Question 1

To evaluate a client's reason for seeking care, the nurse performs deep palpation. The purpose of
deep palpation is to assess which of the following?
Skin turgor
Hydration
Organs
Question 2
A client is brought to the emergency department and the physician determines he has
gastrointestinal (GI) bleeding. In planning for his care, which of the following would be first priority?
assessment of vital signs
complete abdominal examination
insertion of a nasogastric tube and Hematest of emesis
thorough investigation of precipitating events

Incorrect. The answer is

assessment of vital signs
Explanation:
The Correct answer is:
assessment of vital signs
Vital sign assessment would be the priority nursing intervention. This would provide an indication of the amount of
blood loss that has occurred and also provide a baseline by which to monitor the progress of treatment. The other
answers (b, c, and d) are important but not priority actions.
Question 3
When providing instructions to the adolescent regarding physical development of her body, the RN
should do all of the following EXCEPT
Discuss the importance of avoiding social events in order to stay out of trouble.
Explain that body hair distribution increases and is normal.
Discuss that it is normal to gain weight during puberty.
Instruct on active sebaceous and sweat glands.

Correct. The answer is

Discuss the importance of avoiding social events in order to stay out of trouble.

Explanation:
The Correct answer is:
Discuss the importance of avoiding social events in order to stay out of trouble.
Socialization is very important to teenagers and is a normal part of their development. The other answers (b, c,
and d) are all accurate instructions and discussions for the adolescent regarding development.
Question 4

The nurse is developing discharge plans for a 65-year-old client. The discharge plans indicate the
client will be discharged home with home health nursing care. The nurse provides the home health
agency with details regarding the needs of the patient. The nurse made which of the following to the
home health agency?
A care plan.
A referral.
A transfer to another unit.
A request for at home physical therapy.

Incorrect. The answer is

A referral.
Explanation:
Correct answer:
A referral
A referral is recommending home care services or giving information to an home care service regarding the client
and the client's needs. Typically the sources of referral to a home care agency are family members, nurses,
physicians, social workers, discharge planners or therapists.
Question 5
Which of the following is the normal serum electrolyte level for magnesium?
98 to 106 mEq/L.
1.3 to 2.1 mEq/L.
4.5 to 5.3 mEq/L.
135 to 148 mEq/L.

Incorrect. The answer is

1.3 to 2.1 mEq/L.
Explanation:
Correct answer:
1.3 to 2.1 mEq/L
Choice A is the normal value for chloride. Choice C is the normal value for calcium and choice D, sodium.
Question 5
Which of the following is the normal serum electrolyte level for magnesium?
98 to 106 mEq/L.
1.3 to 2.1 mEq/L.
4.5 to 5.3 mEq/L.
135 to 148 mEq/L.

Incorrect. The answer is

1.3 to 2.1 mEq/L.
Explanation:

Correct answer:
1.3 to 2.1 mEq/L
Choice A is the normal value for chloride. Choice C is the normal value for calcium and choice D, sodium.
Question 6
The school nurse is approached by a mother who explains that her kindergarten child is constantly
scratching the perianal area and that the area is irritated. The RN understands that she should
instruct the mother to obtain a rectal specimen by a tape test and that the mother should obtain the
specimen when?
After bathing.
When the child is put to bed.
In the morning, when the child awakens.
After toileting.

Incorrect. The answer is

In the morning, when the child awakens.
Explanation:
The Correct answer is:
in the morning, when the child awakens
Visualization of pinworms by means of a tape test is necessary for the diagnosis. Transparent tape is lightly
touched to the anus and then applied to a slide for microscopic examination. The best specimen is obtained as the
child awakens, before toileting or bathing.
Question 7

A 20-year-old patient is admitted to the hospital with respiratory failure. Hes intubated, given
oxygen, and is coughing with copious secretions in his lungs. What should be done first?
Suction the lungs
Call his family
Call for assistance in restraining the patient
Check his heart rate and blood pressure

Correct. The answer is

Suction the lungs
Explanation:
The correct answer is A.
The first priority is to make sure the clients airways are clear and that he can breathe. The other choices can be
addressed after ensuring the client can breathe.

Question 7

A 20-year-old patient is admitted to the hospital with respiratory failure. Hes intubated, given
oxygen, and is coughing with copious secretions in his lungs. What should be done first?

Suction the lungs

Call his family
Call for assistance in restraining the patient
Check his heart rate and blood pressure

Correct. The answer is

Suction the lungs
Explanation:
The correct answer is A.
The first priority is to make sure the clients airways are clear and that he can breathe. The other choices can be
addressed after ensuring the client can breathe.

Question 8
A high school student is referred to the school nurse for suspected substance abuse. Following the
nurse's assessment and intervention, what would be the MOST desirable outcome?
The student discusses conflicts over drug use
The student accepts a referral to a substance abuse counselor
The student agrees to inform his parents of the problem
The student reports increased comfort with making choices

Incorrect. The answer is

The student accepts a referral to a substance abuse counselor
Explanation:
The correct answer is the student accepts a referral to a substance abuse counselor. All of the outcomes stated
are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional
substance abuse counselor.
Question 9
The RN is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician
for the client with seizures. Which of the following solutions will the nurse use to dilute this
medication?
Normal saline (0.9%) solution.
Dextrose 5% and half-normal saline (0.45%) solution.
Dextrose 5% solution.
Lactated ringer's solution.

Correct. The answer is

Normal saline (0.9%) solution.
Explanation:
The Correct answer is:
normal saline (0.9%) solution

Phenytoin (Dilantin) should be administered by injection into a large vein by intermittent intravenous infusion.
Normal saline (0.9%) solution is the preferred solution. Dextrose should be avoided because of medication
precipitation.
Question 10
Which of the following terms corresponds with the phrase: a woman that is pregnant?
Octomomesis
Placenta previa
Gravida
Spermatogonia

Incorrect. The answer is

Gravida
Explanation:
The correct answer is C. Gravida is another word for pregnancy. Spermatogonia refers to male sperm cells.
Question 11

12-24 hours.
30-36 hours.
37-48 hours.
72-96 hours.

Question 13
A woman is two months pregnant when her five-year-old child develops rubella. What is most likely
to be given to her?
Immune serum globulin
RhoGam
Rubella antitoxin
MMR

Incorrect. The answer is

Immune serum globulin
Explanation:
The correct answer is immune serum globulin. Immune serum globulin gives her a passive immunity and helps
keep her from developing rubella, which can have devastating effect on her unborn child. MMR is a live virus and
is not given to pregnant women. RhoGam prevents anti Rh antibody development. There is no such thing as
rubella antitoxin.
Question 14
What is the normal value of urine potassium?
12-17 mEq/24 hr
135-145 mEq/24 hr
25-100 mEq/24 hr
0.3-1.7 mEq/24 hr

Incorrect. The answer is

25-100 mEq/24 hr
Explanation:
Correct answer:
25-100 mEq/24 hr
The normal value for urine potassium is 25-100 mEq/24 hr

Question 15
Before applying a cord clamp, the nurse assesses the umbilical cord for the presence of vessels. The
findings that are often associated with genitourinary abnormalities are what?
one artery, one vein.
two arteries, one vein.
two veins, one artery.
two veins, two arteries.

Correct. The answer is

one artery, one vein.
Explanation:
The correct answer is
one artery, one vein.
Two arteries and one vein are present in a normal umbilical cord. The presence of one artery in the umbilical cord
is associated with genitourinary abnormalities.
Question 16

You are assigned to educated the nursing assistants regarding caring for the older adult. It is
important that the assistants understand that which of the following situations portrays ageism?
Accepting differences among older adults.
Advising older adults to forgo aggressive treatment.
Allowing older adults to make decisions.
Informing the older adult of their rights.

Incorrect. The answer is

Advising older adults to forgo aggressive treatment.
Explanation:
The Correct answer is:
Advising older adults to forgo aggressive treatment.
Ageism is a form of prejudice in which older adults are stereotyped by characteristics found in only a few members
of their group. Fundamental to ageism is the view that older persons are different from "me" and will remain
different from "me." The other answers (a, c, and d) identify supporting roles of the nurse for the older person.
Question 17
When taking a dietary history from a newly admitted client, the nurse should remember that which
of the following foods is a common allergen?
bread
carrots
oranges
strawberries

Correct. The answer is

strawberries
Explanation:
The correct answer is
strawberries.
Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots and
oranges rarely cause allergic reactions.
Question 17
When taking a dietary history from a newly admitted client, the nurse should remember that which
of the following foods is a common allergen?

bread
carrots
oranges
strawberries

Correct. The answer is

strawberries
Explanation:
The correct answer is
strawberries.
Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots and
oranges rarely cause allergic reactions.
Question 18
A nurse who violates the civil rights of an individual may be committing what?
A tort.
Negligence.
Malpractice.
An unintentional tort.

