MIX NCLEX REVIEW QUESTIONS: BASIC CARE & COMFORT

1. Nurse Jessie is caring for an elderly woman who has had a fractured hip repaired. In the first few days following the surgical repair, which of the following nursing measures will best facilitate the resumption of activities for this client? a. arranging for the wheelchair b. asking her family to visit c. assisting her to sit out of bed in a chair qid d. encouraging the use of an overhead trape e !. "hat do you think is the most important nursing order in a client with ma#or head trauma who is about to receive bolus enteral feeding? a. measure intake and output. c. monitor glucose levels. b. check albumin level. d. increase enteral feeding $. "hat is the pathological process causing esophageal varices is a. ascites and edema. c. portal hypertension. b. systemic hypertension. d. dilated veins and varicesitis. %. "hich of the following interventions will help lessen the effect of &'() *acid reflu+,? a. 'levate the head of the bed on %-. inch blocks. b. /ie down after eating. c. Increase fluid intake #ust before bedtime. d. "ear a girdle. 0. "hat is the main benefit of therapeutic massages is1 a. to help a person with swollen legs to decrease the fluid retention. b. to help a person with duodenal ulcers feel better. c. to help damaged tissue in a diabetic to heal. d. to improve circulation and muscles tone. .. "hich of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophgeal reflu+ disease *&'(),? a. /ettuce c. 2hocolate b. 'ggs d. 3utterscotch 4. "hich of the following should be included in a plan of care for a client receiving total parenteral nutrition *56N,? a. "ithhold medications while the 56N is infusing. b. 2hange 56N solution every !% hours. c. 7lush the 56N line with water prior to initiating nutritional support. d. 8eep client on complete bed rest during 56N therapy. 9. "hich of the following should be included in a plan of care for a client who is lactose intolerant? a. (emove all dairy products from the diet. b. 7ro en yogurt can be included in the diet. c. )rink small amounts of milk on an empty stomach. d. :pread out selection of dairy products throughout the day. ;. 6ain tolerance in an elderly patient with cancer would1 a. stay the same. c. be increased. b. be lowered. d. no effect on pain tolerance. 1<. "hat is the main advantage of cutaneous stimulation in managing paint1 a. costs less. b. restricts movement and decreases. c. gives client control over pain syndrome. d. allows the family to care for the patient at home. 11. 5he nurse is instructing a .0 year-old female client diagnosed with osteoporosis. 5he most important instruction regarding e+ercise would be to1 a. e+ercise doing weight bearing activities b. e+ercise to reduce weight c. avoid e+ercise activities that increase the risk of fracture d. e+ercise to strengthen muscles and thereby protect bones 1!. = client in a long term care facility complains of pain. 5he nurse collects data about the client>s pain. 5he first step in pain assessment is for the nurse to1 a. have the client identify coping methods b. get the description of the location and intensity of the pain c. accept the client>s report of pain d. determine the client>s status of pain 1$. "hich statement best describes the effects of immobility in children? a. Immobility prevents the progression of language and fine motor development b. Immobility in children has similar physical effects to those found in adults c. 2hildren are more susceptible to the effects of immobility than are adults d. 2hildren are likely to have prolonged immobility with subsequent complications 1%. =fter a myocardial infarction, a client is placed on a sodium restricted diet. "hen the nurse is teaching the client about the diet, which meal plan would be the most appropriate to suggest? a. $ o . broiled fish, 1 baked potato, ? cup canned beets, 1 orange, and milk b. $ o . canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple c. = bologna sandwich, fresh eggplant, ! o fresh fruit, tea, and apple #uice d. $ o . turkey, 1 fresh sweet potato, 1@! cup fresh green beans, milk, and 1 orange 10. = nurse is assessing several clients in a long term health care facility. "hich client is at highest risk for development of decubitus ulcers? a. = 4; year-old malnourished client on bed rest b. =n obese client who uses a wheelchair c. =n incontinent client who has had $ diarrhea stools d. =n 9< year-old ambulatory diabetic client 1.. As. 8elly. has had a 2B= *cerebrovascular accident, and has severe right-sided weakness. :he has been taught to walk with a cane. 5he nurse is evaluating her use of the cane prior to discharge. "hich of the following reflects correct use of the cane? a. Colding the cane in her left hand, As. 8elly. moves the cane forward first, then her right leg, and finally her left leg b. Colding the cane in her right hand, As. 8elly. moves the cane forward first, then her left leg, and finally her right leg c. Colding the cane in her right hand, As. 8elly. moves the cane and her right leg forward, then moves her left leg forward. d. Colding the cane in her left hand, As. 8elly. moves the cane and her left leg forward, then moves her right leg forward 14. 5he nurse is instructing a woman in a low-fat, high-fiber diet. "hich of the following food choices, if selected by the client, indicate an understanding of a low-fat, high-fiber diet? a. 5una salad sandwich on whole wheat bread. b. Begetable soup made with vegetable stock, carrots, celery, and legumes served with toasted oat bread c. 2hef>s salad with hard boiled eggs and fat-free dressing d. 3roiled chicken stuffed with chopped apples and walnuts 19. =n 90-year-old male patient has been bedridden for two weeks. "hich of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility? a. :tiffness of the right ankle #oint c. :hort-term memory loss. b. :oreness of the gums d. )ecreased appetite. 1;. =n eleven-month-old infant is brought to the pediatric clinic. 5he nurse suspects that the child has iron deficiency anemia. 3ecause iron deficiency anemia is suspected, which of the following is the most important information to obtain from the infant>s parents? a. Normal dietary intake. b. (elevant sociocultural, economic, and educational background of the family. c. =ny evidence of blood in the stools d. = history of maternal anemia during pregnancy !<. = %.-year-old female with chronic constipation is assessed by the nurse for a bowel training regimen. "hich factor indicates further information is needed by the nurse? a. 5he client>s dietary habits include foods high in bulk. b. 5he client>s fluid intake is between !0<<-$<<< ml per day c. 5he client engages in moderate e+ercise each day d. 5he client>s bowel habits were not discussed. !1. =n older patient asks a nurse to recommend strategies to prevent constipation. "hich of the following suggestions would be helpful? Note1 Aore than one answer may be correct. a. &et moderate e+ercise for at least $< minutes each day. b. )rink .-9 glasses of water each day. c. 'at a diet high in fiber. d. 5ake a mild la+ative if you donDt have a bowel movement every day. !!. =n infant with congestive heart failure is receiving diuretic therapy at home. "hich of the following symptoms would indicate that the dosage may need to be increased? =. :udden weight gain. 2. :low, shallow breathing. 3. )ecreased blood pressure. ). 3radycardia.

