CD-Rom: Practice Examination #3

CD Rom: Practice Exam 3

CD-Rom: Practice Examination 3

1. A client who has hypothyroidism and has 4. A nurse in the prenatal clinic has a nutri-
been taking levothyroxine (Synthroid) for tional conference with a primigravida who
four weeks is seen in the clinic for follow-up is ten weeks pregnant. Which of these com-
care. Which of these client statements ments, if made by the woman, would be an
would indicate a need to alter the dosage of accurate statement about nutritional needs?
the medication? A. “Since I don’t like to drink milk, I’ve been
A. “I have lost two pounds in three weeks.” using it in my cooking and eating extra
B. “My fingernails are growing so slowly.” cheese.”
C. “I had diarrhea one day last week.” B. “I’m being careful with my weight. I’ll be sure
D. “I have difficulty falling asleep.” to gain no more than sixteen pounds with
the pregnancy.”
2. A child has a suprapubic catheter following a C. “I’ll be using a salt substitute instead of salt
re-implantation of the ureters into the urinary throughout my pregnancy.”
bladder. Prior to administering an antispas- D. “If I take multivitamins, then it will be all right
modic to the child, the nurse should make for me to continue to omit my lunch.”
which of these assessments?
A. Does the child have pain in the thoracic area 5. An infant who has pyloric stenosis has been
of the back? receiving fluids intravenously. An expected
B. Does the child have cramping pain in the outcome of this therapy would be manifested
legs? by an increase in the child’s
C. Does the child have incisional pain? A. appetite.
D. Does the child have intermittent cramping B. pulse rate.
pain in the lower abdomen? C. weight.
D. level of consciousness.
3. A client is admitted to the hospital with
acute adrenocortical insufficiency 6. A homeless man who is poorly nourished
(Addisonian crisis) and is to receive a corti- attends the clinic to have blood work done.
costeroid preparation intravenously. During Because of his malnourished condition, the
the drug therapy, which of these assess- nurse would expect a decrease in which of
ments of the client is important? these blood values?
A. Measuring abdominal circumference A. Blood urea nitrogen
B. Determining presence of pedal edema B. Serum glucose
C. Recording urinary output C. Serum total protein
D. Counting respiratory rate D. Serum creatinine

7. A client who had a myocardial infarction has

an order for digoxin (Lanoxin) 0.25 mg po
daily and furosemide (Lasix) 40 mg intra-
venously, stat. Because the client is receiving
these medications, the client should be
assessed for which of the following
manifestations?
A. Oliguria
B. Hypertension
C. Tachycardia
D. Hypokalemia

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 CD Rom: Practice Exam 3

8. A woman who is in a methadone program 13. An 80-year-old woman who lives alone is
delivers a full-term infant. Her infant would be brought to the emergency room by ambu-
expected to have which of these symptoms? lance when her daughter finds her on the
A. High-pitched cry floor, too weak to get up by herself. At the
B. Poor sucking reflex time of admission, which of these assess-
C. Decreased deep tendon reflexes ments should the nurse do initially?
D. Jaundice A. Test deep tendon reflexes
B. Obtain vital signs
9. A client who has a diagnosis of glaucoma C. Check pupillary response
should be instructed to avoid which of these D. Evaluate mental status
activities?
A. Lifting heavy objects 14. A client who is receiving intravenous fluids
B. Lying flat in bed complains of pain at the intravenous inser-
C. Drinking beverages that are high in caffeine tion site. The nurse should be aware that
D. Eating foods that are high in potassium which of these observations indicates intra-
venous infiltration?
10. A young man is being assessed for early A. Red streak along the vein
signs of narcotic withdrawal, which include B. Blood return in the tubing when the
A. yawning and perspiring. intravenous bag is lowered
B. syncope and pulse deficit. C. Edema at the needle insertion site
C. drowsiness and fruity order of the breath. D. Increased warmth of the skin over the
D. bradycardia and headache. needle site

11. An 18-month-old is brought to the well-baby
clinic. The nurse should expect the child to
manifest which of these behaviors if the
child’s growth and development is within
normal range?
A. The child speaks in sentences of three to
four words.
B. The child identifies her own sex when asked.
C. The child can copy a circle.
D. The child points to specific body parts upon
request.
15. Methimazole (Tapazole) is ordered for a
client with hyperthyroidism. Since Tapazole
may cause leukopenia, the nurse should give
the client which of these instructions?
A. “Eat two or three servings of foods high in
iodine each day.”
B. “Contact the doctor if you develop a sore
throat.”
C. “Be sure to drink approximately three liters
of fluid daily.”
D. “Use a soft toothbrush to brush your teeth.”

12. Shortly after a transfusion is started, the 16. A client who has hypothyroidism is given
client complains of lower back pain. Which instructions about levothyroxine
of these actions should the nurse take first? (Synthroid). Which of these client state-
ments would indicate the need for further
A. Notify the physician instructions?
B. Reposition the client
C. Discontinue the transfusion A. “I will need to take the medication daily for
D. Check the client’s temperature the next year.”
B. “I will plan to take the medication every day
at bedtime.”
C. “I will take the medication with a glass of
water.”
D. “I will weigh myself before I take the
medication.”

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 CD Rom: Practice Exam 3

17. A hospitalized client is being treated for 21. An individual who is addicted to narcotics
depression. Which of the following behav- has been on a methadone program. Which
iors indicates an improvement in the client’s of these client symptoms would indicate to
depression? the nurse that the methadone dose was not
A. He eats his meals in his room sufficient?
B. He makes an appointment with the barber A. Anxiety
C. He indicates a need to meet with his B. Hypertensive crisis
girlfriend C. Hallucinations
D. He expresses a desire to be discharged D. Syncope

18. A 7-year-old has pediculosis capitis (head 22. A client has a prescription for ferrous glu-
lice). His mother is given medicated sham- conate (Fergon). In order to increase the
poo and information about head lice and its absorption of Fergon, the client should be
treatment. Which of these comments by the instructed to include which of these foods in
mother indicates that she needs further the diet?
instructions? A. Milk
A. “I’ll get rid of my child’s head lice as soon as B. Yellow vegetables
possible so that he won’t start losing his hair.” C. Whole wheat bread
B. “I’ll use a fine tooth comb to remove all the D. Orange juice
eggs from my child’s hair.”
C. “I’ll be sure to wash all the bed linen and 23. A client has been admitted to the psychiatric
towels in hot, soapy water.” unit with an eating disorder. Which of these
D. “I’ll have everyone in the family shampoo measures should be included in the client’s
their hair with the medicated shampoo.” care plan?
A. Restricting the client’s fluid intake before
19. At ten weeks of pregnancy, a woman is most meals
likely to make which of these comments B. Sitting with the client during and after meals
when describing her physical well being C. Encouraging the client to eat in the cafeteria
during the first trimester? with her family
A. “I seem to have so much energy lately.” D. Having the dietitian select a high-protein diet
B. “My breasts feel tender.” for the client
C. “I’ve been having some hard stools lately.”
D. “Sometimes I have palpitations when I climb 24. To determine if a client has symptoms of
a flight of stairs.” hyperkalemia, which of these assessments
would provide the most accurate information?
20. A nurse in the prenatal clinic notices that a A. Test the client’s patellar reflex
woman at thirty-six weeks of pregnancy has B. Auscultate the client’s abdomen
1+ ankle edema. To assess the significance of C. Evaluate the client’s heart rhythm
this finding, the nurse should obtain the D. Take the client’s blood pressure
answer to which of these questions?
A. “Do you have any pain on urination?”
B. “Have you noticed that your rings are some-
times tight on your fingers?”
C. “How much fluid do you drink in a day?”
D. “Which spices do you add to your food
when you are cooking?”

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 CD Rom: Practice Exam 3
25. Two weeks after a 10-year-old has been treated
in the hospital for an acute asthma attack, he
asks the nurse, “Can I rejoin my baseball team
because practice starts in two weeks?” Which
of these responses would be appropriate for
the nurse to make?
A. “You should participate mainly in sedentary
and noncompetitive activities.”
B. “You should continue in any activities that
you can tolerate.”
C. “It would be best for you to engage in indoor
sports.”
D. “It would be best for you to limit activities that
would increase your respiratory rate.”
26. Following abdominal surgery, a child has a
nasogastric tube connected to suction.
Several hours after surgery, the child tells
the nurse that he is nauseated and then vom-
its approximately 200 ml of fluid. Which of
these actions should the nurse take first?
A. Notify the physician
B. Check if the nasogastric tube can be
irrigated
C. Discontinue the section attached to the
nasogastric tube
D. Auscultate for bowel sounds
27. A client who had a right pneumonectomy
should be assessed for the development of a
mediastinal shift. To detect a manifestation
of this condition, which of these assess-
ments should the nurse consider?
A. Is there a hyperresonance over the client’s
left chest?
B. Do the client’s breath sounds have a high-
pitched whistling tone on
expiration?
C. Are the client’s intercostal muscles in
spasm?
D. Has the client’s trachea shifted to the left of
his midline?
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28. A woman is admitted to the hospital in labor.
On admission, the fetal heart rate is 136 beats
per minute. One half-hour later the fetal
heart rate is 124 beats per minute. Which of
these actions should the nurse take first?
A. Elevate the client’s legs so that they are
higher than her uterine fundus
B. Continue to monitor the fetal heart rate
C. Discuss the findings with the physician
D. Instruct the client to take deep breaths
through her mouth
29. To encourage a client with type 2 diabetes to
comply with his prescribed diet, the nurse
should obtain the answer to which of these
questions?
A. Does the client include at least one serving
of each of the basic food groups in every
meal?
B. At what times does the client eat meals?
C. What are the client’s food preferences?
D. What method of food preparation does the
client use?
30. The mother of a 1-month-old girl tells the
nurse in the well baby clinic that her 2-year-
old son does not seem to like the baby. He
pretends that he is going to kiss the baby but
instead pinches or hits her. Which of these
responses would be appropriate for the
nurse to make to the mother?
A. “Could you spend time with your 2-year-old
while your infant is sleeping?
B. “Have you tried pinching your 2-year-old
whenever he does it to your daughter so
that he knows how it feels?”
C. “It’s a good idea to keep your infant and
your 2-year-old separated as much as pos-
sible until he stops this behavior.”
D. “Whenever your 2-year-old pinches or hits
your infant, say ‘no’ to him and give him a
toy to distract him.”

