1. The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump?

a. Checking for the last bowel movement

b. Checking for residual stomach contents

c. Client's head of bed elevated at least 15 degrees

d. Last medication for nausea

2. The nurse is teaching growth and development activities to the parents of a 3-month-old infant. Which statements does the nurse include in the teaching plan? Select all that apply.

a. 'Your child should be able to show the grasp reflex.'

b. 'Your child should be able to coo, babble, and chuckle.'

c. 'Your child should be able to pull at blankets or clothes.'

d. 'Your child should be able to put feet into the mouth when supine.'

e. 'Your child's head can come up to a 45- to 90-degree angle from the table.'

3. To reduce the risk of recurrent painful gout attacks, the nurse teaches the client to avoid which foods? Select all that apply.

a. Eggs

b. Liver

c. Cheese

d. Salmon

e. Shellfish

4. Which medication should the nurse anticipate the health care provider will prescribe to relieve the pain experienced by a client with rheumatoid arthritis?

a. Acetylsalicylic acid (Aspirin)

b. Hydromorphone (Dilaudid)

c. Meperidine (Demerol)

d. Alprazolam (Xanax)

5. In the postanesthesia care unit it is reported that the client received intrathecal morphine intraoperatively to control pain. Considering the administration of this medication, what should the nurse include as part of the client's initial 24-hour postoperative care?

a. Assessing the client for tachycardia

b. Monitoring of respiratory rate hourly

c. Administering naloxone every three to four hours

d. Observing the client for signs of central nervous system (CNS) excitement

6. A father asks the nurse about the immunization schedule for his 15-month-old toddler, who is being treated for acute lymphoid leukemia. What vaccine is contraindicated for a child undergoing chemotherapy?

a. Hib (influenza)

b. HepB (hepatitis B)

c. MMR (measles, mumps, rubella)

d. DTaP (diphtheria, tetanus, acellular pertussis)

7. A parent and 3-month-old infant are visiting the well-baby clinic for a routine examination. What instruction should the nurse include in the accident-prevention teaching plan?

a. Remove small objects from the floor.

b. Cover electric outlets with safety plugs.

c. Remove toxic substances from accessible areas.

d. Test the temperature of water before bathing.

8. The nurse is caring for an Asian-American client with a diagnosis of depression. While interviewing this client the nurse notes that the client maintains traditional cultural beliefs and values. What is the most important information for the nurse to obtain about the client?

a. Dietary practices

b. Concept of space

c. Immigration status

d. Role within the family

9. A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? Select all that apply.

a. Take the aspirin with meals or a snack.

b. Make an appointment with a dentist if bleeding gums develop.

c. Do not chew enteric-coated tablets.

d. Switch to Tylenol (acetaminophen) if tinnitus occurs.

e. Report persistent abdominal pain.

10. A nurse is planning to give a preschool child an immunization consisting of bacterial cells that have been modified. What is the substance called?

a. A toxoid

b. A vaccine

c. An allergen

d. An antitoxin

11. A client in a hospice home care program is experiencing severe pain. Morphine (MS Contin) has been prescribed for pain management. Which information should the nurse plan to explain to the client in preparation for this pain management regimen?

a. Drug addiction is a concern with this drug

b. Request the medication before the pain becomes severe

c. Intermittent administration of the drug is possible after an intermittent lock is inserted

d. Dosages of the drug will be given automatically at regular intervals around the clock

12. A client with a spinal cord injury tends to assume the low-Fowler position excessively. What area of the body is most vulnerable to the development of a pressure ulcer in this client?

13. A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force?

a. Maintain the head of the bed at 35 degrees or less.

b. With the help of another staff member, use a drawsheet when lifting the client in bed.

c. Reposition the client at least every 2 hours and support the client with pillows.

d. At least once every 8 hours, perform passive range-of-motion exercises of all extremities.

