1. The nurse develops a care plan for an elderly man with dementia. The nurse should include which of the following measures? a. b. c. d.
Leave the television in his room on all day. Frequently orient him to his surroundings. Provide him with newspapers and magazines. Assign a staff member to stay with him while he is awake.
2. In developing a plan of care for a patient with Alzheimer's disease who is confused and incontinent of urine, the nurse should include which of the following measures? a. b. c. d.
Insert an indwelling urinary drainage catheter. Perform intermittent catheterization every four hours. Offer the bedpan to the patient every two hours. Assist the patient to a bedside commode every two hours.
3. A 48-year-old woman is being treated for congestive heart failure. The patient is placed on a 2 gram sodium diet. The nurse performs dietary teaching. Which of the following statements, if made by the patient, would indicate that further teaching is necessary? a. "Some medications and seasonings such a MSG contain sodium." b. "Milk, fish, and celery are foods naturally high in sodium." c. "I need to avoid soups and seasoned rice when eating at the restaurant." d. "I can eat any food I like as long as I don't add additional salt to my food." 4. A 72-year-old man brings his wife to the physician. She has been diagnosed with Alzheimer's disease. He tells the nurse that he is concerned because he seems to be forgetting things more frequently. Which of the following responses, if made by the nurse, would be MOST appropriate? a. "Are you afraid that you are developing Alzheimer's disease?" b. "There are many reasons for memory loss; tell me more about what you have noticed." c. "Don't worry, we all lose some memory as we get older." d. "I'll make an appointment with your wife's physician if you are concerned."
5. A 50-year-old woman with congestive heart failure is to be discharged on a low-sodium diet. Which of the following beverage, if selected by the patient, would indicate that she understands the instructions given to her? a. b. c. d.
lemonade skim milk ginger ale tomato juice
6. The nurse teaches a 28-year-old woman who is lactose intolerant alternative ways to obtain adequate amount of calcium in her diet. Which of the following items, if selected by the patient, would indicate that she understand which foods to eat? a. b. c. d.
eggs and green, leafy vegetables instant breakfast mixes and skim milk cottage cheese and yogurt custard and mashed potatoes
7. One evening, the nurse observes an elderly woman with congestive heart failure eating a dill pickle with her dinner. The physician has ordered the patient to receive a low-sodium, high-potassium diet. The patient's son, who is visiting, tells the nurse, "Mother just loves dill pickles. I bring her one every evening". Which of the following responses by the nurse would be MOST appropriate? a. "Giving your mother salty food will only make her condition worse." b. "Didn't your mother tell you that she is on a low-sodium diet?" c. "I'd like to discuss which you which foods your mother will be allowed to eat on her new diet." d. "You should talk to your mother's doctor about her new diet restrictions." 8. A 69-year-old woman with Insulin dependent diabetes mellitus (IDDM), is admitted to the hospital for treatment of a gangrenous toe on her right foot and a skin ulcer on her right lower leg. A femoral angiogram is scheduled. Prior to the angiogram, it would be MOST important for the nurse to take which of the following actions? a. b. c. d.
shave and prep the groin area locate and note the presence of peripheral pulses restrict fluids teach coughing and deep breathing exercises
9. In caring for a patient during the acute phase of a cerebral vascular accident (CVA), the nurse should give HIGHEST priority to
a. b. c. d.
maintaining musculoskeletal function maintaining nutritional status maintaining respiratory function maintaining skin integrity
10. The nurse cares for a patient postoperatively after a transurethral prostatectomy (TURP) for treatment of benign prostatic hypertrophy (BPH). The patient has continuous bladder irrigation through a three-way urinary catheter with a 30 ml balloon tip. When changing the patient's bed, the nurse notices that the sheets are wet. Which of the following BEST explains this finding? a. b. c. d.
The patient's catheter is too large. the patient is experiencing autonomic dysreflexia The patient has a urinary tract infection. The patient is having bladder spasms.
11. When performing a Guaiac test on a patient's stool, the nurse is checking for the presence of which of the following? a. b. c. d.
white blood cells red blood cells ova and parasites mucus
12. The nurse cares for a 23-year-old woman admitted with Crohn's disease (Regional enteritis). The nurse would expect the patient to be placed on which of the following diets? a. b. c. d.
high-fat, high protein, high-residue low-fat, low-protein, low-residue low-fat, high-protein, low-residue high-fat, low-protein, high residue
13. A 65-year-old patient with pneumonia is receiving Garamycin (Gentamycin). It would be MOST important for a nurse to monitor which of the following laboratory values in this patient? a. b. c. d.
