompression is essential to relieve tension

pneumothorax. Chest tubes and supportive therapies are provided after the
decompression.

690. A client sustained injuries to his chest in a motor vehicle accident. He is having
respiratory distress with paradoxical movements of the chest wall. A chest x-ray
reveals multiple fractured ribs. What is this condition?

A. flail chest
B. cardiac tamponade
C. hemothorax
D. open pneumothorax

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 Correct answer: A

Rationale: Paradoxical movements of the chest coupled with multiple fractured ribs are
classic signs of flail chest. The client may have other issues such as hemothorax, but the
description is consistent with a flail chest.

691. The classic triad of symptoms characteristic of a pulmonary embolism includes all of
the following except:

A. chest pain
B. shortness of breath
C. hemoptysis
D. fever

Correct answer: D

Rationale: The classic triad of symptoms which characterize pulmonary embolism

include chest pain, dyspnea, and hemoptysis. The triad only appears in about 20% of
clients who develop a pulmonary embolism. Other symptoms include fever, cough, a
sudden change in mental status, pleuritic chest pain, and a change in heart sounds.

692. The most common cause of cor pulmonale is:

A. COPD
B. acute MI
C. pneumonia
D. pulmonary embolism

Correct answer: A

Rationale: Most cases of cor pulmonale are due to COPD. Pulmonary hypertension
creates extra pressure on the right ventricle of the heart and the right ventricle
enlarges.

693. A client had a lung transplant one week ago. She is showing signs of rejection. What
kind of medication is needed?

A. aminoglycoside
B. beta blocker
C. calcium channel blocker

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 D. corticosteroid

Correct answer: D

Rationale: Acute rejection following lung transplant is common. The client needs three
days of intravenous corticosteroid therapy.

694. Smokers and clients who work in dusty, environmentally poor environments are likely
to develop lung tissues which are characterized by:

A. fibrosis
B. pulmonary hypertension
C. pulmonary edema
D. the collapse of the alveoli

Correct answer: A

Rationale: Environmental toxins and cigarette smoke create chronic inflammation in the
lung tissues. Scarring and fibrosis develop.

695. A client comes to the emergency department in respiratory distress due to asthma.
Upon arrival, the nurse hears widespread wheezing when he auscultates the client’s
lungs. Medications are administered. The client remains in distress, but the wheezing
stops. His chest is silent when the nurse auscultates it. This indicates that:

A. airways are opening up

B. medications are taking the desired effects
C. mechanical ventilation may be needed
D. the client is more relaxed

Correct answer: C

Rationale: The absence of wheezing in the presence of a silent chest and dyspnea can
indicate a medical emergency. The client may need mechanical ventilation.

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696. A nurse is providing instructions to a client who has a new prescription for a dry
powder inhaler. The nurse instructs the client to do all of the following except:

A. take a deep breath in when using your inhaler

B. hold your breath for 20 seconds after you inhale
C. do not shake the container
D. seal your lips tightly around the mouthpiece

Correct answer: B

Rationale: Clients need to hold their breath for 10 seconds or longer if they can when
using an inhaler.

697. This may develop among clients who have advanced COPD as the body tries to
compensate for chronic hypoxemia:

A. polycythemia
B. pernicious anemia
C. thalassemia
D. macrocytic anemia

Correct answer: A

Rationale: Polycythemia may develop as the body attempts to compensate for low
oxygen levels in the blood. Hemoglobin concentrations may be high. However, chronic
anemia may develop simultaneously.

4.4F CARDIOVASCULAR SYSTEM

698. All of the following are modifiable risks related to hypertension except:

A. smoking
B. sedentary lifestyle
C. age
D. high sodium diet

Correct answer: C

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 Rationale: Smoking, sedentary lifestyle, advanced age, and a high sodium diet can
increase the likelihood of hypertension. Modifiable risks can be changed. The client's
age cannot be changed.

699. A client is hospitalized with a hypertensive crisis. Which of the following medications
is indicated?

A. sodium nitroprusside
B. warfarin
C. atropine
D. epinephrine

Correct answer: A

Rationale: Sodium nitroprusside, also known as Nipride, is a direct vasodilator. It is

administered intravenously. The solution must be protected from light. It may cause
hypotension, muscle twitching, nausea, and vomiting.

700. What is the leading cause of death among women?

A. lung cancer
B. breast cancer
C. coronary artery disease
D. COPD

Correct answer: C

Rationale: The leading cause of death among women in the United States regardless of
age, race, or cultural background is coronary artery disease. More women than men die
of sudden cardiac death before reaching the hospital.

701. All of the following supplements are used to enhance cardiovascular health except:

A. echinacea
B. red yeast rice
C. garlic
D. omega-3 fatty acids

Correct answer: A

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 Rationale: Many herbs and supplements improve cardiovascular health. Red yeast rice,
garlic, omega-3 fatty acids, ginkgo, plant sterols, niacin, and flaxseed are among the
beneficial supplements. Echinacea is primarily used to support immune health.

702. A client takes statin drugs. What needs to be monitored?

A. CBC
B. renal function tests
C. liver function tests
D. PT/PTT

Correct answer: C

Rationale: Statins work in the liver. Liver damage and myopathy may occur. Clients must
be monitored for the presence of muscular weakness or aches. Coenzyme Q 10 is a
valuable supplement to take when statins are administered.

703. A client takes cholestyramine, Questran. The nurse provides the client with all the
following information except:

A. the medication reduces levels of LDL-cholesterol in the body

B. it is safe and effective for long-term use
C. do not take it at the same time that you take Coumadin, warfarin
D. you may experience flushing and irritation of your skin

Correct answer: D

Rationale: Cholestyramine is used to lower cholesterol levels. It can cause

gastrointestinal disturbances. The medication comes in a powder form. It does not taste
good.

704. Which of the following clients is most likely to experience silent ischemia?

A. A 43-year-old man with elevated lipid levels

B. 72-year-old female smoker
C. A 50-year-old male with diabetes
D. A 60-year-old female with early onset dementia

Correct answer: C

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 Rationale: People with diabetes are most likely to experience silent ischemia due to
neuropathy.

705. This type of angina is characterized by increasing frequency or severity. It occurs at

rest. What type of angina is it?

A. chronic stable
B. Prinzmetal’s
C. microvascular
D. unstable

Correct answer: D

Rationale: Unstable angina is characterized by increasing frequency or severity. It may

occur with minimal exertion or at rest.

706. 90% of myocardial infarctions occur as a result of:

A. hypercholesterolemia
B. congestive heart failure
C. uncontrolled diabetes
D. thrombus formation

Correct answer: D

Rationale: The majority of myocardial infarctions occur as a result of thrombus

formation. Perfusion of the myocardium is blocked distal to the thrombus. The lack of
oxygen and nutrients creates necrosis.

707. How long does it take for cardiac cells to die due to ischemia?

A. one minute
B. six minutes
C. twenty minutes
D. one hour

Correct answer: C

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 Rationale: Cell death from ischemia occurs within 20 minutes. The innermost tissue dies
first. It may take up to 12 hours for the full thickness of the myocardium to become
necrotic.

4.4G NERVOUS SYSTEM/MENTAL HEALTH

708. A child is given intravenous phenytoin. All of the following statements are true
regarding administration except:

A. phenytoin is an anticonvulsant
B. phenytoin is incompatible with saline
C. the medication must be slowly given if administered via IV push
D. if the child goes home with a prescription for the medicine, drug levels must be
monitored

Correct answer: B

Rationale: Phenytoin, Dilantin, is not compatible with dextrose. It must be given with
saline or else a precipitate will form.

709. A woman calls the emergency department. She states that her three-year-old
daughter is having a febrile seizure. The seizure has lasted for 10 minutes. What does
the nurse instruct the woman to do?

A. administer acetaminophen and a tepid tub bath

B. bring the child to the hospital
C. call 911
D. position the child on her side

Correct answer: C

Rationale: The woman should call 911 since the febrile seizure has lasted more than five
minutes. The nurse can initiate the call to 911. The woman should not drive the child to
the hospital herself.

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710. A child has a shunt to treat hydrocephalus. The nurse advises the parents that the
main problem(s) encountered with shunts is/are:

A. infection
B. malfunction
C. A and B are correct
D. none of the above

Correct answer: C

Rationale: The most common problems with shunts are infection and malfunction. The
shunt may move, separate, or kink. Infection can be serious. It is most likely to occur
within 1 to 2 months after placement.

711. An 87-year-old woman has been caring for her 93-year-old husband. She brings him to
the hospital and states “I can't take care of him anymore. I am exhausted”. What is
the nursing diagnosis for the woman?

A. ineffective coping
B. caregiver role strain
C. anxiety
D. defensive coping

Correct answer: B

Rationale: Caregivers may become exhausted and ill if they do not have adequate
support. The woman has signs of caregiver role strain.

712. Chronic stress is linked to:

A. cancer
B. accidents
C. suicide
D. all of the above

Correct answer: D

Rationale: Chronic stress is related to quality-of-life issues, fatigue, mental functioning,

emotional health, aging, social interactions, and physical illness.

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713. Stress:

A. decreases activity of the natural killer cells

B. increases activity of the natural killer cells
C. increases production of cytokines
D. activates the immune system

Correct answer: A

Rationale: Stress inhibits immune system functions. It decreases the activity of

protective natural killer cells and reduces the production of cytokines.

714. The client had a stroke. A clot developed in an artery due to a buildup of plaque. What
kind of stroke did the client have?

A. thrombotic-ischemic
B. embolic-ischemic
C. intracerebral-hemorrhagic
D. subarachnoid-hemorrhagic

Correct answer: A

Rationale: Thrombotic strokes occur as a result of a clot building up in an artery due to

plaque. Blood can't get past the blockage. It is the most prevalent kind of stroke.

715. A client presented to the emergency room with a stroke. The use of tPA is being
considered. What needs to occur before the decision can be made?

A. the onset of symptoms needs to be determined

B. an MRI or CT of the brain needs to be performed
C. the client needs to be screened for recent trauma, surgery, or bleeding
D. all of the above

Correct answer: D

Rationale: tPA is only administered when the onset of the stroke was within a few
hours. An MRI or CT of the brain needs to be performed to rule out a hemorrhagic
stroke. Clients who sustained recent trauma or who are at risk for bleeding may not
receive tPA unless the risk is outweighed by the benefit.

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716. Which of the following medications should not be stopped abruptly due to a risk of
seizures?

A. sumatriptan
B. topiramate
C. fiorinal
D. paroxetine

Correct answer: B

Rationale: Topiramate, also known as Toprinal, may cause seizures if it is abruptly

withdrawn. The medication is used to treat migraine headaches.

717. A client has had continuous seizure activity for two hours. He is having tonic-clonic
seizures. The client is hypoxic. He has a fever of 102. He is acidotic and having
dysrhythmias. What type of seizure activity is he having?

A. myoclonic
B. tonic
C. atonic
D. status epilepticus

Correct answer: D

Rationale: The client is experiencing status epilepticus. It is the most severe type of
seizure and can be fatal.

Take a break if you need one

4.4H GASTROINTESTINAL SYSTEM

718. Universal screening for lead exposure is recommended:

A. upon birth
B. between six and 18 months
C. between ages one and two years
D. before admission to kindergarten

Correct answer: C

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 Rationale: The Centers for Disease Control recommends all children be screened for
lead between the ages of one and two years. Children who are between the ages of
three and six should be tested if they have not been previously.

719. A child consumed an unknown quantity of multivitamins. The daycare provider called
the physician's office asking what to do. All of the following are correct statements
regarding the ingestion of the vitamins except:

A. poison control needs to be contacted immediately

B. the most dangerous ingredient in multivitamins is iron
C. symptoms may not arise for several hours
D. the child should immediately be given syrup of ipecac

Correct answer: D

Rationale: The Poison Control Center needs to be contacted before providing

treatment. Iron is the most dangerous ingredient in a multivitamin. Symptoms may be
delayed when iron toxicity occurs

720. An eight-month-old baby has severe abdominal pain. He passes stools which look like
cranberry jelly. What is a possible medical diagnosis?

A. celiac disease
B. imperforate anus
C. appendicitis
D. intussusception

Correct answer: D

Rationale: Acute intussusception is characterized by colicky abdominal pain. Stools look

like cranberry jelly. Children with chronic intussusception may experience lack of
appetite, diarrhea, intermittent pain and vomiting.

721. Which of the following women have a higher than average likelihood of delivering a
baby who has a cleft lip?

A. a woman who takes phenytoin during pregnancy for a seizure disorder

B. a woman smokes during pregnancy
C. a woman who has type I diabetes
D. A and B are correct

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 Correct answer: D

Rationale: Phenytoin and smoking contribute to the occurrence of cleft lip. Other
anticonvulsants and consumption of alcohol during pregnancy may also be factors.

722. The tape test is used to diagnose:

A. hookworms
B. trichinosis
C. pinworms
D. giardia

Correct answer: C

Rationale: The tape test is used to detect pinworms. A loop of double-sided transparent
tape is applied to a tongue depressor. The tongue depressor is gently applied to a child's
anal area upon waking in the morning.

723. Infection with E. coli can lead to:

A. hemorrhagic colitis
B. renal failure
C. abdominal cramping
D. all of the above

Correct answer: D

Rationale: Infection with E. coli can lead to hemorrhagic colitis, abdominal cramping,
renal failure, and hemolytic uremic syndrome.

724. A client has chronic peptic ulcer disease. He had an onset of upper abdominal pain
which developed suddenly. His abdomen is rigid. He has nausea and vomiting. The
client is tachycardic and hypotensive. Which is a likely cause of his distress?

A. dyspepsia
B. perforation
C. gastric outlet obstruction
D. hemorrhage

Correct answer: B

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 Rationale: The client is displaying symptoms of perforation. Perforation has a rapid
onset.

725. Routine colorectal screening begins:

A. at age 40 for men and 50 for women

B. at age 50 for both sexes
C. at age 55 for both sexes
D. at age 25 for people with a family history of colorectal cancer

Correct answer: B

Rationale: Routine colorectal screening should begin at age 50 for both sexes.
Colonoscopy is the gold standard for screening for colorectal cancer. Testing is
necessary because symptoms do not usually appear until the disease is advanced.

726. Which of the following foods is acceptable for a client with a diagnosis of celiac
disease to eat?

A. oatmeal
B. corn chips
C. spaghetti
D. whole-wheat bread

Correct answer: B

Rationale: The client can eat corn. Oats spaghetti and whole-wheat bread contain
gluten. Therefore, they must be avoided. Gluten-free cereals, bread, and pasta are
available.

727. A client has a diagnosis of diverticulitis. He may eat all of the following foods except:

A. almonds
B. whole-grain cereals
C. fried chicken
D. popcorn

Correct answer: C

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 Rationale: People with diverticular disease need to consume high-fiber foods. A low-fat
diet should be eaten. Avoiding seeds and nuts is not necessary. Red meat should be
limited or avoided.

4.4I HEPATIC SYSTEM

728. Hepatitis A spreads due to:

A. unsanitary conditions
B. contaminated food and water
C. infected food handlers
D. all of the above

Correct answer: D

Rationale: Hepatitis A is primarily spread through fecal contamination and oral

ingestion. Unsanitary conditions, contaminated food and water, and infected food
handlers help spread the disease. Sexual contact and IV drug use can also cause the
disease to spread.

729. Hepatitis B is transmitted by all of the following except:

A. IV drug use
B. sexual activity
C. being born to an infected mother
D. contaminated food

Correct answer: D

Rationale: Hepatitis B is primarily spread through sexual activity and IV drug use. Babies
born to infected mothers may contract the disease during birth.

730. Signs of acute hepatitis include all of the following except:

A. left lower quadrant pain

B. pruritus
C. dark-colored urine
D. weight loss

Correct answer: A

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 Rationale: Clients with acute hepatitis experience right upper quadrant pain. Other
signs and symptoms of acute hepatitis include pruritus, dark-colored urine, weight loss,
anorexia, nausea, and vomiting. Stools are light in color. There may be diarrhea or
constipation. Malaise, fever, headache, and joint pain may also be present. The spleen
and liver may be enlarged.