Incorrect. The answer is

A tort.
Explanation:
Correct answer:
A tort
A tort is the process of violating civil law when dealing with an individual or an individual's property. The types of
torts are commission and omission. Further, negligence and malpractice are not the best choices as these deal with
unintentional torts.
Question 19
A patient with Addison's disease has been given an inadequate steroid dosage. Which of the
following are NOT symptoms the patient could experience?
Weight gain.
Fatigue.
Weakness.
Dizziness.

Correct. The answer is

Weight gain.
Explanation:
Correct answer:
Weight gain
Weight loss is more likely. Choices B, C, and D are often indicated.

Question 19
A patient with Addison's disease has been given an inadequate steroid dosage. Which of the
following are NOT symptoms the patient could experience?
Weight gain.
Fatigue.
Weakness.
Dizziness.

Correct. The answer is

Weight gain.
Explanation:
Correct answer:
Weight gain
Weight loss is more likely. Choices B, C, and D are often indicated.
Question 19
A patient with Addison's disease has been given an inadequate steroid dosage. Which of the
following are NOT symptoms the patient could experience?
Weight gain.
Fatigue.
Weakness.
Dizziness.

Correct. The answer is

Weight gain.
Explanation:
Correct answer:
Weight gain
Weight loss is more likely. Choices B, C, and D are often indicated.
Question 20
Which of the following behavior does NOT show improvement in a client with Obsessive Compulsive
Disorder?
Client uses will power to stop rituals.
Refrains from rituals during stress.
Client uses thought stopping when obsessive thoughts occur.
Client verbalizes a relationship between stress and rituals.

Incorrect. The answer is

Client uses will power to stop rituals.

Explanation:
Correct answer:
Client uses will power to stop rituals
The client can employ appropriate intervention techniques and more about the disease process such as B, C and
D. Will power alone will not be effective in dealing with Obsessive Compulsive Disorder.
Question 21
Of the following, which is the normal respirations range for an adult?
16-20
24-32
20-24
12-20

Incorrect. The answer is

12-20
Explanation:
The correct answer is D.
Choice A is the normal range for an adolescent. Choice B is normal for a toddler and Choice C, for an adolescent.
Question 22
Which of the following is the generic name for Nizoral?
Ketoconazole.
Isotretinoin.
Nystatin.
Flucinonide.

Correct. The answer is

Ketoconazole.
Explanation:
Correct answer:
Ketoconazole
Choice B is the generic name for Accutane. Choice C is the generic name for Mycostatin and choice D, a generic
name for Lidex.
Question 23
Which of the following is not a goal for a client with social phobia?
Manage fear in groups.
Verbalize feelings in stressful situations.
Develop a plan for stressful situations.
Use suppression.

Correct. The answer is

Use suppression.
Explanation:
Correct answer:
Use suppression
A client needs concrete goals, such as A, B and C, to pursue. Suppression would be very counterproductive to a
person with social phobia.
Question 24
A client has had pain in the right leg for 3 weeks. The nurse understands that the MOST LIKELY effect
of this pain is?
The disruption of sleep.
Irregular heart beat.
Dizziness.
Drowsiness.

Correct. The answer is

The disruption of sleep.
Explanation:
Correct answer:
The disruption of sleep
Pain can have many effects on the human body. Clients with acute pain may have a decrease in appetite, decrease
in fluid intake, nausea, vomiting and disruption in sleep.
Question 25
Which of the following is the sixth provision of the Code of Ethics for Nurses?
The nurse owes the same duties to self as to others, including the responsibility to
preserve integrity and safety, to maintain competence, and to continue personal and
professional growth.
The nurse participates in establishing, maintaining, and improving health care
environments and conditions of employment conducive to the provision of quality
health care and consistent with the values of the profession through individual and
collective action.
The nurse participates in the advancement of the profession through contributions to
practice, education, administration, and knowledge development.
The profession of nursing, as represented by associations and their members, is
responsible for articulating nursing values, for maintaining the integrity of the
profession and its practice, and for shaping social policy.
Correct. The answer is
The nurse participates in establishing, maintaining, and improving health care environments and
conditions of employment conducive to the provision of quality health care and consistent with the values
of the profession through individual and collective action.
Explanation:
Correct answer:
The nurse participates in establishing, maintaining, and improving health care environments and
conditions of employment conducive to the provision of quality health care and consistent with the values
of the profession through individual and collective action

Choice A is provision number five of the code of ethics for nurses. Choice C is provision number seven and choice
D, provision number nine.
Question 25
Which of the following is the sixth provision of the Code of Ethics for Nurses?

The nurse owes the same duties to self as to others, including the responsibility to
preserve integrity and safety, to maintain competence, and to continue personal and
professional growth.
The nurse participates in establishing, maintaining, and improving health care
environments and conditions of employment conducive to the provision of quality
health care and consistent with the values of the profession through individual and
collective action.
The nurse participates in the advancement of the profession through contributions to
practice, education, administration, and knowledge development.
The profession of nursing, as represented by associations and their members, is
responsible for articulating nursing values, for maintaining the integrity of the
profession and its practice, and for shaping social policy.
Correct. The answer is
The nurse participates in establishing, maintaining, and improving health care environments and
conditions of employment conducive to the provision of quality health care and consistent with the values
of the profession through individual and collective action.
Explanation:
Correct answer:
The nurse participates in establishing, maintaining, and improving health care environments and
conditions of employment conducive to the provision of quality health care and consistent with the values
of the profession through individual and collective action

Choice A is provision number five of the code of ethics for nurses. Choice C is provision number seven and choice
D, provision number nine.
Question 26
Which of the following is a brand name for Raberprazole?
Zantac.
Aciphex.
Carafate.
Azulfidine.

Incorrect. The answer is

Aciphex.
Explanation:
Correct answer:
Aciphex
Choice A is a brand name for Ranitidine. Choice C is a brand name for Sucralfate and choice D, for Sulfasalazine.
Question 26
Which of the following is a brand name for Raberprazole?
Zantac.
Aciphex.
Carafate.
Azulfidine.

Incorrect. The answer is

Aciphex.

Explanation:
Correct answer:
Aciphex
Choice A is a brand name for Ranitidine. Choice C is a brand name for Sucralfate and choice D, for Sulfasalazine.
Question 27
Which of the following is MOST likely a characteristic found with individuals who are diagnosed with
borderline personality disorder?
timidness
social discomfort
fear of negative feedback
identity disturbance

Incorrect. The answer is

identity disturbance
Explanation:
The correct answer is identify disturbance. Individuals with borderline personality have an identity disturbance
where the individual has difficulty keeping a stable mood and self image. Characteristics of personality disorders
are unpredictable behavior, impulsiveness, and irritability. Timidness, social discomfort and fear of negative
feedback are not typical with borderline personality but are found in individuals diagnosed with avoidant personality
disorder.
Question 27
Which of the following is MOST likely a characteristic found with individuals who are diagnosed with
borderline personality disorder?
timidness
social discomfort
fear of negative feedback
identity disturbance

Incorrect. The answer is

identity disturbance
Explanation:
The correct answer is identify disturbance. Individuals with borderline personality have an identity disturbance
where the individual has difficulty keeping a stable mood and self image. Characteristics of personality disorders
are unpredictable behavior, impulsiveness, and irritability. Timidness, social discomfort and fear of negative
feedback are not typical with borderline personality but are found in individuals diagnosed with avoidant personality
disorder.
Question 28
The nurse at the family planning clinic has performed teaching on oral contraceptives. The nurse
knows that the teaching has been effective when one of the clients responds:
"I can't take 'the pill' if I'm over 30."
"I can take 'the pill,' even though I smoke heavily."
"My periods will become slightly heavier when I take 'the pill'."

"I can't take 'the pill' if I have gallbladder disease."