31. A nurse in the antepartal clinic discusses
health practices during pregnancy with a
woman who is six weeks pregnant. Which of
these comments by the woman indicates that
further discussion is necessary?
A. “I plan to continue my jogging for at least
the next 3 to 4 months.”
B. “I’m hoping to continue working as a
secretary until two weeks before my
due date.”
C. “My husband and I are going to drive about
500 miles to visit my parents, but we’ll stop
to exercise periodically.”
D. “My husband and I enjoy wine every day
with our dinner.”
32. A nurse should observe a child on steroid
therapy for adverse effects, which include
A. hair loss.
B. a decrease in pulse rate.
C. hypertrophy of the gums.
D. an increase in appetite.
33. A client who has a history of bipolar disor-
der is admitted to a psychiatric unit with
signs of a manic episode. Which of these
measures would be most effective in assur-
ing the client’s safety in the hospital?
A. Setting clear limits
B. Allowing the client to establish his own
schedule
C. Ignoring the client’s behavior
D. Encouraging expression of anger
34. It is determined that a woman who is six
weeks pregnant is susceptible to rubella. It
would be appropriate for the pregnant
woman to receive rubella immunization at
which of these times?
A. Immediately
B. During the second trimester
C. Within the two weeks before her expected
delivery
D. During her postpartum hospitalization
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CD Rom: Practice Exam 3
35. A client who had chest surgery has a water
seal drainage system in place. Which of
these measures should be included in the
client’s care plan?
A. Irrigating the chest tube every 3-4 hours prn.
B. Clamping the chest tube for 10 minutes
every 4 hours.
C. Marking the level of drainage on the
collection device at least every 8 hours.
D. Changing the drainage bottle every day.
36. When assessing the growth and development
of a 6-week-old, the nurse should be aware
that which of these behaviors is within nor-
mal range?
A. Watching the mother’s face as she talks
to him.
B. Reaching for an object when it is held in
front of him.
C. Turning from his abdomen to his back.
D. Lifting his head from the mattress when lying
on his back.
37. A client is scheduled for large bowel surgery.
Preoperatively, neomycin sulfate (Mycifradin)
is ordered for which of these purposes?
A. To stimulate production of antibodies
B. To prevent respiratory infection
C. To reduce bacteria in the colon
D. To promote wound healing
38. A client had an above the knee amputation
of the right leg. To prevent contractures of
the right hip, which of these measures
should be included in the client’s care plan?
A. Having the client use an overhead trapeze to
move in the bed
B. Turning the client onto the abdomen
several times a day
C. Elevating the client’s right thigh on a pillow
D. Encouraging the client to stay out of bed
and in a chair as much as possible
 CD Rom: Practice Exam 3
39. A 24-year-old man with a diagnosis of chronic
schizophrenia is admitted to the psychiatric
unit. He is talking loudly as the nurse
approaches him. When asked who he is talk-
ing to, he says, “I hear God’s voice.” Which of
these responses by the nurse would be best?
A. “It must make you feel important to talk with
God.”
B. “I don’t hear a voice, but I know it’s real to
you.”
C. “Why do you think you’re hearing a voice?”
D. “What could be God’s reason for talking to
you?”
40. A male client who is on the psychiatric unit
asks a female nurse to go out to dinner with
him when he gets out of the hospital. Which
of these actions by the nurse would be
therapeutic?
A. Accept the invitation and comment on the
therapeutic purpose of accepting.
B. Refuse the invitation and explain that it is
inappropriate to meet clients outside of the
hospital.
C. Decline the invitation and make up a reason
for refusing.
D. Acknowledge the compliment implied by the
invitation and clarify the respective roles of
the nurse and the client.
41. A child who has cystic fibrosis is to have
postural drainage four times a day. The
nurse should plan to do this treatment at
which of these times?
A. Approximately one hour before meals and at
bedtime
B. Within thirty minutes after meals and at bed-
time
C. Every six hours around the clock
D. At times that are convenient for the child
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42. A 45-year-old premenopausal woman is
admitted to the hospital for treatment of
fibroid tumors of her uterus. When taking a
nursing history, which of these additional
data about her menstrual cycle would be
most significant?
A. Experiences painful intercourse at
mid-cycle.
B. Experiences mood swings for a week prior
to the onset of her menstrual period.
C. Has dysmenorrhea for twenty hours after
onset of menses.
D. Changes sanitary pads every 2 hours during
the first two days of her menstrual period.
43. An 8-year-old child who is hospitalized with
rheumatic fever makes all of the following
comments to the nurse. Which one is indica-
tive of a symptom of rheumatic fever?
A. “Sometimes I have pain in my knees, then it
goes away and my elbows hurt.”
B. “I don’t feel hungry in the mornings anymore.”
C. “I have a big black and blue spot on my hip
where I got hit by a baseball yesterday.”
D. “I’ve been yawning a lot lately.”
44. Following a tonsillectomy, it is important to
include which of these measures in the
child’s care plan?
A. Observing for frequent swallowing
B. Encouraging deep breathing and coughing
C. Applying warm compresses to the neck
D. Palpating the neck for edema
45. A teenager who has been on a course of
chemotherapy has a blood test the reveals a
low platelet count. Which of these measures
should be included in the teenager’s care plan?
A. Having the teenager use a soft-bristled
toothbrush.
B. Providing the teenager’s visitors with masks.
C. Encouraging the teenager to take
frequent rests.
D. Urging the teenager to have a high fluid
intake.

46. A nurse is planning to discuss nutritional
needs during pregnancy with a teenager.
Which of these measures should initially be
included in the teaching plan?
A. Asking her whether she eats most of her
meal’s at home.
B. Obtaining a list of foods she eats during a
typical forty eight hour period.
C. Furnishing her with a list of foods that are
contained in the basic food groups.
D. Giving her information about which foods
are high in iron.
47. A client is receiving peritoneal dialysis. The
nurse instills 2000 ml of dialysate solution.
The return is 1000 ml. The nurse should take
which of these actions next?
A. Irrigate the client’s catheter.
B. Instill the next prescribed amount of
dialysate to the client.
C. Turn the client from side to side.
D. Replace the client’s drainage tubing.
48. A 6-month-old infant is receiving an antibiot-
ic in 25 ml of intravenous fluid during a forty
minute period. The intravenous apparatus
delivers 60 drops per milliliter. The infant
should receive how many drops per minute?
A. 18
B. 28
C. 38
D. 48
49. A 31/2 -year-old is prescribed digoxin
(Lanoxin) po. In view of the child’s age,
which of these approaches by the nurse
would be most effective in getting the child
to take his medication?
A. “If you take your medicine, you’ll get to go
home sooner.”
B. “I know that you are a good boy and will
take your medicine for me.”
C. “Here is your medicine. Do you want to take
it with water or juice?”
D. “Are you ready to take your medicine now,
or do you want me to come back in ten
minutes?”
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CD Rom: Practice Exam 3
50. On the second day postpartum, a nurse
assesses a woman who had a normal deliv-
ery. The nurse should expect which of these
types of lochia at this time?
A. Creamy yellowish discharge streaked with
red
B. Dark red discharge without clots
C. Clear thin pink-tinged discharge
D. Light brown discharge with a few clots
51. A client has an order to receive 1000 ml of
intravenous fluids in 8 hours. The intra-
venous set delivers 60 microdrops per ml.
The nurse should administer approximately
how many microdrops of fluid per minute?
A. 21
B. 40
C. 63
D. 125
52. The mother of a 2-month-old says to the
nurse in the pediatrician’s office, “I plan to
start feeding cereal to my baby because she
doesn’t seem satisfied with her formula. She
still wakes up a couple of times a night to be
fed.” Which of these responses should the
nurse make?
A. “How much formula is your baby taking now?”
B. “That sounds like a good idea. Probably you
could add some rice cereal to your baby’s
bedtime formula.”
C. “Have you thought about giving your baby
some strained fruit for her first food?”
D. “Do you think your baby doesn’t like the
taste of the cereal?”
53. A 4-month-old infant on the pediatric unit is
to receive elixir of digoxin (Lanoxin) 39
micrograms po. The bottle of Lanoxin is
labeled 50 micrograms per ml. The infant
should receive how many milliliters of the
medication?
A. 0.06
B. 0.08
C. 0.6
D. 0.8
 CD Rom: Practice Exam 3
54. An infant on the pediatric unit suddenly starts
to have generalized seizure activity. Which of
these actions should the nurse take first?
A. Insert a padded tongue blade into the
infant’s mouth.
B. Note the duration of the infant’s seizure.
C. Test the infant’s pupillary response to light at
least twice during the seizure.
D. Suction the infant’s oropharynx several times
during the seizure.
55. A nurse is discussing nutrition with a client
who has a permanent colostomy because of
cancer in the bowel. The client says, “Can I
eat everything”? Which of these responses
would give the client accurate information?
A. “You will have to remain on a low residue
diet.”
B. “You can eat any food that agrees with you.”
C. “You will need to wait until healing is
complete before you can tell.”
D. “You will have intermittent diarrhea if a diet
isn’t followed.”
56. To prevent the development of dumping
syndrome after a client has had a gastrecto-
my, the nurse should give the client which
of these instructions?
A. “Eliminate fatty foods from your diet.”
B. “Eat a diet high in carbohydrates.”
C. “Sit upright in a chair for at least thirty
minutes after each meal.”
D. “Refrain from drinking liquids with your
meals.”
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57. The mother of a preschooler who occasion-
ally has symptoms of croup at night says to
the nurse in the physician’s office, “I wish I
knew what to do to help my child when this
happens to her.” Which of these instructions
would be appropriate for the nurse to give to
the mother?
A. “Whenever your child begins to have symp-
toms of croup, take her to the bathroom
and turn on the hot water.”
B. “If your child begins to have symptoms of
croup, give her sips of a mixture of lemon
and honey.”
C. “Your child will be less apt to get croup if
you withhold milk and milk products before
her bedtime.”
D. “Your child will be less apt to get croup if
her bed linen is washed with a hypoaller-
genic soap.”
58. Which of these behaviors indicates that a
client who has chronic schizophrenia is
establishing trust?
A. The client approaches the nurse and calls
the nurse by name.
B. The client describes his delusions in detail.
C. The client dresses in his own clothes.
D. The client expresses a desire for his own
apartment.
59. A mother in the well baby clinic makes the
following comments about her 8-month-old
infant son. Which comment should definite-
ly be discussed with the mother?
A. “His four year old sister helps me diaper him.”
B. “He enjoys feeding himself crackers.”
C. “He is drooling a lot lately.”
D. “He likes to take his naps on our bed.”

60. A 3-month-old infant is transferred from the
neonatal intensive care unit following sur-
gery to repair a meningomyelocele in the
lumbosacral area. In view of the infant’s sur-
gery, it is essential for the nurse to make
which of these assessments of the infant?
A. Color of the stools.
B. Mobility of the lower extremities.
C. Quality of the patellar reflex.
D. Capillary refill.
61. One day after a client has a right femoral
popliteal bypass graft all of the following
assessments are made. Which assessment
reveals that the surgical procedure has
achieved the desired outcome?
A. The client’s affected leg feels warm to touch.
B. The client’s blood pressure is stable.
C. The client’s serum electrolytes are within
normal limits.
D. The client’s leg dressing has no evidence of
bleeding.
62. A client who is scheduled for a pulmonary
function test is instructed by the nurse as to
what the test will involve. Which of these
client statements indicates an understanding
of the procedure?
A. “My heart and lung function will be meas-
ured while I am riding a stationary bike.”
B. “My blood will be drawn while I am
breathing room air and receiving oxygen.”
C. “I will be asked to breathe into a machine
using maximum effort on inspiration and
expiration.”
D. “I will have blood drawn to measure oxygen
levels before and after the nebulizer
treatment.”
63. In preparing a client for an intravenous pyelo-
gram (IVP), which of these statements should
be included in the nurse’s teaching?
A. “The x-ray table will be tilted while your
x-rays are taken.”
B. “You will need to drink several glasses of
fluid the morning of the procedure.”
C. “You will experience a warm sensation when
the dye is injected.”
D. “You will need to remain flat in bed for six
hours after the procedure.”
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CD Rom: Practice Exam 3
64. At 16 months of age, an infant would most
likely receive a immunization against
A. measles.
B. typhoid.
C. roseola.
D. chicken pox.
65. Four mothers and their children are attend-
ing the clinic. While discussing nutrition, the
mothers make the following comments
about their children. The comment of which
mother indicates that the nurse should dis-
cuss the situation with the mother?
A. The mother of an 11-month-old girl says,
“My daughter drinks about one and a half
liters of milk a day.”
B. The mother of a 15 month old boy says, “My
son will eat nothing unless he can pick it up
and eat it with his fingers.”
C. The mother of a 2-year-old boy says, “My
son won’t eat cooked green beans, but he
eats them raw.”
D. The mother of a 3-year old girl says, “My
daughter eats everything that her father and
I eat, even spicy foods that I learned to eat
only as an adult.”
66. A mother makes all of the following com-
ments to the nurse in the pediatric clinic
about her 3-year-old son. Which one should
be investigated?
A. “My son is dry most of the time during the
day, but still wets the bed at night.”
B. “We leave a small light on in my son’s room
at night.”
C. “My son carries his blanket everywhere. He
even has a small piece of it that he keeps in
his pocket.”
D. “Sometimes my son seems so clumsy. He
bumps into furniture that is in his way.”
 CD Rom: Practice Exam 3

