NLE practice exam with answers

8/18/2019 NLE practice exam with answers

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1. A pregnant woman who is at term is admitted to the

birthing unit in active labor. The client has only progressed

from 2cm to 3 cm in 8 hours. She is diagnosed with

hypotonic dystocia and the physician ordered Oxytocin

(Pitocin) to augment her contractions. Which of the following

is the most important aspect of nursing intervention at this

time?

A. Timing and recording length of contractions.

B. Monitoring.

C. Preparing for an emergency cesarean birth.

D. Checking the perineum for bulging.

2. A client who hallucinates is not in touch with reality. It is

important for the nurse to:

A. Isolate the client from other patients.

B. Maintain a safe environment.

C. Orient the client to time, place, and person.

D. Establish a trusting relationship.

3. The nurse is caring to a child client who has had a

tonsillectomy. The child complains of having dryness of the

throat. Which of the following would the nurse give to the

child?

A. Cola with ice

B. Yellow noncitrus Jello

C. Cool cherry Kool-Aid

D. A glass of milk

4. The physician ordered Phenylephrine (Neo-Synephrine)

nasal spray to a 13-year-old client. The nurse caring to the

client provides instructions that the nasal spray must be used

exactly as directed to prevent the development of:

A. Increased nasal congestion.

B. Nasal polyps.

C. Bleeding tendencies.

D. Tinnitus and diplopia.

5. A client with tuberculosis is to be admitted in the hospital.

The nurse who will be assigned to care for the client must

institute appropriate precautions. The nurse should:

A. Place the client in a private room.

B. Wear an N 95 respirator when caring for the client.

C. Put on a gown every time when entering the room.

D. Don a surgical mask with a face shield when entering the

room.

6. Which of the following is the most frequent cause of

noncompliance to the medical treatment of open-angle

glaucoma?

A. The frequent nausea and vomiting accompanying use of

miotic drug.

B. Loss of mobility due to severe driving restrictions.

C. Decreased light and near-vision accommodation due to

miotic effects of pilocarpine.

D. The painful and insidious progression of this type of

glaucoma.

7. In the morning shift, the nurse is making rounds in the

nursing care units. The nurse enters in a client’s room and

notes that the client’s tube has become disconnected from

the Pleurovac. What would be the initial nursing action?

A. Apply pressure directly over the incision site.

B. Clamp the chest tube near the incision site.

C. Clamp the chest tube closer to the drainage system.

D. Reconnect the chest tube to the Pleurovac.

8. Which of the following complications during a breech birth

the nurse needs to be alarmed?

A. Abruption placenta.

B. Caput succedaneum.

C. Pathological hyperbilirubinemia.

D. Umbilical cord prolapse.

9. The nurse is caring to a client diagnosed with severe

depression. Which of the following nursing approach is

important in depression?

A. Protect the client against harm to others.

B. Provide the client with motor outlets for aggressive, hostilefeelings.

C. Reduce interpersonal contacts.

D. Deemphasizing preoccupation with elimination,

nourishment, and sleep.

10. A 3-month-old client is in the pediatric unit. During

assessment, the nurse is suspecting that the baby may have

hypothyroidism when mother states that her baby does not:

A. Sit up.

B. Pick up and hold a rattle.

C. Roll over.

D. Hold the head up.

11. The physician calls the nursing unit to leave an order.

The senior nurse had conversation with the other staff. The


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newly hired nurse answers the phone so that the senior

nurses may continue their conversation. The new nurse does

not knowthe physician or the client to whom the order

pertains. The nurse should:

A. Ask the physician to call back after the nurse has read the

hospital policy manual.

B. Take the telephone order.

C. Refuse to take the telephone order.

D. Ask the charge nurse or one of the other senior staff

nurses to take the telephone order.

12. The staff nurse on the labor and delivery unit is assigned

to care to a primigravida in transition complicated by

hypertension. A new pregnant woman in active labor is

admitted in the same unit. The nurse manager assigned the

same nurse to the second client. The nurse feels that the

client with hypertension requires one-to-one care. What

would be the initial actionof the nurse?

A. Accept the new assignment and complete an incident

report describing a shortage of nursing staff.