731. The complication from cirrhosis which requires emergent care is:

A. bleeding esophageal varicies

B. ascites
C. thrombocytopenia
D. leukopenia

Correct answer: A

Rationale: Bleeding esophageal varicies requires immediate attention. Esophageal

varices develop due to portal hypertension.

732. A client has acute pancreatitis. Which of the following hematology values is likely to
be present?

A. decreased triglycerides
B. increased amylase
C. reduced lipase
D. reduced glucose

Correct answer: B

Rationale: Clients with acute pancreatitis have elevated levels of amylase, lipase,
glucose, and triglycerides.

4.4J RENAL SYSTEM

733. The nurse is teaching a client how to collect a 24-hour urine specimen. Which of the
following steps is necessary?

A. discard the first voided urine and then start the collection.
B. do not use the first voided specimen in the morning as it contains epithelial cells
C. catheterize immediately after voiding
D. obtain the first voided specimen in the morning

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 Correct answer: A

Rationale: A 24-hour urine begins by discarding a sample. The collection starts after the
first discarded specimen. A 24-hour urine may start at any time. If any urine is
inadvertently discarded, the collection is terminated, discarded and restarted. Some
samples need refrigeration or additives.

734. All of the following increase the likelihood of kidney stone development except:

A. living in the southeastern United States

B. family history
C. consuming large amounts of dairy products
D. eating a low-protein diet

Correct answer: D

Rationale: Clients who live in warm climates such as the southeastern United States
have a greater risk of developing kidney stones than people who live in colder climates
do. Eating diets high in protein, oxalate, and calcium increases the likelihood of kidney
stone formation. Family history and sedentary lifestyles are contributing factors.

735. A client had a kidney stone. He was placed on a low oxalate diet. He needs to avoid all
of the following foods except:

A. spinach
B. rhubarb
C. black tea
D. yogurt

Correct answer: D

Rationale: The client should avoid foods high in oxalates including most dark green
vegetables, tomatoes, chocolate, tea, and nuts.

736. What is the most prevalent life-threatening genetic disease in the world?

A. cystic fibrosis
B. polycystic kidney disease
C. type I diabetes
D. glomerulonephritis

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 Correct answer: B

Rationale: Polycystic kidney disease is the most common life-threatening genetic

disease worldwide. There are two kinds of polycystic kidney disease. One type arises
during childhood and the other during adulthood.

737. A client is incontinent of urine. Incontinence occurs when the client laughs or sneezes.
The incontinence doesn't happen every day. A small amount of urine leaks. What kind
of incontinence does the client have?

A. urge
B. stress
C. overflow
D. reflex

Correct answer: B

Rationale: The client is exhibiting signs of stress incontinence. It is most common among
women. Men may develop it in response to prostate disease or surgery. Pelvic floor
exercises are beneficial.

4.4K MUSCULOSKELETAL SYSTEM

738. The elbow is an example of this kind of joint:

A. hinge
B. gliding
C. saddle
D. pivot

Correct answer: A

Rationale: The elbow is an example of a hinge joint. Muscles flex and extend the joint.
The knees are also hinge joints.

739. As clients age, they may become less aware of their bodies in relation to the
environment. This is known as decreased:

A. self-image
B. proprioception

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 C. mobility
D. range of motion

Correct answer: B

Rationale: As proprioception decreases, clients are at an increased risk for falls and
other injuries.

740. Encouraging clients to wear nonskid shoes, eliminate clutter from the home, and use
adaptive equipment prevents:

A. cardiovascular accidents
B. falls
C. stress
D. muscle strain

Correct answer: B

Rationale: Falls are a significant cause of death and disability particularly among older
adults. Strategies to reduce fall risk include using walkers and canes, wearing rubber-
soled shoes, good lighting, and keeping walkways unobstructed.

741. Conservative treatment for an intact anterior cruciate ligament, ACL, injury includes all
of the following except:

A. NSAIDs
B. ice
C. elevation
D. surgery

Correct answer: D

Rationale: Conservative treatments for ACL injuries include rest, elevation, NSAIDs, and
crutch walking as tolerated. Physical therapy and immobilizers may be employed.

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742. A client fractured a long bone. The bone broke horizontally across the entire
midsection splitting the bone in two. What kind of fracture did the client sustain?

A. greenstick
B. open
C. transverse
D. oblique

Correct answer: C

Rationale: A transverse fractures occur at a 90° angle from the length of the bone. They
are horizontal across long bones.

4.4L ENDOCRINE SYSTEM

743. Aldosterone:

A. influences bone development

B. mobilizes the body's defenses during stress
C. suppresses inflammation
D. regulates the balance of sodium

Correct answer: D

Rationale: Aldosterone is responsible for controlling sodium balance. Thyrocalcitonin

influences bone development. Glucocorticoids mobilize the body's defenses during
stress. They suppress inflammation and support metabolism.

744. A child is diagnosed with diabetes insipidus. What symptoms does the nurse expect to
observe?

A. anorexia and vomiting

B. polyuria and polydipsia
C. dry skin and delayed growth
D. tremor and goiter

Correct answer: B

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 Rationale: Classic signs of diabetes insipidus include polyuria and polydipsia. Diabetes
insipidus develops from a lack of vasopressin or antidiuretic hormone. Children with
diabetes insipidus need to be encouraged to drink as they do not perceive thirst.

745. Signs of Cushing's syndrome include all of the following except:

A. weight loss
B. facial hair growth
C. moon face
D. poor wound healing

Correct answer: A

Rationale: Signs of Cushing's syndrome include weight gain, the increase of facial hair,
moon phase, and poor wound healing. Other signs include red cheeks, bruising, and red
abdominal striae.

746. A client presents with abdominal pain, nausea, and vomiting. He says his mouth feels
dry and he is thirsty. He's restless and having difficulty breathing. His skin is flushed
and dry. He has a weak pulse. The client is tachycardic. His temperature is 38°C. He is
frequently urinating. A rapid urine dipstick test shows the presence of glucose in
ketones in his urine. What is the likely diagnosis?

A. hypoglycemia
B. diabetic ketoacidosis
C. adrenal crisis
D. renal failure

Correct answer: B

Rationale: The client is exhibiting signs of diabetic ketoacidosis. His blood sugar is very
high. The client needs insulin, sodium bicarbonate, fluid replacement with normal
saline, and oxygen therapy.

747. A 35-year-old female presents to the clinic. She is nervous and irritable and complains
of being hot and losing weight. Her eyes are bulging. She has a pulse of 110. What is a
possible diagnosis?

A. Grave’s disease
B. hypothyroidism

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 C. syndrome of inappropriate antidiuretic hormone
D. growth hormone excess

Correct answer: A

Rationale: Grave’s disease results from hyperthyroidism. Graves' disease is treated with
beta blockers and medications which block thyroid hormone production. A
thyroidectomy may be needed. Radioactive iodine may be employed to destroy thyroid
tissue.

748. All of the following interventions are appropriate while providing care for a person
with a diagnosis of hypothyroidism except:

A. placing a fan in the room

B. teaching the client how to prevent constipation
C. encouraging the use of moisturizers on the skin
D. limiting the use of sedative medications

Correct answer: A

Rationale: Clients who have hypothyroidism are usually cold. They need a warm
environment to flourish.

4.4M MALE REPRODUCTIVE SYSTEM

749. What sexually transmitted disease must be reported to the health department?

A. chlamydia
B. gonorrhea
C. syphilis
D. B and C are correct

Correct answer: D

Rationale: Gonorrhea and syphilis are infectious diseases that must be reported to the
health department. Gonorrhea has become increasingly resistant to antibiotics in recent
years.

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750. A client has benign prostatic hypertrophy, BPH. All of the following medications are
likely to be employed except:

A. finasteride, Proscar
B. terazosin, Hytrin
C. tamsulosin, Flomax
D. leuprolide, Lupron

Correct answer: D

Rationale: Leuprolide, Lupron, is used to treat men who have a diagnosis of prostate
cancer.

751. When should males begin performing testicular self-examination?

A. puberty
B. age 25
C. age 40
D. age 50

Correct answer: A

Rationale: Testicular cancer affects young men. Testicular self-exams should begin at
puberty.

4.4N FEMALE REPRODUCTIVE SYSTEM

752. If a woman has a 28-day old menstrual cycle, the follicular phase of the menstrual
cycle usually occurs:

A. midcycle
B. with the onset of menses
C. between days one and thirteen
D. between days fourteen to twenty-eight

Correct answer: C

Rationale: The follicular stage prepares the uterus for implantation of a fertilized egg.

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753. What happens when ovulation occurs?

A. the basal body temperature increases by 0.4-1°F

B. the basal body temperature decreases by 0.4-1°F
C. menstruation starts
D. human gonadotrophin levels rise

Correct answer: A

Rationale: The basal body temperature increases by 0.4-1°F when ovulation occurs.
Monitoring the basal body temperature is helpful for women who want to know when
they are at the time of peak fertility. The information can be used to aid or prevent
conception.

754. A painless round, red, firm lesion on the perineal area may indicate:

A. human papillomavirus
B. syphilis
C. chlamydia
D. gonorrhea

Correct answer: B

Rationale: The first sign of syphilis may be a firm round lesion at the entry site of the
bacteria. It disappears without intervention.

755. A woman is saturating a menstrual pad every hour. What is she experiencing?

A. dysmenorrhea
B. amenorrhea
C. menorrhagia
D. oligomenorrhea

Correct answer: C

Rationale: The woman has excessive menstrual flow. That is known as menorrhagia.

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756. A woman is four months pregnant. She has frequent, persistent nausea and vomiting.
What is this called?

A. hyperemesis gravidarum
B. morning sickness
C. GERD
D. pressure due to the upward expansion of the growing uterus

Correct answer: A

Rationale: Morning sickness should subside by the end of the first trimester. The
woman has hyperemesis gravidarum.

Abruptio placenta is characterized by all of the following except:

A. painless bleeding
B. rigid abdomen
C. clots
D. abdominal pain

Correct answer: A

Rationale: Abruptio placenta is life-threatening to mother and child. Dark red blood
with clots may appear. The abdomen is painful and board-like.

757. A woman was raped last night. She came to the emergency room today. All of the
following actions need to be conducted during her time in the emergency room
except:

A. following the established protocol for collecting forensic evidence

B. vaccinating the woman against hepatitis B
C. obtaining baseline screening for sexually transmitted infections and HIV
D. collecting urine to evaluate creatinine levels

Correct answer: D

Rationale: Clients who are raped must sign a consent form. The victim's safety needs
are addressed. Care for current injuries, and preventive measures against future disease
or trauma are provided. Referrals are made for future physical and emotional care.

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758. A woman was raped six weeks ago. All of the following tests are done now except
screening for:

A. HIV
B. syphilis
C. hepatitis B
D. tuberculosis

Correct answer: D

Rationale: HIV, syphilis, and hepatitis B testing is performed six weeks after the rape
occurs. HIV testing and other indicated screenings are repeated at three and six months
post-rape.

You've been working very hard! Take a break if you need one.

4.4O IMMUNE SYSTEM

759. HIV infected newborns who have an early onset of the disease usually die within the
first year or two because of:

A. opportunistic infections
B. vascular complications
C. renal failure
D. hemorrhage

Correct answer: A

Rationale: Most HIV-infected newborns do not have an early onset of disease. Those
that have an early onset, within 48 hours of birth, usually die within two years. The most
common opportunistic infections that kill these babies are Candida and Pneumocystis
carinii.

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760. Children with AIDS are at risk all of the following conditions except:

A. failure to thrive
B. developmental delay
C. hepatosplenomegaly
D. constipation

Correct answer: D

Rationale: Children who have AIDS may have chronic or recurrent diarrhea.

761. All of the following are considered to be autoimmune diseases except:

A. COPD
B. psoriasis
C. systemic lupus erythematosus
D. rheumatoid arthritis

Correct answer: A

Rationale: Many illnesses are autoimmune disorders. They include diverse conditions
including type I diabetes, rheumatoid arthritis, psoriasis, and systemic lupus
erythematosus.

762. Characteristics of chronic fatigue syndrome include all of the following except:

A. new, persistent, unexplainable fatigue

B. a sore throat
C. nausea and vomiting
D. decreased short-term memory

Correct answer: C

Rationale: Signs and symptoms of chronic fatigue include tiredness, impaired short-term
memory, reduced concentration, sore throat, headaches, lymph node tenderness, joint
and muscle pain.

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763. Signs and symptoms of mononucleosis include all of the following except:

A. a sore throat
B. swollen lymph nodes
C. diarrhea
D. fever

Correct answer: C

Rationale: Signs and symptoms of mononucleosis include a sore throat, tender,

enlarged lymph nodes, and fever. The infection usually resolves on its own. However,
rupture of the spleen is a complication. Other complications include pneumonia,
encephalitis, airway obstruction, and myocarditis.

764. Signs and symptoms of rheumatoid arthritis include all of the following except:

A. unilateral changes in the joints of the hands and feet

B. fatigue
C. joint stiffness upon awakening
D. red, warm joints

Correct answer: A

Rationale: Clients with rheumatoid arthritis usually have bilateral joint changes in the
bones of the hands and feet.

765. The procedure which separates and removes components of blood to treat
autoimmune diseases is called:

A. gene therapy
B. apheresis
C. autologous donation
D. monoclonal antibody therapy

Correct answer: B

Rationale: Apheresis separates and removes components of blood to treat autoimmune

diseases and other health conditions. Specific components removed depend upon the
individual and the disease being treated.

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4.4P HEMATOLOGICAL SYSTEM AND ONCOLOGY
766. Chest syndrome is a medical emergency which occurs to people with a diagnosis of:

A. acute lymphocytic leukemia

B. lung cancer
C. sickle-cell disease
D. thalassemia

Correct answer: C

Rationale: Chest syndrome affects people who have sickle-cell disease. Severe pain in
the chest, abdomen or back occurs. Fever, congestion, and cough develop. Severe
dyspnea and accompanying tachypnea occur.

767. Aplastic anemia results from:

A. bone marrow suppression

B. blood loss
C. a lack of intrinsic factor
D. nutritional deficiencies

Correct answer: A

Rationale: Aplastic anemia develops from bone marrow suppression. It may result from
infections such as hepatitis; radiation; or medications, including chemotherapeutic
agents. Exposure to toxins, such as benzene, may suppress the bone marrow. People
with leukemia or lymphoma are at risk for aplastic anemia. In some cases, the cause of
bone marrow suppression is not known.

768. What site is used to perform a bone marrow aspiration in young children?

A. posterior iliac crest

B. femur
C. sternum
D. B and C are correct

Correct answer: A

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 Rationale: The posterior and anterior iliac crests are used. The tibia may be used to
perform a bone marrow aspiration biopsy on an infant.

769. Myelosuppression causes all of the following except:

A. infection
B. bleeding
C. nausea
D. anemia

Correct answer: C

Rationale: Infection, bleeding, and anemia often develops secondary to

myelosuppression. Cancers, such as leukemia, and chemotherapeutic agents cause
myelosuppression.

770. Disseminated intravascular coagulation, DIC, requires treatment of:

A. the underlying cause of bleeding

B. diarrhea
C. a dissecting aneurysm
D. cerebral edema

Correct answer: A

Rationale: DIC is a medical emergency that results in uncontrolled hemorrhage. The

underlying cause of the problem should be addressed. Transfusions, fluids, and other
emergency measures are implemented to stabilize the client.

771. What kind of cancer kills more men and women in the United States each year than
any other kind?

A. colon
B. lung
C. lymphoma
D. esophageal

Correct answer: B

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 Rationale: More adults in the United States die due to lung cancer than any other type
of cancer. Since smoking has become more popular among women, rates of lung cancer
in women have also increased.