!$. = patient arrives at the emergency department with severe lower leg pain after a fall in a touch football game. 7ollowing routine triage, which of the following is the appropriate ne+t step in assessment and treatment? =. =pply heat to the painful area. 2. E-ray the leg. 3. =pply an elastic bandage to the leg. ). &ive pain medication. !%. = nurse is evaluating a post-operative patient and notes a moderate amount of serous drainage on the dressing !% hours after surgery. "hich of the following is the appropriate nursing action? =. Notify the surgeon about evidence of infection immediately. 3. /eave the dressing intact to avoid disturbing the wound site. 2. (emove the dressing and leave the wound site open to air. ). 2hange the dressing and document the clean appearance of the wound site. !0. = patient returns to the emergency department less than !% hours after having a fiberglass cast applied for a fractured right radius. "hich of the following patient complaints would cause the nurse to be concerned about impaired perfusion to the limb? =. :evere itching under the cast. . 3. :evere pain in the right shoulder. 2. :evere pain in the right lower arm ). Increased warmth in the fingers. !.. = nurse is caring for an elderly Bietnamese patient in the terminal stages of lung cancer. Aany family members are in the room around the clock performing unusual rituals and bringing ethnic foods. "hich of the following actions should the nurse take? =. (estrict visiting hours and ask the family to limit visitors to two at a time. 3. Notify visitors with a sign on the door that the patient is limited to clear fluids only with no solid food allowed. 2. If possible, keep the other bed in the room unassigned to provide privacy and comfort to the family. ). 2ontact the physician to report the unusual rituals and activities. !4. = nurse is caring for a patient who has had hip replacement. 5he nurse should be most concerned about which of the following findings? =. 2omplaints of pain during repositioning. 3. :cant bloody discharge on the surgical dressing. 2. 2omplaints of pain following physical therapy. ). 5emperature of 1<1.9 7 *$9.4 2,. !9. = nurse cares for a patient who has a nasogastric tube attached to low suction because of a suspected bowel obstruction. "hich of the following arterial blood gas results might be e+pected in this patient? =. pC 4.0!, 62F! 0% mm Cg. 2. pC 4.!0, 62F! !0 mm Cg. 3. pC 4.%!, 62F! %< mm Cg. ). pC 4.$9, 62F! $. mm Cg. !;. = nurse is performing routine assessment of an IB site in a patient receiving both IB fluids and medications through the line. "hich of the following would indicate the need for discontinuation of the IB line as the ne+t nursing action? =. 5he patient complains of pain on movement. 3. 5he area pro+imal to the insertion site is reddened, warm, and painful. 2. 5he IB solution is infusing too slowly, particularly when the limb is elevated. ). = hematoma is visible in the area of the IB insertion site. $<. = patient with =ddisonDs disease asks a nurse for nutrition and diet advice. "hich of the following diet modifications is NF5 recommended? =. = diet high in grains. 2. = high protein diet. 3. = diet with adequate caloric intake. ). = restricted sodium diet. $1. = patient with a history of diabetes mellitus is in the second postoperative day following cholecystectomy. :he has complained of nausea and isnDt able to eat solid foods. 5he nurse enters the room to find the patient confused and shaky. "hich of the following is the most likely e+planation for the patientDs symptoms? =. =nesthesia reaction. 2. Cypoglycemia. 3. Cyperglycemia. ). )iabetic ketoacidosis. $!. = nurse assigned to the emergency department evaluates a patient who underwent fiberoptic colonoscopy 19 hours previously. 5he patient reports increasing abdominal pain, fever, and chills. "hich of the following conditions poses the most immediate concern? =. 3owel perforation. 2. 2olon cancer. 3. Biral gastroenteritis. ). )iverticulitis. $$. = physician has diagnosed acute gastritis in a clinic patient. "hich of the following medications would be contraindicated for this patient? =. Napro+en sodium *Naprosyn,. 2. 2larithromycin *3ia+in,. 3. 2alcium carbonate. ). 7urosemide */asi+,.