B. Report the incident to the nursing supervisor and request

to be floated.

C. Report the nursing assessment of the client in transitional

labor to the nurse manager and discuss misgivings about the

new assignment.

D. Accept the new assignment and provide the best care.

13. A newborn infant with Down syndrome is to be

discharged today. The nurse is preparing to give the

discharge teaching regarding the proper care at home. The

nurse would anticipate that the mother is probably at the:

A. 40 years of age.

B. 20 years of age.C. 35 years of age.

D. 20 years of age.

14. The emergency department has shortage of staff. The

nurse manager informs the staff nurse in the critical care unit

that she has to float to the emergency department. What

should the staff nurse expect under these conditions?

A. The float staff nurse will be informed of the situation

before the shift begins.

B. The staff nurse will be able to negotiate the assignments

in the emergency department.

C. Cross training will be available for the staff nurse.

D. Client assignments will be equally divided among the

nurses.

15. The nurse is assigned to care for a child client admitted

in the pediatrics unit. The client is receiving digoxin. Which of

the following questions will be asked by the nurse to the

parents of the child in order to assess the client’s risk for

digoxin toxicity?

A. “Has he been exposed to any childhood communicable

diseases in the past 2-3 weeks?”

B. “Has he been taking diuretics at home?”

C. “Do any of his brothers and sisters have history of cardiac

problems?”

D. “Has he been going to school regularly?”

16. The nurse noticed that the signed consent form has an

error. The form states, “Amputation of the right leg” instead of

the left leg that is to be amputated. The nurse has

administered already the preoperative medications. What

should the nurse do?

A. Call the physician to reschedule the surgery.

B. Call the nearest relative to come in to sign a new form.

C. Cross out the error and initial the form.

D. Have the client sign another form.

17. The nurse in the nursing care unit checks the fluctuation

in the water-seal compartment of a closed chest drainage

system. The fluctuation has stopped, the nurse would:

A. Vigorously strip the tube to dislodge a clot.

B. Raise the apparatus above the chest to move fluid.

C. Increase wall suction above 20 cm H2O pressure.

D. Ask the client to cough and take a deep breath.

18. The pediatric nurse in the neonatal unit was informed

that the baby that is brought to the mother in the hospital

room is wrong. The nurse determines that two babies wereplaced in the wrong cribs. The most appropriate nursing

action would be to:

A. Determine who is responsible for the mistake and

terminate his or her employment.

B. Record the event in an incident/variance report and notify

the nursing supervisor.

C. Reassure both mothers, report to the charge nurse, and

do not record.

D. Record detailed notes of the event on the mother’s

medical record.

19. Before the administration of digoxin, the nurse completes

an assessment to a toddler client for signs and symptoms of

digoxin toxicity. Which of the following is the earliest and

most significant sign of digoxin toxicity?


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A. Tinnitus

B. Nausea and vomiting

C. Vision problem

D. Slowing in the heart rate

20. Which of the following treatment modality is appropriate

for a client with paranoid tendency?

A. Activity therapy.

B. Individual therapy.

C. Group therapy.

D. Family therapy.

21. The client with rheumatoid arthritis is for discharge. In

preparing the client for discharge on prednisone therapy, the

nurse should advise the client to:

A. Wear sunglasses if exposed to bright light for an extended

period of time.

B. Take oral preparations of prednisone before meals.

C. Have periodic complete blood counts while on the

medication.

D. Never stop or change the amount of the medication

without medical advice.

22. A pregnant client tells the nurse that she is worried about

having urinary frequency. What will be the most appropriate

nursing response?

A. “Try using Kegel (perineal) exercises and limiting fluids

before bedtime. If you have frequency associated with fever,

pain on voiding, or blood in the urine, call your doctor/nurse-

midwife.

B. “Placental progesterone causes irritability of the bladder

sphincter. Your symptoms will go away after the baby

comes.”C. “Pregnant women urinate frequently to get rid of fetal

wastes. Limit fluids to 1L/daily.”

D. “Frequency is due to bladder irritation from concentrate

urine and is normal in pregnancy. Increase your daily fluid

intake to 3L.”

23. Which of the following will help the nurse determine that

the expression of hostility is useful?