772. The first sign of bladder cancer is usually:

A. pelvic pain
B. back pain
C. urinary retention
D. hematuria

Correct answer: D

Rationale: Gross hematuria is almost always the first sign of bladder cancer. It may be
constant or intermittent.

4.4Q ILLNESS MANAGEMENT

773. Phototherapy is most commonly prescribed for:

A. clients with extensive burns

B. the treatment of psoriasis
C. treatment of depression
D. neonatal hyperbilirubinemia and jaundice

Correct answer: D

Rationale: Phototherapy is primarily used to treat neonatal hyperbilirubinemia and

jaundice. Skin color, bilirubin levels, and stool color should be monitored when
phototherapy is employed.

774. A client is in sickle-cell crisis. What medication is administered?

A. doxorubicin
B. Cytoxan
C. hydroxyurea
D. heparin

Correct answer: C

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 Rationale: Doxorubicin and Cytoxan are chemotherapeutic agents. Heparin is a
thrombolytic medication. Hydroxyurea prevents red blood cells from sickling. The client
will also need medicine to treat pain and other symptoms.

775. A client receives immune globulin as an injection. What type of immunity does the
client have as a result?

A. natural active
B. artificial active
C. artificial passive
D. passive natural

Correct answer: C

Rationale: Artificial immunity arises after immunization. Immune globulin is an

antibody. It creates a passive immunity since the body did not create its own antibodies.

776. Radiation therapy can cause which of the following:

A. fibrosis
B. immunosuppression
C. gastrointestinal distress
D. all of the above

Correct answer: D

Rationale: Radiation therapy can cause many side effects. It causes fibrosis, immune
suppression, gastrointestinal distress, hair loss, skin damage, oral changes, anorexia,
bone marrow suppression, cataracts, and pneumonia.

777. Clients with smallpox need this kind of isolation precautions implemented;

A. airborne
B. contact
C. droplet
D. A and B are correct

Correct answer: D

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 Rationale: Airborne and contact precautions are required for people who are infected
with smallpox. Concern has arisen over the potential use of the smallpox virus as a
weapon for bioterrorism.

778. A client is in hypovolemic shock. All of the following are correct actions except:

A. administer lactated ringer's IV

B. infuse packed red blood cells
C. place the client supine
D. position the client in Trendelenburg

Correct answer: C

Rationale: It is preferable to put the client in Trendelenburg position to maintain the

circulation of the vital organs. Lactated Ringer's and blood products are indicated for
clients in hypovolemic shock.

4.4R UNEXPECTED RESPONSE TO TREATMENT

779. When premature babies are given too much oxygen this can occur:

A. pneumonia
B. blindness
C. tetany
D. cerebral edema

Correct answer: B

Rationale: Premature newborns may become blind if they receive too much oxygen.
Basing oxygen administration on needs and weight helps prevent blindness.

780. Indwelling urinary catheters are removed as soon as possible due to:

A. cost
B. client discomfort
C. potential infections
D. hematuria

Correct answer: C

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 Rationale: Indwelling urinary catheters increase the risk of bladder infections. Their use
is minimized to prevent infection.

781. A client has a swollen red arm where an IV catheter is inserted. What is the first thing
that the nurse does?

A. contacts the physician

B. removes the IV catheter
C. applies warm moist heat to the arm
D. applies ice to the arm

Correct answer: B

Rationale: The IV catheter should be removed. The client likely has an infection at the
site.

782. A nurse is going to administer medication via the intravenous route. The client has an
IV solution running. The nurse does not know whether the drug is compatible with the
IV solution. What does the nurse do?

A. ask the charge nurse

B. call the physician
C. slowly administer the medication
D. use a compatibility chart

Correct answer: D

Rationale: A compatibility chart provides quick information that the nurse can use to
determine whether the drug and the solution are compatible.

783. The risk of extravasation is highest for the client who is receiving:

A. Taxotere
B. packed red blood cells
C. total parenteral nutrition
D. 50% dextrose

Correct answer: A

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 Rationale: The risk of extravasation is highest when chemotherapeutic drugs are
administered.

784. A client is receiving total parenteral nutrition. His skin is cool and clammy. He says he
feels dizzy and weak. He is sweating. The client says that his vision is blurry. What is
likely causing his symptoms?

A. embolus
B. infection
C. fluid overload
D. hypoglycemia

Correct answer: D

Rationale: Clients who receive total parenteral nutrition are at risk for hyper and
hypoglycemia. The client is showing signs of hypoglycemia. The blood sugar level should
be checked. If it is low, carbohydrates should be administered immediately. Unchecked
hypoglycemia may result in loss of consciousness and seizure activity.

4.4S MEDICAL EMERGENCIES

785. Heart failure is most likely to arise in the:

A. left atrium
B. right atrium
C. left ventricle
D. right ventricle

Correct answer: C

Rationale: Left ventricular failure is most common. Right-sided heart failure often
occurs as a result of left-sided heart failure.

786. A client has no urinary output. His blood pressure is 40/30 and pulse is 130. The
respiratory rate is 40. His oxygen saturation level is 64. He is unresponsive. The central
venous pressure is elevated. Peripheral pulses are not palpable. The pulse pressure is
becoming narrower. The jugular vein is distended. What procedure may be needed?

A. pericardiocentesis
B. cardioversion

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 C. defibrillation
D. cricoid thoracotomy

Correct answer: A

Rationale: The client is showing signs of cardiac tamponade. Pericardiocentesis may be

required to relieve the accumulation of fluid from the pericardial sac. The heart cannot
function due to the collection of fluid.

787. All of the following medications are used to treat a client who is in a hypertensive
crisis except:

A. atropine
B. nitroprusside
C. ace inhibitors
D. beta blockers

Correct answer: A

Rationale: Nitroprusside is given in combination with an ACE inhibitor or beta-blocker to

treat life-threatening hypertensive crisis.

788. Blood cannot return normally to the heart due to increased pressure when the
following condition is present:

A. hypovolemic shock
B. cardiogenic shock
C. superior vena cava syndrome
D. cor pulmonale

Correct answer: C

Rationale: Compression of the vena cava prevents circulating blood from returning to
the heart when superior vena cava syndrome occurs. Clients should be placed on a
ventilator and provided with oxygen. Seizures, respiratory and cardiac arrest may
develop.

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789. A client is hospitalized with an infection of C. difficile. What type of shock is most
likely to develop?

A. septic
B. cardiogenic
C. neurogenic
D. obstructive

Correct answer: A

Rationale: The client is at risk for infection to spread throughout the entire body.
Untreated septic shock can lead to multiorgan failure. It can be fatal.

790. Neurogenic shock is most often due to:

A. cardiovascular accident
B. status epilepticus
C. brain tumor
D. spinal cord injury

Correct answer: D

Rationale: Spinal cord injuries due to trauma or spinal anesthesia may cause neurogenic
shock.

791. A woman had an in vitro fertilization procedure done. She has come to the emergency
department complaining of severe abdominal pain and shortness of breath. The
woman states that she is thirsty and not producing much urine. She has diarrhea.
What is the likely cause of her symptoms?

A. something other than the in vitro procedure

B. gestational diabetes
C. ovarian hyperstimulation syndrome
D. pelvic inflammatory disease

Correct answer: C

Rationale: The woman is at risk for developing ovarian hyperstimulation syndrome after
in- vitro fertilization. Ovarian hyperstimulation syndrome can lead to pericardial
effusion, coagulopathy, ascites, and death if it is untreated.

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792. Untreated mastoiditis can lead to:

A. meningitis
B. deafness
C. death
D. all of the above

Correct answer: D

Rationale: Mastoiditis can lead to meningitis, deafness, and death. Tissues may become
necrotic, and abscesses may form.

793. The tympanic membrane may rupture due to all of the following except:

A. infection
B. a loud blast
C. a cochlear implant
D. inserting a cotton swab into the ear

Correct answer: C

Rationale: A cochlear implant is a device used to treat deafness.

794. Airbags in vehicles may cause all of the following except:

A. seatbelt sign
B. blindness
C. burns
D. retinal detachment

Correct answer: A

Rationale: Seatbelt sign consists of bruising along the lines where a seatbelt crosses the
body. It is caused when the seatbelt tightens upon impact during a motor vehicle
accident.

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795. A client complains of a sudden onset of straight lines looking curvy. He says he has a
lot of floaters and it seems like there are flashing lights going off in his right eye. What
is a likely cause of the visual changes?

A. corneal abrasion
B. cataract
C. acute wide-angle glaucoma
D. retinal detachment

Correct answer: D

Rationale: The client has signs of retinal detachment. It is a medical emergency. Surgery
needs to be performed, or else blindness will result if it is a complete detachment.

796. The nurse is working as a volunteer at a baseball game in the community. The umpire
is hit in the face by a baseball. His tooth is knocked out. What does the nurse do?

A. place the tooth in milk

B. put the tooth in orange juice
C. cover the tooth with black tea
D. cover the tooth with vodka

Correct answer: A

Rationale: A tooth should be placed in normal saline or milk when it is knocked out.

797. A client has extensive, deep, full-thickness burns surrounding the entire trunk. He is
dyspneic. What procedure may be needed?

A. wound debridement
B. escharotomy
C. endotracheal tube placement
D. chest tube insertion

Correct answer: B

Rationale: The client needs an escharotomy to relieve pressure so that his lungs can
fully expand. He may require a fasciotomy which is an incision through the eschar and
the fascia.

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798. Acute respiratory distress syndrome is usually due to:

A. trauma
B. near drowning
C. sepsis
D. opioid overdoses

Correct answer: C

Rationale: Most cases of acute respiratory distress syndrome are due to sepsis. Clients
with multiple risk factors are at a much higher risk of developing acute respiratory
distress syndrome. Other common causes include aspiration, pneumonia, and trauma.

799. A client is receiving an intravenous infusion of nitroglycerin. The following statements

are true regarding the treatment except:

A. the medication lowers the client's blood pressure

B. blood pressure and heart rate are monitored continuously as reflex bradycardia may
occur
C. the infusion container is made of glass
D. the drug is indicated to treat cardiogenic shock

Correct answer: B

Rationale: the blood pressure and pulse are continuously monitored as reflex
tachycardia may occur during intravenous infusions of nitroglycerine.

Congratulations you have finished with the topic review sections of your preparation course!
Get some rest before completing the final part.

Set aside a few hours for the next session. I recommend that you take it all at one time so that
you will be well prepared when you take and pass your NCLEX-RN exam.

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PART FIVE MIXED REVIEW

This section consists of 201 random questions. The questions are in the same format we have
been using. You will be asked a question and given four multiple-choice answers to select from.
The rationale will then be provided.

A child is brought to the emergency department with a fractured humerus. He is

accompanied by an adult family friend. The child received emergency assistance and
the fracture is stable. The child’s parents are on vacation in another state. How is a
surgical consent to optimally obtained if the parents are not physically present?

A. The family friend gives written consent

B. The friend gives verbal consent
C. Two healthcare providers call the family and simultaneously listen while verbal
consent is provided over the telephone
D. The hospital’s legal team contacts family court to arrange for an order of temporary
guardianship

Correct answer: C

Rationale: Two health care providers listening by telephone simultaneously may obtain
telephone consent. They must document they heard the parents give permission over
the phone.

800. A client has a chest tube. He has subcutaneous emphysema. This may be indicative of:

A. Infection
B. chronic bronchitis
C. An incomplete seal at the chest tube insertion site.
D. Pneumonia

Correct answer: C

Rationale: Subcutaneous emphysema indicates an incomplete seal at the chest tube

insertion site. It is assessed by palpating the tissues around the site.

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801. Shared governance provides staff nurses with opportunities to have all of the
following except:

A. authority
B. responsibility
C. accountability
D. unity of command

Correct answer: D

Rationale: Shared governance offers staff nurses authority, responsibility, and

accountability for their practices.

802. The Uniform Determination of Death Act describes death as the irreversible cessation
of:

A. the cerebrum and cerebellum but not the brain stem

B. circulation, respiration, and higher brain function
C. circulation, respiration, and function of the entire brain
D. circulation, respiration, and cerebral function

Correct answer: C

Rationale: The Uniform Determination of Death Act describes death as the irreversible
cessation of circulation, respiration, and function of the entire brain including the brain
stem.

803. A client has esophageal cancer. He is difficulty swallowing and is losing weight. Who
should he be referred to?

A. dietitian and speech therapist

B. the speech therapist
C. dietitian
D. the oral surgeon

Correct answer: A

Rationale: A dietitian can offer a plan for high nutrient foods. The speech therapist can
conduct a swallow evaluation. Together, they can create a program which addresses
dysphagia and weight loss.

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804. Bioethics addresses concerns that result from:

A. The progress of science, medicine, and technology

B. Limited resource availability
C. Epidemics of influenza
D. The distribution of care among uninsured or underinsured individuals

Correct answer: A

Rationale: Bioethics addresses concerns that result from the progress of science,
medicine, and technology. Examples include cloning and genetic engineering.

805. A client enquires about his roommate. They were discussing each other’s health issues
earlier in the day. The roommate has been out of the room for a diagnostic test which
is taking longer than expected. The nurse states that:

A. he cannot disclose information about the roommate

B. the test often takes longer than expected
C. the client developed a complication for the procedure and was taken to surgery
D. The client needs further testing and will be back in one hour

Correct answer: A

Rationale: Healthcare workers are prohibited from disclosing information about clients
unless permission has been granted by the client.

806. Laws which advocate for client rights, regulate healthcare, ensure professional
accountability and regulate health care financing are:

A. Good Samaritan laws

B. public health laws
C. part of the Health Insurance Portability and Accountability Act (HIPAA)
D. responsibilities of the Joint Commission

Correct answer: B

Rationale: Public health laws protect the public. They encompass healthcare regulation
and financing. Public health laws pertain to professional practice and accountability.
They advocate for the health and wellness of the population.

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807. How often should a testicular self-examination be performed?

A. weekly
B. monthly
C. every three months
D. annually

Correct answer: B

Rationale: Testicular self-examination is conducted monthly and should begin at

puberty.

808. A client is being discharged from a rehabilitation center after repair of a fractured hip.
Who is qualified to go to the client’s home to evaluate it for safety and recommend
modifications such as handrails and ramps?

A. nurse practitioner
B. occupational therapist
C. prosthetist
D. orthopedic surgeon

Correct answer: B

Rationale: Occupational therapists may provide home evaluations for safety and make
recommendations for home modifications.

809. The speech therapist is providing services for your client who has failed a bedside
swallow evaluation. The therapist asks you whether the client’s fractured knee is
improving. The speech therapist:

A. is entitled to information about the client’s knee as she is caring for the client
B. is requesting information which is beyond her “right to know.”
C. may need to know about the knee so that she can provide speech therapy services
D. is seeking required information so that she can provide comprehensive services.

Correct answer: B

Rationale: Caregivers only have the right to know information necessary to carry out
their duties.

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810. A client is showing signs of malignant hyperthermia. What medication needs to be
administered?

A. acetylcholine
B. Anectine
C. dantrolene
D. diazepam

Correct answer: D

Rationale: Dantrolene, also known as Dantrium, is the treatment for malignant

hyperthermia. It slows down the metabolic rate, relaxes muscles, and prevents the
catabolic changes that occur in the presence of malignant hyperthermia.

811. All of the following may help prevent a confused and forgetful client from dislodging
an intravenous catheter except:

A. applying a Posey vest restraint

B. keeping the intravenous tubing out of sight
C. using a sitter
D. frequent monitoring

Correct answer: A

Rationale: A vest restraint does not restrict hand movement. Therefore it would not
effectively prevent a client from removing an intravenous catheter.

812. Corticosteroid medications produce all of the following effects except:

A. hypotension
B. increased susceptibility to infection
C. mood and behavioral changes
D. protein depletion

Correct answer: A

Rationale: Corticosteroid medications elevate blood pressure.