$%. 5he nurse is conducting nutrition counseling for a patient with cholecystitis. "hich of the following information is important to communicate? =. 5he patient must maintain a low calorie diet. 3. 5he patient must maintain a high protein@low carbohydrate diet. 2. 5he patient should limit sweets and sugary drinks. ). 5he patient should limit fatty foods. $0. = patient with leukemia is receiving chemotherapy that is known to depress bone marrow. = 232 *complete blood count, reveals a platelet count of !0,<<<@microliter. "hich of the following actions related specifically to the platelet count should be included on the nursing care plan? =. Aonitor for fever every % hours. 3. (equire visitors to wear respiratory masks and protective clothing. 2. 2onsider transfusion of packed red blood cells. ). 2heck for signs of bleeding, including e+amination of urine and stool for blood. $.. = two-year-old child has sustained an in#ury to the leg and refuses to walk. 5he nurse in the emergency department documents swelling of the lower affected leg. "hich of the following does the nurse suspect is the cause of the childDs symptoms? =. 6ossible fracture of the tibia. 3. 3ruising of the gastrocnemius muscle. 2. 6ossible fracture of the radius. ). No anatomic in#ury, the child wants his mother to carry him. $4. = clinic patient has a hemoglobin concentration of 1<.9 g@d/ and reports sticking to a strict vegetarian diet. "hich of the follow nutritional advice is appropriate? =. 5he diet is providing adequate sources of iron and requires no changes. 3. 5he patient should add meat to her dietG a vegetarian diet is not advised. 2. 5he patient should use iron cookware to prepare foods, such as dark green, leafy vegetables and legumes, which are high in iron. ). = cup of coffee or tea should be added to every meal. $9. = patient is about to undergo bone marrow aspiration and biopsy and e+presses fear and an+iety about the procedure. "hich of the following is the most effective nursing response? =. "arn the patient to stay very still because the smallest movement will increase her pain. 3. 'ncourage the family to stay in the room for the procedure. 2. :tay with the patient and focus on slow, deep breathing for rela+ation. ). )elay the procedure to allow the patient to deal with her feelings. $;. = client with a closed chest drainage system tries to get out of bed alone and disconnects the chest tube from the drainage system, which falls on the floor. "hich of the following actions should the nurse take first upon entering the clientDs room? a. :ubmerge the tube in sterile water or saline. b. :et up and attach a new closed chest drainage system. c. =ssess the clientDs respiratory status. d. 2heck the clientDs pulse and blood pressure. %<. = client is receiving radiation to the head and neck area for treatment of cancer. "hat interventions would you use to help the client>s complaint of a dry mouth? a. Cave client eat prior to radiation therapy. b. 'ncourage the client to eat larger portions of food. c. =dvise the client to use mouthwash. d. :uggest the use of sugar-free candies. %1. =n adolescent client is competing in a long-distance running event. 5he nurse is teaching the client about eating for competition. 5he nurse e+plains that which of the following is an appropriate meal before the competition? a. :ausages, eggs, biscuits, and gravy b. 6ancakes with fresh strawberries, orange #uice, wheat toast, and fresh melon slices c. Hogurt, milk fortified with dry skim milk powder, and a protein bar d. 2heese omelet, hash brown potatoes, bacon, and coffee %!. = client is using music therapy to treat pain. 5o achieve the therapeutic outcome of being pain-free, the client should practice music therapy1 a. 7ive minutes every hour. c. 'very other day for 1< minutes. b. Fnce a day for %0 minutes. d. 5wenty minutes, twice a day. %$. = client is admitted to the hospital with a primary diagnosis of hip fracture and a secondary diagnosis of :#Igren>s syndrome. "hich one of

the following orders would be of most concern with regard to the nutritional status of the client? a. N6F after midnight for surgery with a 41$< a.m. case b. IB of lactated (inger>s at 1!0 m/@hr c. Aaintain diet as tolerated d. (estrict oral fluids to 1,<<< m/@day %%. 5he nurse taught the clientDs wife how to perform a back massage on the client. "hich observation by the nurse indicates that the spouse understands how to give a back massage? a. 2lient is in his pa#amas lying in bed. b. 5he spouse is rubbing his back with large, circular motions. c. 5he spouse is using cold lotion when performing the massage. d. 5he spouse massages the clientDs back for $-0 minutes. %0. = !$-year-old postpartum client is breastfeeding. 5he nurse has completed teaching about dietary changes and is evaluating teaching effectiveness. "hich of the following statements by the client indicates the teaching was effective? a. JI need to increase my caloric intake by about 40< calories per day.J b. JI need to increase my consumption of protein-rich foods such as legumes.J c. JNow is the time to decrease my calories so I can lose my pregnancy weight.J d. JAy calcium consumption must increase to be able to produce the milk.J %.. 5he relative health and well-being of the nurse in relation to helping clients constitutes a vital force in the healing process. = method that would be helpful to nurses in fostering their own health is1 a. 5rying to do things independently, so as to not bother the other nurses. b. "orking through breaks to meet the needs of the clients. c. :etting unrealistic goals. d. (eflecting on their own beliefs and values, and making self-care a priority. %4. Hou have been invited to talk to the "omanDs &uild in your community about the cautions of aromatherapy. "hich of the following would be correctly presented to the audience? a. =romatic oils are produced by a standard-quality formula. b. 5he oils can be stored in any type of container. c. 5he skin should always be tested for allergies by applying a small amount of oil to the area before treatment. d. Fils should not be used during pregnancy. %9. = client is taking a full fluid diet following gastric surgery. 5he nurse evaluates the health teaching to be successful when the family brings in which of the following for the client to eat? a. 6ureed fruits c. :oft cake b. 2ustard d. 2hopped vegetables %;. 5he family of a dying client is hesitant to stop IB fluids because they are concerned it will cause suffering for their dying father. It would be helpful for the nurse to e+plain which of the following to the family? a. :topping fluids will alleviate edema and hearth failure. b. = lack of water will prevent the client from having loose stools immediately after death. c. 5heir father cannot live without water, so he will not suffer for long. d. )ehydration increases ketone production, causing sleepiness, euphoria, and a decrease in pain. 0<. 5he nurse has completed a comprehensive health assessment of a Cispanic client. :ome cultural food practices place the client at risk for cardiovascular disease. "hich suggestion by the nurse is appropriate for this client? a. J5ry to stop eating so many comple+ carbohydrates.J b. J/ean meats should replace the beans and nuts in your diet.J c. J5ry to bake some foods instead of frying them.J d. J)o not stop stewing meat and vegetables togetherG it is a healthy cooking method.J 01. 5he client is to receive dinoprostone *6repidil, for cervical ripening prior to induction of labor. 7or the administration of this medication, the client should be placed in which of the following positions? a. Fn her hands and knees b. Fn her left side c. Fn her right side d. Fn her back, with knees bent and apart 0!. "hen e+amining the throat of a 0-year-old, the nurse should position a tongue blade to the side of the child>s tongue primarily to avoid1