Incorrect. The answer is

"I can't take 'the pill' if I have gallbladder disease."
Explanation:
The correct answer is
"I can't take 'the pill' if I have gallbladder disease."
Oral contraceptive is contraindicated in women with gallbladder disease and those who are heavy smokers. There
is not an age specification. Menstrual flow is decreased with the use of oral contraceptives.
Question 29
Which of the following clinical signs would the nurse expect to see in a child with respiratory
depression?
Sleep apnea.
Increased pulse rate.
Shallow breathing.
Unstable angina.

Correct. The answer is

Shallow breathing.
Explanation:
Correct answer:
Shallow breathing
Respiratory depression is the breaths per minute that are less than 12 breaths per minute in a child who is two
years of age and younger. Respiratory depression is one of the complications associated with opioids (for example
morphine, codeine, Demerol, Oxycodone), which are a common analgesic given to client's after surgery or to treat
a severe injury. Children who experience respiration depression exhibit clinical signs such as shallow breathing,
sleepiness and small pupils.
Question 30
Which of the following possible blood transfusion reactions is a rare, severe reaction in which the
donated blood type is not compatible with that of the patient?
Allergic
None of these
Hemolytic
Febrile

Incorrect. The answer is

Hemolytic
Explanation:
The correct answer is C. Choice A is usually due to a patients sensitivity to the plasma proteins of the donors
blood. Choice D is a reaction caused by the incompatibility of leukocytes.
Question 31
A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse
expects this client's stool to look like which of the following?

Coffee ground-like.
Clay-colored.
Black and tarry.
Bright .

Correct. The answer is

Black and tarry.
Explanation:
Correct answer:
Black and tarry
Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of
digestive enzymes in the blood. Vomitus associated with upper GI tract bleeding is commonly described as coffee
ground-like. Clay-colored stools are associated with biliary obstruction. Bright red stools indicate lower GI tract
bleeding.
Question 32
A client is scheduled to have a blood transfusion. The client asks the nurse, "What types of diseases
are transmitted through blood transfusions?" The nurse should respond that there is a low risk of
contracting diseases through blood transfusions. However, a possible illness is which of the following?
Cytomegalovirus.
Hypertension.
Seizure disorder.
Cushing's disease.

Correct. The answer is

Cytomegalovirus.
Explanation:
Correct answer:
Cytomegalovirus
Blood borne diseases and diseases that are transmitted through a transfusion are Hepatitis B, Hepatitis C, HIV,
Cytomegalovirus and Malaria,to name a few. Also, the nurse should assure the client that the transmission of these
diseases is low since blood banks have rigorous screening procedures to test blood.
Question 32
A client is scheduled to have a blood transfusion. The client asks the nurse, "What types of diseases
are transmitted through blood transfusions?" The nurse should respond that there is a low risk of
contracting diseases through blood transfusions. However, a possible illness is which of the following?
Cytomegalovirus.
Hypertension.
Seizure disorder.
Cushing's disease.

Correct. The answer is

Cytomegalovirus.
Explanation:

Correct answer:
Cytomegalovirus
Blood borne diseases and diseases that are transmitted through a transfusion are Hepatitis B, Hepatitis C, HIV,
Cytomegalovirus and Malaria,to name a few. Also, the nurse should assure the client that the transmission of these
diseases is low since blood banks have rigorous screening procedures to test blood.
Question 33
In which of the following stages of reaction toward stress does a body increase in hormone levels in
order to mobilize for a fight?
Alarm.
Exhaustion.
None of these.
Resistance.

Incorrect. The answer is

Alarm.
Explanation:
Correct answer:
Alarm
During the exhaustion stage, the body becomes "exhausted" because it did not positively respond to the stress.
The body undergoes many physiological changes such as taking more air into the lungs in order to prepare for fight
or flight during the resistance stage.
Question 34
In a client with acute hepatitis, the nurse assesses the client's aspartate aminotransferase (AST)
range on the laboratory test at 520 units. What should the nurse understand about this test value?
The AST is normal.
The AST is decreased.
The AST is elevated.
The AST is stable.

Correct. The answer is

The AST is elevated.
Explanation:
Correct answer:
The AST is elevated
In clients with acute hepatitis, liver disease and myocardial infarction, the aspartate aminotransferase (AST) is
elevated. The normal range for this enzyme in the blood is 10 to 26 units per liter. In clients with acute hepatitis, the
enzyme may be elevated four times above the normal range.
Question 35
The nurse who teaches nutrition at a community center is asked "how much water does a person
need to drink daily". The nurse's best response would be:
two quarts
two pints

one gallon
four cups

Incorrect. The answer is

two quarts
Explanation:
The correct answer is two quarts. The average adult needs eight glasses, or two quarts, of water per day. The
remaining answer choices are not correct.
Question 35
The nurse who teaches nutrition at a community center is asked "how much water does a person
need to drink daily". The nurse's best response would be:
two quarts
two pints
one gallon
four cups

Incorrect. The answer is

two quarts
Explanation:
The correct answer is two quarts. The average adult needs eight glasses, or two quarts, of water per day. The
remaining answer choices are not correct.
Question 36
Which of the following tasks can a registered nurse delegate to a nursing assistant in an acute mental
health setting?
Assessing mental status on admission.
Checking for sharp objects.
Administering medication.
Discussing the treatment plan.

Incorrect. The answer is

Checking for sharp objects.
Explanation:
Correct answer:
Checking for sharp objects
A nursing assistant may be assigned to search a client's luggage or room for potentially harmful objects, such as
glass or sharp metal. A mental status assessment should be conducted by the nurse on admission. Administering
medication cannot be delegated to an unlicensed person. A nurse or physician must discuss the treatment plan with
the client.
Question 37
The nurse observes a child's nasal discharge. The discharge is clear in both nasal cavities. The
discharge most likely indicates what type of condition?
nosebleed

upper respiratory infection

allergy
foreign body

Correct. The answer is

allergy
Explanation:
The correct answer is allergy. A child who has clear, watery discharge is associated with allergies. The remaining
answer choices are not the best options as bloody discharge is indicative of a nosebleed or a trauma. Itchy mucus
containing discharge indicates an upper respiratory infection. If there is mucoid or purulent nasal discharge in one
side of the nostrils, the child may have a foreign body lodged in the nostril.
Question 38
A female client who complains of chest pain is admitted. The nurse can expect which of the following
laboratory tests ordered by the physician to confirm a myocardial infarction diagnosis?
creatine kinase
electrocardiogram
radionuclide imaging
hemodynamic monitoring

Incorrect. The answer is

creatine kinase
Explanation:
The correct answer is creatine kinase. The physician orders laboratory tests and diagnostic tests to confirm a
diagnosis of myocardial infarction. Creatine kinase is an enzyme located in the cardiac muscle, brain and skeletal
muscle. As this enzyme rises, there is injury to the muscle cells. Further, the higher the serum CK, the more the
muscle tissue that is damaged. Electrocardiogram, radionuclide imaging and hemodynamic monitoring are used to
diagnosis a myocardial infarction. However, these are diagnostic tests and not laboratory tests.
Question 39
The nurse is providing breast cancer education at a community facility. The American Cancer Society
recommends that women get mammograms
yearly after age 40
after the birth of the first child and every 2 years thereafter
after the first menstrual period and annually thereafter
every 3 years between ages 20 and 40 and annually thereafter

Correct. The answer is

yearly after age 40
Explanation:
The correct answer is yearly after age 40.
The American Cancer Society recommends a mammogram yearly for women over age 40. The other statements
are not correct. It is recommended that women between ages 20 and 40 have a professional breast examination
(not a mammogram) every 3 years.
Question 40
The client had a nephrectomy for the removal of kidney due to major lacerations two hours ago.

What is a nursing priority?

Asses the client's bladder for distention.
Decrease the client's fluid intake to under 2500 mL.
Encourage client to do breathing exercises.
Maintain the drainage tube patency.

Incorrect. The answer is

Maintain the drainage tube patency.
Explanation:
Correct answer:
Maintain the drainage tube patency

The nurse should monitor the drainage tube patency every 4 hours for 24 to 48 hours after the client's nephrectomy
procedure. By doing so, the nurse can ensure the client's tubes drain freely and help prevent hydronephrosis, which
is urine collected in the renal pelvis because of obstruction with the outflow of the urine.
Question 40
The client had a nephrectomy for the removal of kidney due to major lacerations two hours ago.
What is a nursing priority?
Asses the client's bladder for distention.
Decrease the client's fluid intake to under 2500 mL.
Encourage client to do breathing exercises.
Maintain the drainage tube patency.