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813. Trousseau’s and Chvostek’s signs indicate:

A. Hypoglycemia
B. Hypercalcemia
C. Hyperglycemia
D. Hypocalcemia

Correct answer: D

Rationale: Trousseau’s sign is demonstrated by flexion of the hand and wrist when a
blood pressure cuff is inflated higher than a client’s systolic pressure. Chvostek’s sign is
indicated by facial twitching when the area of the cheekbone and ear intersection is
tapped.

814. A client has a blood sugar of 30. He is awake and oriented but tired. All of the
following treatments are indicated except:

A. administer IV insulin
B. administer 50 mL of 50% dextrose solution
C. administer glucagon
D. provide a quick acting oral carbohydrate

Correct answer: A

Rationale: The client’s blood sugar is dangerously low. Glucagon, 50% dextrose solution,
and oral carbohydrates will increase his blood sugar level. Insulin is contraindicated as it
will cause the level to drop.

815. Who may safely use an automated external defibrillator?

A. Staff who have expertise in advanced cardiac life support

B. Members of the general public
C. Emergency room physicians
D. All of the above

Correct answer: D

Rationale: Automated external defibrillators are designed to be used by the general

public. Health care workers may use them, however they do not replace standard
defibrillators when available.

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816. What type of insulin may be administered intravenously as a continuous drip?

A. none
B. regular
C. NPH
D. Lantus

Correct answer: B

Rationale: Regular insulin may be administered intravenously. Long-acting insulins are

not given intravenously as they may cause hypoglycemia which persists for an extended
period.

817. The Joint Commission on the Accreditation of Health Care Organizations and other
regulating authorities require that healthcare staff members receive training about
emergency response plans and practice emergency drills at least:

A. monthly
B. four times per year
C. twice yearly
D. annually

Correct answer: C

Rationale: The Joint Commission on the Accreditation of Health Care Organizations and
other regulating authorities require that healthcare staff members receive training
about emergency response plans and practice emergency drills at least twice yearly.
However, many healthcare organizations practice emergency drills more frequently.

818. A nurse has to draw blood so that the client's blood alcohol level can be evaluated.
The nurse carries out the following steps when completing the procedure except:

A. ask the client to make a fist if drawing from the arm

B. wipe the site with an alcohol gauze pad.
C. insert the needle with the bevel facing up
D. place the specimen in a bag that indicates it's a biohazard

Correct answer: B

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 Rationale: Do not wipe the site with an alcohol gauze pad before drawing blood that will
be used to measure a blood alcohol level.

819. All of the following help to prevent circulatory problems postoperatively except:

A. using compression stockings

B. administering anticoagulant medications
C. administering antibiotics
D. ensuring proper fluid intake

Correct answer: C

Rationale: Prevent postoperative circulatory issues by encouraging clients to perform

leg exercises, wear compression stockings, ambulate, avoid crossing the legs, and
consume plenty of fluids.

820. Common side effects of muscle relaxants include all of the following except:

A. fatigue
B. blurred vision
C. a headache
D. hyperactivity

Correct answer: D

Rationale: Muscle relaxants help to relieve pain due to spasms. Side effects include
fatigue, blurred vision, gastrointestinal distress, and headaches. Large doses may create
respiratory depression, low blood pressure, or tachycardia. There is the potential for
abuse among some clients.

821. The nurse prepares to give a client medication. What does the nurse first say to the
client?

A. Have you ever taken this medication before?

B. Hello Mrs. Smith, I have brought your medication.
C. Would you please tell me your name and date of birth?
D. Do you have any medication allergies?

Correct answer: C

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 Rationale: It is essential first to establish the identity of the client. All of the other
questions are irrelevant if you don't have the right client. Ask the client to tell you his or
her name because sometimes clients answer to other people's names.

822. Another name for participative management is:

A. autocratic
B. relational
C. democratic
D. transformational

Correct answer: C

Rationale: The democratic style of management is also known as the participative

management style.

823. A client has a continuous morphine infusion running at 2 mg per hour. He can receive
a bolus dose of 0.5 mg every 15 minutes. He is receiving patient-controlled analgesia.
He repeatedly pushes the button to receive a bolus dose. What does the nurse do?

A. takes the button away from him

B. explains to him that there is a lockout period for the bolus
C. evaluates him to see if the basal rate needs to be increased
D. B and C are correct

Correct answer: D

Rationale: The client may have the knowledge deficit regarding the PCA. The nurse
needs to provide appropriate education. If the client continues to push the button to
receive a bolus, the nurse should evaluate his pain level and notify the physician as the
basal rate may be too low.

824. The most common hospital-acquired infections that affect geriatric clients are caused
by:

A. Methicillin-resistant Staphylococcus aureus. MRSA

B. Clostridium difficile, C-diff
C. indwelling Foley catheters
D. vancomycin-resistant enterococci, VRE

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 Correct answer: C

Rationale: Elderly clients are more prone to contracting hospital-acquired infections

than younger adults are. The most common type of hospital-acquired infection among
older adults are urinary tract infections which are related to indwelling urinary
catheters.

825. A woman comes to the emergency department. The woman says that she is a couple
of months pregnant, but isn’t sure how far along she is. She is experiencing right-sided
abdominal pain and sudden sharp right-sided shoulder pain. Her pulse is 100. Her
blood pressure is 88/60. She complains of nausea and thirst. What do these signs most
likely indicate?

A. labor
B. miscarriage
C. ectopic pregnancy
D. urinary tract infection

Correct answer: C

Rationale: The woman is pregnant. She may be developing shock which is resulting in
thirst and changes in her vital signs. The right-sided abdominal pain is likely caused by
rupture of the fallopian tube. The right-sided shoulder pain is referred pain due to
stretching or rupture of the tube. This situation is a medical emergency. The woman
needs immediate surgery.

826. Which is a true statement about do not resuscitate orders?

A. Do not resuscitate orders mean that resuscitative medications but not chest
compressions may be administered
B. Do not resuscitate orders can only be revoked by a judge
C. The client’s guardian, health care surrogate, health care proxy, or next of kin can
revoke a do not resuscitate order at any time.
D. A physician may disregard a do not resuscitate order if they thinks resuscitation is
possible

Correct answer: C

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 Rationale: The client’s guardian, health care surrogate, health care proxy, or next of kin
can revoke a do not resuscitate order at any time.

827. The client overdosed on a barbiturate. What should be administered?

A. naloxone
B. activated charcoal
C. flumazenil
D. beta blockers

Correct answer: B

Rationale: There is no antidote for barbiturates. Administering activated charcoal will

help to absorb the barbiturate from the gastrointestinal tract. This action will prevent or
limit absorption of the barbiturate into the body.

828. Which does not present a major risk to clients in a healthcare environment?

A. Equipment related accidents

B. Falls
C. Procedure-related injuries
D. Contracting respiratory infections

Correct answer: D

Rationale: The four main risks to clients in health care settings are falls and injuries
related to themselves, equipment, and procedures.

829. C-reactive protein levels measure:

A. nonspecific inflammation
B. cardiovascular risks
C. bacteria levels
D. male hormones

Correct answer: A

Rationale: The C-reactive protein level increases when inflammation is present. It is not
a specific test used to diagnose specific diseases. Additional testing is required to
determine the source of inflammation.

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830. The nurse practitioner ordered a new medication. The order reads buspirone 5mg now
x one dose. What does the nurse do?

A. administers 5 mg of buspirone
B. questions the order because the dose is not what is usually administered
C. asks the client whether or not he is ever received the medication before
D. contacts the nurse practitioner as the order is incomplete

Correct answer: D

Rationale: The nurse must contact the nurse practitioner because the order is
incomplete. The route of administration is missing from the order.

831. Alice has a diagnosis of bipolar depression. She has stage III kidney disease. A home
health care management nurse provides care for an ulcer that developed on Alice’s
foot as a result of uncontrolled diabetes. Who takes the lead in Alice's healthcare?

A. primary care provider

B. Alice
C. endocrinologist
D. home health nurse

Correct answer: B

Rationale: The client is responsible for his or her own health and healthcare.

832. A client sustained an acute kidney injury. What is the most common fatal
complication?

A. hemorrhage
B. infection
C. toxemia
D. hypertension

Correct answer: B

Rationale: Death from acute kidney injury is most commonly caused by infection.

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833. A client receives TPN. He is at risk for hemothorax and pneumothorax. The nurse is
alert for the client experiencing:

A. dyspnea
B. chest pain
C. nausea and vomiting
D. A and B are correct

Correct answer: D

Rationale: Signs and symptoms of hemothorax and pneumothorax include chest pain
and dyspnea.

834. Which of the following interventions is appropriate when providing care for a client
who is at risk for harming others?

A. administering amphetamines, and seclusion

B. insisting that the client remain in bed rather than walk around
C. administering haloperidol and setting limits
D. reinforcing positive behaviors and administering oxycodone

Correct answer: C

Rationale: Haloperidol is an effective medication for reducing agitation. It may lower

the client’s risk of harming others. Setting limits is a useful intervention. Amphetamines
may increase agitation. Seclusion is an appropriate intervention. Encouraging clients to
engage in physical activity may help diffuse excess energy and should be encouraged.
The nurse should speak calmly and quietly while maintaining eye contact. Reinforcing
positive behaviors is an excellent strategy for reducing agitation. Oxycodone will not
decrease the client's irritability unless he or she is suffering from pain.

835. Deceased organ donors may provide:

A. Kidneys, pancreas, and corneas

B. Heart, lungs, and skin
C. Intestines, veins, and heart valves
D. All of the above

Correct answer: D

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 Rationale: Deceased donors may provide all of the above. They may also donate tissues,
the liver, skin, bones, and corneas.

836. While caring for a newborn immediately after birth, primary goals include all of the
following except:

A. ensuring the child nurses or drinks

B. prevention of infection
C. maintenance of temperature
D. ensuring airway patency

Correct answer: A

Rationale: The highest priority goals of newborn care immediately after birth include
preventing of infections, supporting body temperature, and ensuring airway patency.

837. Older adults typically need:

A. more calories than younger adults

B. an increased intake of calcium, and vitamins A, and C
C. less protein and more carbohydrates than younger adults
D. increased iron and decreased fat-soluble vitamins

Correct answer: B

Rationale: Older adults often need increased intake of calcium, and vitamins A and C.
Ideally, the nutrients are obtained through the diet, however supplementation is usually
required.

838. The following suffixes indicate time-released medications except:

A. LA
B. Contin
C. SR
D. IR

Correct answer: D

Rationale: LA stands for long-acting. Contin means continuous release .SR stands for
sustained [Link] means instant release. Time released, and enteric-coated oral

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 medications may not be crushed or altered. Spansules are time released beads in
capsules and may not be crushed.

839. Alterations in elimination patterns may occur postoperatively. The nurse does all of
the following to monitor and promote restoration of healthy elimination patterns
except:

A. monitor the abdomen for bladder distention

B. administer stool softeners
C. encourage the intake of fluids
D. administer narcotic pain-relieving medications

Correct answer: D

Rationale: It is vital to support fluid intake postoperatively. Bladder distention and

constipation may result from anesthesia. The nurse needs to monitor for bladder
distention. Stool softeners may enhance comfort and elimination. Narcotics may cause
urinary retention and constipation.

840. Most people who have a new diagnosis of pancreatic cancer live:

A. less than one year

B. 3 to 5 years
C. 5 to 10 years
D. Indefinitely, as the cancer is highly curable

Correct answer: A

Rationale: Most clients diagnosed with pancreatic cancer live between 6 to 12 months
after diagnosis. Less than 5% survive five years.

841. A woman is pregnant. Transvaginal ultrasound may be preferable to abdominal

ultrasound because:

A. it allows for better visualization of pelvic structures

B. better visualization is obtained when the client is obese
C. the need for a full bladder is eliminated
D. all of the above are correct

Correct answer: D

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 Rationale: Transvaginal ultrasound is a painless procedure. Women may feel pressure as
the sensor is moved. Transvaginal ultrasound allows for imaging of the pelvic structures.
It is useful when evaluating obese clients as fat layers may make abdominal imaging
challenging. Women sometimes prefer the transvaginal ultrasound as they do not need
to have a full bladder as they do for an abdominal one.

842. Situations, habits, developmental stages, spiritual beliefs, and physiological states
impact:

A. risk factors
B. grounded theory
C. diversity
D. durability

Correct answer: A

Rationale: Risk factors are impacted by multiple aspects of an individual's life. Mental
and physical health, genetics, socioeconomic background, and beliefs are contributing
factors. Community wellness impacts risk factors.

843. A two-year-old child weighs 22 pounds. A medication is ordered. 30 mg per kilogram

of body weight of the drug is to be administered. How much medicine does the child
receive?

A. 300 mg
B. 600 mg
C. 1200 mg
D. 2400 mg

Correct answer: A

Rationale: Divide the child's weight in pounds by 2.2 to get the weight in kilograms. A
child who weighs 22 pounds weighs 10 kg. 10 kg multiplied by 30 mg per kilogram of
medication equals 300 mg.

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844. What is a correct description of assent?

A. A procedure for obtaining telephone consent when parents cannot provide written
consent for the care of their minor child
B. Older minor children who are clients are provided with information about treatment
and agree with having it performed
C. Informed consent that is obtained with the assistance of an interpreter
D. Consent supplied by responsible adults who are non-verbal or cannot write

Correct answer: B

Rationale: Assent occurs when older minor children who are clients are provided with
information about treatment and agree with having it performed.

845. What substances support a healthy intestinal biome yet aren't microorganisms?

A. probiotics
B. prebiotics
C. antibiotics
D. antioxidants

Correct answer: B

Rationale: Prebiotics activate and promote the growth of needed microorganisms in the
intestines.

846. Which of the following conditions may cause a white blood cell count to be elevated?

A. infection
B. chemotherapy
C. leukemia
D. A and C are correct

Correct answer: D

Rationale: Infection, leukemia, and inflammation may cause a white blood cell count to
rise. Trauma due to an accident or surgery may temporarily increase the white blood
cell count. Chemotherapy reduces the white blood cell count.

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847. The primary risk to a woman who is miscarrying is:

A. emotional distress
B. pain
C. blood loss and shock
D. an inability to carry future pregnancies to term

Correct answer: C

Rationale: The woman is likely to suffer emotional distress and pain. She may or may
not be able to carry future pregnancies to term. The immediate, potentially most
serious problem is the risk of blood loss resulting in shock.

848. The nurse administers a medication which is used to treat atrial fibrillation with a
rapid ventricular response. Which drug does the nurse administer?

A. diltiazem
B. furosemide
C. morphine
D. atropine

Correct answer: A

Rationale: Diltiazem is a calcium channel blocker. It slows conduction of electrical

impulses through the AV and sinus nodes. Diltiazem is used to treat atrial fibrillation,
supraventricular tachycardias, hypertension, and angina.

849. Complications related to immobility include:

A. Orthostatic hypotension
B. Increased risks for thrombus formation
C. Hydrostatic pneumonia
D. All of the above.

Correct answer: D

Rationale: Immobility increases risk for thrombus formation and diminishes function
throughout the entire body. All systems are impacted. Potential complications include
all of the above.

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850. The production of antibodies that neutralize or kill pathogens is known as:

A. The primary defense system

B. The secondary defense system
C. Mitosis
D. The humoral immune response

Correct answer: D

Rationale: The humoral immune response is the production of antibodies that

neutralize or kill pathogens

851. Longer lengths of stay and reduced revenues of health care facilities are the result of:

A. Healthy People 2020 Initiatives

B. Medication errors
C. Mandates that health care facilities provided care for uninsured people
D. Poor staffing

Correct answer: B

Rationale: Medication errors are expensive financially as they result in longer lengths of
stay and legal actions being taken against health care providers and organizations.

852. The nurse provides education to a client who has diabetes. They discuss management
of hypoglycemia. The nurse advises the client to consume protein and 15 g of
carbohydrates when the blood sugar is low. What food contains 15 g of
carbohydrates?