hemoglobin and hematocrit BUN and creatinine Platelet count and clotting time Sodium and potassium
14. The nurse describes the procedure for collecting a clean-catch urine for culture and sensitively to a male patient. Which of the following explanations, if made by the nurse, would be the MOST accurate? a. "The urinary meatus is cleansed with an iodine solution and then a urinary drainage catheter is inserted to obtain urine." b. "You will be asked to empty your bladder one half hour before the test; you will then be asked to void into a container." c. "Before voiding, the urinary meatus is cleansed with an iodine solution and urine is voided into a sterile container; the container must not touch the penis." d. "You must void a few drops of urine, then stop; then void the remaining urine into a clean container that should be immediately covered." 15. A 35-year-old man is admitted to the hospital for evaluation of hematuria. An intravenous pyelogram (IVP) is ordered. The patient asks the nurse to explain what will happen to him during the IVP. Which of the following explanations, if made by the nurse, is MOST accurate? a. “An intravenous line will be inserted, dye injected into it, and then xrays will be taken of your kidneys, ureters, and bladder.” b. “A scope will be inserted into your penis so that the inside of your bladder can visualize.” c. “A catheter will be inserted into your penis, dye injected into it, and then x-rays will be taken of your kidneys, ureters, and bladder.” d. “A small incision is made in the kidney, dye injected into it, and then xrays will be taken of your kidneys, ureters, and bladder.” 16. A man is returned to his room in stable condition after a transurethral resection prostatectomy (TURP). He has continuous bladder irrigation through a three-way urinary drainage catheter with a 30ml balloon tip. Tension has been applied to the catheter. The patient complains that he feels pressure in his bladder and rectum and feels as though he has to urinate. Which of the following actions should the nurse take FIRST? a. b. c. d.
assess the patency of the catheter give the patient a bedpan empty the urinary drainage bag decrease the tension on his catheter
17. Metamucil is ordered for a patient postoperatively. When administering Metamucil, the nurse should use which of the following techniques. a. Mix Metamucil with six ounces of orange juice; let stand for one minute, then administer it. b. Mix Metamucil with eight ounces of water; administer it immediately followed by another eight ounces of water c. Sprinkle Metamucil on the patient’s food; add four ounces of water and mix until well blended d. Pour Metamucil into eight ounces of milk; let it stand for one minute, then administer it 18. Which of the following sequences represents the order in which the nurse should perform an assessment of a patient’s abdomen? a. b. c. d.
observe, auscultate, percuss, palpate auscultate, observe, percuss, palpate palpate, percuss, auscultate, observe percuss, palpate, auscultate, observe
19. Propantheline (Pro-Banthine) is ordered for a patient. The nurse knows that Pro-Banthine has which of the following effects on the gastrointestinal system? a. b. c. d.
increases bowel motility reduces bowel motility neutralizes gastric acid secretion increases gastric acid secretion
20. A 26-year-old woman is admitted to the hospital to have an ileostomy performed for treatment of Crohn’s disease. To assist this patient in adjusting to the ileostomy after the surgery, the nurse should take which of the following actions INITALLY? a. b. c. d.
increase the schedule visiting hours for her family encourage her to discuss her fears and ask questions require her to perform her own care for the ileostomy perform care for the ileostomy until the patient is able to do it herself
21. A 68-year-old man is being discharged after having a transurethral prostatectomy (TURP) for benign prostatic hypertrophy (BPH). The nurse’s discharge teaching plan should reinforce adherence to which of the following measures? a. b. c. d.
avoiding vigorous exercise for three weeks avoiding cold foods for one week avoiding hot baths for one month avoiding high-residue foods for two weeks
22. A 30-year-old woman is admitted to the hospital with complaints of severe abdominal cramping and diarrhea. The nurse evaluates the effectiveness of the patient’s intravenous therapy. Which of the following laboratory tests BEST reflects hydration status? a. b. c. d.
erythrocyte sedimentation rate white blood cell count hematocrit serum glucose
23. A 22-year-old woman has an ileostomy performed for treatment of ulcerative colitis. To prepare her for discharge ,the nurse teaches her how to care for the ileostomy. Which of the following comments, if made by the patient, would indicate that she needs further instruction? a. “The skin around the stoma should be cleaned with warm water and thoroughly dried.” b. “The appliance should be changed several times each day to control odors.” c. “The appliance should fit snugly to prevent leakage around the stoma.” d. “When I change the appliance, I should check the skin for irritation.” 24. A 22-year-old man is admitted to the hospital with complaints of fatigue and weight loss. Physical examination reveals pallor and multiple bruises on his arms and legs. The results of the patient’s test reveal acute lymphocytic leukemia and thrombocytopenia. Which of the following nursing diagnoses MOST accurately reflect his condition? a. b. c. d.
potential for injury self-care deficit potential for self-harm alteration in comfort
25. A 33-year-old multipara woman comes to the hospital at 29 weeks gestation with complaints of backache and pelvic pressure “on and off all day.” Which of the following assessments, if made by the nurse, would be MOST important in determining if the patient is in premature labor? a. b. c. d.
the patient’s history of her subjective symptoms the cervix is 50% effaced, 1 centimeter dilated the presenting part is at –1 station regular contractions are noted on a monitor tracing
26. A 68-year-old woman is admitted to the hospital complaining of persistent lower back pain. The nurse puts her in bed in semi-fowler’s position with her hips and knees moderately flexed. The rationale for this position is to a. b. c. d.
relive tension at the lumbosacral region maintain proper alignment of the vertebral joints improve breathing for better oxygen supply to the sacral musculature increase blood flow to the spinal cord
27. A 65-year-old recently retired salesman is brought to the psychiatric hospital by his wife. His wife states that since his retirement he is listless and roams around the house complaining that he has nothing to do. The patient states “Without a job I have no purpose in life.” His wife adds that he has recently lost 10 pounds and sleeps for only two to three hours each night. In order to prioritize the patient’s nursing care, the nurse should assess which of the following areas FIRST? a. b. c. d.