Incorrect. The answer is

Maintain the drainage tube patency.
Explanation:
Correct answer:
Maintain the drainage tube patency

The nurse should monitor the drainage tube patency every 4 hours for 24 to 48 hours after the client's nephrectomy
procedure. By doing so, the nurse can ensure the client's tubes drain freely and help prevent hydronephrosis, which
is urine collected in the renal pelvis because of obstruction with the outflow of the urine.

Question 41
The nurse is talking with a woman who has been told she will never be able to bear children. The
woman states, "I have decided to adopt a baby, because there are so many children in the world
who need the kind of home I could provide a child." The nurse recognizes this woman is using what
defense mechanism?
denial
displacement

rationalization
compensation

Incorrect. The answer is

compensation
Explanation:
The correct answer is compensation. Compensation is covering a weakness with a more desirable trait or
behavior, such as replacing the desire to have children with adopting a child. Denial is avoiding unwanted realities
by refusing to acknowledge they exist, such as the woman who refuses to accept that she is unable to bear
children. Rationalization is justifying behavior with faulty logic, such as the woman who uses drugs or alcohol and
says that it is due to being unable to have children. Displacement is discharging emotion from one person or object
to another person or object, such as the woman who learns she cannot have children and goes home and argues
with her husband.
Question 41
The nurse is talking with a woman who has been told she will never be able to bear children. The
woman states, "I have decided to adopt a baby, because there are so many children in the world
who need the kind of home I could provide a child." The nurse recognizes this woman is using what
defense mechanism?
denial
displacement
rationalization
compensation

Incorrect. The answer is

compensation
Explanation:
The correct answer is compensation. Compensation is covering a weakness with a more desirable trait or
behavior, such as replacing the desire to have children with adopting a child. Denial is avoiding unwanted realities
by refusing to acknowledge they exist, such as the woman who refuses to accept that she is unable to bear
children. Rationalization is justifying behavior with faulty logic, such as the woman who uses drugs or alcohol and
says that it is due to being unable to have children. Displacement is discharging emotion from one person or object
to another person or object, such as the woman who learns she cannot have children and goes home and argues
with her husband.
Question 42
A client is admitted with tuberculosis. The client should be placed in which type of precaution based
isolation?
Droplet.
Contact.
Protective.
Airborne.

Correct. The answer is

Airborne.
Explanation:
Correct answer:
Airborne

The nurse should use airborne precautions when caring for a client with known or suspected tuberculosis to reduce
the spread of the tuberculosis. Precautions that are employed are private room that has its own hand washing
station and bathroom, special ventalation system that is separate from the hospital wide ventilation system and
providing masks for anyone entering the room to see the client.
Question 43
Which clinical indicator is the nurse most likely to identify when exploring the history of a client with
insomnia?
Enuresis.
Irritability.
Sleep talking.
Sleepwalking.

Correct. The answer is

Irritability.
Explanation:
Correct answer:
Irritability
Insomnia is the inability to fall asleep or stay sleep. Individuals who experience insomnia complain of unrefreshed
sleep, daytime sleepiness, trouble concentrating, irritability, and waking up several times at night.
Question 43
Which clinical indicator is the nurse most likely to identify when exploring the history of a client with
insomnia?
Enuresis.
Irritability.
Sleep talking.
Sleepwalking.

Correct. The answer is

Irritability.
Explanation:
Correct answer:
Irritability
Insomnia is the inability to fall asleep or stay sleep. Individuals who experience insomnia complain of unrefreshed
sleep, daytime sleepiness, trouble concentrating, irritability, and waking up several times at night.
Question 44
The physician prescribes home oxygen therapy for a client with pulmonary fibrosis. The nurse
collaborates with the social worker assigned to the client about arranging the home oxygen therapy.
Which health team member will be responsible for evaluating the client's knowledge of home oxygen
use?
home health nurse
physician
hospital staff nurse

social worker

Incorrect. The answer is

home health nurse
Explanation:
Correct answer
home health nurse
The home health nurse is responsible for evaluating the client's knowledge of home oxygen use. The social worker
is only responsible for coordinating the services. The hospital staff nurse and physician do not observe the client in
the home, so they cannot adequately evaluate the client's knowledge of home oxygen use.
Question 44
The physician prescribes home oxygen therapy for a client with pulmonary fibrosis. The nurse
collaborates with the social worker assigned to the client about arranging the home oxygen therapy.
Which health team member will be responsible for evaluating the client's knowledge of home oxygen
use?
home health nurse
physician
hospital staff nurse
social worker

Incorrect. The answer is

home health nurse
Explanation:
Correct answer
home health nurse
The home health nurse is responsible for evaluating the client's knowledge of home oxygen use. The social worker
is only responsible for coordinating the services. The hospital staff nurse and physician do not observe the client in
the home, so they cannot adequately evaluate the client's knowledge of home oxygen use.
Question 45
The normal blood glucose range is which of the following?
60-100 mg/dl

80-140 mg/dl

100-150 mg/dl
70-120 mg/dl

Correct. The answer is

70-120 mg/dl
Explanation:
The correct answer is D.

Any reading higher than 126 ml should prompt the nurse to check with the doctor for follow-up. However, a recent
ingestion of sugar or carbohydrates could cause a high reading.
Question 46
Which is a FALSE statement regarding the factors contributing to its development?
In most theories of schizophrenia, stress plays an essential role in triggering schizophrenic
episodes.
Some investigators suggest that communication disorders in parents and family
members may be a predisposing factor for schizophrenia.
The dopamine hypothesis fits only some cases of schizophrenia.
In order for someone to be diagnosed with schizophrenia, they must show brain
damage on a brain scan.
Incorrect. The answer is
In order for someone to be diagnosed with schizophrenia, they must show brain damage on a brain scan.
Explanation:
Correct answer:
In order for someone to be diagnosed with schizophrenia, they must show brain damage on a brain scan
It is becoming more clear ever day, the damage schizophrenia is doing to the brain, but researchers are nowhere
near finding all of the answers. Different researchers are still arguing over the conclusiveness of the data that does
exist. Other scientists are trying to discover the cause of schizophrenia.
Question 46
Which is a FALSE statement regarding the factors contributing to its development?
In most theories of schizophrenia, stress plays an essential role in triggering schizophrenic
episodes.
Some investigators suggest that communication disorders in parents and family
members may be a predisposing factor for schizophrenia.
The dopamine hypothesis fits only some cases of schizophrenia.
In order for someone to be diagnosed with schizophrenia, they must show brain
damage on a brain scan.
Incorrect. The answer is
In order for someone to be diagnosed with schizophrenia, they must show brain damage on a brain scan.
Explanation:
Correct answer:
In order for someone to be diagnosed with schizophrenia, they must show brain damage on a brain scan
It is becoming more clear ever day, the damage schizophrenia is doing to the brain, but researchers are nowhere
near finding all of the answers. Different researchers are still arguing over the conclusiveness of the data that does
exist. Other scientists are trying to discover the cause of schizophrenia.
Question 47
Pain has which of the following effects on respiratory rate?
None.
Decreases.
Increases.

First decreases, then increases.

Correct. The answer is

Increases.
Explanation:
Correct answer:
Increases
Pain will increase respiratory and heart functions. This can be counteracted with morphine if indicated.
Question 47
Pain has which of the following effects on respiratory rate?
None.
Decreases.
Increases.
First decreases, then increases.

Correct. The answer is

Increases.
Explanation:
Correct answer:
Increases
Pain will increase respiratory and heart functions. This can be counteracted with morphine if indicated.
Question 48
What hormone does the anterior pituitary produce?
Follicle-stimulating hormone.
Antidiuretic hormone.
Oxytoxin.
Thyroid releasing hormone.

Incorrect. The answer is

Follicle-stimulating hormone.
Explanation:
Correct answer:
Follicle-stimulating hormone.
The anterior pituitary regulates several physiological processes including stress, growth, and reproduction. Its
regulatory functions are achieved through the secretion of various peptide hormones that act on target organs
including the adrenal gland, liver, bone, thyroid gland, and gonads.