A. One slice of bread

B. One slice of toast with jelly
C. Two strips of bacon
D. 1/2 cup of ice cream

Correct answer: A

Rationale: A slice of bread contains approximately 15 g of carbohydrates.

853. An 85-year-old female has an IV running at 80 mL per hour. The nurse assesses the
client. The client’s blood pressure is 188/94. Her pulse is 96. The woman's respiratory

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 rate is 24. She is afebrile. The nurse hears crackles and rales when she listens to the
client’s lungs. The woman states it is difficult to breathe. Her neck veins are distended.
She has 2+ edema in her lower legs. What is a possible diagnosis?

A. fluid volume deficit

B. fluid volume excess
C. impaired respiratory effort
D. alteration in comfort

Correct answer: B

Rationale: Signs and symptoms of fluid overload include distention of the neck veins,
hypertension, tachycardia, and difficulty breathing. Crackles and rales may be heard in
the lungs. Edema may be present. Geriatric clients and individuals with a history of
cardiovascular disease are at risk for developing fluid volume excess. The nurse needs to
slow or stop the IV and notify the physician immediately. The client has pulmonary
edema.

854. Advance directives generally include client preferences regarding:

A. Treatments that they want to have should they be unable to voice their preferences
B. Care and procedures that they do not want to be provided if they are incapacitated
C. Nutrition, hydration, and pain medications in the event they are incapacitated.
D. All of the above

Correct answer: D

Rationale: Advance directives are individualized. They state client preferences regarding
treatments to be provided or withheld should they become incapacitated. Common
areas addressed include pain management, ventilation, artificial fluids, artificial
nutrition and resuscitative modalities.

855. All of the following changes occur with menopause except:

A. the risk of heart attacks increases

B. weight loss
C. vaginal dryness
D. bladder capacity decreases

Correct answer: B

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 Rationale: Women are at risk for gaining weight after menopause due to reductions in
estrogen levels. Fat is redistributed.

856. Which of the following medications should not be administered to a client who takes
an anticoagulant agent?

A. psyllium
B. Colace
C. lactulose
D. senna

Correct answer: B

Rationale: Colace softens stools. It blocks the absorption of fat-soluble vitamins,

including vitamin K. The risk of bleeding may increase when clients who take
anticoagulant medications use stool softeners or lubricants. Other medicines that are
softeners or lubricants include Peri-Colace, surfak, mineral oil, and oil retention enemas.

857. A client has a new order for cromolyn sodium. How long will it take for the medication
to take effect?

A. 3 to 5 minutes
B. one hour
C. 72 hours
D. 4 to 8 weeks

Correct answer: D

Rationale: Cromolyn sodium may take up to eight weeks to be effective. Clients must
take it continuously for the treatment of asthma. It must not be stopped abruptly, or an
asthma attack could occur.

858. A 40-year-old woman with a history of early-stage breast cancer which was treated by
surgical removal of the tumor. She is not had chemotherapy or radiation. The woman
asked the nurse for recommendations regarding contraception. What are the nurse’s
recommendations?

A. no contraception is necessary due to the history of cancer and the woman's age
B. transdermal contraceptive patches, transvaginal contraceptive rings, and oral
contraceptives are convenient

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 C. options include sterilization, diaphragms, and condoms
D. natural family planning methods may be used with emergency contraceptive pills
if needed

Correct answer: C

Rationale: Having a history of cancer and being 40 years old does not mean a woman
cannot become pregnant. The woman must avoid the use of any hormonally based
contraceptive methods. Therefore, sterilization and the use of a diaphragm or condoms
are healthy options.

859. Iron deficiency anemia, abdominal pain, diarrhea, bloating, and flatulence are signs of:

A. gallstones
B. hepatitis C
C. celiac disease
D. pregnancy

Correct answer: C

Rationale: The symptoms described are signs of celiac disease. A biopsy is needed to
confirm the diagnosis.

860. A client suffers from expressive aphasia after a stroke. What tools are used to aid
communication?

A. A paper tablet and communication board

B. Plate guards and curved forks
C. The Bobath approach
D. Constraint-induced movement therapy (CIMT)

Correct answer: A

Rationale: All of the listed tools are used when rehabilitating individuals with a history
of a cerebrovascular accident. However, only the tablet and communication board
directly aid communication. The other tools aid mobility, independence, and body
awareness.

861. A client has a central line. When the nurse is delegating care to other staff she needs
to ensure that the team understands:

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 A. Blood should not be drawn from the limb that the central line is inserted into.
B. Not to take blood pressures on the limb with the central line it
C. Not to turn the client the client towards the side of the arm which contains the
central line
D. A and B are correct

Correct answer: D

Rationale: Blood draws and pressures are not obtained from the limb which includes
the central line. Clients may be turned on the side of the arm providing the line is not
occluded.

862. A child presents to the emergency department having an asthma attack. He has no
prior history of asthma. What medication is administered first?

A. nebulized albuterol
B. cromolyn sodium
C. guaifenesin
D. codeine

Correct answer: A

Rationale: Albuterol is administered via nebulizer in an emergency situation. Nebulized

medicines get to the lungs quickly and efficiently. Albuterol is a bronchodilator which
works quickly. Cromolyn sodium is not used to treat acute occurrences of asthma.
Guaifenesin and codeine are used to relieve coughs. The immediate need is to dilate the
airways.

863. A client is being discharged. She is concerned about being able to afford nutritious
food for herself and her family since she will be unable to work for six weeks. Who
should be consulted?

A. the facilities chief financial officer

B. protective services
C. the social worker
D. the labor board

Correct answer: C

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 Rationale: Social workers provide a vast array of services for clients. They may act as
liaisons with community agencies to assist clients with financial concerns.

864. What is the first thing a nurse does while providing care to a six-year-old boy who was
raped by his uncle?

A. provide for the boy’s physical and safety needs

B. contact child protective services
C. call the police
D. encourage the parents of the child to obtain mental health counseling for the boy

Correct answer: A

Rationale: The highest priority is to ensure the child is safe and his immediate physical
needs are met. The nurse needs to report the abuse to child protective services and
follow facility protocol for doing so. The police need to be notified, and the child will
need counseling.

865. Diabetic neuropathy is an example of the following type of pain:

A. mononeuropathic
B. deafferentation
C. sympathetically maintained
D. polyneuropathic

Correct answer: D

Rationale: People who experience diabetic neuropathy have pain that is due to
stimulation of many peripheral nerves. This is known as polyneuropathic pain.
Mononuropathic pain is associated with damage to a specific peripheral nerve. Phantom
limb pain is an example of deafferentation pain. Sympathetically maintained pain is
associated with the autonomic nervous system. An example of sympathetically
maintained pain is regional pain syndrome.

866. A competent client was instructed not to walk to the bathroom without assistance
due to her increased fall risk. She declined to use the call system and fell while walking
to the bathroom unattended. What type of variance is this?

A. clinical
B. institutional

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 C. client
D. practitioner

Correct answer: C

Rationale: Variances which occur due to irregularities with clients rather than
practitioners or institutions are called client or patient variances.

867. Parents of a three-month-old infant report that their bottle-fed baby has yellow
stools. The child has a bowel movement twice daily. The stool is soft. The description
of the stools and bowel pattern are indicative of:

A. A normal bowel pattern

B. Constipation
C. Liver disease
D. Hirschsprung's Disease

Correct answer: A

Rationale: Infant stools are usually yellow. Bottle fed babies have one to three bowel
movements daily. Breastfed infants have approximately six stools per day.

868. Which of the following can create a false positive result when testing stools for occult
blood?

A. Menstrual blood
B. Hemorrhoids
C. Warfarin
D. All of the above.

Correct answer: D

Rationale: False-positive results can occur when testing for occult blood. Bleeding
hemorrhoids, contamination with menstrual blood and several medications can cause a
false positive result. Medications which are likely to cause false positives include
NSAIDs, salicylates, iron, high doses of vitamin C, anticoagulants, colchicine, and
corticosteroids.

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869. A client’s urine specific gravity is elevated. Her hemoglobin, hematocrit, BUN, and
creatinine levels are high. The lab values are indicative of:

A. A fluid volume deficit

B. A fluid volume excess
C. Anemia
D. Cholelithiasis

Correct answer: A

Rationale: Specific gravity, hemoglobin, hematocrit, BUN, and creatinine levels increase
when a fluid volume deficit is present. These indicate dehydration.

870. A client is trying to stop smoking. What are some signs and symptoms of withdrawal
from nicotine?

A. Irritability, depression, cravings, inability to concentrate, anger, and increased

appetite
B. emotional mood swings, flashbacks, panic, and intolerance to loud noises
C. dilated pupils, hypertension, irritability, weight loss, and insomnia
D. tachycardia, panic, agitation, reddened eyes, and shortness of breath

Correct answer: A

Rationale: Signs of nicotine withdrawal include irritability, restlessness, anger, anxiety,

depression, cravings, increased appetite, and poor concentration.

871. A client is on long-term therapy of prednisone. What is the client at risk for?

A. hyperglycemia
B. thinning of the skin
C. weight gain
D. all of the above

Correct answer: D

Rationale: Clients are at risk for developing multiple side effects when they are on long-
term steroid therapy. Side effects include but are not limited to hyperglycemia, thinning
of the skin, weight gain, irritability, gastrointestinal changes and mood disorders.
Insomnia is common.

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872. A pregnant woman has frequent vaginal yeast infections. Which food does the nurse
suggest that the client include in her diet?

A. low-fat milk
B. whole grain bread
C. Greek yogurt
D. tomatoes

Correct answer: C

Rationale: Active cultures in yogurt promote healthy vaginal flora. Greek yogurt is an
excellent choice for pregnant women because it contains plenty of protein and calcium.
Whole grains are essential during pregnancy because they provide iron. Whole-grains
relieve constipation and support healthy blood pressure. Low-fat milk contains protein
and calcium. Tomatoes, mainly cooked, are excellent sources of lycopene.

873. A 25-year-old client is waking up from general anesthesia. He is thrashing, agitated,

and confused. What is a likely cause of his condition?

A. dementia
B. depression
C. delirium
D. withdrawal

Correct answer: C

Rationale: The client is likely experiencing emergence delirium. It may be caused by

medications, pain, hypoxia, bladder distention, the presence of an endotracheal tube, or
residual neuromuscular blockade.

874. Most deaths that are due to medical errors are the result of:

A. Infections
B. Medications
C. Multifaceted systemic problems within the healthcare industry
D. Neglect

Correct answer: C

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 Rationale: Most deaths due to medical errors result from systemic problems within the
healthcare industry. Poor staffing levels, fragmented care, and inadequate safety
measures contribute to medical errors.

875. The nurse tells the teenage parents of a newborn to keep plastic bags away from the
baby. The nurse instructs the parents to keep a hand on the baby while providing care.
Why is the nurse doing this?

A. neonates are at risk for injury and death due to falls and suffocation
B. these activities enhance bonding between parent and child
C. plastic bags have germs, and the child may get sick
D. infants thrive when they are touched

Correct answer: A

Rationale: Newborns and infants are at risk for injury and death due to falls, suffocation,
and strangulation.

876. Which client is likely to receive a delayed prosthetic fitting?

A. The 31-year-old veteran who had a below the knee amputation due to trauma
B. A 40-year-old female who underwent an above the knee amputation due to a car
accident
C. A 55-year-old paralyzed woman who had her right arm amputated due to a blood
clot.
D. An 85-year-old male suffering from dementia who has severe diabetes which
necessitated an above the knee amputation due to gangrene

Correct answer: B

Rationale: Clients who have above the knee or below the elbow amputations may need
a delayed prosthetic fitting. The 55 and 85-year-old individuals are not likely to be
candidates for prostheses.

877. Elderly clients are at risk for constipation due to all of the following except:

A. Immobility
B. Low fiber diets
C. Increased levels of hydrochloric acid in the stomach
D. Reduced mucus production within the intestinal tract

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 Correct answer: C

Rationale: Hydrochloric acid levels decrease among elders.

878. A client presents to the urgent care center with poorly localized abdominal pain,
nausea, vomiting, and an inability to pass flatus. The client’s abdomen is tender and
distended. Borborygmi are present. What is a likely diagnosis?

A. intestinal obstruction
B. acute diverticulitis
C. GERD
D. pancreatitis

Correct answer. A

Rationale: The client is displaying symptoms of intestinal obstruction. Vomiting may be

projectile. Pain may be temporarily relieved by vomiting. Bowel sounds may be absent,
loud, or frequent. High-pitched pinging sounds may be auscultated above the
obstruction. Borborygmi refers to loud bowel sounds that are audible without a
stethoscope.

879. Unusual disease patterns, clusters of clients from specific locations, unusual antibiotic
resistance, and atypical symptoms may be signs of:

A. Nosocomial infections
B. Community acquired infections
C. Bioterrorism
D. Antibiotic resistant organisms

Correct answer: C

Rationale: The presence of unusual disease patterns, clusters of clients from specific
locations, unusual antibiotic resistance, and atypical symptoms may indicate
bioterrorism.

880. Which of the following clients is most likely to have an IV port?

A. A client with a fractured femur

B. the client who is undergoing chemotherapy
C. the man who has congestive heart failure

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 D. a woman with preeclampsia

Correct answer: B

Rationale: Ports are surgically implanted for long-term use. They are used for
chemotherapy and other invasive treatments.

881. The posterior fontanelle closes:

A. three days after birth

B. between one and two weeks after birth
C. when the child is between two and three months old
D. between the ages of 15 and 18 months

Correct answer: C

Rationale: The posterior fontanelle closes between the end of the second and third
month.

882. Ethical dilemmas may impact:

A. Clients, their families, and staff members

B. Clients
C. Staff
D. Clients and family members

Correct answer: A

Rationale: Clients, families, staff and many others may be impacted by ethical
dilemmas. Performance of specific procedures, care decisions, and a lack of resources
may create ethical dilemmas for staff members.

883. A woman is pregnant. Her BMI is 23. The nurse provides nutritional education. What
does the nurse say to the woman?

A. Reduce your caloric intake to 1200 calories per day

B. Eat as much as you desire since you are eating for two
C. Increase your caloric intake to 3000 calories per day
D. Increase your caloric intake by 300 calories per day

Correct answer: D

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 Rationale: The woman’s BMI is in a healthy range. Pregnant women must increase their
daily caloric intake by 300 calories per day when their pre-pregnancy weight is within a
healthy range.

884. The Dimensions model of health is used to:

A. evaluate risk factors for children less than two years old
B. promote healthy aging activities
C. assess the health status of a community
D. reduce rates of unhealthy behaviors among teens

Correct answer: C

Rationale: The Dimensions model of health assesses and evaluates the health status of
communities.

885. The client had surgery. The nurse noticed burns on the client that were not there
before the surgical procedure. What is the likely cause of those burns?

A. poor positioning during surgery

B. pressure from having to be positioned without moving for an extended period
C. improper placement of an electrical cautery grounding pad
D. friction and shearing

Correct answer: C

Rationale: If electric cautery grounding pads are not correctly placed, burns may result.

886. A client is receiving TPN. The nurse knows that he is at risk for all of the following
except:

A. hyperglycemia
B. hypoglycemia
C. embolism
D. aspiration pneumonia

Correct answer: D

Rationale: The client is not at risk for aspiration pneumonia related to the TPN because
the nutrients are going into his bloodstream, not gastrointestinal tract. Clients who

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 receive TPN are at risk for high and low blood sugars. Embolism, fluid overload, and
infection. The client is at risk for pneumothorax, and hemothorax during catheter
insertion.

887. Sexual abusers:

A. choose vulnerable children, groom their victims, and often choose activities or
professions which allow them easy access to children.
B. usually, have no pre-existing history which puts them at a higher likelihood of
abusing children than other members of society
C. generally only abuse one victim
D. are always male

Correct answer: A

Rationale: Sexual abusers choose vulnerable victims. They often groom their victims by
offering friendship, toys or other means. Many sexual abusers choose professions and
activities which allow them easy access to children. Most sexual abusers were victims of
abuse themselves. Sexual abusers usually prey on multiple victims. While most sexual
abusers are male, women do abuse children sexually. Male children may be victims as
well as females.