suicidal ideation level of insight into his problem nutritional deficiencies motivation to solve his personal problems
28. An arterial blood gas (ABG) is ordered for a 46-year-old man following a myocardial infarction. After obtaining the ABG, which of the following measure would be ESSENTIAL for the nurse to implement? a. b. c. d.
obtain ice for the specimen apply a sterile dressing to the site apply direct pressure to the site observe the site for hematoma formation
29. A 72-year-old woman suffer a cerebovascular accident (CVA) in her temporal lobe and is admitted to the hospital. When performing an assessment of the patient, the nurse could expect some impairment in the patient’s a. b. c. d.
control of her left arm glucose metabolism corneal reflex in both eyes speech
30. A 72-year-old woman is brought to the clinic by her daughter who reports that her mother is not eating well but is otherwise healthy. The patient is not taking any medications. The nurse determines that which of the following meals is the BEST choice for this patient’s nutritional needs? a. b. c. d.
grilled cheese sandwich, cookie, tea broiled chicken, broccoli, skim milk raisin toast, tapioca pudding, apple juice liver and onions, decaffeinated coffee, jello
31. An 18-year-old woman reports to the health clinic with complaints of dark urine, fever and flank pain. An initial nursing assessment of the patient would reveal which of the following EARLY symptoms of glomerulonephritis? a. Polyuria b. Oliguria c. Polydipsia d. Enuresis 32. A mother calls the well-baby clinic to report that her 4-month-old son has an upper respiratory infection (URI) with a temperature of 104 degrees Fahrenheit (40ºC). The infant is scheduled to receive his DPT and the TOPV immunization later that day. The mother asks the nurse if she should bring him in for his scheduled immunizations. Which of the following responses by the nurse would be MOST appropriate? a. “Keep him at home. We’ll give him a double dose next time.” b. “Bring him in. His illness will not interfere with his immunizations.” c. “”Keep him at home until his temperature and infection resolve.” d. “Bring him in. We’ll give some antibiotics with the immunizations.”
33. The nurse in the postpartum units cares for a 27-year-old woman who delivered her first child the previous day. During her assessment of the patient, the nurse notes multiple varicosities the patient’s lower extremities. The nurse should a. Teach the patient to rest in bed when the baby sleeps b. Encourage early and frequent ambulation c. Apply warm soaks for 20 minutes every four hours d. Perform passive range of motion exercises three times daily 34. A 26-year-old man fractures his left femur in a bicycle accident. A cast is applied. Which of the following exercises would be MOST beneficial for this patient? a. Passive exercises of the affected limb b. Quadriceps setting of the affected limb c. Active ROM exercises of the unaffected limb d. Passive exercise of the upper extremities 35. The nurse plans care for patient receiving electroconvulsive treatments (ECT). Immediately following a treatment, the nurse should take which of the following actions? a. Orient the patient to time and place b. Talk about events prior to the patient’s hospitalization c. Restrict fluid intake and encourage the patient to ambulate d. Initiate comfort measures to relieve vertigo 36. A patient is to receive 35 mg/hr intravenous aminophylline. The nurse mixes 350 mg of aminophylline in 500 cc D5W. At what rate should this solution be infused? a. 20 cc/hr b. 35 cc/hr c. 50 cc/hr d. 70 cc/hr 37. The nurse prepares an adult client for instillation of ear drops. The nurse should use which of the following methods to administer the ear drops? a. Cool the solution for better absorption. Drop the medication directly into the auditory canal. b. Warm the solution. Flush the medication rapidly into the ear. c. Warm the solution. Drop the medication along the side of the ear canal. d. Warm the solution to 40 degrees centigrade. Drop the medication slowly into the ear canal.
38. A 52-year-old man is receiving intravenous Cimetidine (Tagamet). After twenty minutes of the infusion, the patient complains of headache and dizziness. Which of the following actions should the nurse take FIRST? a. Stop the infusion b. Call the physician c. Take vital signs d. Call the pharmacist 39. A 26-year-old man comes to the emergency room with complains of nausea, vomiting and abdominal pain. He is a type I diabetic (IDDM). Four days earlier, he reduced his insulin dose when flu symptoms prevented him from eating. The nurse performs an assessment of the patient which reveals poor skin turgor, dry mucous membranes, and fruity breath odor. The nurse should be alert for which of the following problems? a. Hypoglycemia b. Viral illness c. Ketoacidosis d. Hyperglycemia nonketotic coma 40.
A 45-year-old homeless man is hospitalized with tuberculosis. The physician’s orders include isoniazid (INH) and pyridoxine (vitamin B6). The patient asks why he is receiving pyridoxine. The nurse’s response should be based on the knowledge that pyridoxine a. b. c. d.
increases INH absorption prevents the development of tolerance to INH decreases the severity of INH side effects prevents INH-associated neuritis
41. An 11-year-old boy is admitted to the hospital for evaluation for a kidney transplant. During the initial assessment, the nurse learns that the patient received hemodialysis for three years due to renal failure. The nurse knows that his illness can interfere with this patient’s achievement of a. b. c. d.