Question 49
The nurse is performing an assessment on a client who is complaining of pain in the abdomen. The
nurse understands to do what?
Use palpation throughout the assessment.

Use palpation at the end of the assessment only.

use palpation at the beginning of the assessment only.
Do not palpate the abdomen during the assessment.

Correct. The answer is

Use palpation at the end of the assessment only.
Explanation:
Correct answer:
Use palpation at the end of the assessment only
When performing an assessment on the abdomen, the palpation of the abdomen should be performed last. The
reason is the pressure placed on the abdominal wall along with the contents will affect the bowel sounds that are
heard through auscultatio
Question 49
The nurse is performing an assessment on a client who is complaining of pain in the abdomen. The
nurse understands to do what?
Use palpation throughout the assessment.
Use palpation at the end of the assessment only.
use palpation at the beginning of the assessment only.
Do not palpate the abdomen during the assessment.

Correct. The answer is

Use palpation at the end of the assessment only.
Explanation:
Correct answer:
Use palpation at the end of the assessment only
When performing an assessment on the abdomen, the palpation of the abdomen should be performed last. The
reason is the pressure placed on the abdominal wall along with the contents will affect the bowel sounds that are
heard through auscultatio
Question 50
Which is the most numerous type of white blood cell (WBC)?
Neutrophil.
Eosinophil.
Basophil.
Lymphocyte.

Correct. The answer is

Neutrophil.
Explanation:
Correct answer:
Neutrophil
Neutrophil are the most numerous of the WBCs, comprising about 65%. Lymphocytes are the second most
abundant. Eosinophils account for about 2%, while basophils are the least abundant.
Question 51

A female client is discharged from the hospital post delivery. The nurse escorts a mother and her
newborn to the car. Which of the following approaches should the nurse instruct the new mother to
place the newborn?
in the mother's lap with the seat beat across both the mother and the baby
on the front passenger side with the car seat facing forward
in the back seat of the car with the car seat facing backwards
in the middle section of the backseat with the baby positioned in the car seat facing
forward
Correct. The answer is
in the back seat of the car with the car seat facing backwards
Explanation:
The correct answer is in the back seat of the car with the car seat facing backwards.
Question 52
The couple with the lowest risk of having a child with sickle cell disease is the one in which what is
true?
The father is HbS and the mother is HbS.
The father is HbS and the mother is HbAS.
The father is HbA and the mother is HbS.
The father is HbAS and the mother is HbAS.

Correct. The answer is

The father is HbA and the mother is HbS.
Explanation:
Correct answer:
The father is HbA and the mother is HbS
If the father has normal hemoglobin (HbA) and the mother has sickle cell disease (HbS), the couple has a 0%
chance of having a child with sickle cell disease. If both parents have sickle disease, the couple has a 100%
chance of having a child with sickle cell disease. If the father has sickle cell disease and the mother has sickle cell
trait (HbAS), the couple has a 50% chance of having a child with sickle cell disease. lf both parents have sickle cell
trait, the couple has a 25% chance of having a child with sickle cell disease.
Question 53
You are reading the result of a Mantoux test on a 2-year- old child. The results indicate an area of
induration that measures 10 mm. What do you interpret these results as?
negative
positive
inconclusive
definitive and requiring a repeat test

Correct. The answer is

positive
Explanation:
The Correct answer is:
positive

Induration measuring 10 mm or more is considered to be a positive result in children younger than 4 years of age
and in those with chronic illness or at high risk for environmental exposure to tuberculosis. For high risk groups, a
reaction of 5mm or more is considered positive. A reaction of 15 mm or more is positive in children 4 years of age
and older who have no risk factors.
Question 54
Of the following, which is the normal blood pressure range for an adolescent?
90-100/50-65
60-80/30-60
110-120/60-80
95-110/55-70

Correct. The answer is

110-120/60-80
Explanation:
The correct answer is C. Choice A is the normal range for a toddler. Choice B is normal for a newborn and
Choice D, for a school-aged child.
Question 55
Which of the following theorists was mentally disturbed?
Gordon Allport.
Hans Eysenck.
Raymond Cattell.
None of the above.

Correct. The answer is

None of the above.
Explanation:
Correct answer:
None of the above
None of these theorists have been identified as being mentally disturbed. Each made great contributions to the field
of mental health.
Question 55
Which of the following theorists was mentally disturbed?
Gordon Allport.
Hans Eysenck.
Raymond Cattell.
None of the above.

Correct. The answer is

None of the above.
Explanation:
Correct answer:

None of the above

None of these theorists have been identified as being mentally disturbed. Each made great contributions to the field
of mental health.
Question 56
A menopausal woman tells her nurse that she experiences discomfort from vaginal dryness during
sexual intercourse, and asks, "What should I use as a lubricant?" The nurse should recommend:
petroleum jelly.
a water-soluble lubricant.
body cream or body lotion.
less-frequent intercourse.

Correct. The answer is

a water-soluble lubricant.
Explanation:
The correct answer is a water-soluble lubricant. A Water-soluble jelly should be used. Petroleum jelly, body creams,
and body lotions are not water soluble. Less-frequent intercourse is an inappropriate response.
Question 56
A menopausal woman tells her nurse that she experiences discomfort from vaginal dryness during
sexual intercourse, and asks, "What should I use as a lubricant?" The nurse should recommend:
petroleum jelly.
a water-soluble lubricant.
body cream or body lotion.
less-frequent intercourse.

Correct. The answer is

a water-soluble lubricant.
Explanation:
The correct answer is a water-soluble lubricant. A Water-soluble jelly should be used. Petroleum jelly, body creams,
and body lotions are not water soluble. Less-frequent intercourse is an inappropriate response.
Question 57
The nurse is teaching a client who heavily drinks alcohol about maintaining a healthy heart. The
nurse should include which point in her teaching?
Smoke in moderation.
Use alcohol in moderation.
Consume a diet high in saturated fats and low in cholesterol.
Avoid exercise.

Correct. The answer is

Use alcohol in moderation.
Explanation:
Correct answer:
Use alcohol in moderation

Alcohol may be used in moderation as long as there are no other contraindications for its use. Having a diet high in
cholesterol and saturated fat, and a sedentary lifestyle are all known risk factors for cardiac disease. The client
should be encouraged to quit smoking, exercise three to four times per week, and consume a diet low in cholesterol
and saturated fat.
Question 58
You are caring for a client with a chest tube. You enter the room and find that the client has turned
onto the side of the tube and disconnected the tube accidentally from the machine but is still
connected to the patient. The appropriate initial action is to:
Place the tube in a bottle of sterile water.
Immediately replace the chest tube system.
Call the physician.
Place a sterile dressing over the site.

Correct. The answer is

Place the tube in a bottle of sterile water.
Explanation:
The Correct answer is:
Place the tube in a bottle of sterile water.
Once the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water and held
below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. The
physician may be notified, but this is not the initial action necessary. Placing a dressing over the disconnection site
will not prevent complications.
Question 59
Which of the following will MOST help an elderly, hearing impaired client admitted to the hospital?
Invite all family members to come and visit any time.
Keep the television volume at high.
Leave the door open so the patient can hear everything going on in the hall.
Limit bedside conversation to that which directly pertains to the patient.

Correct. The answer is

Limit bedside conversation to that which directly pertains to the patient.
Explanation:
The correct ansCorrect answer:
Limit bedside conversation to that which directly pertains to the patient
This creates the least amount of auditory disturbance for the patient. Lots of noise can be upsetting to those with
hearing impairments.
Question 60
Which of the following is the most common source of airway obstruction in an unconscious victim?
A foreign object.
Saliva or mucus.
The tongue.

Edema.

Incorrect. The answer is

The tongue.
Explanation:
Correct answer:
The tongue
The muscles in many cases that control the tongue relax, causing the tongue to obstruct the airway. When this
occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back in place. If a neck
injury is suspected, the jaw-thrust maneuver must be performed.
Question 61
The nurse understands a child with HIV who is classified as Category C has which of the following
manifestations?
anemia
encephalopathy
cystomegalovirus
toxoplasmosis

Incorrect. The answer is

encephalopathy
Explanation:
The correct answer is encephalopathy.
The clinical manifestations that are seen with the category C classification of HIV are recurrent and multiple
infections, encephalopathy, kaposi's sarcoma, lymphoma and wasting syndrome. The remaining answer choices
are not the best selections as these are clinical manifestations of the Category B HIV classification.
Question 62
The nurse knows that in the past, inadequate community and occupational skills often limited clients
who had severe mental illness. Today, though some teaching is best done in the client's own setting,
priority community-based teaching would be for what?
Conflict management skills.
ADL skills.
Job training.
Social skills training.