888. Babies born to women who have poorly controlled diabetes are at risk for:

A. hyperglycemia at birth
B. hypoglycemia and respiratory distress
C. hypoglycemia in utero
D. being an excessive size and experiencing hypoglycemia in utero

Correct answer: B

Rationale: Babies are at risk of hyperglycemia in utero when mothers have poorly
controlled diabetes. This results in large babies. Hyperinsulinemia interferes with lung
maturation, putting the child at risk for respiratory distress. The child may develop
hypoglycemia at birth.

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889. A client has a cast on due to a fractured tibia and fibula. The nurse asks the client to
wiggle his toes, which he does freely. The client’s toes are blanchable, warm, and pink.
The client states that he isn’t experiencing numbness or tingling of the extremity or
toes. The nurse concludes that the client has:

A. Adequate circulation to the leg

B. Inadequate blood flow to the limb
C. Nerve damage to the leg
D. Normal muscle tone in the leg

Correct answer: A

Rationale: These are signs that the client’s neurovascular status is adequate: Digits are
blanchable, warm, and of normal skin tone when they are getting sufficient circulation.
Clients should be able to wiggle the digits freely. Numbness and tingling should be
absent.

890. A client is on neutropenic precautions. Which of the following is present?

A. low white blood cell count

B. elevated white blood cell count
C. low creatinine level
D. high creatinine level

Correct answer: A

Rationale: Clients are put on neutropenic precautions because they are at risk for
developing infections. The white blood cell count is low. This is often due to treatments
for cancer such as chemotherapy or a bone marrow transplant. Creatinine levels
indicate the health of the kidneys.

891. A client is taking ferrous sulfate to treat anemia. He does not take any other
medications. What beverage does the nurse offer the client to drink when the ferrous
sulfate is administered?

A. orange juice
B. milk
C. water
D. coffee

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 Correct answer: A

Rationale: Administer iron with vitamin C for maximum absorption and utilization of the
mineral.

892. Which of the following risk factors is not modifiable?

A. Genetic make-up
B. inadequate sleep
C. overeating
D. chewing tobacco

Correct answer: A

Rationale: Modifiable risk factors are correctable. They can be changed with behavioral
choices. Non-modifiable risk factors can’t be changed. Examples of nonmodifiable risk
factors include genetics, age, and sex.

893. The client is smoking in bed while using oxygen. What is the highest priority nursing
diagnosis?

A. Risk for injury

B. Altered breathing pattern
C. Noncompliance
D. Altered thought process

Correct answer: A

Rationale: Client safety is the highest priority. Immediate action must be taken to
ensure safety. Altered breathing, noncompliance, and altered thought processes may or
may not be present. Regardless of their presence or absence, safety comes first.

894. A 20-year-old male is hospitalized with a diagnosis of schizophrenia. He has a flat

affect, low energy level, and no motivation to get well. He has difficulty speaking and
does not seem to enjoy anything. What kind of signs and symptoms is he
experiencing?

A. cognitive
B. paranoid
C. positive

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 D. negative

Correct answer: D

Rationale: These are examples of negative symptoms.

895. The use of an incorrect plan or action to reach a goal, or not performing a therapeutic
action correctly is called a:

A. sentinel event
B. near miss
C. medical error
D. preventable adverse event

Correct answer: C

Rationale: A medical error results when a therapeutic action is not carried out as
planned. An error may also occur when an incorrect action is taken, or a wrong plan is
put in place.

896. This birth control method may result in increased menstrual flow and cramping. Risks
include ectopic pregnancy and pelvic infection. What method of birth control is this?

A. Combination estrogen and progesterone pill

B. Depo-Provera injections
C. Norplant
D. IUD

Correct answer: IUDs initially increase menstrual flow and cramping. Some types
relieve those symptoms over time. The risk of pelvic infection and ectopic pregnancy
increases when IUDs are used. IUDs may become displaced without the woman
knowing it. Pregnancy may result.

897. When an organization or unit is said to have one objective for members or staff to
work towards, that is called having:

A. unity of command
B. unity of direction
C. an organizational culture
D. cultural diversity

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 Correct answer: B

Rationale: Requiring all members of an organization work towards a common goal is

known as the unity of direction.

898. A client sprained his ankle yesterday. He called the nurse support line as he is
experiencing 3/10 constant achy pain in the ankle. What recommendations does the
nurse make to the client?

A. Rest, ice, apply a compression wrap, and elevate the ankle.

B. Apply heat to the ankle and take two ibuprofen
C. Go to urgent care or the emergency department immediately.
D. Rest, apply a hot pack alternating with an ice pack to the ankle, do not use any wrap
or bandage, and elevate the ankle

Correct answer: A

Rationale: Acute sprains are treated by RICE: Rest, Ice, Compress, and Elevation.

899. Which of the following people is most at risk for committing suicide?

A. A 15-year-old transgender person who comes from a home where substance abuse
and violence are ongoing. The client uses methamphetamine and has a diagnosis of
bipolar depression.
B. A 32-year-old female whose husband has a terminal illness. The woman provides
care for her husband, three young children, and elderly mother.
C. A 47-year-old single father who is worried about his son’s decision to go into the
military and his daughter’s choice of a boyfriend.
D. A 12-year-old female who was recently diagnosed with migraines.

Correct answer: A

Rationale: The 15-year-old has many risk factors for committing suicide. They include
age, sexual orientation other than male or female, dysfunctional family, family history of
substance abuse and violence, personal history of drug use, and diagnosis of bipolar
depression. 32 and 47-year-olds are unlikely to commit suicide due to family
commitments. The 12-year-old doesn't have risk factors which indicate that she is at risk
for self-injury.

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900. A client has an IV running. He suddenly complains of severe shortness of breath and
chest pain. The nurse contacts the physician and places a tourniquet above the IV site.
What is a likely cause of the client’s distress?

A. infection
B. embolus
C. congestive heart failure
D. severe bradycardia

Correct answer: B

Rationale: A pulmonary embolus causes severe shortness of breath and chest pain. The
onset is sudden. An embolus may result from the tip of an intravenous catheter
breaking, thrombus, air in a blood vessel, or fat. It is a medical emergency.

901. While ambulating a client, the nurse notes that the rubber tip is missing on the
bottom of a walker. What does the nurse do first if a replacement tip is not readily
available?

A. Contact the charge nurse

B. Notify the physical therapy department
C. Call the department responsible for provision and maintenance of durable medical
equipment
D. Remove the walker from service

Correct answer: D

Rationale: Faulty equipment must be immediately removed from service.

902. Risks commonly associated with blood transfusions include all of the following except:

A. allergic reactions
B. sepsis
C. hemolysis
D. hemorrhage

Correct answer: D

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 Rationale: People who receive blood transfusions are at risk for allergic reactions. They
may be mild or anaphylactic. Sepsis may arise due to contaminated blood. Hemolysis
results when the donor’s and recipient’s blood are not compatible.

903. Using sedative hypnotics to treat older adults who have sleep disorders may often
cause all of the following except:

A. an increased risk for falls

B. confusion
C. daytime drowsiness
D. increased appetite

Correct answer: D

Rationale: The use of sedative-hypnotic medications can cause falls, ataxia, confusion,
and daytime drowsiness, mainly when administered the geriatric population.

904. Parents with children that have extensive medical needs may feel stress due to:

A. their own inability to earn as much income as they did previously

B. concern about the child's physical health
C. worries about being able to take time off from work to take the child to medical
appointments
D. all of the above

Correct answer: D

Rationale: Families with children that have chronic medical needs suffer from a wide
array of stressors.

905. When intracranial pressure increases beyond the point that the skull can maintain this
happens:

A. cardiovascular accident
B. seizure activity
C. brain herniation
D. coma

Correct answer: C

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 Rationale: Seizure activity and a coma may precede brain herniation. The brain can
herniate downward, laterally, or medially.

906. A nurse didn’t notice that an order was written for a one-time dose of Lasix. She failed
to administer the medication. The client had shortness of breath for the rest of the
day. What type of event occurred?

A. An error of omission
B. A sentinel event
C. An ameliorable adverse event
D. A root cause analysis

Correct answer: A

Rationale: The nurse failed to carry out care by not administering the needed
medication. The omission resulted in harm to the client.

907. The triad of Parkinson's disease includes all of the following except:

A. bradykinesia
B. rigidity
C. tremor
D. hallucinations

Correct answer: D

Rationale: The triad of Parkinson's disease comprises bradykinesia, rigidity, and tremor.
Hallucinations and dementia may develop.

908. In utero, the heart begins beating at:

A. two weeks
B. four weeks
C. eight weeks
D. four months

Correct answer: B

Rationale: The heart beats at four weeks of embryonic development.

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909. Using physical and chemical restraints, facing the client at all times, and not allowing a
client to stand between a staff member and the door of her room are strategies for:

A. protecting clients from self-harm

B. safeguarding staff from injury while caring for violent clients
C. examples of unauthorized restraint
D. means of preventing clients from committing suicide

Correct answer: C

Rationale: While caring for violent or potentially violent clients, it is essential that
medical personnel protect themselves from injury. They can do this by utilizing physical
and pharmacological interventions and restraints. It is crucial to face the client at all
times and not allow the client to block an escape route from the room.

910. All of the following are example of bureaucratic leaders’ beliefs except:

A. staff are motivated internally

B. policies and procedures are the primary guidelines for making decisions
C. staff are motivated externally
D. performance of staff is impacted by reward and punishment

Correct answer: A

Rationale: Bureaucratic leaders believe that people are motivated by external rewards
and punishments. They rely heavily on organizational policies and procedures to make
decisions.

911. While getting a client out of bed for the first time after surgery, the client becomes
pale. He says that he feels dizzy. What does the nurse do?

A. Contact the charge nurse

B. Take the client’s vital signs
C. Help the client back into bed
D. B and C are correct

Correct answer: D

Rationale: Promptly assist the client back to bed. Take vital signs. The charge nurse can
be advised later.

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912. Adult day care centers provide all of the following benefits except:

A. residential facilities
B. providing breaks for exhausted family members
C. socialization for clients with dementia
D. safe environments for clients who have behavioral challenges

Correct answer: A

Rationale: Adult day care centers do not provide residential treatment.

913. A client states that she always has difficulty sleeping. She says when she gets home
from the hospital, she would like to try some over-the-counter remedies to promote
sleep. What are some treatments that may help her?

A. melatonin, and calcium

B. chamomile and green tea
C. hot chocolate and vitamin C
D. milk and iron supplements

Correct answer: A

Rationale: Melatonin and calcium calm the nervous system and may enhance sleep.
Green tea and hot chocolate both contain caffeine, which would keep her awake. Iron
supplements are unlikely to affect her rest.

914. The client has a fan in brought in from home while being treated at the rehabilitation
center following hospitalization for COPD. What does the nurse say to the client?

A. I am glad have a fan. It will help you feel more comfortable and you may breathe
better.
B. I just checked your fan. It seems to be in good working order. I will plug it in for you.
C. I need to have the fan inspected by appropriate personnel prior to allowing its use.
D. You may not use the fan as it may blow germs around too much.

Correct answer: C

Rationale: Home equipment must be inspected for safety before it is used. Nurses are
not qualified or authorized to inspect electrical equipment for safety.

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915. A man was sexually abused as a child. He doesn't recall the actual abuse. He indulges
in high-risk behaviors as a result of wounds caused by the abuse. This is an example
of:

A. depression
B. repression
C. displacement
D. a conversion reaction

Correct answer: B

Rationale: Repression occurs when memories are buried. They may still impact
emotions and behaviors.

916. What is the drug of choice for the treatment of anaphylaxis?

A. amiodarone
B. epinephrine
C. diphenhydramine
D. prednisone

Correct answer: B

Rationale: Intravenous epinephrine provides the most rapid, effective treatment for
anaphylaxis. It may be administered by other routes, particularly in community settings.
Diphenhydramine and prednisone help to relieve symptoms of allergic reactions.
Amiodarone is used to treat cardiovascular problems.

917. A five-year-old child is having difficulty concentrating in school. He behaves poorly.

The child is clingy and cries easily. These behaviors have been occurring for two
months. What is the most likely cause of the child's behaviors?

A. a cold
B. stress
C. autism
D. a developmental delay

Correct answer: B

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 Rationale: Stress is a common cause of changes in children's behavior. If the child is
coming down with a cold, similar reactions may occur, but they are likely to be short-
lived. Autism and developmental delays may result in persistent behavioral concerns.

918. The client is receiving chemotherapy at a treatment center located far from his home.
He tells the nurse that he can’t attend his next treatment because he doesn't have
money for transportation or anyone who can give him a ride. The nurse contacts the
American Cancer Society to see if assistance is available. What is the nurse doing?

A. providing spiritual support

B. advocating for the client
C. overstepping her role
D. following chain of command

Correct answer: B

Rationale: The nurse is advocating for the client in an attempt to resolve a client
concern.

919. The nurse is teaching a client how to use an incentive spirometer after surgery. All of
the following instructions are correct except:

A. create a tight seal around the mouthpiece with your lips

B. inhale with a rapid deep breath
C. hold the breath in for two seconds
D. exhale through the mouthpiece

Correct answer: B

Rationale: Clients need to inhale slowly and deeply when using a spirometer.

920. Drugs that are classified as sedative-hypnotics:

A. cause sleep
B. promote relaxation
C. create hypnosis
D. are sedating when administered in low doses and produce sleep when given in
higher doses

Correct answer: D

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 Rationale: Sedative-hypnotics generate relaxation and sedation in small doses. Larger
doses promote sleep.

921. A woman just delivered a baby. The woman has genital herpes. How is the soiled linen
disposed of?

A. it is permanently removed from service

B. it is removed in a way that prevents exposure to skin and mucous membranes,
clothing, and the environment
C. it is removed in the same manner that is used to remove all soiled linen
D. B and C are correct

Correct answer: D

Rationale: All dirty linen is handled in the same manner. Soiled linen is always removed
in a way that prevents exposure to skin, mucous membranes, and clothing. It is removed
and stored so that it does not contaminate the environment.

922. A 42-year-old female is hospitalized after overdosing on drugs and alcohol. Family
therapy is recommended. The woman's partner questions why the rest of the family
needs to go to therapy since the 42-year-old is the person with the problem. What
does the nurse say?

A. family therapy can be helpful because when one member of the family has a
problem, everyone else is affected too
B. it's crucial for you to attend so that the 42-year-old will get well
C. this is what is needed to prepare for an intervention
D. there are problems in the family that caused the woman to overdose.

Correct answer: A

Rationale: The nurse must not be judgmental. When one family member is struggling,
the entire family is impacted.

923. A client is on droplet precautions. All of the following protective measures need to be
followed except:

A. people need to wear a mask when they are within 3 feet of the client
B. transport to other areas of the facility should be minimized
C. personnel need to wear an N-95 mask

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 D. if transportation of the client is required outside of the hospital room, a mask should
be worn by the client

Correct answer: C

Rationale: Standard masks are appropriate when droplet precautions are used.

924. An eight-year-old child has a fever and cough. He is expectorating thick, green mucus.
The child says he is thirsty. The nurse offers him all of the following beverage choices
except:

A. chamomile tea
B. apple juice
C. whole milk
D. ginger ale

Correct answer: C

Rationale: Whole milk may increase the presence of thick mucus. Clear liquids are
preferable.

925. A woman is receiving Pitocin. She is having prolonged contractions. What does the
nurse need to consider first as a possible cause?

A. she is moving into the second phase of labor

B. the medication is effective
C. fetal distress
D. uterine tetany

Correct answer: D

Rationale: Pitocin may cause uterine tetany. A sign of uterine tetany is defined as
contractions that last for more than 60 seconds.