a. 'liciting the gag refle+ c. Curting any of the teeth b. Fbstructing the airway d. Interfering with the visual e+amination 0$. 5he advantage of a gastrostomy tube feeding over a nasogastric tube is that1 a. 5here is less chance of aspiration b. 5he procedure does not require gravity c. 5he client can self-administer the feeding d. Aore tube feeding mi+ture can be given each time 0%. "hen preparing a teaching plan for a client on hemodialysis, the nurse recalls that a substance that passes through the semipermeable membrane during hemodialysis is1 a. (32s c. &lucose b. :odium d. 3acteria 00. 5he ma#or nursing problem in caring for a client with hyperthyroidism would be1 a. 6roviding sufficient rest c. 6roviding an adequate diet b. Aodifying hospital routines d. 8eeping the bed linen neat 0.. "hen a client with kidney shutdown complains of thirst, the nurse should offer1 a. 2arbonated soda c. = glass of milk b. :our ball candy d. = bowl of clear soup 04. = client with a history of chronic arterial occlusive disease complains of pain in the legs while walking. "hich would be the best action for the nurse to implement? a. 2ontinue the e+ercise b. &ive the client a break and then resume the e+ercise c. :top the e+ercise and administer a narcotic d. 6lace the client on bedrest and notify the physician 09. "hich of the following laboratory results best indicates to the nurse the nutritional status of a %0-year-old man with left-sided weakness from a 2B=? a. 3lood glucose 9< mg@dl c. :erum cholesterol !<< mg@dl b. =lbumin $.< g@dl d. Cematocrit %.K 0;. 5he nurse supervises the nurse>s aide providing care to a patient with a chest tube on the left side, which is attached to a three-chamber water-seal drainage system *6leur-evac,. 5he patient should be placed1 a. on his left side c. Fn his back b. 7lat with his feet elevated d. "ith his head elevated .<. 5he school nurse is performing health screening for scoliosis on a group of si+th graders. 5he nurse would be most concerned if1 a. = child complains of a painful right knee b. = child>s feet turn inward c. = child shifts his weight from the right foot to the left foot d. = child>s left shoulder is higher than the right shoulder .1. = $4-year-old man is undergoing testing for amyotrophic lateral sclerosis *=/:,. 5he nurse would e+pect the client to e+hibit1 a. Incontinence of bowel and bladder b. )ifficulty swallowing c. 6aresthesia of the face d. )isorientation of time and place .!. = .<-year-old woman comes to the hospital with a fracture of her right femur. 5he nurse would be most concerned if1 a. 5he patient>s 36 changes from 1!<@4! to 1$<@9< b. 5he patient complains of abdominal pain and eructates frequently c. 5he patient is incontinent of urine and stool d. 5he patient plucks at the bed covers and talks to the wall .$. 5he nurse is caring for a patient with a casted left leg. "hich of the following e+ercises should the nurse recommend? a. 6assive e+ercise of the affected limb b. Luadriceps setting of the affected limb c. =ctive (FA e+ercises of the unaffected limb d. 6assive e+ercise of the upper e+tremities .%. 5he nurse is aware that a 1<-month-old infant on a regular diet could be fed1 a. =pplesauce, carrots, chicken, and formula b. 6ears, green beans, turkey, and whole milk c. 3ananas, sweet potatoes, ham, and formula d. 6eaches, corn, cottage cheese, and whole milk .0. In management of a child with newly diagnosed with chronic celiac disease, the primary nursing goal is to1 a. 6revent celiac crisis and resulting complications b. 6revent complications from respiratory involvement c. 5each the parents to control the diet to promote normal growth d. Celp the parents and child ad#ust to the lifelong dietary restrictions

... 5he regulation of diabetes in a newly diagnosed #uvenile is best accomplished by1 a. Insulin, dietary control, and e+ercise b. )ietary control, e+ercise, and urine testing c. )ietary control, e+ercise, and blood glucose monitoring d. Fral hypoglycemic agents, dietary control, and e+ercise .4. 5he center of gravity in a person in an upright position is located in the1 a. mid pelvis area about midway between the umbilicus and the symphysis pubis. b. center of the sternual area about midway between the epiglotus and the stomach. c. midsection of a personDs waistline. d. spinal column at about the 9th thoracic vertebrae. .9. "hen working with a client who is inactive, the nurse does a range of motion e+ercises mainly for which of the following reasons? a. to prevent the skin from breaking down b. to prevent the #oints from being fi+ed in a fle+ed position c. to increase cardiac and respiratory function to the ma+imum d. to help the client learn to do self e+ercises .;. = family member of a client who is at risk for contractures asks the nurse to e+plain contractures. "hich of the following statements could the nurse share as a true statement regarding the prevention and e+planation of contractures? a. = contracture means that the muscle fibers have become stretched. b. 2ertain contractures, such as foot drop, are related to diet deficiencies. c. 2ontractures are irreversible e+cept by surgical intervention. d. In contractures all the muscles have become equally weakened. 70. "hen you attempt to get one of your immobili ed clients to stand up, the client complains of feeling faint. 5he most likely e+planation for the client feeling faint is1 a. dietary deficiency. 2. poorly functioning thyroid gland. b. orthostatic hypotension. ). sudden o+ygen overload. 41. "hen working with an immobile elderly client or a postoperative client who is on bed rest, you reali e that the amount of surfactant the client normally produces is decreased and the client is now at risk for which of the following problems? a. paralytic illeus c. gastritis b. pulmonary edema d. atelectasis 4!. 5he family of a client who is immobili ed in an assisted living center asks you why the client has to take calcium tablets when they drink two glasses of milk each day. "hich of the following answers would be most accurate? a. J/ack of weight-bearing causes calcium loss from bones.J b. JAilk is not a particularly good source of calcium.J c. J2alcium need is doubled after age .0 and tripled at 40.J d. J)ietary calcium is not as good as the calcium in tablets.J 4$. Hou are planning the dayDs activities for your newly assigned client. /ooking in the chart at documentation by the nurses for the last two days, which of the following documentations, in addition to the client seeming to tolerate the activity well, would be best in predicting the clientDs tolerance for similar activities? a. J:miled and #oked with this nurse while getting out of bed and into the chair. J b. J:kin color remained constant during a 1<-minute walk from the room to the nurses> station.J c. J6ulse returned to baseline of 9% within 0 minutes of rest after going to the bathroom.J d. J(espirations did not e+ceed !% during a 0-minute walk from the bed to the end of hall.J 4%. Hou have begun working in a hospital, and this is your first day to work with assigned clients. 5he physician orders 7owlerDs position during waking hours for one of your clients. "hich of the following actions would be best on your part? a. (aise the clientDs head and trunk to a $<- to %0-degree angle. b. 2heck the agency manuals to clarify meaning of 7owlerDs position in this agency. c. (aise the head of the bed ;< degrees without fle+ing the knees. d. =sk a nursing peer about how much to raise the head of the bed and fle+ the knees. 40. "hich of the following bed positions could you place an adult client in periodically that would allow full e+tension of the hip and knee #oints and help prevent fle+ion contractures of the hips and knees? a. high 7owlerDs c. lateral