67. A 3 year old girl has gluten-induced 71. A child who is on a course of chemotherapy
enteropathy (celiac disease) and is to receive for osteogenic carcinoma develops neutrope-
a diet that is low in gluten. The child’s heath nia. It is important for the nurse to include
problem and diet are discussed with her which of these measures in the child’s
mother. Which of the following statements care plan?
indicates that the mother needs further A. Applying a lanolin-based emollient to the
instruction about the child’s diet? child’s skin.
A. “She has an egg for breakfast about three B. Determining whether the child has pain in
times a week.” the lower extremities.
B. “I peel the skin from fruit before I give any C. Observing the child for signs of infection.
to her.” D. Encouraging the child to drink fluids high in
C. “I’m glad she likes chicken.” vitamin C.
D. “She loves spaghetti with tomato sauce.”
72. A client who has anorexia nervosa refuses to
68. A client who has diabetes mellitus has been eat. Which of these interpretations of the
taught to recognize symptoms of hypo- client’s behavior is correct?
glycemia. Which if these client comments A. It is a way of gaining some control over
would indicate an understanding of the others.
instructions? B. It is an attempt to distract attention from the
A. “My mouth and lips will be dry.” real problem.
B. “I won’t have any appetite.” C. It is an indication that the client has an
C. “I may experience hot flashes.” organic change.
D. “I will feel quite nervous.” D. It is an indication that the client thinks the
food is poisonous.
69. A client who has an acute asthmatic attack is
being treated with epinephrine hydrochloride 73. A nurse should assess a client with an enlarged
(Adrenalin). The client should be observed prostate for which of these symptoms?
for side effects of Adrenalin, which include A. Suprapubic pain
A. epistaxis. B. Flank discomfort
B. bradycardia. C. Polyuria
C. tremors. D. Urinary frequency
D. tearing.
74. A multigravida has varicosities in both legs
70. Naloxone hydrochloride (Narcan) is admin- and is wearing antiembolic stocking. She
istered intravenously to a client who has had been given instructions about the care
overdosed on meperidine hydrochloride of her legs at the antepartal clinic during a
(Demerol). Which of these changes in the previous visit. Which of these client state-
client’s condition would indicate that the ments indicates a correct understanding of
desired effect has been achieved? the teaching?
A. The client’s blood pressure will decrease. A. “I’ve stopped crossing my legs at the
B. The client’s anxiety will lessen. knees.”
C. The client will become alert. B. “I put my stockings on as soon as my ankles
D. The client will begin to vomit. begin to swell.”
C. “I’m walking less and doing as much work
as I can while sitting at the kitchen table.”
D. “I usually apply a lotion to my legs before I
put on my stockings.”

10

75. A client in the emergency department has a
tentative diagnosis of acute anxiety attack.
Which of these actions should the nurse take
first?
A. Having the client breathe into a paper bag
B. Raising the head of the client’s stretcher
C. Putting side rails on the client’s stretcher
D. Obtaining an order to give oxygen to the
client
76. A client who has had a transurethral prosta-
tectomy is receiving intravenous fluids and
has an indwelling urethral (Foley) catheter
attached to gravity drainage. One hour earli-
er, there was drainage from the Foley
catheter, but now the nurse notes that there
is no drainage. Because of this finding,
which of these actions should be taken by
the nurse?
A. Increase the flow rate of the client’s
intravenous fluids.
B. Percuss the client’s abdomen for bladder
distention.
C. Irrigate the client’s catheter.
D. Change the client’s catheter.
77. A client who has diabetes mellitus has been
instructed in the care of her feet. Which of
these client statements would indicate the
need for further instruction?
A. “I’ll remember to cut my toenails straight
across.”
B. “I’ll stop walking around in my bare feet.”
C. “I’ll dry between my toes more carefully.”
D. “I’ll use alcohol to clean my calluses after I
trim them.”
78. A client on the psychiatric unit who has a
diagnosis of schizophrenia spends his days
sitting alone staring into space. Which of
these changes in the client’s behavior would
indicate his readiness for a rehabilitation
program?
A. He seldom hallucinates.
B. He goes to the coffee shop alone more
often.
C. He approaches the nurse at frequent
intervals.
D. He is able to sleep through the night.
11
CD Rom: Practice Exam 3
79. A child who has rheumatic fever should be
observed for symptoms of carditis. To detect
an early symptom of carditis, which of these
measures should be included in the child’s
assessment?
A. Asking the child if he has discomfort in the
left shoulder.
B. Checking the color of the buccal mucosa.
C. Obtaining the pulse rate when at rest.
D. Observing for development of dependent
edema.
80. To help meet the developmental needs of a
3-day-old infant, which of these measures is
essential to include in the infant’s care plan?
A. Giving a pacifier whenever the infant starts
to cry.
B. Stroking and talking to the infant.
C. Pacing a colorful toy within the infant’s line
of vision.
D. Turning the infant’s head from side to side at
regular intervals.
81. A client is to receive 90 ml of an antibiotic
intravenously within twenty minutes. The
drop factor of the intravenous set is 15
drops per milliliter. To give the medication
within the prescribed time, the solution
should be administered at approximately
how many drops per minute?
A. 38
B. 50
C. 68
D. 80
82. Because a child who has asthma is dyspneic,
which of these measures should be included
in the nursing care plan?
A. Offering sips of cold liquids frequently
B. Applying pressure to the epigastric area dur-
ing exhalations
C. Communicating in a way that requires the
child to use a few words to reply
D. Suctioning the nasopharyngeal area when-
ever the child has a productive sounding
cough
 CD Rom: Practice Exam 3
83. Because an infant has a meningomyelocele
in the lumbosacral area, the infant should be
observed for early symptoms of hydro-
cephalus, which include
A. An increase in head circumference
B. A soft, flat anterior fontanel
C. Overriding of cranial bones
D. Prominent scalp veins
84. A 24-year-old woman who is ten weeks preg-
nant is attending the antepartal clinic for the
first time. When the nurse is taking her his-
tory, the woman sighs and says, “I’ve wanted
to be pregnant for so long, but now I don’t
think I’m ready to be a mother.” Which of
these interpretations of the woman’s com-
ment is most justifiable?
A. She is having a normal response to the con-
firmation of her pregnancy.
B. She is displaying behavior typical of multi-
gravida but unusual for a primigravida.
C. She is demonstrating behavior that
suggests she may have difficulty coping with
the pregnancy.
D. She is at risk for developing a problem in
bonding with her newborn infant.
85. Following a transurethral prostatectomy, the
client is receiving continuous bladder irriga-
tion. Which of these findings would indicate
that the irrigation was effective?
A. Absence of infection
B. Absence of clot formation
C. Presence of diluted urine
D. Presence of urinary continence
86. A client is taking acetylsalicylic acid (aspirin)
four times daily. To minimize possible com-
plications of this therapy, the nurse should
give the client which of these instructions?
A. Avoid taking the aspirin with dairy products.
B. Drink a glass of water with the aspirin.
C. Take the aspirin one hour before meals.
D. Take the aspirin with food.
12
87. Which of these manifestations in a client
who is in alcohol withdrawal would indicate
impending delirium tremens?
A. Agitation
B. Drowsiness
C. Double vision
D. Dilation of the pupils
88. Lithium carbonate (Eskalith), 300 mg, qid, po
has been ordered for a client who has bipolar
disorder, manic type. After three weeks of
therapy, the client’s blood lithium level is 2.2
mEq per liter. Which of these nursing actions
would be appropriate?
A. Ask the physician to increase the dosage.
B. Give the medication as ordered.
C. Assess the client for symptoms of toxicity.
D. Obtain an order for sedation.
89. Following a subtotal gastrectomy, a client has
a nasogastric tube attached to low intermittent
suction. Eight hours after surgery, the client
complains of being nauseated. The nurse
should take which of these actions first?
A. Instruct the client to take deep breaths.
B. Apply a cool cloth to the client’s forehead.
C. Administer antiemetic medication to the
client.
D. Check the patency of the client’s
nasogastric tube.
90. On the second postoperative day, a woman
who gave birth to a baby girl by cesarean
operation makes all of the following com-
ments to the nurse. Which comment most
strongly suggests that there may be a problem
in bonding between the mother and baby?
A. “I won’t let the baby forget what she did to
me.”
B. “I have a picture of my baby. She is not very
pretty.”
C. “I haven’t decided between two names for
my baby.”
D. “I’m so tired. I don’t feel like going to the
nursery to feed my baby.”
 CD Rom: Practice Exam 3

91. A client is to receive heparin sodium 20,000 96. A 26-year-old is brought to the psychiatric
units in 1,000 ml. The intravenous is to be unit because of suicidal thoughts. To deter-
regulated to deliver 50 ml of solution each mine if one-to-one observation is indicated
hour. The client will receive how many units for this client, the nurse should ask which of
of heparin each hour? the following questions?
A. 500 A. Has anyone in your family ever attempted
B. 1,000 suicide?
C. 1,500 B. Do you have a plan for committing suicide?
D. 2,000 C. Have you had a recent loss of someone or
something close to you?
92. Three hours after receiving an insulin injec- D. Do you have a social support system?
tion (Regular Insulin), a client is diaphoretic.
Which of these actions should the nurse take 97. A 9-month-old is to have a lumbar puncture.
first? A major role of the nurse during this proce-
A. Notify the physician. dure is to
B. Ask the client for a urine specimen. A. palpate the child’s anterior fontanel
C. Give the client a glass of juice to drink. periodically.
D. Take a finger stick blood sugar reading. B. employ measures to prevent the child from
crying.
93. The bowel retraining program for a client C. check the child’s pedal pulses periodically.
who has had a cerebrovascular accident (CVA) D. hold the child in the chest to knee
should include which of these measures? side-lying position.
A. Checking for impaction daily
B. Increasing intake of milk products 98. Diphenoxylate hydrochloride with atropine
C. Using incontinent pads until control is sulfate (Lomotil) is prescribed for a client.
achieved The nurse would evaluate the therapeutic
D. Establishing a consistent time for effectiveness of Lomotil by assessing the
elimination client’s
A. weight.
94. The wife of a client who is admitted to the B. number of daily bowel movements.
hospital with a cerebrovascular accident C. amount of daily food intake.
(CVA) begins to cry while giving her hus- D. skin turgor.
band’s medical history. The nurse should
make which of these comments in response 99. A nurse obtains a diet history from a client
to the wife’s behavior? who has ulcerative colitis. The nurse should
A. “Are you unable to continue our provide diet counseling if the client includes
discussion?” which of the following foods in his diet?
B. “This discussion must be painful for you.” A. Celery
C. “It is important that we obtain your B. Bananas
husband’s history.” C. White rice
D. “Please try to answer a few more D. Roast chicken
questions.”