14. A nurse is assessing four clients for risk factors for developing a pressure ulcer. List in order of priority the client with the greatest risk for developing a pressure ulcer to the client with the smallest risk.
1.
78-year-old female, admitted to the hospital for knee replacement surgery, no sensory impairment, continent, and ambulatory

2.
70-year-old male, admitted with metastatic bone cancer, weighing 80 lbs, dehydrated, and bed bound

3.
62-year-old female, admitted because of a brain attack (CVA), left hemiplegia, incontinent of urine and stool, and transfers to a chair via a mechanical lift

4.
25-year-old male, diagnosed with sepsis, average height and weight, developmentally disabled, unable to communicate except with grunts, incontinent of urine, and ambulatory

15. A nurse is teaching a client and family about the characteristics of dementia of the Alzheimer type. What physiological characteristic should the nurse include?

a. Periodic exacerbations

b. Aggressive acting-out behavior

c. Hypoxia of selected areas of brain tissue

d. Areas of brain destruction called senile plaques

16. The nurse is teaching crutch-walking to a 12-year-old child. What does the child do that indicates the need for more teaching?

a. Takes short steps of equal length

b. Looks forward to maintain balance

c. Looks down when placing the crutches

d.Assumes an erect posture when walking

17. A client reports having a bad cold and chest pain that worsens when the client takes deep breaths. Where should the nurse place the stethoscope to determine the presence of a pleural friction rub? Choose the appropriate location marked on the image.

A.

B.

C.

D.

18. While reviewing the admission assessment the nurse finds that a 2-year-old child has not received immunization for measles, mumps, and rubella (MMR). At what age should the child have received this vaccine?

a. 2 months

b. 4 months

c. 6 months

d. 12 months

19. An infant is receiving intermittent nasogastric tube feedings. In what position should the nurse place the infant?

a. Prone

b. Semi-Fowler

c. Left side-lying

d. Supine with the head turned

20. A nurse is educating a client with diabetes about insulin and appropriate nutritional intake. Which statement indicates that the client understands the teaching?

a. 'I can eat what I want as long as I take enough insulin.'

b. 'I can eat lots of foods as long as I stick to my exchange units.'

c. 'I should take my regular insulin at night on an empty stomach.'

d. 'I should eat a really small breakfast so I don't overwhelm my morning insulin.'

21. A 10-year-old child who is developmentally delayed and blind must be fed all meals. The child has problems swallowing and frequently chokes and coughs during the feeding. What technique should the nurse use when feeding this child?

a. Holding the child in an upright position and using a soft-tipped bulb syringe

b. Placing the child in the supine position and turning the child's head to the right

c. Seating the child in a wheelchair, giving small bites of food with metal tableware, and encouraging participation

d. Propping the child in a semisitting position, providing chopped food, and placing it in the child's mouth with plastic tableware

22. A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report?

a. A statement that the nursing staff was not at fault because the client initiated the accident.

b. A listing of facts related to the incident as witnessed by the nurse.

c. The name of the nurse who was responsible for implementing the restraints.

d. The potential reasons why the restraints were not in place at the time of the fall.

23. A slightly overweight client is to be discharged from the hospital after a cholecystectomy. What is most important for the nurse to include in teaching the client about nutrition?

a. Listing those fatty foods that may be included in the diet.

b. Explaining that fatty foods may not be tolerated for several weeks.

c. Teaching the importance of a low-calorie diet to promote weight reduction.

d. Encouraging the client to join a weight reduction program in the local community.

24. An infant has been vomiting after each feeding. Physical assessment reveals poor skin turgor, a sunken anterior fontanel, and tremors. The infant's acid-base balance is outside the expected range. What does the nurse suspect as the cause of this imbalance?

a. Retention of potassium in the cells

b. Loss of fluid by way of the kidneys

c. Loss of chloride ions through vomiting

d. Reduction of blood supply to body cells

25. How can a nurse best accomplish therapeutic communication with an adolescent?

a. By using teen language

b. By relating on a peer level

c. By establishing a relationship over time

d. By interacting with the use of concrete concepts