b. dorsal recumbent d. prone 4.. Hou are working with a cllient who has recently had a cerebral vascular accident *stroke, and is a hemiplegic. "hich of the following e+ercises would be most helpful to the client and most needs to be included in the plan of care? a. passive (FA progressing to active-assistive (FA, then active (FA b. using a ball to squee e in the hand that is e+periencing weakness c. throwing bean bags at a target progressing from lightweight bags to heavier bags d. working with molding soft clay with both hands 77. =n elderly client whose middle-age daughter recently died of breast cancer now complains of mild abdominal pain, five-pound weight loss, insomnia, and fatigue. "hen no physiological cause can be found, the nurse suspects these are symptoms of1 a. Normal grieving. 2. :piritual distress. b. )enial. ). Cypochondria. 49. = nurse who works effectively with elderly clients who are dying and their families recogni es that1 a. 5he nurse must be comfortable with her own concerns and feelings about death. b. =t least some pain accompanies most deaths. c. Aost people are not afraid to die if they have adequate information about what is happening. d. Cospice services are preferable as death nears. 4;. It is important for a nurse to understand the grieving process because1 a. It assists the nurse to understand the dynamics of grieving. b. It assists the nurse in guiding the bereaved through the stages of grieving in the optimal order. c. It is important to understand the tra#ectory of grief. d. Mnderstanding might influence how the nurse deals with death. 9<. 5he goal of nursing interventions for a bereaved elderly person is to1 a. =ssist the bereaved individual to achieve a healthy ad#ustment to the loss. b. 'ncourage verbali ation about the loved one. c. 5each about the grieving process and offer support. d. &uide the bereaved individual through the stages of grief in the usual order. 91. =n elderly person in end-stage renal disease is admitted to a nursing home for palliative care. Nursing interventions will be1 a. 6ain relief. 2. =mbulation as desired. b. =ssessment for urinary output. ). 26( if needed. 9!. = nurse is uncomfortable discussing spiritual concerns with a dying client. 5he most helpful action for the client would be for the nurse to plan to1 a. (equest a member of the pastoral care staff visit the client. b. =sk to be removed from the care of that client. c. Aake an attempt to meet the client>s needs in this area, even if uncomfortable. d. :eek personal counseling to improve skills in this area. 9$. "hen opioids are prescribed for pain at the end of life, the nurse should understand that1 a. )eath is likely to be soon. b. Fpioids most likely will be a 6(N order. c. :ide effects still must be treated. d. Fther medications are no longer useful for the client. 9%. = priority nursing intervention for an elderly person who is dying and e+periencing an+iety is to1 a. =llow the client time alone to conduct a life review. b. 2ontact family members to alert them and enlist their help. c. =ssist the individual to identify fears. d. '+plain that an+iety is a common e+perience. 90. "hich of the following statements, if made by a dying client, would indicate that spiritual needs most likely are being met? 5he individual states that1 a. N5here have been many positive things about my life, and I have hope.O b. N7amily is the most important part of my life.O c. N5he afterlife is the best place.O d. NI no longer fear pain.O 9.. "hen an elderly client e+presses a wish to forgo additional treatment for cancer and to die, a priority action of the nurse would be1

a. '+plore the client>s understanding of the consequences of such a decision. b. :uggest the client reconsider the finality of the decision. c. 2all the family. d. 2all the physician. 94. = client comes to the doctorDs office with the complaints of going to the bathroom all the time, pain on urination, small amounts of urine being passed when voiding, and a foul smell to the urine. = urine specimen has been sent for analysis. 3ased on the signs and symptoms e+pressed by the client, which of the following health problems would be anticipated? a. =cute renal failure c. Mrinary tract infection b. (enal stone d. 2hronic renal failure 99. =n appropriate health goal for clients with urinary elimination problems would include1 a. Ignoring normali ation of voiding pattern. 5hat the patient has the ability to void is the most important aspect of care. b. 'ncouraging the client to follow measures to show a larger than normal urine output to flush to kidneys c. =lways assisting the client with toileting activities in order to monitor amount d. 6reventing associated risks, such as infections and fluid and electrolyte imbalances. 9;. "hich nursing assessment in the home care environment for clients with urinary elimination problems is inappropriate? a. 2lient self-care abilities b. )istance and barriers to accessing the bathroom c. Need@use of ambulatory aids as required d. No dietary restrictions needed ;<. Hou are requested to perform teaching to a client in the 'mergency )epartment related to the diagnosis of a urinary tract infection. =n intervention to be followed by the client includes1 a. =void tight-fitting pants or clothing b. )rink si+ glasses of water per day c. 5ype of soap when bathing has no significance in this area. d. Boiding pattern in the course of the day has no significance with this problem. ;1. Mrinary incontinence is not a normal part of aging. =n intervention used by nurses to assist clients to regain or maintain continence with individuals suffering from this problem would not include1 a. 3ladder training c. 6rompted voiding b. Cabit training d. 7luid restriction ;!. Mrinary catheteri ation is carried out for clients only when absolutely necessary. "hich of the following candidates@situations would not warrant the need for this procedure? a. = client having abdominal surgery b. = client who is completely paraly ed c. = client in need of decompression of the bladder d. 5o collect a random urine specimen for evaluation ;$. 5he goal of nursing care of the client with an indwelling catheter and continuous drainage is largely directed at preventing infection of the urinary tract and encouraging urinary flow through the drainage system. "hich of the following interventions encouraged by nurses working with these clients would not be appropriate in meeting this goal? a. Caving the client drink up to $<<<m/ per day b. 'ncouraging the client to eat foods that increase the acid in the urine c. (outine hygienic care d. 2hanging indwelling catheters every 4! hours. ;%. = urinary diversion is the surgical rerouting of urine from the kidneys to a site other than the bladder. "hich type of client would this type of procedure be performed on? a. =n abdominal trauma victim b. = renal failure client c. = client with kidney stones d. =n individual suffering from a urinary tract infection ;0. = practice guideline for nurses to use in preventing catheterassociated urinary infection includes which of the instructions listed below? a. Aaintain clean technique when inserting the catheter into the client. b. )isconnect the catheter and drainage tubing once a shift to rinse the unit in cleaning the device. c. :ince you are wearing gloves, it is not necessary to wash your hands.