95. A 10-month-old who has bacterial meningitis

is to be observed for signs of increasing
intracranial pressure, which include
A. depressed anterior fontanel.
B. weak cry.
C. vomiting.
D. sudden diuresis.

13
 CD Rom: Practice Exam 3
100. An individual who has a diagnosis of depres-
sion makes all of the following remarks to
the nurse during hospitalization. Which
comment suggests improvement in the
client’s condition?
A. “I’m planning my schedule for tomorrow.”
B. “I’d like to go to the chapel.”
C. “I cooperate with the staff to the best of my
ability.”
D. “Let me help you make the beds.”
101. A pregnant woman has varicosities of her
legs and is instructed about wearing antiem-
bolic stockings. Which of these comments, if
made by the woman, indicates that she
understood the instructions?
A. “I put the stockings on when my legs begin
to swell.”
B. “I put the stockings on before I get out of
bed in the morning.”
C. “I remove the stockings if I get cramps in my
legs or feet.”
D. “I remove the stockings only when I bathe.”
102. A client complains of eye pain and is suspect-
ed of having glaucoma. Which of the
following assessments should the nurse make?
A. “Do your eyes tear a lot?”
B. “Do you see floating spots in front of
your eyes.”
C. “Does everything look hazy to you?”
D. “Do you see halos around light?”
103. A 10-month-old is admitted to the hospital
with bacterial meningitis. The nurse assesses
the child for symptoms of meningitis, which
include
A. stiff neck.
B. periorbital edema.
C. distended neck veins.
D. degreased patellar reflexes.
14
104. A client who has had a laryngectomy is
being prepared for discharge. Which of
these questions, if asked by the client, would
indicate an the client understanding of the
instructions?
A. “What type of humidifier would you
recommend?”
B. “What are the best foods for a high-fiber
diet?”
C. “How long would you suggest that I keep
the plug for the laryngectomy tube in a
disinfectant?”
D. “How long do I have to worry that I may
aspirate food?”
105. A client who had a transurethral resection of
his prostate has an indwelling urethral
(Foley) catheter attached to gravity drainage.
Twelve hours after surgery, he complains of
bladder spasms. The nurse should take
which of these actions first?
A. Palpate the client’s abdomen for bladder
distention.
B. Determine the patency of the client’s
drainage system.
C. Administer the prescribed analgesic to the
client.
D. Observe the color of the client’s urine.
106. A client who is delusional and hyperactive is
in restraints and confined to a seclusion
room. Which of these measures would most
likely foster the client’s trust in the nurse?
A. Remaining within arm’s reach of the client at
all times
B. Expressing concern about the client’s well
being
C. Calling the client by name during
interactions
D. Giving verbal and nonverbal messages
to the client that are in agreement with each
other
 CD Rom: Practice Exam 3

107. The wife of a client who was abusive and 111. A 14-year-old is admitted to the hospital after
hyperactive tells the nurse that she is con- being hit by a car while riding her bicycle.
cerned about her husband’s impending She was unconscious for several minutes
discharge and the possibility of his striking after the accident. Which of the following
her again. Which of these actions by the assessment findings should the nurse inves-
nurse would be appropriate at this time? tigate further?
A. Find out from her if her husband expressed A. The girl doesn’t remember anything about
regret for attacking her. the accident.
B. Assess her ability to recognize early signs of B. The girl is confused about what day it is.
overactivity. C. The girl has clear drainage from her left ear.
C. Involve her in identifying her contribution to D. The girl’s pupils contract in response to light.
the problem.
D. Tell her to remind her husband that the 112. A client is scheduled for a cerebral arteri-
police had to intervene. ogram. After the procedure is preformed,
which of these assessments would be most
108. When doing an initial assessment of a client important for the nurse to make?
admitted with a diagnosis of cerebrovascular A. Palpating the client’s pulses distal to the dye
accident (CVA), it would be most important injection site.
for the nurse to make which of these assess- B. Auscultating the client’s lungs.
ments of the client’s upper extremities? C. Testing the client’s patellar reflexes.
A. Strength of hand grip D. Checking the client’s pupillary response.
B. Comparison of radial and brachial pulses
C. Temperature of both arms 113. A teenager with acne says to the nurse in the
D. Color of nail beds physician’s office, “Look at my face! No mat-
ter how often I clean my face, I still get
109. A nurse instructs a client in deep breathing pimples.” The nurse should explain to the
and coughing techniques. Which of these teenager that a contributing cause of acne in
actions should the nurse take to evaluate the adolescents is
instructions? A. eating a large amount of foods high in fat.
A. Ask the client to demonstrate the deep B. eating foods that are high in complex
breathing and coughing exercises. carbohydrates.
B. Ask the client to explain the purpose of C. an increase on secretions of the
deep breathing and coughing exercises. sebaceous glands.
C. Ask the client to note the times when she D. an increase in secretions of the adrenal
performs deep breathing and coughing glands.
exercises.
D. Ask the client to repeat the instructions for 114. A primigravida who has had no prenatal
deep breathing and coughing. care is admitted to the hospital in active
labor. Her cervix is dilated 8 cm. She starts
110. A client who has hyperthyroidism is taking to push with a contraction. During her next
methinazole (Tapazole) and attends the clin- contraction, the nurse should take which of
ic regularly. To evaluate the effectiveness of these actions?
Tapazole therapy, the nurse should consider A. Instruct the client to take short, rapid
which of these questions? breaths.
A. Has the client’s vision improved? B. Tell the client to take a deep breath, hold it,
B. Has the client’s appetite improved? and then bear down.
C. Has the client’s need for sleep decreased? C. Help the client to assume a semi-sitting
D. Has the client’s pulse rate decreased? position and to hold her knees on a flexed
position while bearing down.
D. Apply firm pressure to the client’s lower
back.

15
 CD Rom: Practice Exam 3
115. A client who is a paraplegic is placed in a
side-lying position by the nurse’s aide.
Which of these observations would require
corrective action by the nurse?
A. The client’s upper hip is slightly forward.
B. The client’s has a pillow at the back, extend-
ing lengthwise from the shoulders to the
buttocks.
C. The client’s upper leg is resting on the
lower leg.
D. The client’s upper leg is flexed at the knee.
116. A 61-year-old male is admitted to the hospi-
tal with a right-sided cerebrovascular
accident (CVA). When discussing the client’s
medical history with his wife, the nurse
obtains all of the following information.
Which information most strongly indicates
that the client has had previous transient
ischemic attacks?
A. He has throbbing frontal headaches when
he becomes emotionally upset.
B. He has often been very fatigued after return-
ing from work.
C. He has recently been irritable and less
happy than usual.
D. He has occasionally appeared to be in a
daze during their conversations.
117. During the fourth stage of labor, the nurse
notes that the client’s uterine fundus is
boggy and in the midline. Which of these
actions should the nurse take first?
A. Massage the client’s uterine fundus.
B. Apply downward pressure to the client’s
uterine fundus while she is voiding.
C. Discuss with the physician the client’s need
for an oxytocic medication.
D. Check the characteristics of the client’s
lochia.
118. A client who has Alzheimer’s disease is told
by the nurse to brush his teeth. He shouts
angrily, “Tomato soup!” Which of these com-
ments by the nurse would be appropriate?
A. “You seem upset.”
B. “I don’t understand what you mean by
“tomato soup.”
C. “Here is your toothbrush. First get your
toothpaste, then wet your brush.”
D. “I’ll brush your teeth for you.”
16
119. Which of these infants should the nurse sus-
pect of having a developmental delay?
A. A 4-month-old who does not sit unless well
supported.
B. A 4-month-old who does not hold rattle that
is placed in his hand.
C. A 5-month-old who does not look for
objects she sees being hidden.
D. A 5-month-old who does not demonstrate
the parachute reflex.
120. A woman who has glaucoma begins sneezing
as she is leaving the eye clinic. She com-
ments that she is allergic to pollen and that
she takes nonprescription medication for
her symptoms. The nurse should respond to
the woman in which of these ways?
A. Instruct her to avoid products that
contain atropine sulfate.
B. Schedule an appointment for her with an
allergist.
C. Tell her to limit outdoor activity when the
pollen count is high.
D. Suggest that she cover her nose and mouth
when in contact with allergens.
121. A pregnant woman has external hemor-
rhoids and varicosities of the vulva that are
painful at times. To help relieve the varicosi-
ties, which of these suggestions should the
nurse give to the woman?
A. “Lie down with a pillow under your hips for a
few minutes several times a day.”
B. “Lie on your abdomen and expose the
affected areas to the air for ten minutes
three or four times a day.”
C. “Apply pressure to the perineum with a per-
ineal pad.”
D. “Massage the affected areas with a
lanolin based cream after each voiding
and stool.”
122. A 7-year-old is hospitalized in sickle cell cri-
sis. To which of these goals should the nurse
give priority during the crisis?
A. To prevent contractures
B. To prevent bleeding
C. To promote hydration
D. To promote nutrition