A. Expression of anger dissipates the energy.

B. Energy from anger is used to accomplish what needs to

be done.

C. Expression intimidates others.

D. Degree of hostility is less than the provocation.

24. The nurse is providing an orientation regarding case

management to the nursing students. Which characteristics

should the nurse include in the discussion in understanding

case management?

A. Main objective is a written plan that combines discipline-

specific processes used to measure outcomes of care.

B. Main purpose is to identify expected client, family and staff

performance against the timeline for clients with the same

diagnosis.

C. Main focus is comprehensive coordination of client care,

avoid unnecessary duplication of services, improve resource

utilization and decrease cost.

D. Primary goal is to understand why predicted outcomes

have not been met and the correction of identified problems.

25. The physician orders a dose of IV phenytoin to a child

client. In preparing in the administration of the drug, which

nursing action is not correct?

A. Infuse the phenytoin into a smaller vein to prevent purple

glove syndrome.

B. Check the phenytoin solution to be sure it is clear or light

yellow in color, never cloudy.

C. Plan to give phenytoin over 30-60 minutes, using an in-

line filter.

D. Flush the IV tubing with normal saline before starting

phenytoin.

26. The pregnant woman visits the clinic for check –up.

Which assessment findings will help the nurse determine

that the client is in 8-week gestation?

A. Leopold maneuvers.

B. Fundal height.

C. Positive radioimmunoassay test (RIA test).D. Auscultation of fetal heart tones.

27. Which of the following nursing intervention is essential

for the client who had pneumonectomy?

A. Medicate for pain only when needed.

B. Connect the chest tube to water-seal drainage.

C. Notify the physician if the chest drainage exceeds

100mL/hr.

D. Encourage deep breathing and coughing.

28. The nurse is providing a health teaching to a group of

parents regarding Chlamydia trachomatis. The nurse is

correct in the statement, “Chlamydia trachomatis is not only

an intracellular bacterium that causes neonatal conjunctivitis,

but it also can cause:


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A. Discoloration of baby and adult teeth.

B. Pneumonia in the newborn.

C. Snuffles and rhagades in the newborn.

D. Central hearing defects in infancy.

29. The nurse is assigned to care to a 17-year-old male

client with a history of substance abuse. The client asks the

nurse, “Have you ever tried or used drugs?” The most

correct response of the nurse would be:

A. “Yes, once I tried grass.”

B. “No, I don’t think so.”

C. “Why do you want to know that?”

D. “How will my answer help you?”

30. Which of the following describes a health care team with

the principles of participative leadership?

A. Each member of the team can independently make

decisions regarding the client’s care without necessarily

consulting the other members.

B. The physician makes most of the decisions regarding the

client’s care.

C. The team uses the expertise of its members to influence

the decisions regarding the client’s care.

D. Nurses decide nursing care; physicians decide medical

and other treatment for the client.

31. A nurse is giving a health teaching to a woman who

wants to breastfeed her newborn baby. Which hormone,

normally secreted during the postpartum period, influences

both the milk ejection reflex and uterine involution?

A. Oxytocin.

B. Estrogen.

C. Progesterone.D. Relaxin.

32. One staff nurse is assigned to a group of 5 patients for

the 12-hour shift. The nurse is responsible for the overall

planning, giving and evaluating care during the entire shift.

After the shift, same responsibility will be endorsed to the

next nurse in charge. This describes nursing care delivered

via the:

A. Primary nursing method.

B. Case method.

C. Functional method.

D. Team method.

33. The ambulance team calls the emergency department

that they are going to bring a client who sustained burns in a

house fire. While waiting for the ambulance, the nurse will

anticipate emergency care to include assessment for:

A. Gas exchange impairment.

B. Hypoglycemia.

C. Hyperthermia.

D. Fluid volume excess.

34. Most couples are using “natural” family planning

methods. Most accidental pregnancies in couples preferred

to use this method have been related to unprotected

intercourse before ovulation. Which of the following factor

explains why pregnancy may be achieved by unprotected

intercourse during the preovulatory period?

A. Ovum viability.

B. Tubal motility.

C. Spermatozoal viability.

D. Secretory endometrium.

35. An older adult client wakes up at 2 o’clock in the morning

and comes to the nurse’s station saying, “I am having

difficulty in sleeping.” What is the best nursing response to

the client?