d. 6revent contamination of the catheter with feces in the incontinent client. ;.. Hou are counseling a young mother who complains of having stress incontinence continuing for three months after her pregnancy. It has been recommended that she practice pelvic muscle e+ercises to strengthen her bladder muscles. "hat action would the nurse recommend to this client in order to perform this activity correctly? a. :topping urination midstream b. :tanding tall and stretching out her arms and touching her toes c. 'mptying her bladder completely d. Aoving her bowels ;4. 7ruits, vegetables and cereals are potent sources of1 a. =ntio+idants c. :aturated fat b. Mnsaturated fat d. 7ree radicals ;9. 5he leading source of antio+idants in the M.:. diet is1 a. 2itrus fruits c. 2offee b. :pinach d. 'gg yolks ;;. 5he essential fatty acids that must be derived from the diet are1 a. :tearidonic acid and eicosatetraenoic acid b. 'icosapentaenoic acid and docosapentaenoic acid c. /inoleic and alpha-linoleic acid d. &amma-linoleic acid and arachidonic acid 1<<. =ll of the following statements about omega-$ fatty acids are true e+cept1 a. 5hey help to maintain healthy triglyceride and high-density lipoprotein b. 5hey have significantly contributed to the obesity epidemic c. 5hey are necessary for healthy infant growth and development d. 5hey play an important role in the production of hormones that govern numerous metabolic and biological processes 1<1. =ll of the following may be associated with scurvy e+cept1 a. /oss of appetite and irritability b. )iarrhea and fever c. 5enderness and swelling in legs d. 7irst symptom is altered mental status 1<!. 5he only fat-soluble antio+idant synthesi ed in the body is? a. Bitamin ) c. =scorbic acid b. 5hiamine d. 2oL1< 1<$. &ood source of vitamin ) include all e+cept1 a. blueberries c. :almon, tuna sardines and mackerel b. :unlight d. 7ortified milk and other dairy products 1<%. Fne of the fat-soluble vitamins involved in coagulation is1 a. Bitamin 8 c. Bitamin ) b. Bitamin = d. Bitamin ' 1<0. 6roducts that contain live microorganisms in sufficient numbers to alter intestinal microflora and promote intestinal microbial balance are known as1 a. =ntibiotics c. 7ruits and vegetables b. 6robiotics d. )igestive en ymes 1<.. Nondigestible food ingredients that stimulate the growth and activity of certain bacteria in the colon are called1 a. Insoluble fiber c. 6rebiotics b. 6robiotics d. 2ellulose 1<4. = deficiency of thiamine *vitamin 31, in the diet causes1 a. Fsteopenia c. 6rotein malnutrition b 3eri-beri d. :curvy 1<9. :ymptoms of trigeminal neuralgia may include all of the following e+cept1 a. '+treme, intermittent facial pain in the #aw or cheek b. 5ingling or numbness on one side of the face c. 6ain triggered by contact with the face or facial movements d. Inability to swallow 1<;. =ll of the following are true about 5ourette syndrome e+cept1 a. )rug treatment completely eliminates symptoms b. It is involuntary and may be a chronic condition c. :ymptoms are generally most severe during adolescence d. :ymptoms are generally detected in children 11<. 5he M:)= )ietary &uidelines for =mericans advise1 a. /imiting carbohydrates to 1< percent of daily calories b. /imiting total fat intake to !< to $0 percent of calories c. /imiting protein to 1< percent of daily calories d. /imiting intake of fats and oils to 1< percent of daily calories 111. =ll of the following statements about vitamin 3$ *niacin, are true e+cept1

a. It helps to release energy in carbohydrates, fat, and protein b. It improves blood lipid levels c. )eficiency causes beriberi d. It is involved in the synthesis of se+ hormones 11!. 5he average =merican consumes appro+imately how much sodium per day? a. !,$<< mg b. !$< mg c. $%< mg d. $,%<< mg 11$. =ll of the following are potentially modifiable risk factors for osteoporosis e+cept1 a. =nore+ia nervosa b. 2hronically low intake of calcium and vitamin ) c. 2hronically low intake of vitamins 2 and 3. d. '+cessive alcohol consumption 11%. 2onsuming fewer than 1$< grams of carbohydrate per day may lead to1 a. Cypoglycemia c. Aarasmus b. 8washiorkor d. 8etosis 110. 2haracteristics of successful dieters include all of the following e+cept1 a. Aaintaining a daily food #ournal b. 2ounting calories c. =dhering to a strict eating plan d. 'liminating all carbohydrates from their diets 11.. Iron supplements are frequently recommended for all of the following e+cept1 a. "omen who are pregnant c. 5eenage girls b. Infants and toddlers d. 6ost-menopausal women 114. A cyanotic client it! an "n#no n $ia%no&i& i& a$'itte$ to t!e e'e(%ency (oo'. In (elation to o)y%en* t!e +i(&t n"(&in% action o"l$ ,e to a. "ait until the clientDs lab work is done b. Not administer o+ygen unless ordered by the physician c. =dminister o+ygen at ! liters flow per minute d. =dminister o+ygen at 1< liters flow per minute and check the clientDs nail beds 119. W!ile on a ca'-in% t(i-* a +(ien$ &"&tain& a &na#e ,ite +(o' a -oi&ono"& &na#e. T!e 'o&t e++ecti.e initial inte(.ention o"l$ ,e to a. 6lace a restrictive band above the snake bite b. 