123. To detect for signs of bleeding following a
thyroidectomy, it is most important for the
nurse to include which of these measures in
the client’s care plan?
A. Palpating around the client’s dressing
B. Lifting up the edge of the client’s dressing
C. Turning the client’s head to the side
D. Feeling the dressing at the sides and back
of the client’s neck
124. When talking with a mother whose child is
admitted to the hospital in sickle cell crisis,
the nurse obtains the following data about
the child. Which information is most likely
related to the onset of the sickle cell crisis?
A. The child had a negative reaction to a tuber-
culin skin test that administered a couple of
days ago.
B. The child has had a gastrointestinal upset
with nausea and vomiting for the past few
days.
C. The child’s intake of foods high in fat has
increased recently.
D. The child’s best friend recently moved to
another town.
125. A client has an arteriovenous fistula created
in his left forearm and is given discharge
instructions. Which of these behaviors
would indicate that the client needs further
instruction in self-care?
A. He wears sleeveless shirts.
B. He keeps a dry dressing on his arm.
C. He wears a watch on his left wrist.
D. He prefers to take a shower rather that a
tub bath.
126. A woman who is dependent on alcohol is
admitted to the detoxification unit. The
answer to which of these questions is essen-
tial for the nurse to obtain from the client
on admission?
A. How does her husband react to her
problem?
B. When did she have her last drink?
C. How old she was when she began to drink?
D. What did she eat in the past four hours?
17
CD Rom: Practice Exam 3
127. A 4-year-old admitted with acute lymphocyt-
ic leukemia has a low platelet count. Which
of these measures should be considered
essential to the child’s care?
A. Assisting the child with active range of
motion exercises.
B. Observing the child’s gums for bleeding.
C. Encouraging the child to eat foods high
in iron.
D. Restricting the child’s interaction with other
children on the unit.
128. A nurse gives a postpartal woman instruc-
tion about the use of diaphragms. Which of
these comments, if made by the woman,
indicates the needs for further instruction?
A. I have a diaphragm that I can start to use as
soon as I’m ready to have intercourse.
B. I always wash my diaphragm with soap and
water.
C. I use a spermicidal jelly with the diaphragm.
D. I leave my diaphragm in place at least six
hours after intercourse.
129. A client who has insulin dependent diabetes
mellitus (type1) has a nursing diagnosis of
alteration in sensory perception related to vas-
cular insufficiency. The nurse should make
which of these assessments?
A. Does the client go barefoot at home?
B. How often does the client trim her toenails?
C. Does the client elevate her feet when she is
sitting?
D. How regularly does the client exercise?
130. A toddler has a temperature of 103.6ºF
(39.8ºC) and is given a tepid sponge bath.
When giving the child the bath, the nurse
should terminate the procedure if which of
these events occurs?
A. The child begins to shiver.
B. The child starts to cry.
C. The child’s pulse rate decreases by
8-10 beats.
D. The child’s temperature decreases by 0.5ºF
(0.3ºC) within the first ten minutes.
 CD Rom: Practice Exam 3
131. During a discharge planning discussion with
a postpartum client who has several chil-
dren, the woman makes all of the following
comments. Which comment indicates a need
for further discussion?
A. “My 4 year old is looking forward to
helping me change the baby’s diapers.”
B. “I have several little presents to give my
2 year old if he becomes upset while I’m
caring for the baby.”
C. “My husband is taking several vacation days
so that we can share the care of the children.”
D. “I’ll make sure to spend time with my other
children while the baby is sleeping.”
132. A client has a serum potassium of 2.9 mEq.
per liter. Potassium replacement therapy is
ordered. Which of these statements, if made
by the client, indicates a therapeutic
response to the potassium therapy?
A. “I no longer have diarrhea.”
B. “My appetite is getting better.”
C. “My legs don’t feel so weak.”
D. “I’m having less joint pain.”
133. A client is scheduled for a computerized
axial tomography (CAT) scan of the head.
The procedure is explained to the client.
Which of these statements by the client
would indicate that further teaching is
required?
A. “I may find it difficult to remain still during
the procedure.”
B. “The coolness in the room may make my
joints ache.”
C. “I hope the electrodes on my head will not
be painful.”
D. “I have never liked being in confined areas.”
134. A client who has a left frontal lobe tumor
has a craniotomy. Four hours after surgery,
the nurse obtains the following data. Which
of these data would be most indicative of
increasing intracranial pressure?
A. The client’s blood pressure has changed
from160/94 to140/90 mm Hg.
B. The client is difficult to rouse.
C. The client’s Babinski response is negative.
D. The client is incontinent of urine
18
135. Four mothers and their children are attend-
ing the clinic. The mothers have previously
attended sessions at which the nutritional
needs of children were discussed. The moth-
ers of which of these children needs further
instruction?
A. A 7-month-old who feeds himself 2-3 plain
crackers a day.
B. A 14-month-old who drinks 2 liters of milk
a day.
C. A 3-year-old who refuses to eat cooked veg-
etables, but will eat them uncooked.
D. A 6-year-old who eats a cheese sandwich
for breakfast every day.
136. A staff nurse is observed transferring a client
who has had a cerebrovascular accident
(CVA) with paralysis of the left side. Which
of these techniques would indicate that the
nurse was using a correct technique when
transferring the client from bed to chair?
A. Supporting the client’s left side while assist-
ing the client to sit up in bed.
B. Moving the client to the left side of the bed.
C. Instructing the client how to pivot with the
affected leg.
D. Getting the client out of bed on the
unaffected side.
137. A mother makes all of the following com-
ments about her 14-month-old son’s
behavior. Which behavior should the nurse
discourage?
A. “My son loves to feed himself slices of
peeled apple.”
B. “My son takes his favorite blanket with him
whenever he leaves the house.”
C. “My son gets up on his knees and rocks
himself to sleep.”
D. “My son takes a bottle of juice to bed with
him and sucks on it if he wakes during the
night.”

138. A 25 year old is admitted to the psychiatric
unit with a diagnosis of borderline personal-
ity disorder. During the first few days of his
hospitalization, staff should give priority to
which of these goals?
A. Meeting his dependency needs.
B. Improving his interpersonal relationships.
C. Keeping him from hurting himself.
D. Improving his self-concept.
139. A woman who is twelve weeks pregnant tells
the nurse in the antepartal clinic that she
swims in the town pool at least three times a
week. The nurse should make which of these
responses to the woman?
A. “Swimming in water that is less than body
temperature may lower the
temperature of the amniotic fluid.”
B. “Swimming in a public pool has a high prob-
ability of causing a uterine infection.”
C. “Swimming may be too strenuous an activity
after the second trimester of pregnancy.”
D. “Swimming is an appropriate activity
during pregnancy.”
140. A client who has a borderline personality dis-
order asks the nurse on the psychiatric unit if
she may stay up beyond the designated bed-
time. When the nurse says no, the client says,
“The nurse on duty last night let me stay up
late.” Which of these responses by the nurse
would be therapeutic?
A. “You shouldn’t have been given that
privilege.”
B. “Everyone is required to go to bed now.”
C. “You can stay up for one more hour.”
D. “Why do you want to stay up?”
141. A child who has responded to treatment for
sickle cell crisis is to be discharged from the
hospital. Which of the following measures
should be included in the child’s discharge
plan?
A. Limit intake of foods high in sodium.
B. Apply a soothing lotion to the skin at least
once a day.
C. Eat a food high in simple carbohydrates with
each meal.
D. Avoid strenuous activity.
19
CD Rom: Practice Exam 3
142. A client who has had a total gastrectomy is
given instructions on measures to prevent
development of dumping syndrome. Which
of these statements would indicate a correct
understanding of the instructions?
A. “I will have a bedtime snack.”
B. “I will rest for one hour before each meal.”
C. “I will avoid concentrated sugars.”
D. “I will include high fiber foods in my diet.”
143. A woman who is thirty weeks pregnant has
symptoms of pregnancy-induced hyperten-
sion. Which of these findings is indicative of
this disorder?
A. “I’ve been getting short of breath when I
climb the second flight of stairs to my
family’s apartment.”
B. “I’ve had a craving for salty foods lately.”
C. “I started getting headaches about a month
ago.”
D. “I have gained three pounds (1.4 kgs) during
the past month.”
144. A woman is seen in the physician’s office
because of nutritional anemia. During a
nursing history, the client makes all of the
following comments. Which comment would
be indicative of nutritional anemia?
A. “I get a headache about twice a week.”
B. “I have trouble sleeping at night.”
C. “I get pain in my lower back.”
D. “I always feel tired and weak.”
145. When a child is to be discharged after having
a tonsillectomy, the child’s care at home is
discussed with the mother. Which of these
comments by the child’s mother indicates a
need for additional teaching?
A. “I won’t be surprised if my child’s throat is
sore for a week or so.”
B. “I have an ice collar for my child if she will
use it.”
C. “I’ll have my child gargle with warm salt
water a couple of times a day.”
D. “I’ll give my child liquids and soft foods for
the next week.”
 CD Rom: Practice Exam 3
146. A client who is receiving iron therapy for
nutritional anemia should implement which
of these measures related to activity?
A. Avoiding sustained activity without rest
periods.
B. Limiting weigh-lifting activity to five pounds
(2.7 kgs).
C. Refraining from participating in an organized
exercise program.
D. Restricting heavy housekeeping activities.
147. A staff nurse is giving shift report on a client
with a diagnosis of psychophysiologic disor-
der. Which of these statements by the nurse
would be consistent with the client’s therapy?
A. “Encourage the client to elaborate on his
symptoms.”
B. “Assure the client that there is no
physical basis for his symptoms.”
C. “Tell the client that the symptoms reflect his
need for attention.
D. “Direct the client’s focus away from his
symptoms.”
148. A 12-year-old has a long leg cast applied to
her left leg. She is being instructed on crutch
walking with no weight bearing on her left
leg. Which of these observations indicates
that the girl needs further teaching?
A. She is using the three-point gait.
B. Her elbows are slightly flexed.
C. She places the crutches approximately six
to eight inches (15 to 20 cm.) in front of her
with each step.
D. She is supporting her weight on the axillary
bars and hand pieces of the crutches.
20
149. A nurse instructs a client in the care of his
tracheostomy. Which of these client actions
during tracheostomy care indicates an under-
standing of the nurse’s teaching?
A. Applying no suction as the catheter is insert-
ed and constant suction as the catheter is
withdrawn.
B. Applying suction as the catheter is inserted
and as the catheter is withdrawn.
C. Applying intermittent suction as the catheter
is inserted and constant suction as the
catheter is withdrawn.
D. Applying constant suction as the catheter is
inserted and no suction as the catheter is
withdrawn.
150. Which of these comments would a client
with an antisocial personality be most likely
to make?
A. “The police are always arresting me for
nothing.”
B. “I’m feeling guilty because I’ve disappointed
my family.”
C. “I’m becoming very anxious.”
D. “I’ve learned my lesson, and I’ll never do
that again.”
151. A child in sickle cell crisis has reduced abili-
ty to concentrate his urine. Which of these
instructions should the nurse give to his
mother?
A. “Have your son apply gentle pressure over
his bladder each time he urinates.”
B. “Have your son drink at least eight ounces
of fruit juice a day.”
C. “Be sure that your son’s teacher knows that
he will probably have to urinate more fre-
quently than his classmates.”
D. “Give your son only sips of fluid after the
evening meal.”
152. The nurse should include which of these
measures in a client’s care plan to detect
possible laryngeal nerve damage following a
thyroidectomy?
A. Asking the client to speak
B. Stimulating the client’s gag reflex
C. Determining the client’s ability to swallow
D. Telling the client to extend the tongue