A. “I’ll give you a sleeping pill to help you get more sleep

now.”

B. “Perhaps you’d like to sit here at the nurse’s station for a

while.”

C. “Would you like me to show you where the bathroom is?”

D. “What woke you up?”

36. The nurse is taking care of a multipara who is at 42

weeks of gestation and in active labor, her membranes

ruptured spontaneously 2 hours ago. While auscultating for

the point of maximum intensity of fetal heart tones beforeapplying an external fetal monitor, the nurse counts 100

beats per minute. The immediate nursing action is to:

A. Start oxygen by mask to reduce fetal distress.

B. Examine the woman for signs of a prolapsed cord.

C. Turn the woman on her left side to increase placental

perfusion.

D. Take the woman’s radial pulse while still auscultating the

FHR.

37. The nurse must instruct a client with glaucoma to avoid

taking over-the-counter medications like:

A. Antihistamines.

B. NSAIDs.


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48. Which of the following will best describe a management

function?

A. Writing a letter to the editor of a nursing journal.

B. Negotiating labor contracts.

C. Directing and evaluating nursing staff members.

D. Explaining medication side effects to a client.

49. The parents of an infant client ask the nurse to teach

them how to administer Cortisporin eye drops. The nurse is

correct in advising the parents to place the drops:

A. In the middle of the lower conjunctival sac of the infant’s

eye.

B. Directly onto the infant’s sclera.

C. In the outer canthus of the infant’s eye.

D. In the inner canthus of the infant’s eye.

50. The nurse is assessing on the client who is admitted due

to vehicle accident. Which of the following findings will help

the nurse that there is internal bleeding?

A. Frank blood on the clothing.

B. Thirst and restlessness.

C. Abdominal pain.

D. Confusion and altered of consciousness.

51. The nurse is completing an assessment to a newborn

baby boy. The nurse observes that the skin of the newborn is

dry and flaking and there are several areas of an apparent

macular rash. The nurse charts this as:

A. Icterus neonatorum

B. Multiple hemangiomas

C. Erythema toxicum

D. Milia

52. The client is brought to the emergency department

because of serious vehicle accident. After an hour, the client

has been declared brain dead. The nurse who has been with

the client must now talk to the family about organ donation.

Which of the following consideration is necessary?

A. Include as many family members as possible.

B. Take the family to the chapel.

C. Discuss life support systems.

D. Clarify the family’s understanding of brain death.

53. The nurse is teaching exercises that are good for

pregnant women increasing tone and fitness and decreasing

lower backache. Which of the following should the nurse

exclude in the exercise program?

A. Stand with legs apart and touch hands to floor three times

per day.

B. Ten minutes of walking per day with an emphasis on good

posture.

C. Ten minutes of swimming or leg kicking in pool per day.

D. Pelvic rock exercise and squats three times a day.

54. A client with obsessive-compulsive behavior is admitted

in the psychiatric unit. The nurse taking care of the client

knows that the primary treatment goal is to:

A. Provide distraction.

B. Support but limit the behavior.

C. Prohibit the behavior.

D. Point out the behavior.

55. After ileostomy, the nurse expects that the drainage

appliance will be applied to the stoma:

A. When the client is able to begin self-care procedures.

B. 24 hours later, when the swelling subsided.

C. In the operating room after the ileostomy procedure.

D. After the ileostomy begins to function.

56. A female client who has a 28-day menstrual cycle asks

the community health nurse when she get pregnant during

her cycle. What will be the best nursing response?

A. It is impossible to determine the fertile period reliably. So it

is best to assume that a woman is always fertile.

B. In a 28-day cycle, ovulation occurs at or about day 14.

The egg lives for about 24 hours and the sperm live for about

72 hours. The fertile period would be approximately between

day 11 and day 15.

C. In a 28- day cycle, ovulation occurs at or about day 14.

The egg lives for about 72 hours and the sperm live for about24 hours. The fertile period would be approximately between

day 13 and 17.

D. In a 28-day cycle, ovulation occurs 8 days before the next

period or at about day 20. The fertile period is between day

20 and the beginning of the next period.