intimacy trust industry identity
42. The nurse assesses a patient with a history of Addison’s disease who has received steroid therapy for several years. The nurse could expect the patient to exhibit which of the following changes in appearance? a. buffalo hump, girdle-obesity, gaunt facial appearance b. tanning of the skin, discoloration of the mucus membranes, alopecia, weight loss c. emaciation, nervousness, breast engorgement, hirutism d. truncal obesity, purple striations on the skin, moon face 43. Haloperidol (Haldol) 5 mg tid is ordered for a patient with schizophrenia. Two days later, the patient complains of “tight jaws and stiff neck.” The nurse should recognize that these complaints are a. common side effects of antipsychotic medications that will diminish over time b. early symptoms of extrapyramidal reactions to the medication c. psychosomatic complaints resulting from a delusional system d. permanent side effects of Haldol 44. A 54-year-old man returns to the physician two weeks after discharge from the hospital. He has been taking warfarin sodium (Coumadin) 2 mg PO daily. Which of the following statements, if made by the patient to the nurse, indicates that further teaching is necessary? a. “Last week I felt like I was getting a cold, so I took an antihistamine before bed.” b. “I had a headache yesterday and took two aspirins for relief.” c. “I have been taking a multivitamin everyday.” d. “I take Mylanta if my stomach gets upset.” 45. The nurse cares for a 65-year-old woman following surgery for removal of a cataract in her right eye. The patient complaint of severe eye pain in her right eye. The nurse knows this symptom a. b. c. d.
is expected and should administer analgesic to the patient is expected and should maintain the patient on bed rest is unexpected and may signify a detached retina is unexpected and may signify hemorrhage
46. A patient returns to his room following a lower GI series. When he is assessed by the nurse, he complains of weakness. Which of the following nursing diagnoses should receive priority in planning his care? a. b. c. d.
alteration in sensation-perception, gustatory constipation, colonic high risk for fluid-volume deficit nutrition, less than body requirements
47. A patient hospitalized with a gastric ulcer is scheduled for discharge. The nurse teaches the patient about an antiulcer diet. Which of the following statements, if made by the patient, would indicate to the nurse that dietary teaching was successful? a. b. c. d.
“I must eat bland foods to help my stomach heal.” “I can eat most foods, as long as they don’t bother my stomach.” “I cannot eat fruits and vegetables because they cause too much gas.” “I should eat a low-fiber diet to delay gastric emptying.”
48. A 6-year-old boy is returned to his room following a tonsillectomy. He remains sleepy from the anesthesia but is easily awakened. The nurse should place the child in which of the following positions? a. b. c. d.
sim’s side-lying supine prone
49. A 22-year-old woman is preparing to take her one-day old infant home from the hospital. The nurse discusses the test for phenylkotonuria (PKU) with the mother. The nurse’s teaching should be based on an understanding that the test is MOST reliable a. b. c. d.
after a source of protein has been ingested after the meconium has been excreted after the danger of hyperbilirubinemia has passed after the effects of delivery have subsided
50. A 54-year-old man is being treated for Addison’s disease. The physician orders cortisone 25 mg PO daily. The nurse should explain to the patient that adjustment of the dosage may be required in which of the following situations? a. dosage is increased when the blood glucose level increases b. dosage is decreased when dietary intake is increased c. dosage is decreased when infection stimulates endogenous steroid secretion d. dosage is increased relative to an increase in the level of stress 51. A 48-year-old woman is hospitalized with a diagnosis of bipolar disorder. While she is in the patient activities room on the psychiatric unit, she flirts with male patients and disrupts unit activities. Which of the following approaches would be MOST appropriate for the nurse to take at this time? a. b. c. d.
set limits on the patient’s behavior and remind her of the rules distract the patient and escort her back to her room instruct the other patients to ignore this patient’s behavior tell the patient that she is behaving inappropriately and send her to her room
52. A 33-year-old man is brought to the emergency room bleeding profusely from a stab wound in the left chest area. The nurse’s assessment reveals a blood of pressure of 80/50, pulse of 110, and respiratory rate of 28. The nurse should expect which of the following problems? a. b. c. d.
hypovolemic shock cardiogenic shock neurogenic shock septic shock
53. A 42-year-old man is admitted to the hospital for surgical repair of a detached retina in the right eye. In planning care for this patient postoperatively, the nurse should a. b. c. d.
encourage self-activities maintain patches over both eyes limit movements of his eyes caution him against excessive talking
54. The nurse cares for a patient receiving full strength Ensure by tube feeding. The nurse knows that the MOST complication of a tube feeding is a. b. c. d.
edema diarrhea hypokalemia vomiting
55. A 6-week-old infant is brought to the hospital for treatment of pyloric stenosis. The nurse enters the following nursing diagnosis on the infant’s care plan: fluid volume deficit related to vomiting. “ Which of the following assessments supports this diagnosis? a. b. c. d.
the infant eagerly accepts feedings the infant vomited once since admission the infant’s skin is warm and moist the infant’s anterior fontanel is depressed
56. A 68-year-old woman is diagnosed with thrombocytopenia due to acute lymphocytic leukemia. She is admitted to the hospital for treatment. The nurse should assign the patient a. To a private room so she will not infect other patients and health care workers b. To a private room so she will not be infected by other patients and health care workers c. To have a semiprivate room she will have stimulation during her hospitalization d. To a semiprivate room so she will have the opportunity to express her feeling about her illness 57. A 28-year-old woman comes to the clinic because she thinks she is pregnant. Tests are performed and the pregnancy is confirmed. The patient’s last menstrual period began on September 8 and lasted for 6 days. The nurse calculates that her expected date of confinement (EDC) is a. b. c. d.