153. A toddler who has nephrosis has generalized
edema and is lethargic. Which of these meas-
ures should be included in the child’s care?
A. Positioning the legs above the level of the
heart for twenty minutes every 3-4 hours.
B. Applying a lanolin-based cream to the skin
once or twice a day.
C. Helping the child to do postural drainage
exercises three or four times a day.
D. Assisting the child in changing position
periodically.
154. A client is admitted to the psychiatric unit
after striking his wife with a cooking utensil.
He is hyperactive and in handcuffs. Which of
these behaviors would indicate that the
client needs continued restraints?
A. He pushes the attendant out of his way
B. He shouts curses at the nurse
C. He tears up his chart
D. He makes obscene gestures
155. A hyperactive client who is on the psychi-
atric unit is too busy to sit down and eat a
meal. Which of these measures should be
included on the client’s care plan?
A. Seat the client with a group of friendly
clients at mealtime.
B. Offer the client high calorie portable snacks.
C. Provide the client with his favorite foods.
D. Remain with the client in the dining room
until each meal is finished.
156. A client who is being treated for a manic
episode is easily over-stimulated. The client
comes to the nurse and says, “There’s noth-
ing to do around here.” Which of these
activities would be therapeutic for the client
at this time?
A. Taking an escorted walk out of doors
B. Participating in the music therapy band
C. Playing a game of chess
D. Playing in the table tennis tournament
21
CD Rom: Practice Exam 3
157. Which of these behaviors would indicate the
greatest improvement in a client
who was admitted to the hospital with
hyperactivity?
A. The client completes an assigned task.
B. The client frequently apologizes for her
behavior.
C. The client takes naps during the day.
D. The client shows interest in the young men
on the unit.
158. In the initial interview with a client who has
primary dementia of the Alzheimer’s type
and his wife, which of these data should be
obtained in order to plan his care?
A. His occupational skills
B. His normal daily routine
C. The quality of the marital relationship
D. History of dementia
159. A 30-year-old primigravida at thirty-eight
weeks gestation is admitted to the hospital in
labor. When timing the frequency of contrac-
tions, the nurse should note the time from
A. the beginning of one contraction to the
beginning of the next contraction
B. The beginning of one contraction to the end
of that contraction
C. The end of one contraction to the
beginning of the next contraction
D. The end of one contraction to the peak of
the next contraction
160. Following a prostatectomy, the pathology
report reveals that the client has cancer of
the prostate. Which of these blood test
results would support this diagnosis?
A. Decreased uric acid
B. Decreased serum creatinine
C. Elevated serum calcium
D. Elevated prostate specific antigen
161. When a newborn is twelve hours old, the
nurse is to give him his first bath. The nurse
should first obtain which of these newborn
assessments?
A. His temperature
B. The amount of weight loss since birth
C. The size of his posterior fontanel
D. His passing of meconium
 CD Rom: Practice Exam 3
162. The mother of a 6-year-old girl who is hospi-
talized says to the nurse, “My 9-year-old son
wants to come to the hospital to see his sis-
ter. What do you think about this?” Which of
these responses would be appropriate for
the nurse to make?
A. “The hospital environment would probably
frighten your son.”
B. “Do your son and daughter get along with
each other?”
C. “Do you think that your son is wondering if it
is his fault that his sister is ill?”
D. “The hospital does not allow children to visit.”
163. A client with a laryngectomy who is being
discharged should be cautioned about using
which of these personal items?
A. Deodorant soap
B. After shave lotion
C. Talcum powder
D. Mouthwash
164. The nursing care plan for a client detoxify-
ing from alcohol should include which of
these measures?
A. Keeping the client restrained
B. Orienting the client frequently
C. Providing a quiet, well lighted room
D. Helping the client recover repressed
memories
165. The mother of a child who is to undergo
chemotherapy begins crying and says, “I
can’t believe it. We are going to lose our
child. He is too young to die.” Which of
these responses would be appropriate for
the nurse to make to the child’s mother?
A. “Most children who receive chemotherapy
live at least five years, and some are then
considered cured.”
B. “Parents of children who receive chemother-
apy often suffer more that the children do.”
C. “Let’s review what the physician told you
about your child.”
D. “Did you not suspect that your child’s
illness was this serious?”
22
166. A woman attends the clinic when she is
twenty weeks pregnant. The nurse should
expect a woman at this stage of pregnancy
to have
A. urinary frequency.
B. dyspnea while walking up a flight of stairs.
C. fetal movement.
D. leg cramps.
167. A woman has a history of repeated rages, self-
destructive behavior, impulsivity, and
manipulation of others. The woman improves
following therapy. Which of these factors per-
taining to life a year later suggests that the
woman has achieved a long-term goal?
A. The woman has not required hospitalization.
B. The woman says her new boss is perfect.
C. The woman has an intense relationship with
her spouse.
D. The woman is pregnant.
168. A child is to be discharged on maintenance
chemotherapy that includes prednisone
(Deltasone). After discussing the child’s
home therapy, his mother makes all of the
following comments to the nurse. Which
one indicates that the mother needs further
teaching?
A. “My child should have received an oral
poliovirus vaccine last month.”
B. “My child and I have discussed his expected
behavior at home.”
C. “I’ll wait until we are home for two weeks
before I invite any of my child’s friends to
visit him.”
D. “My child is going to choose his own meals
for the next several days.”
169. A hyperactive client who is on the psychi-
atric unit is changing his clothes in the day
room. Which of these interventions by the
nurse would most likely be effective?
A. Ask him why he is doing this in front of other
people.
B. Take him to his room to finish the activity.
C. Encourage the other clients to comment to
him about his behavior.
D. Lock up all his clothes except those he is
wearing.

170. A client who has Alzheimer’s disease calls the
nurse by his wife’s name. Which of these
measures by the nurse would be appropriate?
A. Responding to whatever name the client
uses for the nurse.
B. Asking the client to remember the nurse’s
name.
C. Stating the nurse’s name at each contact
with the client.
D. Allowing the client extra time in which to
remember the nurse’s name.
171. Disulfiram (Antabuse) is prescribed for a
client who abuses alcohol. The nurse should
be aware that the medication will have its
desired effect if the client
A. can drink alcohol without experiencing
intoxicating effects.
B. can tolerate alcohol in moderation.
C. loses her craving for alcohol.
D. stops drinking alcohol.
172. The nurse teaches a woman who is planning
to breast-feed her infant about measures to
prevent her nipples from becoming sore.
Which of these comments, if made by the
woman, would indicate that she understood
the instructions?
A. “I’ll use a nipple shield with every other
breast feeding during my first
postpartum week.”
B. “I’ll cleanse my nipples with soap and water
before each feeding.”
C. “I’ll expose my nipples to the air several
times a day.”
D. “I’ll apply an antiseptic cream to my
nipples after each feeding.”
23
CD Rom: Practice Exam 3
173. A 10-month-old has responded satisfactorily
to treatment for bacterial meningitis and is to
be discharged. The child’s mother says to the
nurse, “My child was a good eater before he
got sick. Now he wants nothing but his bot-
tle. He hasn’t eaten any solid food since he
has been in the hospital. What am I going to
do with him at home?” Which of these sug-
gestions by the nurse would be most helpful?
A. “Cut bigger holes in the nipple and gradually
add more strained foods to his bottle.”
B. “Withhold his bottle until he eats at least half
the amount of solid food expected of an
infant his age.”
C. “Dilute his milk with more and more water.
By the time he is drinking mostly water, he
will be hungry for solid food.”
D. “Before he satisfies his hunger with milk,
offer him foods that he used to like.”
174. A client is suspected of having renal failure.
Which of these laboratory values should the
nurse anticipate?
A. Blood urea nitrogen (BUN) 10mg/dl
B. Serum creatinine 3.1mg/dl
C. Serum albumin 3.5 g/dl
D. Hemoglobin 15g/dl
175. A client who is in chronic renal failure has an
elevated serum potassium level. It would be
appropriate for the nurse to make which of
these assessments of the client?
A. Check the client’s handgrips.
B. Evaluate the client’s orientation to time and
place.
C. Take the client’s apical pulse.
D. Elicit the client’s Babinski response.
176. The nurse is assessing a client with a vascu-
lar disorder. Which of the following client
statements indicates that the client is experi-
encing symptoms of arterial insufficiency in
the lower extremities?
A. “My legs feel weak when I get up to walk.”
B. “My legs hurt when I walk, but they feel bet-
ter when I sit down.”
C. “My feet and ankles become swollen after
walking.”
D. “My feet burn if I walk on a hard surface.”
 CD Rom: Practice Exam 3
177. A nurse observes that a client who has left-
sided paralysis related to a cerebrovascular
accident (CVA) eats only the food on the right
half of her meal tray. Which of these actions
should the nurse take?
A. Ask the client what she does not like about
the rest of the food.
B. Remind the client to turn her head to see the
rest of the tray.
C. Assist the client in completing her meals.
D. Determine if the client wears eyeglasses and
is not using them.
178. A nurse in a fertility clinic discusses the
early signs of pregnancy with a client, which
include
A. fatigue.
B. hypersalivation.
C. episodes of feeling warm.
D. discomfort on either side of the lower
abdomen.
179. Four adolescent girls who have scoliosis are
attending the clinic. They have been wearing
Milwaukee braces for periods of 1-3 months.
Each of the girls makes a comment about
her situation as indicated below. Which girl
needs further instruction about her care?
A. “I haven’t gained any weight since I started
wearing the brace.”
B. “Everyone was so surprised that I could
dance so well even with my brace on.”
C. “I’ll be able to play on the school
basketball team, even though I’m
wearing the brace.”
D. “Even with my brace on, I took a five-mile
hike with my friends the other day.”
180. Which of these observations of a child post
tonsillectomy should the nurse report to the
physician immediately?
A. Drooling pink-tinged saliva
B. Vomiting a moderate amount of dark brown
material
C. Swallowing frequently
D. Having a small amount of serous drainage
from the left ear
24
181. A woman is found to have a twin pregnancy
at eighteen weeks. Which of these findings
would be consistent with the diagnosis?
A. Rapid uterine growth
B. Low hematocrit
C. Decreased amniotic fluid
D. Urinary frequency
182. A physician tell a 30-year-old client who had
an above the knee amputation that he will
not be able to return to his construction
work. Which of these long-term goals would
be an appropriate expectation of the client?
A. He will develop alternate vocational skills.
B. He will acknowledge his loss.
C. He will identify his areas of interest.
D. He will engage in occupational therapy.
183. An infant has a ventriculoperitoneal shunt
inserted to control her hydrocephalus. At the
time of discharge, the parents are given
home care instructions. Which of these com-
ments by the infant’s mother indicates a
need for further instruction?
A. “It will probably be a few weeks before I feel
comfortable leaving my daughter with a
baby sitter.”
B. “I can’t wait to give my daughter a bath in
the infant tub that I bought for her.”
C. “We plan to have our daughter sleep in our
room for a few weeks.”
D. “I’ll probably have our daughter back here
tomorrow.”
184. A newborn develops jaundice shortly after
birth and receives phototherapy. While the
newborn is receiving phototherapy, which
of these measures should be included in the
newborn’s care plan at regular intervals?
A. Testing the newborn’s urine for glucose
B. Changing the newborn’s position
C. Assessing the newborn for symptoms of
dependent edema
D. Applying an emollient to the newborn’s skin