926. A client is receiving tube feedings. She develops diarrhea. Which of the following may
be responsible?

A. administering the formula directly from the refrigerator

B. increasing the total volume of formula infused
C. keeping the client in a seated position during formula administration

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 D. A and B are correct

Correct answer: D

Rationale: Diarrhea may occur when clients receive tube feedings. Administering a cold
formula or increasing the amount of formula are common causes of diarrhea. Clients
may be sensitive to ingredients, such as lactose, which is contained in some formulas.
Diarrhea may result if the tube is not secured well and moves into the small intestine.

927. A client is going to have an EEG the following morning at 8 A.M. What instructions
does the nurse give to the client?

A. wash your hair

B. be prepared to walk on a treadmill during the procedure.
C. do not drink any caffeine-containing beverages or eat chocolate after midnight
D. A and C are correct

Correct answer: D

Rationale: The client must avoid caffeine as it can interfere with the results of the EEG.
The client's hair needs to be washed before and after the procedure.

928. Spending time in nature, prayer, meditation, and using herbs for healing can be
considered:

A. physical exercise
B. spiritual practices
C. religious doctrines
D. high-risk behaviors

Correct answer: B

Rationale: Spiritual practices are often informal. They may be practiced within or
outside of religion.

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929. The nurse just administered 15 units of regular insulin. When is the client at the
highest risk for developing hypoglycemia?

A. within 15 minutes
B. within 30 to 90 minutes
C. within 2 to 3 hours
D. within 4 to 6 hours

Correct answer: C

Rationale: Regular insulin has an onset of 30 to 60 minutes. Its peak action is between 2
to 3 hours after administration. The time of peak action is when hypoglycemia is most
likely to occur. Regular insulin lasts for a duration of 3 to 6 hours. Regular insulin is
short-acting insulin. Examples include Humulin R and Novolin R.

930. The use of negative reinforcements when a client engages in bullying or verbal
outbursts is called:

A. operant conditioning
B. desensitization
C. aversion therapy
D. modeling

Correct answer: C

Rationale: Aversion therapy is used to decrease negative behaviors. It may involve

restrictions on activities or require clients to perform undesirable tasks.

931. A client is bedbound. He needs to be repositioned at least:

A. Every 2 hours
B. Every 3 hours
C. Every 4 hours
D. Every 6 hours

Correct answer: A

Rationale: Clients need to be repositioned at least every two hours when bed bound to
avoid problems related to immobility.

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932. All of the following are true about acute rheumatic fever except:

A. it is a systemic inflammatory disease

B. small bony joints are damaged first
C. it develops after a group A streptococcal infection
D. cardiovascular damage may be permanent

Correct answer: B

Rationale: Acute rheumatic fever damages the valves of the heart.

933. Peak sexual drive in males usually occurs:

A. in the teens and early 20s

B. between ages 20 to 30
C. between ages 18 to 35
D. between ages 30 to 40

Correct answer: A

Rationale: Peak sexual drive in males usually occurs in the teens and early 20s.

934. Radiation exposure risk is affected by all of the following except:

A. Distance from the source

B. Ratio of fat to lean muscle mass in adults
C. Total time of exposure
D. Presence or absence of shielding

Correct answer: B

Rationale: Radiation exposure is impacted by distance from the source of radiation,

total time of exposure and the presence or absence of shields.

935. A restraint was applied by a nurse without a complete order regarding instructions for
use and frequency that it was to be removed. The restraint was left on for six hours
longer than the length of time it was ordered for. What is this situation called?

A. A harmless oversight
B. A chemical restraint
C. False imprisonment

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 D. Practicing beyond the nurse’s scope of practice

Correct answer: C

Rationale: When a restraint is applied without a complete and valid order it is

considered to be false imprisonment.

936. The nurse is preparing to teach a client. The client is a 45-year-old female who is 70
pounds overweight. The client states that she would like to lose 10 pounds before her
high school reunion which will occur in three months. What does the nurse focus on
teaching the client?

A. the importance of weight loss as it relates to cardiovascular health

B. the necessity of losing weight as a means to reduce the likelihood of developing type
II diabetes
C. actionable tips for losing 10 pounds in less than three months
D. strategies for losing 10% of the woman's weight over a six-month period

Correct answer: C

Rationale: It is essential to mold teaching to meet the client's goals. Adult learners need
actionable steps which result in measurable achievements.

937. A client fell at the mental health clinic. She stated that she bumped her elbow but it is
not uninjured. The first action that the nurse takes is to:

A. Reassure the client

B. Document the event in the client’s medical record.
C. Notify the physician.
D. Conduct an assessment

Correct answer D

Rationale: The nurse needs to conduct an assessment. Providing care for the client is
done before taking other steps whenever an incident occurs.

938. A client states that he has throbbing pain in his knee. The pain is localized and non-
radiating. The client rated as a four on the 0 to 10 pain scale. What type of pain the
client most likely experiencing?

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 A. neuropathic
B. psychosomatic
C. somatic
D. acute

Correct answer: C

Rationale: Somatic pain is usually localized. It originates in the muscles, joints, skin, or
connective tissue. There is no indication that the client is experiencing neuropathic pain
which is often described as burning or tingling. There is no evidence the pain is
psychosomatic in origin. No information is given regarding the duration of the pain.

939. Serum calcium levels rise in the presence of:

A. glioblastoma
B. astrocytoma
C. bone metastases
D. hemangioma

Correct answer: C

Rationale: Calcium is released when bone is destroyed. Serum calcium levels rise as a
result. An increase in serum calcium levels occurs with metastatic disease to the bone.

940. A client used LSD and PCP 10 years ago. What is he at risk for currently?

A. alcohol addiction
B. nicotine addiction
C. hallucinogenic drug persisting perception disorder
D. seizures

Correct answer: C

Rationale: The client is at risk for hallucinogenic drug persisting perception disorder. The
disorder can cause visual disturbances and hallucinations years after drug use is
discontinued.

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941. The child who dislikes change and new activities is said to be this type of child:

A. immature
B. easy
C. slow to warm up
D. difficult

Correct answer: C

Rationale: Children who are slow to warm up have difficulty accepting new activities.

942. The intimate zone of personal space measures from an individual's body

A. 0 to 18 inches
B. 6 to 24 inches
C. 1 to 3 feet
D. 2 to 6 feet

Correct answer: A

Rationale: The intimate zone of personal space measures from 0 to 18 inches from a
person's body. Most people feel uncomfortable when another person enters that zone.
There are four zones of personal space.

943. Factors which impact the occurrence of repetitive stress injuries include all of the
following except:

A. posture
B. continuous intense activity
C. working in hot environments
D. stress

Correct answer: C

Rationale: Working in cold environments increases the risk of repetitive stress injuries.

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944. Children at the following stage of development think logically. They understand
relationships between ideas, events, and objects. Friends are significant. What stage is
this?

A. toddler
B. preschool
C. school-age
D. teen

Correct answer: C

Rationale: School-age children can think logically and understand relationships between
things and ideas. Their thoughts are no longer exclusively perception based. Friendships
are very important.

945. Which of the following intravenous solutions is hypertonic?

A. 0.45% sodium chloride

B. lactated Ringer's
C. D5W
D. 0.9% normal saline

Correct answer: A

Rationale: 0.45% sodium chloride is a hypertonic solution. Lactated Ringer's, D5W, and
0.9% normal saline are isotonic solutions. D10W is a hypotonic solution.

946. When Dolophine is used to control pain at end-of-life, nurses need to be aware that:

A. it is highly addictive
B. an oral dose is equal to 1/10 of a parenteral dosage
C. signs of toxicity are cumulative and may not be noticeable for 3 to 5 days
D. a typical starting dose is 100 mg per hour via IV

Correct answer: C

Rationale: Dolophine, also known as methadone, is sometimes used for pain

management at end-of-life. It is a long-acting medication, thus signs of toxicity may be
delayed. The need for comfort and end-of-life supersedes concerns about addiction. An
equagesic oral dose of Dolophine is twice that of an IV dose.

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947. Clients with the following diagnoses are most likely to be at risk for bleeding when
they are being shaved with a hand razor:

A. gastrointestinal bleeding and a fractured femur

B. atrial fibrillation and pulmonary embolism
C. pneumonia and urinary tract infection
D. hepatitis and dementia

Correct answer: B

Rationale: Clients who have diagnoses of atrial fibrillation or pulmonary embolism are
likely to be on anticoagulant medications. Therefore, they are most likely to be at risk
for bleeding while being shaved.

948. A client has a diagnosis of diabetes. The nurse is teaching the client about the
importance of foot care. What does the nurse include in the teaching?

A. the feet should be soaked daily for 20 minutes

B. inspect the feet every day for sores, redness, irritation, cuts, and problems with the
toenails
C. see an orthopedic specialist annually
D. the feet of people with diabetes do not need any special care

Correct answer: B

Rationale: People with a diagnosis of diabetes must be taught to scrutinize their feet
every day.

949. All of the following maternal characteristics are risk factors for a child being born with
congenital heart disease except:

A. alcohol user
B. maternal age greater than 40
C. exposure to measles during pregnancy
D. exposure to chickenpox during pregnancy

Correct answer: D

Rationale: Women who use alcohol during pregnancy or have type I diabetes risk
delivering a baby who has congenital heart disease. Maternal age greater than 40 or

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 exposure to measles during pregnancy increase the likelihood of congenital heart
disease occurring.

950. Which of the following statements is not made when teaching a mother to do cord
care after the birth of her baby?

A. clean the cord area with alcohol

B. give the child a sponge bath rather than a tub bath
C. allow the stump to be exposed to air
D. signs of infection include redness, swelling, or the presence of pus

Correct answer: A

Rationale: It is currently recommended that the cord area is cleaned with plain water,
not alcohol.

951. A variable which increases a person's likelihood of sustaining an injury or contracting a

disease is called a/an:

A. poor health choice

B. negative variable
C. risk factor
D. external variable

Correct answer: B

Rationale: Risk factors increase a person's likelihood of injury or illness. They may be
internal or external.

952. A nurse is administering eye drops to a toddler. The toddler grabs the tip of the open
bottle and pushes the nurse’s hand away. What does the nurse do?

A. contacts the physician

B. notifies the child's parents
C. replaces the bottle with a new container of drops
D. asks the unlicensed assistive personnel member of the team to hold the child while
she administers the drops

Correct answer: C

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 Rationale: The bottle of eye drops must be disposed of. The container is no longer
sterile. The nurse needs to obtain a new container of drops.

953. The main reason that saturated dressings are changed is that:

A. they are uncomfortable

B. they may leak
C. they are unattractive
D. microorganisms can grow on the wet surfaces and cause infection

Correct answer: D

Rationale: The main reason that saturated dressings are changed is to prevent infection.
Microorganisms thrive in warm moist environments. Changing the dressing promotes
comfort, reduces leakage, and looks better, but those are not as important as reducing
the risk of infection.

954. An eight-year-old boy is being evaluated at a community mental health center. The
child is of average height and weight for his age. He enjoys playing with his siblings.
The boy says that he is a good student. He says that he felt sad and cried when his pet
bunny died. What is a possible diagnosis for this child?

A. anxiety disorder related to separation

B. autism spectrum disorder
C. normal behavior
D. impulse control disorder

Correct answer: C

Rationale: Normal behavior in children is demonstrated by acting within social norms,

having age-appropriate reactions to stress, positive self-image, and an ability to interact
and form relationships with others in appropriate manners.

955. Which client should be assigned a room close to the nurses’ station?

A. an 18-year-old male who is on suicide precautions

B. an elderly client who has dementia
C. a 45-year-old female who has severe panic attacks
D. a 60-year-old client who is hospitalized for hepatitis and is a member of Alcoholics
Anonymous

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 Correct answer: A

Rationale: The client who requires suicide precautions has the highest risk of injury.
Therefore he should be housed closest to the nurse’s station in order to facilitate
frequent observation and safety.

956. A 35-year-old male has a pulse rate of 50. His blood pressure is 80/46. The nurse is
preparing to administer one unit of packed red blood cells. Which of the following
terms describes the man’s cardiovascular status?

A. his pulse pressure is high

B. he is tachycardic
C. his cardiac output is low
D. his cardiac output is high

Correct answer: C

Rationale: A low cardiac output is indicated by the slow pulse, low blood pressure, and
fluid volume deficit.

957. The client has asthma. When providing instructions about the disease the nurse
explains to the client that he may have a sensitivity to:

A. acetaminophen
B. aspirin
C. aluminum-containing antacids
D. adrenaline

Correct answer: B

Rationale: Clients with asthma have an increased risk of sensitivity to salicylates and
salicylic acid.

958. While caring for a client who has active tuberculosis, all of the following are needed
except:

A. contact precautions
B. airborne precautions
C. a single occupancy room
D. negative pressure airflow ventilation

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 Correct answer: A

Rationale: Clients who are being treated for active tuberculosis need to be placed in a
private room that has negative pressure airflow ventilation. Airborne precautions must
be in place. HEPA masks are necessary.

959. Piaget's sensorimotor period correlates with Erickson’s stage of:

A. trust versus mistrust

B. initiative versus guilt
C. intimacy versus isolation
D. autonomy versus shame and doubt

Correct answer: A

Rationale: Piaget’s sensorimotor period of cognitive and moral development correlates

with Erikson’s psychosocial stage of trust versus mistrust.

960. A client is being treated for an overdose of heroin. What medication should be
administered?

A. flumazenil
B. naloxone
C. diazepam
D. varenicline

Correct answer: B

Rationale: Naloxone, also known as Narcan, 0.4 to 2 mg should be administered

intravenously or by endotracheal tube.

961. A client has bacterial meningitis. The nurse limits suctioning because it can:

A. Increase intracranial pressure

B. increase cerebral venous drainage
C. decrease blood flow to the brain
D. increase the risk of further infection

Correct answer: A

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 Rationale: It is vital to avoid increasing intracranial pressure when a client has bacterial
meningitis. Suctioning stimulates the cough reflex and the Valsalva maneuver. Both
increase pressure in the brain. Blood flow to the brain temporarily increases. The
cerebral veins experience a decrease in drainage. Suction is limited to prevent the cough
reflex and the Valsalva maneuver.

962. A nurse is educating a client about Teletherapy. The nurse provides the following
information except:

A. radioactive implants will be placed inside your body

B. your skin will be marked with tattoos
C. you may experience hair loss
D. your skin will be irritated, and you may experience fatigue

Correct answer: A

Rationale: Teletherapy uses radiation from an external source. Targets are marked by
tattooing the skin. Hair loss, fatigue, and skin damage are common.

963. A client had a thoracentesis performed one hour ago. He is most at risk for:

A. pneumothorax
B. aspiration pneumonia
C. wound infection
D. gastric reflux

Correct answer: A

Rationale: During the immediate post-procedure phase, the client is most at risk for
pneumothorax. An infection could develop at the site, but it would take longer than one
hour. The client is not at risk for aspiration pneumonia or gastric reflux as a result of the
procedure.

964. Which of the following is considered a normal body temperature when using the
Celsius scale?

A. 37
B. 38.5
C. 98
D. 98.6

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 Correct answer: A

Rationale: 37°C is a normal body temperature.

965. A nurse failed to wear sterile gloves while performing a sterile procedure. What
occurred?

A. Negligence
B. An adverse event
C. An assault
D. Battery

Correct answer: A

Rationale: Negligence occurred because the nurse failed to maintain the standard of
care.

966. The client in the intensive care unit is an adult female. Her urinary output is 10ccs per
hour. She has D5/0.45 NS infusing at 75 milliliters per hour. What does the nurse
conclude?

A. the urinary output is low, and further evaluation or intervention is needed

B. the urinary output is normal, and the current plan of care should be maintained
C. the urinary output is high, and fluids should be reduced or discontinued
D. the urine specific gravity is low

Correct answer: A

Rationale: The urine output is low. Further investigation and interventions are needed.