Incorrect. The answer is

Social skills training.
Explanation:
The correct answer is social skills training. Individuals with severe mental illness often benefit from social skills
training, focusing primarily on the teaching of basic coping skills necessary to live as autonomously as possible in
the community. Job training will come after the client is able to interact well with others. ADL skills are beneficial, but
clients will be taught these skills in their own setting. Conflict management skills will be taught after the social skills
training
Question 63
Which of the following has a a generic name of Albuterol Sulfate?

Serevent.
Brethine.
Robitussin.
Proventil.

Correct. The answer is

Proventil.
Explanation:
Correct answer:
Proventil
Choice A has a generic name of Salmeterol. Choice B has a generic name of Terbutaline Sulfate. Choice C has a
generic name of Guaifenesin.
Question 63
Which of the following has a a generic name of Albuterol Sulfate?
Serevent.
Brethine.
Robitussin.
Proventil.

Correct. The answer is

Proventil.
Explanation:
Correct answer:
Proventil
Choice A has a generic name of Salmeterol. Choice B has a generic name of Terbutaline Sulfate. Choice C has a
generic name of Guaifenesin.
Question 64
When obtaining a health history, the nurse expects a client with a diagnosis of Myasthenia Gravis to
report which of the following signs or symptoms?
Low lying eyelids.
Increased headaches.
A knot on the neck.
Pain in the chest.

Incorrect. The answer is

Low lying eyelids.
Explanation:
Correct answer:
Low lying eyelids
A client with Myasthenia Gravis may report that his or her eyelids feel low or drooping, which is known as ptosis.
Additional signs and symptoms of Myasthenia Gravis is dysphonia, enlarged thymus gland, strabismus, muscle

weakness and diplopia.

Question 64
When obtaining a health history, the nurse expects a client with a diagnosis of Myasthenia Gravis to
report which of the following signs or symptoms?
Low lying eyelids.
Increased headaches.
A knot on the neck.
Pain in the chest.

Incorrect. The answer is

Low lying eyelids.
Explanation:
Correct answer:
Low lying eyelids
A client with Myasthenia Gravis may report that his or her eyelids feel low or drooping, which is known as ptosis.
Additional signs and symptoms of Myasthenia Gravis is dysphonia, enlarged thymus gland, strabismus, muscle
weakness and diplopia.
Question 65
A client is discharged from a hospital's psychiatric unit. The physician writes an order for Zyprexa. As
the nurse prepares the teaching plan for the Zyprexa medication, the nurse should teach the client to
do what?
avoid smoking
get plenty of sunlight
avoid foods containing tyramine
eat a high protein, high carbohydrate diet

Incorrect. The answer is

avoid smoking
Explanation:
The correct answer is to avoid smoking. The serum levels of antipsychotic medications, such as Zyprexa, can be
decreased when an individual smokes tobacco products. When taking Zyprexa, the client should avoid exposure to
direct sunlight. Avoiding foods containing tyramine would be dangerous if the client was prescribed an monoamine
oxidase inhibitor (MAOI). Further, instructing the client to eat a high protein, high carbohydrate diet is not a
requirement for a client who is prescribed Zyprexa. This dietary instruction is recommended for clients with bipolar
disorder.
Question 66
Which must be included in a medication order?
Drug class
Possible adverse reactions
Physician's signature
Client allergies

Incorrect. The answer is

Physician's signature
Explanation:
The correct answer is physician's signature. The physician's signature must be included in a medication order.
Other components of a medication order include the client's full name, drug name, dosage form, dose amount,
administration route, time schedule, and the date and time of the order. The drug class and possible adverse
reactions are not components of a medication order. Client allergies should be recorded in the client's chart, not on
the medication order.
Question 67
The nurse is assessing a client's pulse. Which pulse feature should the nurse document?
Timing in the cycle
amplitude
pitch
intensity

Incorrect. The answer is

amplitude
Explanation:
The correct answer is amplitude. The nurse should document the rate, rhythm, and amplitude of a client's pulse.
Pitch, timing, and intensity are not associated with pulse assessment.
Question 68
Which of the following is a brand name for Metoclopramide HCL?
Reglan.
Compazine.
Phenergan.
Nexium.

Correct. The answer is

Reglan.
Explanation:
Correct answer:
Reglan
Choice B is a brand name for Prochlorperazine. Choice C is a brand name for Promethazine and choice D, for
Esomeprazole Magnesium.
Question 69
A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history
reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a
risk factor for stroke?
Caucasian race.
Female gender.
Obesity.

Bronchial asthma.

Correct. The answer is

Obesity.
Explanation:
Correct answer:
Obesity
Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis
of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, hormonal contraceptive use,
emotional stress, family history of stroke, and advancing age. The clients' race, gender and bronchial asthma are
not risk factors for stroke.
Question 69
A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history
reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a
risk factor for stroke?
Caucasian race.
Female gender.
Obesity.
Bronchial asthma.

Correct. The answer is

Obesity.
Explanation:
Correct answer:
Obesity
Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis
of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, hormonal contraceptive use,
emotional stress, family history of stroke, and advancing age. The clients' race, gender and bronchial asthma are
not risk factors for stroke.
Question 70
Which leadership style is base on the belief that every member of the group should have input into
the development of goals and problem solving?
autocratic leadership
laissez-faire leadership
democratic leadership
situational leadership

Incorrect. The answer is

democratic leadership
Explanation:
The Correct answer is:
democratic leadership
Autocratic leadership is focused and maintains strong control, makes decisions, and addresses all problems. The
autocratic leader dominates and commands rather than seek suggestions or input. The laissez-faire leader
assumes a passive, nondirective, and inactive approach and relinquishes part or all of the leadership
responsibilities to group members. The situational leader uses a combination approach based on the

circumstances.
Question 71

What is the best way for a client with reoccurring kidney stones to prevent further kidney
stones?
Increase dairy intake.
Decrease fatty protein and carbohydrate intake.
Ingest plenty of cranberry juice.
Take vitamin D supplements.

Incorrect. The answer is

Ingest plenty of cranberry juice.
Explanation:
Correct answer:
Ingest plenty of cranberry juice
Cranberry juice increases the acidity of urine, which helps with the dissolving of kidney stones. While the other
foods will add nutrients to the diet, they do not address the development of further kidney stones.
Question 72
The nurse is providing dietary teaching for the parents of a child with celiac disease. This child should
avoid what?
Vegetables.
Fruits.
Prepared puddings.
Rice.

Correct. The answer is

Prepared puddings.
Explanation:
Correct answer:
Prepared puddings
A child with celiac disease must not consume food containing gluten and therefore should avoid prepared puddings,
commercially prepared ice cream, malted milk, and all food and beverages containing wheat, rye, oats, or barley.
The other choices do not contain gluten and are permitted when on a gluten free diet.
Question 73
The client is prescribed morphine. The client is experiencing urinary retention. The nurse understands
the physician may order which of the following?
a lowered dose of morphine
a mild laxative
increased fluid intake

increased fiber intake

Incorrect. The answer is

a lowered dose of morphine
Explanation:
The correct answer is: a lowered dose of morphine. If the client experiences the side effect of urinary retention due
to the morphine, the physician may order a change in the dose or a lowered dosing of morphine. Also, the physician
may instruct the nurse to catherize the client. The remaining answer choices are incorrect as they are orders the
physician may give for other conditions such as constipation.
Question 74
The nurse documents scalp edema that crosses the lines of the skull in the newborn as what?
molding.
cephalohematoma.
cranial distention.
caput succedaneum.

Incorrect. The answer is

caput succedaneum.
Explanation:
The correct answer is caput succedaneum. Since a caput succedaneum is just superficial and beneath the scalp,
the swelling can cross the suture lines. Molding is overriding of the cranial plates, and cephalohematoma does not
cross the suture lines, since it results when blood is trapped beneath the periosteum. Cranial distention is not a
term used in newborn assessment.
Question 74
The nurse documents scalp edema that crosses the lines of the skull in the newborn as what?
molding.
cephalohematoma.
cranial distention.
caput succedaneum.