57. Which of the following statement describes the role of a

nurse as a client advocate?

A. A nurse may override clients’ wishes for their own good.

B. A nurse has the moral obligation to prevent harm and do

well for clients.

C. A nurse helps clients gain greater independence and self-

determination.

D. A nurse measures the risk and benefits of various health

situations while factoring in cost.


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58. A community health nurse is providing a health teaching

to a woman infected with herpes simplex 2. Which of the

following health teaching must the nurse include to reduce

the chances of transmission of herpes simplex 2?

A. “Abstain from intercourse until lesions heal.”

B. “Therapy is curative.”

C. “Penicillin is the drug of choice for treatment.”

D. “The organism is associated with later development of

hydatidiform mole.

59. The nurse in the psychiatric ward informed the male

client that he will be attending the 9:00 AM group therapy

sessions. The client tells the nurse that he must wash his

hands from 9:00 to 9:30 AM each day and therefore he

cannot attend. Which concept does the nursing staff need to

keep in mind in planning nursing intervention for this client?

A. Depression underlines ritualistic behavior.

B. Fear and tensions are often expressed in disguised form

through symbolic processes.

C. Ritualistic behavior makes others uncomfortable.

D. Unmet needs are discharged through ritualistic behavior.

10. The nurse assesses the health condition of the female

client. The client tells the nurse that she discovered a lump in

the breast last year and hesitated to seek medical advice.

The nurse understands that, women who tend to delay

seeking medical advice after discovering the disease are

displaying what common defense mechanism?

A. Intellectualization.

B. Suppression.

C. Repression.

D. Denial.

61. Which of the following situations cannot be delegated by

the registered nurse to the nursing assistant?

A. A postoperative client who is stable needs to ambulate.

B. Client in soft restraint who is very agitated and crying.

C. A confused elderly woman who needs assistance with

eating.

D. Routine temperature check that must be done for a client

at end of shift.

62. In the admission care unit, which of the following client

would the nurse give immediate attention?

A. A client who is 3 days postoperative with left calf pain.

B. A client who is postoperative hip pinning who is

complaining of pain.

C. New admitted client with chest pain.

D. A client with diabetes who has a glucoscan reading of

180.

63. A couple seeks medical advice in the community health

care unit. A couple has been unable to conceive; the man is

being evaluated for possible problems. The physician

ordered semen analysis. Which of the following instructions

is correct regarding collection of a sperm specimen?

A. Collect a specimen at the clinic, place in iced container,

and give to laboratory personnel immediately.

B. Collect specimen after 48-72 hours of abstinence and

bring to clinic within 2 hours.

C. Collect specimen in the morning after 24 hours of

abstinence and bring to clinic immediately.

D. Collect specimen at night, refrigerate, and bring to clinic

the next morning.

64. The physician ordered Betamethasone to a pregnant

woman at 34 weeks of gestation with sign of preterm labor.

The nurse expects that the drug will:

A. Treat infection.

B. Suppress labor contraction.

C. Stimulate the production of surfactant.

D. Reduce the risk of hypertension.

65. A tracheostomy cuff is to be deflated, which of the

following nursing intervention should be implemented before

starting the procedures?

A. Suction the trachea and mouth.

B. Have the obdurator available.

C. Encourage deep breathing and coughing.

D. Do a pulse oximetry reading.

66. A client is diagnosed with Tuberculosis and respiratory

isolation is initiated. This means that:

A. Gloves are worn when handling the client’s tissue,

excretions, and linen.

B. Both client and attending nurse must wear masks at all

times.

C. Nurse and visitors must wear masks until chemotherapy

is begun. Client is instructed in cough and tissue techniques.

D. Full isolation; that is, caps and gowns are required during

the period of contagion.

67. A client with lung cancer is admitted in the nursing care

unit. The husband wants to know the condition of his wife.

How should the nurse respond to the husband?


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A. Find out what information he already has.

B. Suggest that he discuss it with his wife.

C. Refer him to the doctor.

D. Refer him to the nurse in charge.

68. A hospitalized client cannot find his handkerchief and

accuses other cient in the room and the nurse of stealing

them. Which is the most therapeutic approach to this client?