967. A client is resting quietly with her eyes closed. She states her pain level is a 9/ 10 and
requests that pain medication be given. The nurse concludes that the woman:

A. is drug seeking
B. doesn’t understand the pain scale
C. is experiencing a high level of pain
D. must have a low tolerance to pain

Correct answer: C

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 Rationale: No evidence is provided that indicates the woman is drug seeking or doesn’t
comprehend the pain scale. Whether or not the woman has a low pain tolerance is
irrelevant.

968. The woman perceives that she is experiencing a great deal of pain. Not all clients
outwardly

A. demonstrate high levels of pain.

B. All of the following statements are true regarding cystic fibrosis except:
C. cystic fibrosis is the most common autosomal recessive disorder among Caucasians
in the United States
D. clients with cystic fibrosis are affected by chronic respiratory infections females are
more likely than males to develop cystic fibrosis screening newborns for cystic
fibrosis is mandated in the United States

Correct answer: C

Rationale: Most clients with cystic fibrosis are white males. However, females and
people of other races can have cystic fibrosis.

969. Which of the following clients are most at risk for experiencing sensory or cognitive
distortions:

A. a 6-year-old who has a temperature of 39.9 Celsius and is dehydrated due to acute
gastroenteritis
B. a 40-year-old female with a kidney stone and a pain level of 5/10
C. an 80-year-old client with 20/40 vision and a fractured ankle
D. a woman in labor who is about to deliver twins vaginally

Correct answer: A

Rationale: The six-year-old child is most at risk for developing sensory or cognitive
distortions, including hallucinations. The high fever and dehydration are risk factors for
sensory impairment. Children are particularly vulnerable to dehydration because of
their small size.

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970. Alcohol and drug use, rectal sex, and not using condoms increase rates of:

A. pregnancy
B. sexually transmitted diseases
C. hepatic cancer
D. rectal bleeding

Correct answer: B

Rationale: All of these activities increases rates of sexually transmitted diseases

971. A newborn is crying incessantly, arching her back, refusing to nurse, and grimacing.
What tool should be utilized?

A. Apgar scale
B. CRIES scale
C. Bili light
D. Cardiac monitor

Correct answer: B

Rationale: The baby is showing signs of pain. The CRIES scale is used to assess pain in
newborns. The nurse should also check the baby to ensure that the child’s primary
needs for a dry diaper, proper positioning, warmth, and food are met.

972. The client has a chronic debilitating disease. Preventative efforts are put in place to
prevent further decline. What kind of preventative actions is being used?

A. primary,
B. secondary
C. tertiary
D. none. The activities are not preventative since illness is already occurring

Correct answer: C

Rationale: Preventative measures that are used to prevent further decline when disease
or disability is already present are considered to be tertiary preventative measures.

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973. Reassurance, touch, and simply sitting with a client are techniques which may reduce
a client’s:

A. level of physical comfort

B. level of emotional distress
C. knowledge deficit about a procedure
D. level of spiritual comfort

Correct answer: B

Rationale: Words, touch, and being present with a client may reduce emotional distress.

974. Reduced emotional or spiritual distress leads to enhanced physical comfort and a
greater capacity for learning. Ask clients for permission prior to touching them or
sitting with them as some individuals may feel increased distress when touched or in
the presence of healthcare providers. The nurse conducted a physical assessment
examination. The following information is recorded as part of the general survey
except:

A. behavior
B. nutritional status
C. lung sounds
D. level of consciousness

Correct answer: C

Rationale: A general or initial survey includes basic information about a client’s overall
presentation. Vital signs are sometimes added. Nutritional status, behavior, level of
consciousness, ability to move, speech, and general features are recorded. Lung sounds
are evaluated and documented later in the assessment.

975. Clients who have poorly controlled diabetes risk developing impaired sensory
perceptions related to the following stimuli:

A. gustatory and olfactory

B. visual and kinesthetic
C. tactile and auditory
D. olfactory and kinesthetic

Correct answer: B

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 Rationale: Frequently, clients who have a diagnosis of diabetes have visual impairments
and difficulty perceiving touch and temperature. Client care and teaching must address
safety and sensory impairments.

976. At what age does the anterior fontanelle close?

A. 3 months
B. 4 to 6 months
C. 12 months
D. 12 to 18 months

Correct answer: D

Rationale: The anterior fontanelle closes between the ages of 12 and 18 months.

977. 12 step programs:

A. provide residential treatment

B. are available online, in person, and in healthcare and penal institutions
C. utilize treatments including nicotine patches and medications such as dolophine
D. provide individual counseling for participants

Correct answer: B

Rationale: 12 step programs are available for individuals overcoming a wide array of
addictions. There are available for family members as well. 12 step programs can be
found in the community, jails, healthcare settings, and online.

978. The following skin condition is an autoimmune disease:

A. psoriasis
B. acne vulgaris
C. lipoma
D. tinea pedis

Correct answer: A

Rationale: Psoriasis is an autoimmune disease. There are many forms of psoriasis. Some
types are mild while others are severe. Psoriatic arthritis develops in some people.
Psoriasis usually runs in families. The onset is usually before the age of 40.

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979. A client is receiving hospice services in the home setting. A fentanyl patch is ordered
for pain management. When will pain relief likely start to occur after the first patch is
applied?

A. within one hour of application of the patch

B. within 12 hours to 15 hours after the therapy is started
C. within 20 to 24 hours after the patch is applied
D. 48 hours after application

Correct answer: B

Rationale: Pain relief will begin within 12 to 15 hours after application of the patch.
Peak levels of the drug will not be obtained for 48 hours after application.

980. Neurogenic shock is treated with:

A. phenylephrine, Neo-Synephrine
B. sodium nitroprusside, nipride
C. norepinephrine, levophed
D. hydrocortisone, Solu-cortef

Correct answer: A

Rationale: Phenylephrine is used to treat neurogenic shock. Clients need to be

monitored for bradycardia, restlessness, headache, and renal failure. The medication
should be administered via a central line.

981. A woman is in labor. Her cervix is dilated 9 centimeters. She screams, swears, and yells
“don’t touch me.” She demands that she be given a narcotic. She is most likely
showing these behaviors because:

A. she is an addict
B. she has a low tolerance to pain
C. those behaviors are typical of her cultural group
D. she is in the transition phase of labor.

Correct answer: D

Rationale: All of the behaviors are within a range of normal responses for a woman
during the transition stage of labor.

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982. The client has patient-controlled analgesia. He has a 500-milliliter bag of normal saline
hanging. It contains 1000 mg of hydromorphone. The order reads for the client to
receive 4 mg of hydromorphone every hour via continuous infusion. The client may
receive a bolus dose of 1 mg every 15 minutes as needed. What is the bolus dose?

A. 0.1 mL
B. 0.2 mL
C. 0.25 mL
D. 0.5 mL

Correct answer: D

Rationale: The concentration is 2 mg of hydromorphone per milliliter. The desired bolus

dose is one mg of hydromorphone. That is one half of a milliliter.

983. Clients with low levels of serum phosphate are treated with:

A. restriction of dairy products and egg yolks

B. calcium phosphate
C. phosphate binders
D. D 50

Correct answer: B

Rationale: Clients with low levels of serum phosphate need phosphate replaced.
Calcium phosphate may be administered intravenously or by mouth. High phosphorus
foods, such as milk and eggs, are encouraged. The client requires cardiac monitoring if
the deficiency is severe. Clients at risk for phosphate loss include those who lose fluid,
are malnourished, have leukemia, lymphoma, osteomalacia, or are alcoholic. Genetics,
the use of certain diuretics, aluminum-containing antacids, and theophylline use can
contribute to depleting phosphate from the body. Untreated hypophosphatemia is life-
threatening.

984. What is the primary goal of producing a barbiturate coma when someone has a head
injury?

A. to enhance comfort
B. to reduce the metabolic demands on the brain and preserve function
C. prevent seizures

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 D. prevent restlessness

Correct answer: B

Rationale: The barbiturate coma improves comfort, mitigates metabolic demands on

the brain, and prevent seizures and relieves restlessness. The primary purpose is to
preserve the function of the brain by reducing the metabolic demands upon it.

985. Changes in body temperature may result from all of the following except:

A. disorders of the hypothalamus

B. central nervous system disorders
C. hormone fluctuation
D. none of the above

Correct answer: D

Rationale: Body temperature may change due to injury and various illnesses. The
circadian rhythm and hormonal variations cause changes in body temperature. Exposure
to high or very low temperatures may change the temperature of the body.

986. A client has red cloudy urine. She states she has urinary frequency and burning. Her
temperature is 100 degrees Fahrenheit. She has low back pain. What test(s) should be
done first?

A. Urinalysis, urine culture, and sensitivity

B. Serum creatinine
C. Pelvic ultrasound
D. X-rays of the kidney, urethra and bladder

Correct answer: A

Rationale: The woman has classic symptoms of a urinary tract infection. The simplest,
inexpensive, noninvasive test that can be performed quickly is a urinalysis. The culture
and sensitivity results will take time to obtain but the urinalysis will provide immediate
information. The other tests may not be needed.

987. The third highest cause of death in the United States is due to:

A. Cerebrovascular Accidents

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 B. Diabetes Mellitus
C. Medical errors
D. Cancer

Correct answer: C

Rationale: One out of every ten deaths in the USA is due to medical errors.

988. A six-year-old girl is hospitalized for an extended period following a motor vehicle
crash. She is bedbound much of the time. Which of the following would provide her
the most sensory stimulation?

A. Toys, visits with a therapy dog, and age-appropriate learning opportunities

B. Scheduled naps and cartoons
C. Detailed instruction about her health issues
D. Visits with the social worker and chaplain

Correct answer: A

Rationale: Age-appropriate activities provide the most sensory stimulation.

989. A nonverbal client grimaces occasionally. His body is tense intermittently. He

occasionally moans and fidgets. What nursing diagnosis is made?

A. Altered fluid volume balance

B. Alteration in comfort
C. At risk for skin breakdown
D. Altered gaseous exchange

Correct answer: B

Rationale: The client is experiencing signs of discomfort.

990. Which of the following clients has the highest risk of developing a postoperative
infection?

A. 8-year-old who had an appendectomy

B. 26-year-old with diabetes and had a colostomy performed
C. 32-year-old who had a cesarean section
D. 44-year-old who had an open reduction and internal fixation of the right wrist

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 Correct answer: B

Rationale: Clients who undergo bowel surgery have a higher risk of developing an
infection. Individuals who experience surgery as a result of trauma have a higher risk of
infection. Individuals who are malnourished or have chronic illnesses are at risk. Obese
people and people who have diabetes experience poor wound healing and infection.
People who have addictions to drugs and alcohol are at-risk. Individuals who require
immune-suppressing medications are high risk for infection.

991. With of the risk are associated with amniocentesis:

A. infection
B. hemorrhage
C. preterm labor
D. All of the above

Correct answer: D

Rationale: Amniocentesis can cause infection, hemorrhage, preterm labor, and leakage
of amniotic fluid. Alternative studies are used when possible to avoid the risks.

992. Which of the following clients may need to be on a fluid volume restriction?

A. A 60-year-old male with congestive heart failure

B. 32-year-old female after a vaginal hysterectomy
C. A 97-year-old woman who had a cerebrovascular accident
D. A four-year-old boy who has a high fever due to bacterial meningitis

Correct answer: A

Rationale: People who have congestive heart failure are at risk for potential or actual
fluid volume excess and may need to be on a fluid restriction.

993. The nurse just administered 20 units of Novolin N. When is the clients most at risk for
developing hypoglycemia?

A. within 30 to 60 minutes
B. within one to two hours
C. within 4 to 10 hours
D. within 10 to 16 hours

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 Correct answer: C

Rationale: Novolin N is intermediate-acting insulin. It is NPH. Another intermediate-

acting insulin is Humulin N. Intermediate-acting insulins have an onset of 2 to 4 hours
with a long peak of 4 to 10 hours. Hypoglycemia is most likely to occur during the peak.
The duration of action is 10 to 16 hours.

994. A client is receiving a blood transfusion. The client complains of flank pain and
respiratory distress. Her blood pressure is 60/40, and her heart rate is 120. She has
minimal urine output. The urine is dark brown. A diagnosis of hemolysis is made, and
the woman receives emergency treatment. What does the nurse need to do?

A. send the blood and tubing to the laboratory

B. call the Red Cross and notify them of the incident
C. place the woman on neutropenic precautions
D. observe the woman for persistent diarrhea

Correct answer: A

Rationale: Whenever a client has a negative reaction to a blood transfusion, the

transfusion is immediately stopped. Emergency and stabilization care is provided. Urine,
blood samples, blood products, tubing, and filters are returned to the facility’s
laboratory/blood bank.

995. A lump was identified when a client had a routine mammogram. The nurse is
providing education and emotional support for the client. She tells the client that a
diagnosis of cancer has not been made. It can only be made by:

A. removal of the lump

B. biopsy
C. ultrasound
D. performing specific blood tests which identify substances produced by cancerous
cells specific to the breast

Correct answer: B

Rationale: A biopsy is needed to make a definitive diagnosis of cancer. The lump does
not need to be removed to make the diagnosis. A fine needle aspiration biopsy or
stereotactic biopsy technique may be used. An ultrasound is used to differentiate solid

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 tumors from fluid-filled cysts. Blood tests are performed to identify the presence of
specific types of cancer and changes that occur when cancers are present.

996. A client had an endoscopic retrograde cholangiopancreatography (ERCP) study

performed. The nurse monitors the client after the test for signs of:

A. pulmonary edema
B. pneumonitis
C. pancreatitis
D. cholelithiasis

Correct answer: C

Rationale: Pancreatitis may occur after an ERCP. The nurse also needs to monitor for
signs and symptoms of perforation and infection. Vital signs need to be monitored
carefully. The nurse needs to ensure that the client’s gag reflex returns.

997. Phagocytosis, the complement cascade, inflammation, and fever are:

A. primary defenses
B. secondary defenses
C. tertiary defenses
D. pathogens

Correct answer: B

Rationale: Phagocytosis, the complement cascade, inflammation, and fever are the
body’s secondary defenses against infection and disease.

998. What is the purpose of the surgical timeout?

A. to identify the correct client, site, and procedure

B. to allow time for the anesthesia to take effect
C. to allow time for clients to metabolize initial sedating agents before anesthesia is
administered
D. to identify structures within the nervous system

Correct answer: A

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 Rationale: All members of the perioperative team stop activity during a surgical
timeout. Time is taken to identify that the correct procedure will be performed to the
correct site on the correct client.

999. A client has a bundle branch block. He is symptomatic. The problem is ongoing. What
treatment is needed?

A. defibrillation
B. pacemaker
C. cardioversion
D. valve repair

Correct answer: B

Rationale: Clients with a bundle branch block which persists and creates symptoms
need to have a pacemaker inserted. Bundle branch blocks arise due to a conduction
defect in the Purkinje fibers. Bundle branch blocks can also be the result of cardiac
disease or surgery.

1000. Critical adaptations at birth include:

A. A. respiration
B. B. Independent circulation
C. C. urine production
D. D. All of the above

Correct answer: D

Rationale: Newborns must be able to breathe independently. It is a critical adaptation

that occurs at birth. Urine production, thermoregulation, and independent circulation
are also critical adaptations at birth.

1001. A nurse is about to give a child with a fever a tepid bath. While getting supplies
together, the nurse knows that the following would not be necessary for the bath?

A. [Link] pajamas
B. [Link] and washcloths
C. [Link] of alcohol
D. [Link]

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Correct Answer: C.

Rationale: Alcohol can cause chilling, peripheral vasoconstriction, and rapid cooling,
making the temperature rise even more; so it shouldn’t be used when bathing a child
with a fever. Washcloths can be squeezed so that water drips on the child’s body. The
child can then be dried off with towels. Toys can be used as a distraction during the
bath. After the child is dried off, light weight clothing can be put on the child

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Congratulations! You just completed a total of 1001 questions in preparation for your NCLEX-
RN. You will ace the test! All of your hard work is paying off. I will congratulate you in advance
on becoming a Registered Nurse. Welcome to an amazing career!

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