'levate the bite area above the level of the heart c. 6osition the client in a supine position d. Immobili e the limb 11;. T!e(e i& a -!y&ician/& o($e( to i((i%ate a client/& ,la$$e(. W!ic! one o+ t!e +ollo in% n"(&in% 'ea&"(e& ill en&"(e -atency0 a. Mse a solution of sterile water for the irrigation b. =pply a small amount of pressure to push the mucus out of the catheter tip if the tube is not patent c. 2arefully insert about 1<< m/ of aqueous Pephiran into the bladder, allow it to remain for 1< hour, and then siphon it out d. Irrigate with !<m/Ds of normal saline to establish patency 1!<. A +e'ale client !a& o($e(& +o( an o(al c!olecy&to%(a'. 1(io( to t!e te&t* t!e n"(&in% inte(.ention o"l$ ,e to a. 6rovide a high fat diet for dinner, then N6F b. '+plain that diarrhea may result from the dye tablets c. =dminister the dye tablets following a regular diet for dinner d. =dminister enemas until clear 1!1. T!e -!y&ician !a& 2"&t co'-lete$ a li.e( ,io-&y. I''e$iately +ollo in% t!e -(oce$"(e* t!e n"(&e ill -o&ition t!e client a. Fn his right side to promote hemostasis b. In 7owlerDs position to facilitate ventilation c. :upine to maintain blood pressure d. In :imsD position to prevent aspiration 1!!. W!en a client !a& -e-tic "lce( $i&ea&e* t!e n"(&e o"l$ e)-ect a -(io(ity inte(.ention to ,e a. =ssisting in inserting a Ailler-=bbott tube b. =ssisting in inserting an arterial pressure line c. Inserting a nasogastric tube d. Inserting an IB 1!$. T!e -!y&ician !a& o($e(e$ a 345!o"( "(ine &-eci'en. A+te( e)-lainin% t!e -(oce$"(e to t!e client* t!e n"(&e collect& t!e +i(&t &-eci'en. T!i& &-eci'en i& t!en a. )iscarded, then the collection begins b. :aved as part of the !%-hour collection c. 5ested, then discarded d. 6laced in a separate container and later added to the collection 1!%. Follo in% an acci$ent* a client i& a$'itte$ it! a !ea$ in2"(y

an$ conc"((ent ce(.ical &-ine in2"(y. T!e -!y&ician ill "&e C("tc!+iel$ ton%&. T!e -"(-o&e o+ t!e&e ton%& i& to a. Cypoe+tend the vertebral column b. Cypere+tend the vertebral column c. )ecompress the spinal nerves d. =llow the client to sit up and move without twisting his spine 1!0. T!e 'o&t a--(o-(iate n"(&in% inte(.ention +o( a client (e6"i(in% a +in%e( -(o,e -"l&e o)i'ete( i& to a. =pply the sensor probe over a finger and cover lightly with gau e to prevent skin breakdown b. :et alarms on the o+imeter to at least 1<< percent c. Identify if the client has had a recent diagnostic test using intravenous dye d. (emove the sensor between o+ygen saturation readings 1!.. A client ,ein% t(eate$ +o( e&o-!a%eal .a(ice& !a& a Sen%&ta#en5Bla#e'o(e t",e in&e(te$ to cont(ol t!e ,lee$in%. T!e 'o&t i'-o(tant a&&e&&'ent i& +o( t!e n"(&e to a. 2heck that a hemostat is at the bedside b. Aonitor IB fluids for the shift c. (egularly assess respiratory status d. 2heck that the balloon is deflated on a regular basis 1!4. O+ t!e +ollo in% ,loo$ %a& .al"e&* t!e one t!e n"(&e o"l$ e)-ect to &ee in t!e client it! ac"te (enal +ail"(e i& a. pC 4.%;, C2F$ !%, 62F! %. c. pC 4.!., C2F$ !%, 62F! %. b. pC 4.%;, C2F$ 1%, 62F! $< d. pC 4.!., C2F$ 1%, 62F! $< 1!9. A client in ac"te (enal +ail"(e (ecei.e& an IV in+"&ion o+ 789 $e)t(o&e in ate( it! 38 "nit& o+ (e%"la( in&"lin. T!e n"(&e "n$e(&tan$& t!at t!e (ationale +o( t!i& t!e(a-y i& to a. 2orrect the hyperglycemia that occurs with acute renal failure b. 7acilitate the intracellular movement of potassium c. 6rovide calories to prevent tissue catabolism and a otemia d. 7orce potassium into the cells to prevent arrhythmias 1!;. A client !a& !a$ a cy&tecto'y an$ "(ete(oileo&to'y :ileal con$"it;. T!e n"(&e o,&e(.e& t!i& client +o( co'-lication& in t!e -o&to-e(ati.e -e(io$. W!ic! o+ t!e +ollo in% &y'-to'& in$icate& an "ne)-ecte$ o"tco'e an$ (e6"i(e& -(io(ity ca(e0 a. 'dema of the stoma c. (edness of the stoma b. Aucus in the drainage appliance d. 7eces in the drainage appliance 1$<. A client a$'itte$ to a &"(%ical "nit +o( -o&&i,le ,lee$in% in t!e ce(e,("' has vital signs taken every hour to monitor to neurological status. "hich of the following neurological checks will give the nurse the best information about the e+tent of bleeding? a. 6upillary checks b. :pinal tap c. )eep tendon refle+es d. 'valuation of e+trapyramidal motor system 1$1. A yo"n% client i& in t!e !o&-ital it! !i& le+t le% in B"c#/& t(action. T!e team leader asks the nurse to place a footplate on the affected side at the bottom of the bed. 5he purpose of this action is to a. =nchor the traction b. 6revent footdrop c. 8eep the client from sliding down in bed d. 6revent pressure areas on the foot Situation: One important legal and safe nursing responsibility is concerned with administration of medications. 1$!. = pediatric client has been diagnosed with con#unctivitis. 5he nurse is to administer eye drops% times a day. 5he nurse should administer the medication on to which of the following areas? a. 2enter of the cornea c. :clera by the outer canthus b. :clera by the inner canthus d. /ower con#unctival sac 1$$. "hile assessing the client>s intravenous *IB, line, the nurse notes that the area is swollen and cool, causing the client discomfort. 5he nurse suspects which of the following problems1 a. Infiltration b. 6hlebitis c. Infection d.=ir embolism 1$%. 5he client is receiving a 0K de+trose in <.%0K Na2l intravevenously *IB, and report pain at the site, the nurse assesses the site and notes erythema and edema. "hat would be the appropriate action for the nurse to take? a. :low the infusion rate b. )iscontinue the IB and apply a warm compress to the IB site c. =pply antibiotic ointment to the IB site d. &ently pull back the IB access device to reposition it within the vein