May 15 June 15 June 21 July 8
58. A 2-month-old infant is brought to the pediatrician’s office for a well-baby visit. During the examination, congenital subluxation of the left hip is suspected. The nurse knows that symptoms of congenital hip dislocation include a. b. c. d.
lengthening of the limb on the affected side deformities of the foot and ankle asymmetry of the gluteal and thigh folds plantar flexion of the foot
59. After two weeks of receiving lithium therapy, a patient in the psychiatric unit becomes depressed. Which of the following evaluations of the patient’s behavior by the nurse would be MOST accurate? a. the treatment plan is not effective, the patient requires a larger dose of lithium b. this is a normal response to lithium therapy; the patient should continue with the current treatment plan c. this is a normal response to lithium therapy; the patient should be monitored for suicidal behavior d. the treatment plan is not effective; the patient requires an antidepressant 60. A 67-year-old woman is admitted for a treatment of pulmonary edema. During the admission interview, she states she has a six-year history of congestive heart failure (CHF). The nurse performs an initial assessment. When the nurse auscultates the breath sounds, the nurse should expect to hear a. b. c. d.
crackling wheezing whistling absent breath sounds
61. A 63-year-old man is diagnosed with cancer of the larynx and comes to the hospital for a total laryngectomy. When admitting this patient, how should the nurse assess laryngeal nerve function? a. b. c. d.
assess the extent of neck edema check his ability to swallow observe for excessive drooling tap the side of his neck gently and observe for facial twitching
62. The nurse supervises care at an adult day-care center. Four meal choices are available to the residents. The nurse should ensure that a resident on a lowcholesterol diet receives which of the following meals a. b. c. d.
egg custard, boiled liver fried chicken, potatoes hamburger, french fries grilled flounder, green beans
63. The nurse cares for a patient with a possible bowel obstruction. A nasogastric tube is to be inserted. Before inserting the tube, the nurse explains its purpose to the patient. Which of the following explanations, if made by the nurse, is MOST accurate? a. b. c. d.
“It empties the stomach of fluids and gas.” “It prevents spasms of the sphincter of Oddi.” “It prevents air from forming in the small and large intestine.” “It removes bile from the gall bladder.”
64. A 25-year-old man is being treated in the burn unit for second and thirddegree burns over 45% of his body. The physician’s orders include the application of silver sulfadiazine (Silvadene cream). The BEST way to apply this medication is to use a sterile a. b. c. d.
4x4 soaked in saline tongue depressor cotton-dipped applicator gloved hand
65. The nurse teaches a 20-year-old primigravida how to measure the frequency of uterine contractions. The nurse should explain to the patient that the frequency of uterine contractions is determined a. from the beginning of one contraction to the end of the next contraction b. from the beginning of one contraction to the end of the same contraction c. from the beginning of one contraction to the beginning of the next contraction d. by the strength of contraction at its peak
66. The nurse performs teaching with 49-year-old woman receiving estrogen replacement therapy. Which of the following statements, if made by the nurse to the woman, indicates that the nurse is aware of the possible complications of estrogen therapy? a. “Take analgesic before you take estrogen, since estrogen may cause discomfort.” b. “Make sure you keep your clinic appointments, especially your gynecologic checkup.” c. “Limit your fluid intake since estrogen promotes retention of fluids.” d. “Increase roughage in your diet to avoid constipation.” 67. Several days after being admitted for depression, a man is observed sitting alone in the patient’s dining room. The nurse notes that the patient has not finished his meal. Which of the following measures would be MOST appropriate? a. allow the patient to eat in his room until he becomes more comfortable eating with other patients b. ask the patient’s family to bring foods that he likes to eat c. order small frequent meals and sit with the patient while he eats in the dining room d. do not focus on eating behaviors since his appetite will improve over time 68. A 28-year-old woman is being treated for injuries sustained in automobile accident. The patient has a central venous pressure (CVP) line in place. The nurse recognizes threat CVP measurements reflects a. b. c. d.
cardiac output pressure in the left ventricle pressure in the right atrium pressure in the pulmonary artery
69. A mother brings her 4-year-old daughter to the pediatrician for treatment of chronic otitis media. The mother asks the nurse how she can prevent her child from getting ear infections so often. The nurse’s response should be based on an understanding that the recurrence of otitis media can be decreased by a. b. c. d.
covering the child’s ears while bathing treating upper respiratory infections quickly administering nose drops at bedtime isolating her child from other children
70. A patient receives 10 units of NPH insulin every morning at 8:00 a.m. At 4 p.m. the nurse observes that the patient is diaphoretic and slightly confused. The FIRST action the nurse should take is to a. b. c. d.
check vital signs check urine for glucose and ketoses give 6 oz of skim milk call the physician
71. Prior to the patient undergoing a scheduled intravenous pyelogram (IVP), the nurse reviews the patient’s health history. It would be important for the nurse to obtain the answer to which of the following questions? a. b. c. d.
Does the patient have difficulty voiding? Does the patient have any allergies to shellfish or iodine? Does the patient have a history of constipation? Does the patient have frequent headaches?