185. A client who has ulcerative colitis does not
respond to the prescribed therapy and is
admitted to the hospital for a total colectomy
and ileostomy. Which of these measures
should be given priority in the client’s pre-
operative care plan?
A. Promoting the client’s acceptance of an
ileostomy
B. Monitoring the client’s emotional state
C. Preventing the client from developing a
decubitus
D. Correcting the client’s fluid imbalance
186. A client is to be transfused with a unit of
whole blood. If the client were to develop an
allergic reaction, the nurse should expect to
administer which of these drugs?
A. Diphenhydramine (Benadryl)
B. Chlorpheniramine (Chlor-Trimeton)
C. Pseudoephedrine (Sudafed)
D. Promethazine (Phenergan)
187. A client diagnosed with Parkinson’s disease
may need help in dealing with which of
these associated problems?
A. Poor peripheral vision related to weakness of
the motor nerves
B. Diarrhea related to hypermotility of the
bowel
C. Weak pharyngeal muscles related to
accumulation of lactic acid
D. Unsteady balance related to altered center
of gravity
188. A client who has had an ileostomy says to
the nurse, “I will have to be isolated for the
rest of my life because no one will be able to
stand this terrible odor.” Which of these
responses by the nurse would most likely be
reassuring?
A. “The odor will gradually become less
noticeable.”
B. “I can understand your concern, but remain-
ing isolated does not reduce the odor.”
C. “There are techniques that can reduce
the odor.”
D. “The odor is a normal part of your condition
and should not offend people.”
25
CD Rom: Practice Exam 3
189. An 18-month-old is admitted to the hospital.
On admission it is most important for the
nurse to obtain the answer to which of these
questions from the parents?
A. “What is your child’s regular bedtime?”
B. “What are your child’s favorite foods?”
C. “Does your child wet the bed at night?”
D. “Does your child attend a day care center?”
190. A toddler is to receive 250 ml of intravenous
fluid in an 8 hour period. The intravenous set
delivers 60 microdrops per milliliter. The
intravenous infusion is currently running at
31 microdrops per minute. In view of the ini-
tial order, which of these actions should the
nurse take first?
A. Decrease the rate of flow
B. Increase the rate of flow
C. Check the patency of the intravenous tubing
D. Continue to monitor the intravenous
infusion
191. A 68-year-old is admitted to the hospital in
congestive heart failure. Which of these
questions asked of the client would elicit the
most significant data about the symptoms?
A. “When did you last have a chest x-ray?”
B. “How often do you get up to urinate during
the night?”
C. “How many pillows do you use when
sleeping?”
D. “Have you noticed any weight loss lately?”
192. At thirty weeks of pregnancy, a woman who
has been treated for pregnancy-induced
hypertension is admitted to the hospital
because her condition has not improved.
She is placed on bed rest and is started on
magnesium sulfate therapy. Which of these
nursing actions should be included in the
client’s care plan?
A. Obtaining the woman’s weight daily
B. Assessing the woman’s abdominal
circumference daily
C. Observing the woman for jaundice
D. Checking the equality of the woman’s
femoral pulses
 CD Rom: Practice Exam 3
193. A client who has been given a prescription
for daily thyroid extract should be given
which of these instructions by the nurse?
A. “You may have skin irritation due to the
medication.”
B. “You may become irritable if the
medication dosage is too high.”
C. “You will take the medication for the rest of
your life.”
D. “You will need to take the medication with
food.”
194. A child who is in sickle cell crisis has an
order for an analgesic. In addition to giving
the child the prescribed analgesic, which of
these measures is likely to help reduce the
child’s pain?
A. Keeping the child’s lower extremities
elevated at a level higher than the heart.
B. Having the child wear antiembolic stocking
most of the time.
C. Gently massaging the child’s lower
extremities.
D. Appling moist heat to the child’s affected
areas.
195. If steroid therapy is achieving its desired
effect for a child who has nephrosis, which
of these outcomes should the nurse expect?
A. Urine specific gravity is increased.
B. Blood glucose levels are increased.
C. Urine proteins are decreased.
D. Serum sodium concentration is decreased.
196. A 21/2-year-old is being prepared for dis-
charge. In view of the client’s age, it would
be appropriate for the nurse to give the
mother which of these instructions?
A. “You will probably find that being in the
hospital has made your child more
independent than she was before her
hospitalization.”
B. “For about a week or so, try to keep your
child’s routines the same as they were in
the hospital.”
C. “Have the same expectations of your child
that you had before her hospitalization.”
D. “Your child may not want you out of her
sight for a while.”
26
197. A client has a laryngectomy with a laryngeal
tube in place. When suctioning the laryngeal
tube, the nurse should
A. suction the tube for about ten seconds.
B. use clean rather than sterile technique.
C. apply suction while inserting the catheter
into the tube.
D. turn the client’s head to suction one side
and then the other side.
198. A 6-year-old is admitted to the hospital with a
tentative diagnosis of acute lymphocytic
leukemia. When assessing the child for
symptoms of leukemia, the nurse should
consider which of these questions?
A. What reaction does the child have when
tested for the presence of Homan’s sign?
B. What is the color of the child’s sclera?
C. Does the child have a pulse deficit?
D. Does the child have bone pain?
199. A 19-year-old college student is brought to
the emergency room by the police because
he struck his roommate and accused his
roommate of infecting him with the acquired
immune deficiency syndrome (AIDS) virus.
The client’s behavior towards his roommate
is indicative of the client’s
A. inability to identify individual boundaries.
B. immaturity of sexual expression.
C. displacement of the source of danger.
D. deliberate excuse to discharge pent-up
hostility.
200. Staff on a psychiatric unit are considering
removing the restraints from a client who is
delusional. The client will then be free to
leave the seclusion room. Which of these
actions should the nurse take?
A. Before removing the restrains, make a con-
tract with the client specifying how he is to
conduct himself on the unit.
B. While removing the restrains, tell the client
that they will be replaced if he does not
keep out of trouble.
C. Remove the restraints and engage the client
in a group activity every two hours.
D. Administer the prn dose of prescribed med-
ication, wait 15 minutes, and then remove
the client’s restraints.
 CD Rom: Practice Exam 3

201. A client on the psychiatric unit tells the 205. A client is scheduled for an intravenous pyel-
nurse that people want to infect him with a ogram (IVP). Which of these assessments by
fatal disease because he has the secret to the nurse would be most important prior to
preventing famine in the world. Which of the scheduled IVP?
these comments, if made by the nurse, A. Does the client have a history of allergies?
would be therapeutic? B. Does a member of the client’s family have
A. “Tell me more about this.” renal disease?
B. “When did you start believing this?” C. Is the client’s bladder distended?
C. “I know that you believe this, but I don’t see D. What was the client’s recent food intake?
it that way.”
D. “I can’t imagine anyone wanting to prevent 206. A client has not required an analgesic for
you from doing this.” twenty-four hours following an appendecto-
my. Suddenly, the client complains of severe
202. A client who has been treated for delusional pain in the right lower quadrant. The nurse
activity engages in all of the following behav- should make which of these assessments first?
iors. Which behavior would indicate that the A. Palpate the client’s abdomen.
client is improving? B. Determine if the client has had a bowel
A. The client walks away when limits are movement.
being set. C. Inspect the client’s incisional site.
B. The client rationalizes his behavior to those D. Take the client’s temperature.
he offends.
C. The client places the responsibility for his 207. Four days after a subtotal gastrectomy a
pattern of behavior on external forces. client is started on a clear liquid diet. The
D. The client request to be alone in a quiet client would be permitted to have which of
room when he begins to feel upset. these fluids?
A. Tea with milk
203. A pregnant woman who is at term cannot B. Flavored gelatin
get to the hospital in time for delivery of her C. Raspberry sherbet
infant and calls a neighbor, who is a nurse. D. Pineapple juice
After the infant’s head is delivered, the nurse
should take which of these actions? 208. A client who is taking a monoamine oxidase
A. Facilitate delivery of the anterior shoulder inhibitor would demonstrate knowledge
B. Cleanse the infant’s face about the effectiveness of the medication by
C. Stimulate the infant to cry selecting foods that are
D. Check for a nuchal cord A. low in cholesterol.
B. low in tyramine.
204. Which of these questions, asked of a client C. free of gluten.
who has congestive failure, would elicit the D. free of lactose.
most pertinent data about the client’s cardiac
reserve? 209. A client who has nutritional anemia has
A. “Do you develop leg cramps when walking responded satisfactorily to treatment. In
that are relieved by rest? addition to an increased hemoglobin,
B. “Do you feel out of breath after climbing a improvement in the client’s condition would
flight of stairs?” best be indicated by the results of which of
C. “When do you begin to feel tired during these laboratory tests?
the day?” A. Serum protein level
D. “Have you been exercising regularly?” B. Platelet count
C. Leukocyte count
D. Hematocrit determination

27
 CD Rom: Practice Exam 3

210. The nurse discussing methods of stress 214. Which of the following laboratory results
reduction with a client should use which of should the nurse monitor in a client being
these approaches first? treated for a crushed pelvis?
A. Explain to the client the physiological effects A. Myoglobin
of stress. B. Serum calcium
B. Teach the client relaxation techniques that C. Blood glucose
reduce stress. D. Creatine kinase
C. Determine if the client is able to identify
sources of stress. 215. A client is taking rofecoxib (Vioxx) for
D. Describe to the client the benefits of active osteoarthritis. Which of the following client
exercise in coping with stress. statements would indicate to the nurse the
need for further instructions about the
211. A client who has Hodgkin’s disease is receiv- medication?
ing chemotherapy. During treatment it is A. “I don’t crush the medicine or dissolve it in
important that the nurse assess the client for water.”
symptoms of B. “I’m supposed to call the doctor if I notice
A. thrombus formation any bruising on my skin.”
B. ascites C. “I sleep through the night now without any
C. infection difficulty.”
D. splenomegaly D. “I take the Vioxx on an empty stomach.”

212. A client newly diagnosed with Parkinson’s 216. The nurse should observe a client receiving
disease has made increasingly frequent hormonal therapy for cancer of the prostate
requests of the nurse to adjust his pillow, for which of these adverse effects?
straighten his blanket, and change the water A. Pain
in his drinking cup. The nurse should be B. Urinary incontinence
aware that the client C. Severe impotence
A. is probably accustomed to having services D. Hot flashes
provided for him.
B. is exhibiting behavior consistent with the 217. Vasopressin is administered intravenously to
progressive deterioration of his condition. a client with bleeding esophageal varices.
C. is anxious about his ability to adapt to his For which of the following adverse effects
disease. should the nurse assess?
D. is displaying a personality characteristic of A. Intracerebral hemorrhage
the disease. B. Severe hypotension
C. Supraventricular tachycardia
213. A client indicates to the nurse that he wishes D. Chest pain
to review his medical record. The nurse
understands that, based on the client’s Bill of
Rights, the hospital must
A. not allow clients to see their records.
B. allow clients to see their records and have
them explained.
C. have written permission of the physician to
show clients their records.
D. allow clients to see all their records except
physician notes.

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 CD Rom: Practice Exam 3

218. The mother of an infant who remained in the
hospital after the mother’s discharge arrives
to feed her baby. The mother gives the nurse
several bottles of breast milk that she said had
been refrigerated for three days. The best
action by the nurse is to
A. thank the mother and refrigerate the milk for
later use.
B. thank the mother and discard the milk with-
out telling her.
C. ask the mother when the milk was
expressed.
D. tell the mother that the breast milk will have
to be discarded since it was refrigerated for
longer than 2 days.
219. The nurse is caring for a client diagnosed with
meningococcal meningitis. During the 3 PM
assessment, the nurse notes the following
changes from the 1 PM assessment:
1 PM Assessment 3 PM Assessment
Heart rate 72/min 56/min
Blood Pressure 140/88 162/74
Respirations 24/min 16/min
Glasgow coma score 14 12
The nurse would interpret these changes as
A. acute respiratory distress.
B. increased intracranial pressure.
C. the development of septic shock.
D. an improvement in the degree of coma.
220. A child is admitted to the hospital with a
penetrating wound of the foot. Which of the
following client information is essential for
the nurse to elicit from the family?
A. History of previous seizure activity
B. Date of the most recent tetanus inoculation
C. History of blood transfusion reactions
D. Current infections
221. When caring for a client with a peripherally
inserted central venous catheter (PICC line),
the nurse would best assess for catheter
migration by
A. measuring from the insertion site to the
catheter hub during each dressing change.
B. measuring the upper mid-arm circumference
each day.
C. measuring from the catheter hub to the
subclavicular notch daily.
D. comparing the daily chest x-ray report to
that of the previous day.
222. A client with a chest tube is assisted out of
bed and steps on the chest tube pulling it out.
Which of the following materials should the
nurse immediately apply to the chest wound?
A. The bed sheet
B. A sterile dressing
C. A paper towel
D. Adhesive tape
223. A client is instructed about home care fol-
lowing a gastric partitioning. Which of the
following statements by the client indicates
the need for further instruction?
A. “Now I will not have to worry about my
weight anymore.”
B. “Eventually I may not have to take so many
pills for my blood pressure.”
C. “I’m anxious to start seeing the psychologist.”
D. “I expect that I will have to buy new clothes
now.”
224. An elderly client has inadvertently taken
several extra doses of levothyroxine sodium
(Synthroid). The nurse should monitor the
client for which of the following side effects?
A. Hypotension
B. Tachycardia
C. Hypothermia
D. Oliguria