1$0. = patient>s medication order is to take digo+in <.1!0 mg p.o. q.i.d. 5he nurse has on hand /ano+in <.!0 mg tablet. 5he best course of action is to1 a. )ispense 1 ? tab b. )ispense ? tab c. )ispense ! tablets d. (eturn the medication to the pharmacy 1$.. 5he patient is ordered !<<< ml of /actated (inger>s over 1! hours. 5he drop factor is 10gtts@ml. 5he nurse will regulate the IB to how many gtts@min? a. !9 gtts@min b. %! gtts@min c. 0. gtts@min d. 1% gtts@min Situation: The nurse is caring for a group of hospitalized patients. 1$4. "hat should the nurse do first to prevent patient infections? a. 6rovide small bedside bags to dispose of used tissues b. 'ncourage staff to avoid coughing near patients c. =dminister antibiotics as ordered d. Identify patients at risk 1$9. 5he nurse must collect the following specimens. "hich specimen collection does not require the use of surgical aseptic technique? a. :tool for ova and parasites b. :pecimen for a throat culture c. Mrine from a retention catheter d. '+udate from a wound for culture and sensitivity 1$;. 5he nurse identifies that the greatest risk for a wound infection e+ists for a patient with a1 a. :urgical creation of a colostomy b. 7irst degree burn on the back c. 6uncture of a foot by a nail d. 6aper cut on the finger 1%<. 5he nurse understands that the factor that places a patient at the greatest risk for developing an infection is1 a. Implantation of a prosthetic device b. 6resence of an indwelling catheter c. 3urns more than twenty percent of the body d. Aultiple puncture sites from laparascopic surgery 1%1. 5he nurse is caring for a patient with high fever secondary septicemia. "hen the physician orders a cooling blanket, the nurse understands that it is used to achieved heat loss via1 a. (adiation b. 2onvection c. 2onduction d. 'vaporation Situation: The nurse is caring for Mrs. Estrada who has recently diagnosed with ad anced cancer. 1%!. "hich statement reflects 8ubler-(oss stage of denial in the grief process? a. N"hy this have to happen to me now?O b. NAy daughter will live with my sister after I am goneO c. NAaybe they mi+ed up my records with someone else>sO d. NCow could this happen to me when I quit smoking cigarettes?O 1%$. =fter the physician has informed Ars. 'strada that her cancer is inoperable and the prognosis is poor, the patient begins to cry. 5he nurse should1 a. 5ouch the patient>s hand to provide support b. /eave the room to give the patient privacy to cry c. 5elephone the patient>s family to inform them of the diagnosis d. =sk the patient how she feels to encourage ventilation of feelings 1%%. Ars. 'strada became withdrawn and depressed. 5he nursing action that is most therapeutic is1 a. =ssisting the patient to focus on positive thoughts daily b. '+plaining that the patient still accomplish goals c. =ccepting the patient>s behavioral adaptation d. Fffering the patient advice when appropriate 1%0. "hich is the most appropriate inference made by the nurse when a patient says, NI>m the same age as my father when he died. =m I going to die of my cancer?O 5he patient is e+periencing1 a. &rieving associated with perceived impending death b. 6owerlessness associated with feelings of loss of control c. 7ear associated with perceived threat to biological integrity d. Ineffective coping associated with inadequate psychological resources 1%.. Ars. 'strada is now willing to try new therapies. 5he nurse identifies that the patient is in what stage of 8ubler-(oss> stages of grieving? a. )enial b. 3argaining c. )epression d. =cceptance 1%4. 7ollowing several radiation treatments, the nurse observes that a clientDs skin appears wet and weeping. =ccording to protocol, the intervention is to

=, &ive the treatment and instruct the client to use antibiotic lotion on the lesions. 3, Not give the treatment and e+plain to the client not to bathe the skin until the weeping stops. 2, &ive the treatment and make a note on the record concerning the skin condition. ), Not give the treatment and notify the physician. 1%9. = client with a history of Cepatitis 3 has been diagnosed with a low back in#ury. 5he client is allergic to aspirin. 5he (N understands she should question the pain medication ordered for this client if it is any of the following 'E2'651 a. 6ercodan b. 5ylo+ c. =cetaminophen d. Ibuprofen 1%;. = (N works in the urgent care center. =n in#ured child is brought in by his mother, who e+presses being concerned that her son broke his right tibia. 5he patient>s right tibia is bleeding and he is unable to move his foot. 5he nurse understands this is most likely what type of in#ury? a. greenstick fracture c. open or compound fracture b. pathological fracture d. complete fracture 10<. = .<-year old female client has undergone right total knee replacement and she is recovering on the orthopedic floor. = (N has been assigned to her care. 5he nurse understands all of the following are appropriate nursing interventions following surgery 'E2'651 a. 6revent dangling of the leg so dislocation does not occur. b. =ssist with crutch use. c. 6ain medication should be administered prior to using the 26A or 2ontinuous 6assive Aotion machine. d. =ssist client with partial weight bearing.