72. A 6-year-old girl with chicken pox (varicella) is brought by her parents to the physician for evaluation. The nurse knows that the rash characteristic of chicken pox can be described as a. Maculopapular b. Small irregular red spots with minute bluish-white centers c. Round or oval erythematous scaling patches d. Petechiae 73. A 37-year-old primigravida at 28 weeks gestation, takes a three-hour glucose tolerance test. The results indicate a fasting blood sugar of 100mg/dL. Which of the following nursing diagnoses should be considered the HIGHEST priority at this time? a. potential impaired family coping related to diagnosis of gestational diabetes mellitus (GDM) b. potential noncompliance related to pack of knowledge or lack of adequate support system c. potential for altered parenting related to disappointment d. ineffective family coping related to anticipatory grieving
74. The nurse cares for a 45-year-old man admitted for a possible herniated intervertebral disk. Ibuprofen (Motrin), propoxyphene hydrochloride (Darvon), and cyclobenzaprine hydrochloride (Flexeril) are ordered PRN. Several hours after admission, the patient complains of pain. Which of the following actions should the nurse do FIRST? a. b. c. d.
administer ibuprofen (Motrin) call the physician to determine which medication should be given gather more information from the patient about the complaint allow the patient some time to rest and see if the pain subsides
75. When planning care for a 56-year-old man hospitalized with depression, the nurse includes measures to increase his self-esteem. Which of the following actions should the nurse take to meet this goal? a. b. c. d.
encourage him to accept leadership responsibilities in milieu activities set simple, realistic goals with him to help experience success help him to accept his illness and the adjustments that are required assure him that when he is discharged, he will be able to resume his previous activities
76. The nurse finds a visitor unconscious on the floor of a patient’s room during visiting hours at the hospital. Which of the following nursing assessments is consistent with cardiopulmonary arrest? a. b. c. d.
absent pulse, fixed dilated pupils absent respirations, fixed dilated pupils absent pulse and respirations thready pulse and pupillary changes
77. A 68-year-old man is transferred to an extensive care facility following a cerebrovascular accident (CVA). The patient has right-sided paralysis and has been experiencing dysphagia. The nurse observes an aide prepare the patient to eat lunch. Which of the following situations would require an intervention by the nurse? a. b. c. d.
the patient is in bed in high-Fowler’s position the patient’s head and neck are positioned slightly forward the aide puts the food in the back of his mouth on the unaffected side the aide waters down the pudding to help the patient swallow
78. The home care nurse plans care for a patient with pernicious anemia. A monthly intramuscular injection is ordered for the patient. The nurse knows that the best muscle to administer an intramuscular injection in an adult is the a. b. c. d. 79.
gluteus maximus deltoid vastus lateralis dorsogluteal
A 56-year-old man comes to the emergency room complaining of nausea, vomiting, and severe right upper quadrant pain. His temperature is 101.3ºF (38.5 C) and an abdominal x-ray reveals an enlarged gall bladder. He is given a diagnosis of acute cholecystitis and is scheduled for surgery. After administering an analgesic to the patient, the nurse recognizes that which of the following actions is a priority? a. b. c. d.
assessing the patient’s need for dietary teaching assessing the patient’s fluid and electrolyte status examining the patient’s health history for allergies to antibiotics determining whether the patient has signed consent for surgery
80. A mother with four children calls the clinic for advice on how to care fore her oldest child, who has developed chickenpox. Which of the following statements, if made by the mother, indicates a need for further teaching? a. “I should keep my child home from school until the vesicles are crusted.” b. “I can use calamine lotion if needed.” c. “I should remove the crusts so the skin can heal.” d. “I can use mittens if scratching becomes a problem.” 81. A 23-year-old woman comes to the clinic at 32 weeks gestation. A diagnosis of pregnancy-induced hypertension (PIH) is made. The nurse gives health teachings. Which of the following statements, if made by the patient, indicates to the nurse that further teaching is required? a. b. c. d.
“Lying in bed on my left side is likely to increase my urinary output.” “If the bed rest works, I may lose a pound or two in the next few days.” “I should be sure to maintain a diet that has a good amount of protein.” “I will have to keep my room darkened and not watch much television.
82. The nurse evaluates the care provided to a 42-year-old man hospitalized for treatment of adrenal crisis. Which of the following changes would indicate to the nurse that the patient is responding favorably to medical and nursing treatment? a. b. c. d.
the patient’s urinary output has increased the patient’s blood pressure has increased the patient has lost weight the patient’s peripheral edema has decreased
83. After completing an assessment, the nurse determines that a 45-year-old woman is exhibiting early symptoms of dystonic reaction related to the use of an antipsychotic medication. Which of the following actions by the nurse would be MOST appropriate? a. reality test patient and assure her that her physical symptoms are not real b. teach the patient about common side effects of antipsychotic medications c. explain to the patient that there is no treatment that will relieve these symptoms d. notify the physician and obtain an order for I.M. Benadryl 84. The physician orders heparin for a 46-year-old woman. In order to evaluate the effectiveness of the patient’s heparin therapy, the nurse should monitor which of the following laboratory values? a. b. c. d.
platelet count clotting time bleeding time Prothrombin time
85. A 50-year-old woman comes to the clinic for evaluation of acute onset of seizures. A thorough history and physical examination is performed. The nurse would expect which of the following diagnostic tests to be performed FIRST? a. b. c. d.
magnetic resonance imaging (MRI) cerebral anglography electroencephalogram (EEG) electromyogram (EMG)
86. The nurse performs dietary teaching with a patient on a low-protein diet. The nurse would know that teaching had been successful if the patient identified which of the following meals as LOWEST in protein? a. b. c. d.
cranberries and broiled chicken tomatoes and flounder broccoli and veal spinach and tofu
87. A patient has a vagotomy with antrectomy to treat a duodenal ulcer. Postoperatively, the patient develops dumping syndrome. Which of the following statements, if made by the patient, should indicate to the nurse that further dietary teaching is necessary? a. b. c. d.