Incorrect. The answer is

caput succedaneum.
Explanation:
The correct answer is caput succedaneum. Since a caput succedaneum is just superficial and beneath the scalp,
the swelling can cross the suture lines. Molding is overriding of the cranial plates, and cephalohematoma does not
cross the suture lines, since it results when blood is trapped beneath the periosteum. Cranial distention is not a
term used in newborn assessment.
Question 75
A 21-year-old female is diagnosed with dysthymic disorder. When obtaining a history from the
female, what information should the nurse expect?
experienced compulsive behavior
intense fear

irritability
talking excessively

Correct. The answer is

irritability
Explanation:
The correct answer is irritability. In young adults and children, the symptoms noted with dysthymic disorder include
irritability, depression, low self esteem, pessimism, and impaired social skills and social interactions. Talking
excessively is more evident with children who have attention deficit hyperactivity disorder. Intense fear is
associated with anxiety disorders. Further, compulsive behavior is not associated with individuals diagnosed with
dysthymic disorder.
Question 76
The nurse is teaching accident prevention to the parents of a toddler. Which instruction is MOST
appropriate for the nurse to tell the parents?
The toddler should wear a helmet when rollerblading.
Place locks on cabinets containing toxic substances.
Teach the toddler water safety.
Do not allow the toddler to use pillows when sleeping.

Incorrect. The answer is

Place locks on cabinets containing toxic substances.
Explanation:
Correct answer:
Place locks on cabinets containing toxic substances
All household cleaners and poisons should be locked with childproof locks. The toddler's curiosity and the ability to
climb and open doors and drawers makes poisoning a concern in this age group. Rollerblading is not an
appropriate activity for toddlers. Toddlers lack the cognitive development to understand water safety. Pillows should
not be placed in the crib of an infant to avoid suffocation; however, toddlers may use them.
Question 77
A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The
nurse should monitor this client for which of the following?
Nausea and vomiting.
Dyspnea and cyanosis.
Fatigue and weakness.
Thrush and circumoral pallor.

Correct. The answer is

Fatigue and weakness.
Explanation:
Correct answer:
Fatigue and weakness
RBCs carry oxygen throughout the body. Decreased RBC production diminishes cellular oxygen, leading to fatigue
and weakness. Nausea and vomiting may occur in CRF, but do not result from faulty RBC production. Dyspnea and
cyanosis are associated with fluid excess, not CRF. Thrush, which signals fungal infection, and circumoral pallor
which reflects decreased oxygenation, are not signs of CRF.

Question 78
Which of the following is a high risk factor for diabetes mellitus?
A history of being overweight 10 pounds
Native American
A great-grandparent with diabetes
A sweet tooth

Incorrect. The answer is

Native American
Explanation:
The correct answer is B. The highest risk factors include: Native Americans, obesity (BMI of 30 or higher), and an
immediate family history (sibling or parent). African American and Hispanic populations are also at high risk.

Question 79
Which of the following patients would a nurse not administer Erythromycin to?
A person with multiple sclerosis.
A person with pneumonia
A person with a gun shot wound.
A person with an infection after surgery.

Correct. The answer is

A person with multiple sclerosis.
Explanation:
Correct answer:
A person with multiple sclerosis
An antibiotic is indicated if there is a possible infection. Multiple sclerosis is not characterized by infections.
Question 80

There are many rights to the patient when they are hospitalized. Which of the following is NOT a
right to be considered with these patients?
The right to have an advanced directive.
The right to expect that medical records are confidential.
The right to consent or refuse to take part in research.
The right to bring their own personal protection devices and medications into a health
care facility.
Correct. The answer is
The right to bring their own personal protection devices and medications into a health care facility.
Explanation:

The Correct answer is:

The right to bring their own personal protection devices and medications into a health care facility.
The client is not allowed to bring weapons or medications into a health care facility as delegated by hospital rules,
policies, and procedures. The other answers (a, b, and c) are all rights of the client.
Question 81
A client changes topics quickly while relating past psychiatric history. This client's pattern of thinking
is called what?
Looseness of association.
Flight of ideas.
Tangential thinking.
Circumstantial thinking.

Incorrect. The answer is

Flight of ideas.
Explanation:
Correct answer:
Flight of ideas
Flight of ideas describes a thought pattern in which a client moves rapidly from one topic to the next with some
connection. Looseness of association describes a pattern in which ideas lack an apparent logical connection to one
another. Tangential thoughts seem to be related but miss the point. A client who talks around the subject and
includes a lot of unnecessary information is exhibiting circumstantial thinking.
Question 82
The nurse is developing a plan of care for the client in a crisis state. When developing the plan, the
nurse considers which of the following?
Presenting symptoms in a crisis situation are similar for all individuals experiencing a
crisis.
A client's response to a crisis situation is individualized and what constitutes a crisis for
one person may not constitute a crisis for another person.
A crisis state indicates that the individual is suffering from a mental illness.
A crisis state indicates that the individual is suffering from an emotional illness.

Correct. The answer is

A client's response to a crisis situation is individualized and what constitutes a crisis for one person may
not constitute a crisis for another person.
Explanation:
The Correct answer is:
A client's response to a crisis situation is individualized and what constitutes a crisis for one person may
not constitute a crisis for another person.
A crisis response can be described in similar terms, what constitute a crisis for one person may not constitute a
crisis for another person because each person is unique. A crisis state does not mean that the person has an
emotional or mental illness.
Question 83
The nurse is performing wound care. Which of the following practices violates surgical asepsis?
Holding sterile objects above the waist.
Considering a 1" edge around the sterile field as being contaminated.

Pouring solution onto a sterile field cloth.

Opening the outermost flap of a sterile package away from the body.

Incorrect. The answer is

Pouring solution onto a sterile field cloth.
Explanation:
Correct answer:
Pouring solution onto a sterile field cloth
Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry
microorganisms to the sterile field via capillary action. The other choices are practices that help ensure surgical
asepsis.
Question 84
The nurse assesses a child who is dehydrated. The child has lost 15% of his body weight. The nurse
suspects what of the child?
The child is not dehydrated any longer
The child has mild dehydration
The child has moderate dehydration
The child has severe dehydration

Correct. The answer is

The child has severe dehydration
Explanation:
The correct answer is the child has severe dehydration. When a child has lost 10% of his or her body weight during
dehydration, this indicates the child has severe dehydration. Mild dehydration is indicated when the child has lost
up to 5% of his or her body weight. Moderate dehydration is represented when the child has lost 6-9% of his or her
body weight.
Question 85
After running several tests, Dr. Smith realizes that the microorganisms in his patient, Tom are rapidly
multiplying. However, the microorganisms are not causing any damage. This multiplication of
microorganisms is known as which of the following?
Colonization.
Infectious agent.
Particulate respirator.
Reservoir.

Correct. The answer is

Colonization.
Explanation:
Correct answer:
Colonization
An infectious agent is an organism that can cause disease. A particulate respirator is a mask worn on the faces of
medical personnel. They block organisms from entering the body. A reservoir is a place where the conditions are
conducive for the growth and development of microorganisms.
Question 86
A client asks the nurse what treatments are used for xerosis. Which intervention should the nurse

include in a teaching plan for the client?

Use perfumes and lotions with alcohol.
Use hot water when taking a bath.
Use a humidifier.
Apply heating pads to reduce pruritus.

Incorrect. The answer is

Use a humidifier.
Explanation:
Correct answer:
Use a humidifier
Xerosis, which is dry skin, is caused by heat and low humidity. Therefore, it is important to use a humidifier to add
moisture to the air in order to relieve dry, itchy skin.
Question 87
An infant is startled by a loud noise. The nurse understands this reaction to the loud noise is the the
result of:
Tonic neck reflex
Moro reflex
Steeping reflex
Babinski reflex

Incorrect. The answer is

Moro reflex
Explanation:
The correct answer is:
Moro reflex
The Moro reflex is used to determine an infant's nervous system maturity. This reflex goes away when a child
reaches 4 months old. Typically, when a child hears a loud noise or reacts to a sudden change in a position, this
reflex occurs.
Question 88
Which of the following is a brand name for Buspirone?
Librium.
Valium.
BuSpar.
Concerta.