29
 CD Rom: Practice Exam 3

225. The clinic nurse instructs a client scheduling
a Papanicolaou (PAP) smear to prepare
herself by
A. scheduling the test after menstruation.
B. performing a vaginal douche the morning of
her exam.
C. having someone available to drive her home
after the test.
D. restricting food and fluid intake 8 hours prior
to the test.
226. The client taking clopidogrel (Plavix) tells the
nurse that he takes ginkgo biloba everyday to
improve his short-term memory. The nurse
should be alert for which of these potential
alterations in laboratory values?
A. Decreased clotting time
B. Prolonged bleeding time
C. Decreased prothrombin time
D. Increased thromboplastin time
227. When teaching a perimenopausal client
about preventing osteoporosis, the nurse
should encourage the woman to engage in
which of the following exercises?
A. Bicycle riding
B. Walking
C. Swimming
D. Horse back riding
228. The physician has informed a client that her
fetus has a lethal chromosomal abnormality.
The mother has requested an abortion.
Which of the following actions by the nurse
would be appropriate?
A. Telling the client that intrauterine surgery can
prevent the fetus from dying.
B. Informing the client that she will have
difficulty getting pregnant in the future if she
has the abortion.
C. Encouraging the client to consider other
alternatives to terminating the pregnancy.
D. Respecting the client’s decision to terminate
the pregnancy.
229. A client with obsessive compulsive disorder
constantly washes his hands and has severe
skin erosion. Which of the following actions
by the nurse would be most appropriate?
A. Locking the bathroom door so that the client
cannot wash his hands as frequently
B. Explaining to the client that it is harmful to
wash his hands so often
C. Giving the client lotion to use on his hands
D. Exploring other methods of decreasing anxi-
ety with the client
230. A 28 year old mother and her 6-year-old
daughter are homeless. The client presents to
the emergency department with complaints
of fatigue and generally not feeling well. Her
physical examination is normal. The priority
nursing intervention would be to
A. encourage the client to look through the
newspaper for housing.
B. refer the client to social services to locate
temporary housing.
C. refer the client and her daughter to a local
shelter.
D. have the daughter removed from the client’s
custody.
231. A client receiving a lidocaine infusion com-
plains of tingling in both hands. Which of
the following actions should the nurse carry
out first?
A. Lower both arms over the bedside until the
tingling subsides
B. Discontinue the infusion and restart at a dif-
ferent intravenous site
C. Decrease the infusion rate and notify the
physician
D. Stop the infusion and notify the physician.

30

232. A client is comatose after suffering a stroke
(CVA) 2 days ago. The nurse and a nursing
assistant are providing care for the client
when the nursing assistant says, “Isn’t this a
shame to be in this condition?” The nurse’s
best response would be
A. “Let’s take a break and meet in the
conference room.”
B. “You are so right. I would not want to live
like this.”
C. “I’m certain he won’t be around long. I can’t
imagine what it is like.”
D. “It must be very difficult for his family. This
happened to my sister-in-law.”
233. A client complains of severe sudden epigas-
tric pain. The nurse’s immediate action
should be to
A. administer prn Morphine 10 mg IM and doc-
ument results.
B. reposition the client and elevate the head of
the bed.
C. administer 30cc of liquid antacid.
D. notify the physician.
234. A client removes her identification band and
tapes it to the foot of the bed. Which of the
following nursing measures is most appro-
priate prior to administration of medication?
A. Ask the client her name and compare it to
the identification band
B. Obtain a new identification band and apply it
to the client’s arm
C. Validate the client’s identity with another
staff member
D. Hold the medication and complete an inci-
dent report
31
CD Rom: Practice Exam 3
235. The nurse teaches a client about life style
factors that may adversely affect hyperten-
sion. Which of the following statements
indicates that the client understood the
teaching?
A. “I will follow a high fiber diet when I am
discharged.”
B. “I just bought a book on stress reduction
and I am going to try some of the
suggestions.”
C. “Exercise once a week will help to keep
everything under control.”
D. “At least I don’t have to quit smoking. I don’t
think I could do it.”
236. A client is taking ergotamine (Ergostat) for
resistant migraine headaches. Which of the
following instructions should the nurse give
to the client about repeating the dose?
A. Do not repeat the dose.
B. Wait at least 30 minutes before repeating
the dose.
C. Wait at least 1 hour before repeating the
dose.
D. Wait at least 4 hours before repeating the
dose.
237. A man who has suicidal thoughts and dissat-
isfaction with his job is admitted to a
psychiatric unit. Which of the following
approaches would be most likely to elicit his
involvement in scheduled activities?
A. Working with him during activities
B. Asking him if he would like to participate in
activities
C. Waiting for him to show interest in activities
D. Telling him the therapeutic importance of
activities
238. Which of the following factors, if present in
a client’s history, would indicate a predispo-
sition for the development of polycystic
kidney disease?
A. Nephrotic syndrome
B. Familial tendency
C. Diabetes mellitus
D. Cigarette smoking
 CD Rom: Practice Exam 3
239. The nurse should recognize that a client
whose blood test has revealed sickle-shaped
erythrocytes is most at risk for which of the
following nursing diagnoses?
A. Altered tissue perfusion
B. Disuse syndrome
C. Fluid volume overload
D. Body image disturbance
240. To which of the following nursing diagnoses
should a nurse give priority in the care of a
client who has a history of transient
ischemic attacks?
A. Ineffective thermoregulation
B. Decreased cardiac output
C. Altered cerebral tissue perfusion
D. Impaired gas exchange
241. A two-year-old who underwent abdominal
surgery one day previously receives pain
medication as prescribed. The child reports
pain 30 minutes later. Which of the following
actions should the nurse take?
A. Ask the child to visualize a happy
experience
B. Ask the child to take several deep breaths
C. Change the child’s position in bed
D. Play the child’s favorite videotape
242. A nurse should assess a client who has adre-
nal insufficiency for signs of Addison’s
disease, which include
A. striae on the abdomen.
B. acne lesions on the face.
C. bronzed appearance of the skin.
D. buffalo hump on the shoulders.
243. A seven-year-old has varicella zoster. A com-
munity health nurse teaches the child’s
parent about over-the-counter medications
that can be used to comfort the child. Which
of the following medications, if selected by
the parent, would require further instruction?
A. Grape-flavored diphenhydramine (Benadryl)
elixir to reduce itching
B. Acetylsalicylic acid (Aspirin) tablets to
reduce fever
C. Orange-flavored ibuprofen (Pediaprofen)
elixir to minimize discomfort
D. A topical paste of baking soda and water to
relieve itching
32
244. A postpartum client delivered two hours ago.
During rounds the nurse finds that the client
has soaked a number of pads and is lying in
a pool of blood. The nurse’s first action
should be to
A. go to the door and call for help.
B. place the client in reverse trendelenburg
position.
C. increase the client’s intravenous fluid rate.
D. massage the client’s fundus.
245. Which of the following laboratory results is
it important for the nurse to monitor in a
client who has multiple myeloma?
A. Urinary 17-ketosteroids
B. Serum potassium
C. Serum calcium
D. Urine osmolarity
246. A child who is diagnosed with pharyngitis
has a negative throat culture. The child’s
parent asks the nurse, “Why didn’t the doc-
tor give my child a prescription for
antibiotics?” The nurse’s response should be
based on the understanding that
A. antibiotics are not effective against viral
illnesses.
B. viral throat infections can be painful; there-
fore, they may seem more serious than they
are to children and their families.
C. bacterial infection, rather than viral infection,
causes an elevation in temperature.
D. antibiotics are prescribed only if the infection
lasts for more than one week.
247. A client is taking atenolol (Tenormin) 50 mg
daily. The nurse should instruct the client to
notify the physician in which of the follow-
ing situations?
A. Temperature less than 98.6ºF (37ºC)
B. Pulse rate less than 50 beats/min
C. Blood pressure less than 120/70 mm Hg
D. Respirations greater than 18/min
 CD Rom: Practice Exam 3

248. A client has just been hospitalized for

treatment of compulsive hand washing.
The nurse should intervene if staff mem-
bers are seen acting in which of the
following ways?
A. Talking to one another within the client’s
view.
B. Suddenly changing the client’s routine
C. Turning away from the client
D. Touching the client

249. Following an automobile accident a client

is admitted to the hospital with head
injuries. To determine if the client’s con-
dition is deteriorating, the nurse should
assess the client for the
A. escalation of her discomfort.
B. quality of her respirations.
C. narrowing of her pulse pressure.
D. rapidity of her heart rate.

250. A client who has a spinal cord transaction

is in spinal shock. On assessment of the
client’s lower extremities, the nurse should
expect which of the following findings?
A. Loss of sensation
B. Complaints of tingling
C. Excessive diaphoresis
D. Constant tremors

33
 CD Rom: Practice Exam 3

CD-Rom: Answers Practice Examination 3

Correct Answers for CGFNS CD-ROM Practice Examination 3
The following letters are the correct answers for each of the questions in the Practice Examination.

1 D 37 C 73 D 109 A 145 A 181 A 217 D

2 D 38 B 74 A 110 D 146 A 182 A 218 D
3 B 39 B 75 A 111 C 147 D 183 D 219 B
4 A 40 D 76 C 112 A 148 D 184 B 220 B
5 C 41 A 77 D 113 C 149 A 185 D 221 A
6 C 42 D 78 C 114 A 150 A 186 A 222 A
7 D 43 A 79 C 115 C 151 B 187 D 223 A
8 A 44 A 80 B 116 D 152 A 188 C 224 B
9 A 45 A 81 C 117 A 153 D 189 A 225 A
10 A 46 B 82 C 118 C 154 A 190 D 226 B
11 D 47 C 83 A 119 B 155 B 191 C 227 B
12 C 48 C 84 A 120 C 156 A 192 A 228 D
13 B 49 C 85 B 121 A 157 A 193 C 229 D
14 C 50 B 86 D 122 C 158 B 194 D 230 B
15 B 51 D 87 A 123 D 159 A 195 C 231 D
16 A 52 A 88 C 124 B 160 D 196 D 232 A
17 B 53 D 89 D 125 C 161 A 197 A 233 D
18 A 54 B 90 A 126 B 162 C 198 D 234 B
19 B 55 B 91 B 127 B 163 C 199 C 235 B
20 B 56 D 92 D 128 A 164 C 200 A 236 B
21 A 57 A 93 D 129 A 165 C 201 C 237 A
22 D 58 A 94 B 130 A 166 C 202 D 238 B
23 B 59 D 95 C 131 B 167 A 203 D 239 A
24 A 60 B 96 B 132 C 168 A 204 B 240 C
25 B 61 A 97 D 133 A 169 B 205 A 241 A
26 B 62 C 98 B 134 B 170 C 206 C 242 C
27 D 63 C 99 A 135 B 171 D 207 B 243 B
28 B 64 A 100 D 136 C 172 C 208 B 244 C
29 C 65 A 101 B 137 D 173 D 209 D 245 C
30 A 66 D 102 D 138 C 174 B 210 C 246 A
31 D 67 D 103 A 139 D 175 C 211 C 247 B
32 D 68 D 104 A 140 B 176 B 212 C 248 B
33 A 69 C 105 B 141 D 177 B 213 B 249 B
34 D 70 C 106 D 142 C 178 A 214 A 250 A
35 C 71 C 107 B 143 C 179 C 215 D
36 A 72 A 108 A 144 D 180 C 216 D

34
CD Rom: Practice Exam 3
151 171 191 211 231

152 172 192 212 232

153 173 193 213 233

154 174 194 214 234

155 175 195 215 235

156 176 196 216 236

157 177 197 217 237

158 178 198 218 238

159 179 199 219 239

160 180 200 220 240

161 181 201 221 241

162 182 202 222 242

163 183 203 223 243

164 184 204 224 244

165 185 205 225 245

166 186 206 226 246

167 187 207 227 247

168 188 208 228 248

169 189 209 229 249

170 190 210 230 250