“I should eat bread with each meal.” “I should eat smaller meals more frequently.” “I should lie down after eating.” “I should avoid drinking fluids with my meals.”
88. A 25-year-old man is admitted to the hospital with a diagnosis of acquired immune deficiency syndrome (AIDS). He is being treated for Pneumocystis carinii pneumonia. The nurse evaluates the care provided to this patient by other members of the health care team. The nurse should intervene with which of the following situations? a. b. c. d.
a housekeeper cleans up spilled blood with a bleach solution a nursing student takes his blood pressure wearing a mask and gloves a technician wears gloves to perform a veinpuncture a nurse attendant allows visitors to enter his room without masks
89. An 18-year-old woman comes to the physician’s office for a routine prenatal checkup at 34 weeks gestation. Abdominal palpation reveals the fetal position as right occipital anterior (ROA). At which of the following sites would the nurse expect to find the fetal heart tone? a. Below the umbilicus, on the mother's left side b. Below the umbilicus, on the mother's right side c. Above the umbilicus, on the mother's left side d. Above the umbilicus, on the mother's right side
90. A 20-year-old man is admitted to the hospital with complaints of seizures and a high fever. A brain scan is ordered. Before the scan, the patient asks the nurse what position he will be in while the procedure is being done. Which of the following statements, if made by the nurse, is MOST accurate? a. "You will be in a side-lying position, with the foot of the bed elevated." b. ”You will be in a Fowler’s position, with your knees flexed.” c. “You will be lying supine with a small pillow under your head.” d. “You will be in Trendelenburg’s position, with your head elevated by two pillows.” 91. A 28-year-old man is admitted to the psychiatric hospital with a diagnosis of obsessive-compulsive disorder. He is unable to stay employed because his ritualistic behavior causes him to be late for work. Which of the following interpretations of the patient’s behavior, if made by the nurse, is MOST accurate? a. He is responding to auditory hallucinations and trying to gain control over his behavior b. He is fulfilling an unconscious desire to punish himself c. He is attempting to reduce anxiety by taking control of the environment d. He is malingering in order to avoid responsibilities at work 92. A 58-year-old man, diagnosed with a chronic lymphocytic leukemia, is admitted to the hospital for treatment of hemolytic anemia. Which of the following measures, if incorporated into the nursing care plan, would BEST address the patient’s needs? a. Encourage activities with other patients in the day room b. Isolate him from visitors and patients to avoid infection c. Provide a diet high in vitamin C d. Provide a quiet environment to promote adequate rest 93. The nurse plans morning care for a 69-year-old man hospitalized after a cerebrovascular accident (CVA) resulting in left-sided paralysis and homonymous hemlanopsia. During morning care, the nurse should a. Provide care from the patient’s right side b. Speak loudly and distinctively when talking with the patient c. Reduce the level of lighting in the patient’s room to prevent glare d. Provide all of the patient’s care to reduce his energy expenditure
94. The nurse prepares for the admission of a client with a perforated duodenal ulcer. Which of the following should the nurse expect to observe as the primary initial symptom? a. Fever b. Pain c. Dizziness d. Vomiting 95. A 3-week-old boy is admitted with a diagnosis of pyloric stenosis. The mother tells the nurse that this is her first child and asks if there is anything she can do to prevent this form happening to her next child. Which of the following statements, if made by the nurse, BEST addresses her concern? a. “This type of thing generally happens to first children.” b. “When you have your second child at least you’ll know what signs to look for.” c. “This is a structural problem, it is not a reflection of your parenting skills.” e. “This is an inherited condition; it is not your fault.” 96. The nurse in a well-child clinic assesses a 4-year-old girl and observes multiple bruises on her back and buttocks. The parents state they don’t know how the girl sustained the injury. The nurse should a. Confront the parents about the suspected abuse b. Report the suspected child abuse to the appropriate authority c. Refer the family to social services for counseling d. Document the suspicions about child abuse in the child’s medical record 97. The nurse is caring for an Rh negative mother who has delivered an Rh positive child. The mother states, “The doctor told me about RhoGAM, but I’m still a little confused.” Which of the following responses, if made by the nurse is MOST appropriate? a. “RhoGAM is given to your child to prevent the development of antibodies.” b. “RhoGAM is given to your child to supply the necessary antibodies.” c. “RhoGAM is given to you to prevent the formation of antibodies.” d. “RhoGAM is given to you to encourage the production of antibodies.”