Correct. The answer is

BuSpar.
Explanation:
Correct answer:
BuSpar

Choice A is a brand name for Chlordiazepoxide. Choice B is a brand name for Diazepam. Choice D is a brand
name for Methylphenidate HCL.
Question 88
Which of the following is a brand name for Buspirone?
Librium.
Valium.
BuSpar.
Concerta.

Correct. The answer is

BuSpar.
Explanation:
Correct answer:
BuSpar
Choice A is a brand name for Chlordiazepoxide. Choice B is a brand name for Diazepam. Choice D is a brand
name for Methylphenidate HCL.
Question 89
Which of the following phases of disaster management is primarily concerned with physical and
mental health and safety of the disaster response team?
Preparedness.
Recovery.
Mitigation.
Response.

Correct. The answer is

Response.
Explanation:
Correct answer:
Response
Choice A looks for the most effective way of caring for a patient once a disaster occurs. Choice B takes into
consideration the actions necessary for everyone to return to a state of normalcy after a disaster. Choice C takes
into consideration the actions that can help prevent the occurrence of a disaster.
Question 90
The nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to
promote optimal immunologic function. Autoimmunity has been linked to excessive ingestion of what?
Protein.
Fat.
Vitamin A.
Zinc.

Incorrect. The answer is

Fat.

Explanation:
Correct answer:
Fat
A diet containing excessive fat seems to contribute to autoimmunity - overreaction of the body against constituents
of its own tissues. Immune dysfunction has been liked to deficient - not excessive - intake of protein, vitamin A and
zinc.
Question 91
According to studies done on gay and lesbian families, what significant differences might be expected
in parent/child and peer relationships of children raised in a gay/ lesbian household as compared with
traditional heterosexual parenting?
children seem to experience no differences
children fighting more with the biological parent
children fighting more with the partner of the biological parent
children being more inclined to use drugs

Incorrect. The answer is

children seem to experience no differences
Explanation:
The correct answer is children seem to experience no differences. No significant differences have been found.
There is no evidence that children fight with the biological parent or with the partner of the biological parent
significantly more in gay and lesbian families. It has not been found that children in gay and lesbian families are
more inclined to use drugs.
Question 91
According to studies done on gay and lesbian families, what significant differences might be expected
in parent/child and peer relationships of children raised in a gay/ lesbian household as compared with
traditional heterosexual parenting?
children seem to experience no differences
children fighting more with the biological parent
children fighting more with the partner of the biological parent
children being more inclined to use drugs

Incorrect. The answer is

children seem to experience no differences
Explanation:
The correct answer is children seem to experience no differences. No significant differences have been found.
There is no evidence that children fight with the biological parent or with the partner of the biological parent
significantly more in gay and lesbian families. It has not been found that children in gay and lesbian families are
more inclined to use drugs.
Question 92
Which of the following is an adverse reaction of phenelzine sulfate (Nardil)?
Nausea.
Tachypnea.
Headache.

Anxiety.

Incorrect. The answer is

Tachypnea.
Explanation:
Correct answer:
Tachypnea
Phenelzine sulfate (Nardil) is a antidepressant that belongs to the class of drugs called monoamine oxidase
inhibitors (MAOI). When taking this drug, the common adverse reactions are tachypnea, tachycardia, tremors,
seizures and heart block.
Question 93
Which of the following types of wounds is characterized by black, dry tissue?
Yellow wounds.
White wounds.
Red wounds.
Black wounds.

Correct. The answer is

Black wounds.
Explanation:
Correct answer:
Black wounds
Wounds are divided into the following types: black wounds, yellow wounds and red wounds. Black wounds are
necrotic, dry tissue that are prone to infection. In order to remove the dead tissue, surgical abridgement is used.
Question 93
Which of the following types of wounds is characterized by black, dry tissue?
Yellow wounds.
White wounds.
Red wounds.
Black wounds.

Correct. The answer is

Black wounds.
Explanation:
Correct answer:
Black wounds
Wounds are divided into the following types: black wounds, yellow wounds and red wounds. Black wounds are
necrotic, dry tissue that are prone to infection. In order to remove the dead tissue, surgical abridgement is used.
Question 94
A client with major depression frequently is irritable, abrasive, and uncooperative and refuses to
participate in group activities. When working with this client, the nurse should use which approach?
Firmness.

Joyfulness.
Humor.
Aloofness.

Incorrect. The answer is

Firmness.
Explanation:
Correct answer:
Firmness
By taking a firm approach, the nurse sets limits and establishes boundaries for the client's behavior, which helps
ensure safety and gives the client a sense of control. A joyful or humorous approach may make the client feel guilty
about being depressed. An aloof approach does not enable the client to initiate interpersonal contact or encourage
communication.
Question 95
Nurses require leadership skills. Of the following leadership types, which relinquishes some control to
the members of the group?
Democratic.
Situational.
Autocratic.
Laissez-faire.

Incorrect. The answer is

Laissez-faire.
Explanation:
Correct answer:
Laissez-faire
The type of leader in Choice A actively seeks input from members of the group. Situational leaders are flexible and
utilize a combination of the other leadership types depending on the most effective way of completing the task. An
autocratic leader dominates the group rather than seeking suggestions from the group.
Question 96
The nurse has been ordered to collect a sputum specimen from a client. The professional nurse
knows which of the following will facilitate obtaining the specimen?
Having the client take three deep breaths.
Asking the client to spit into the collection container.
Limiting fluids.
Asking the client to obtain the specimen after eating.

Incorrect. The answer is

Having the client take three deep breaths.
Explanation:
The Correct answer is:
Having the client take three deep breaths.
The proper procedure to collect a specimen includes rinsing the mouth out to reduce contamination, breathe

deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit
so as to obtain sputum. Sputum can be thinned by fluids or inhalation respiratory treatments so the best time to
collect the specimen is early a.m. upon arising.
Question 97
When testing a client's pupils for accommodation, the nurse should interpret which findings as
normal?
Constriction and divergence
Dilation and convergence
Constriction and convergence
Dilation and divergence

Correct. The answer is

Constriction and convergence
Explanation:
The correct answer is:
Constriction and convergence
During accommodation, the pupils should constrict and converge equally on an object. Pupils normally dilate in
darkness and when a person stares at an object across a room. Divergence is never a normal response.
Question 98
The nurse is performing a psychosocial assessment on an adolescent age 14. Which emotional
response is typical during early adolescence?
Frequent anger.
Cooperativeness.
Moodiness.
Combativeness.

Correct. The answer is

Moodiness.
Explanation:
Correct answer:
Moodiness
During early adolescence, a child may become moody. Frequent anger and combativeness are more typical of
middle adolescence. Cooperativeness typically occurs during late adolescence.
Question 99
The day after delivery, a new mother asks why her milk is so creamy and yellow. What is the best
response for the nurse to make?
"I would not worry about it."
"This is normal. It will soon turn to real milk."
"You are coming along fine."
"You have not gotten your milk in yet."

Correct. The answer is

"This is normal. It will soon turn to real milk."

Explanation:
The correct answer:
"This is normal. It will soon turn to real milk."
The client is describing colostrum. Milk comes in about 72 hours after delivery. "I would not worry about it" and "you
are coming along fine" do not address the question asked by the mother.
Question 99
The day after delivery, a new mother asks why her milk is so creamy and yellow. What is the best
response for the nurse to make?
"I would not worry about it."
"This is normal. It will soon turn to real milk."
"You are coming along fine."
"You have not gotten your milk in yet."

Correct. The answer is

"This is normal. It will soon turn to real milk."
Explanation:
The correct answer:
"This is normal. It will soon turn to real milk."
The client is describing colostrum. Milk comes in about 72 hours after delivery. "I would not worry about it" and "you
are coming along fine" do not address the question asked by the mother.
Question 100
The nurse is caring for a client with chest trauma. Which nursing diagnosis takes highest priority?
Impaired gas exchange.
Anxiety.
Decreased cardiac output.
Ineffective cardiopulmonary tissue perfusion.

Correct. The answer is

Impaired gas exchange.
Explanation:
Correct answer:
Impaired gas exchange
For a client with chest trauma, a diagnosis of impaired gas exchange takes priority because adequate gas
exchange is essential for survival. Although the other options are possible nursing diagnoses for this client, they
take lower priority.