A. Divert the client’s attention.

B. Listen without reinforcing the client’s belief.

C. Inject humor to defuse the intensity.

D. Logically point out that the client is jumping to

conclusions.

69. After a cystectomy and formation of an ileal conduit, the

nurse provides instruction regarding prevention of leakage of

the pouch and backflow of the urine. The nurse is correct to

include in the instruction to empty the urine pouch:

A. Every 3-4 hours.

B. Every hour.

C. Twice a day.

D. Once before bedtime.

70. Which telephone call from a student’s mother should the

school nurse take care of at once?

A. A telephone call notifying the school nurse that the child’

pediatrician has informed the mother that the child will need

cardiac repair surgery within the next few weeks.

B. A telephone call notifying the school nurse that the child’s

pediatrician has informed the mother that the child has head

lice.

C. A telephone call notifying the school nurse that a child has

a temperature of 102ºF and a rash covering the trunk andupper extremities of the body.

D. A telephone call notifying the school nurse that a child

underwent an emergency appendectomy during the previous

night.

71. Which of the following signs and symptoms that require

immediate attention and may indicate most serious

complications during pregnancy?

A. Severe abdominal pain or fluid discharge from the vagina.

B. Excessive saliva, “bumps around the areolae, and

increased vaginal mucus.

C. Fatigue, nausea, and urinary frequency at any time during

pregnancy.

D. Ankle edema, enlarging varicosities, and heartburn.

72. The nurse is assessing the newborn boy. Apgar scores

are 7 and 9. The newborn becomes slightly cyanotic. What is

the initial nursing action?

A. Elevate his head to promote gravity drainage of

secretions.

B. Wrap him in another blanket, to reduce heat loss.

C. Stimulate him to cry,, to increase oxygenation.

D. Aspirate his mouth and nose with bulb syringe.

73. The nurse is formulating a plan of care to a client with a

somatoform disorder. The nurse needs to have knowledge of

which psychodynamic principle?

A. The symptoms of a somatoform disorder are an attempt to

adjust to painful life situations or to cope with conflicting

sexual, aggressive, or dependent feelings.

B. The major fundamental mechanism is regression.

C. The client’s symptoms are imaginary and the suffering is

faked.

D. An extensive, prolonged study of the symptoms will be

reassuring to the client, who seeks sympathy, attention and

love.

74. An infant is brought to the health care clinic for three

immunizations at the same time. The nurse knows that

hepatitis B, DPT, and Haemophilus influenzae type B

immunizations should:

A. Be drawn in the same syringe and given in one injection.

B. Be mixed and inject in the same sites.

C. Not be mixed and the nurse must give three injections in

three sites.

D. Be mixed and the nurse must give the injection in three

sites.

75. A female client with cancer has radium implants. The

nurse wants to maintain the implants in the correct position.The nurse should position the client:

A. Flat in bed.

B. On the side only.

C. With the foot of the bed elevated.

D. With the head elevated 45-degrees (semi-Fowler’s).

76. The nurse wants to know if the mother of a toddler

understands the instructions regarding the administration of

syrup of ipecac. Which of the following statement will help

the nurse to know that the mother needs additional

teaching?

A. “I’ll give the medicine if my child gets into some toilet bowl

cleaner.”

B. “I’ll give the medicine if my child gets into some aspirin.”


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C. “I’ll give the medicine if my child gets into some plant

bulbs.”

D. “I’ll give the medicine if my child gets into some vitamin

pills.”

77. To assess if the cranial nerve VII of the client was

damaged, which changes would not be expected?

A. Drooling and drooping of the mouth.

B. Inability to open eyelids on operative side.

C. Sagging of the face on the operative side.

D. Inability to close eyelid on operative side.

78. The community health nurse makes a home visit to a

family. During the visit, the nurse observes that the mother is

beating her child. What is the priority nursing intervention in

this situation?

A. Assess the child’s injuries.

B. Report the incident to protective agencies.

C. Refer the family to appropriate support group.

D. Assist the family to identify stressors and use of other

coping mechanisms to prevent further incidents.