98. The nurse performs patient teaching with a 45-year-old woman with osteoarthritis. The patient asks what she can do to effectively decrease pain and stiffness in her joints before beginning her daily routine. The nurse should instruct the patient to a. Perform isometric exercise for 10 minutes b. Do range-of-motion exercises then apply ointment to her joints c. Take a warm bath and rest for a few minutes d. Stretch all muscles groups 99. When caring for a patient with anorexia nervosa, which of the following observations indicate to the nurse that the patient’s condition is improving? a. The patient eats all the food on her meal tray b. The patient asks friends to bring her special foods c. The patient weighs herself daily d. Patient’s weight has increased 100. A 44-year-old man returns to his room following a cardiac catheterization. Which of the following assessments, if made by the nurse, would justify calling the physician? a. Pain at the site of the catheter insertion b. Absence of the pulse distal to the catheter insertion site c. Drainage on the dressing covering the catheter insertion site d. Redness at the catheter insertion site 101. An 8-year-old boy is seen in a clinic for treatment of Attention Deficit Disorder (ADD). Medication has been prescribed for the child along with family counseling. The nurse teaches the parents about the medication and discusses parenting strategies. Which of the following statements, if made by the parents, would indicate that further teaching is necessary? a. “We will give the medication at night so it doesn’t decrease his appetite.” b. ”We will provide a regular routine for sleeping, eating, working, and playing.” c. “We will establish firm, but reasonable limits on his behavior.” d. “We will reduce distractions and external stimuli to help him concentrate.”
102. A client has been taking Amphojel daily for three weeks. The nurse should be alert for which of the following side effects? a. Nausea b. Hypercalcemia c. Constipation d. Anorexia 103. The nurse cares for a 38-year-old man after an appendectomy. The patient continues to complain of discomfort to the nurse shortly after receiving an analgesic. Which of the following measures, if taken by the nurse, would be MOST appropriate? a. Notify the physician b. Place him in a Fowler’s position c. Massage his abdomen d. Provide him with reading material 104. A 68-year-old man returns to his room following a transurethral resection of the prostate (TURP) for benign prostatic hypertrophy (BPH). Which of the following would cause the nurse to suspect postoperative hemorrhage? a. Decreased blood pressure, increase pulse, increased respirations b. Fluctuating blood pressure, decreased pulse, rapid respirations c. Increased blood pressure, bounding pulse, irregular respirations d. Increased blood pressure, irregular pulse, shallow respirations 105. A 22-year-old woman is admitted to the hospital and delivers a healthy 7lb., 2oz. girl. The mother decides to bottle-feed her infant. Which of the following statements, if made by the mother after a teaching session, indicates to the nurse that the patient needs further instruction? a. “I’ll pump my breasts and use warm packs to relieve breast pain.” b. “I’ll use a tight bra and Ice packs to relieve engorgement discomfort.” c. “I’ll take the medication prescribed by the doctor for pain.” d. “I’ll take the pills ordered by my doctor to help stop the production of milk. 106. The nurse performs teaching with a 52-year-old man undergoing a paracentesis for treatment of cirrhosis. The patient asks what position he will be in for the procedure. The nurse’s reply should be based on an understanding that the MOST appropriate position for the patient is a. Sitting with his lower extremities well supported b. Side-lying with a pillow between his knees c. Prone, with his head turned to the left side d. Dorsal-recumbent with a pillow at the back of his head
107. A man calls the Suicide Prevention Hotline and states that he is going to kill himself. Which of the following questions should the nurse ask FIRST? a. “What has happened to cause you want to end our life?” b. “How have you planned to kill yourself?” c. “When did you start to feel as though you wanted to die?” d. “Do you want me to prevent you from killing yourself?” 108. A 45-year-old man is admitted for treatment of congestive heart failure (CHF). The physician orders an IV of 125 cc of normal saline per hour and central venous pressure (CVP) readings every four hours. Sixteen hours after admission, the patient’s CVP reading is 3 cm of H2O. which of the following evaluations of the patient’s fluid status, if made by the nurse, would be MOST accurate? a. The patient has received enough fluid b. The patient’s fluid status remains unaltered c. The patient has received too much fluid d. The patient needs more fluid 109. The nurse performs teaching with the mother of a young child who has recently been diagnosed as having epilepsy. Which of the following statements, if made by the mother, would indicate to the nurse that further teaching is necessary? a. “Epilepsy does not affect my child’s mental capacities.” b. “Grand mal seizures do not cause brain damage.” c. “Epilepsy is a form of mental illness.” d. “Epilepsy can be controlled with medication.” 110. A 72-year-old man is admitted to the hospital complaining of right-sided weakness and difficulty speaking. The patient tells the nurse that he fell while at home. It would be MOST important for the nurse’s initial assessment of the patient to include evaluation for a. Nutritional deficiencies b. Ambulation problems c. Hearing difficulties d. Head injury
American Dream Review Institute Answer Key For SIMULATED CGFNS Exam I (Nursing Part II)
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56.
B D D B A A C B C D B C B C A A B A B B A C B A D A A C D B B C B B A C C A C D C D B B D C B B A D B A B B D B
57. B 58. C 59. C 60. A 61. B 62. D 63. A 64. D 65. C 66. B 67. C 68. C 69. B 70. C 71. B 72. A 73. B 74. C 75. B 76. C 77. D 78. C 79. B 80. C 81. D 82. B 83. D 84. B 85. 86. 87. 88. 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100.B 101.A 102.C 103.B 104.A 105.A 106.A 107.B 108.D 109.C 110.D
C A A B B C C D A B C B C C D