79. The nurse in the neonatal care unit is supervising the

actions of a certified nursing assistant in giving care to the

newborns. The nursing assistant mistakenly gives a formula

feeding to a newborn that is on water feeding only. The nurse

is responsible for the mistake of the nursing assistant:

A. Always, as a representative of the institution.

B. Always, because nurses who supervise less-trained

individuals are responsible for their mistakes.

C. If the nurse failed to determine whether the nursing

assistant was competent to take care of the client.

D. Only if the nurse agreed that the newborn could be fedformula.

80. The nurse is assigned to care for a client with urinary

calculi. Fluid intake of 2L/day is encouraged to the client. the

primary reason for this is to:

A. Reduce the size of existing stones.

B. Prevent crystalline irritation to the ureter.

C. Reduce the size of existing stones

D. Increase the hydrostatic pressure in the urinary tract.

81. The nurse is counseling a couple in their mid 30’s who

have been unable to conceive for about 6 months. They are

concerned that one or both of them may be infertile. What is

the best advice the nurse could give to the couple?

A. “it is no unusual to take 6-12 months to get pregnant,

especially when the partners are in their mid-30s. Eat well,

exercise, and avoid stress.”

B. “Start planning adoption. Many couples get pregnant

when they are trying to adopt.”

C. “Consult a fertility specialist and start testing before you

get any older.”

D. “Have sex as often as you can, especially around the time

of ovulation, to increase your chances of pregnancy.”

82. The nurse is caring for a cient who Is a retired nurse. A

24-hour urine collection for Creatinine clearance is to be

done. The client tells the nurse, “I can’t remember what this

test is for.” The best response by the nurse is:

A. “It provides a way to see if you are passing any protein in

your urine.”

B. “It tells how well the kidneys filter wastes from the blood.”

C. “It tells if your renal insufficiency has affected your heart.”

D. “The test measures the number of particles the kidney

filters.”

83. The nurse observes the female client in the psychiatric

ward that she is having a hard time sleeping at night. The

nurse asks the client about it and the client says, “I can’t

sleep at night because of fear of dying.” What is the best

initial nursing response?

A. “It must be frightening for you to feel that way. Tell me

more about it.”

B. “Don’t worry, you won’t die. You are just here for some

test.”

C. “Why are you afraid of dying?”

D. “Try to sleep. You need the rest before tomorrow’s test.”

84. In the hospital lobby, the registered nurse overhears atwo staff members discussing about the health condition of

her client. What would be the appropriate action for the

registered nurse to take?

A. Join in the conversation, giving her input about the case.

B. Ignore them, because they have the right to discuss

anything they want to.

C. Tell them it is not appropriate to discuss such things.

D. Report this incident to the nursing supervisor.

85. The client has had a right-sided cerebrovascular

accident. In transferring the client from the wheelchair to

bed, in what position should a client be placed to facilitate

safe transfer?


10/43

A. Weakened (L) side of the cient next to bed.

B. Weakened (R) side of the client next to bed.

C. Weakened (L) side of the client away from bed.

D. Weakened (R) side of the cient away from bed.

86. The child client has undergone hip surgery and is in a

spica cast. Which of the following toy should be avoided to

be in the child’s bed?

A. A toy gun.

B. A stuffed animal.

C. A ball.

D. Legos.

87. The LPN/LVN asks the registered nurse why oxytocin

(Pitocin), 10 units (IV or IM) must be given to a client after

birth fo the fetus. The nurse is correct to explain that

oxytocin:

A. Minimizes discomfort from “afterpains.”

B. Suppresses lactation.

C. Promotes lactation.

D. Maintains uterine tone.

88. The nurse in the nursing care unit is aware that one of

the medical staff displays unlikely behaviors like confusion,

agitation, lethargy and unkempt appearance. This behavior

has been reported to the nurse manager several times, but

no changes observed. The nurse should:

A. Continue to report observations of unusual behavior until

the problem is resolved.

B. Consider that the obligation to protect the patient from

harm has been met by the prior reports and do nothing

further.

C. Discuss the situation with friends who are also nurses toget ideas .

D. Approach the partner of this medical staff member with

these concerns.

89. The physician ordered tetracycline PO qid to a child

client who weights 20kg. The recommended PO tetracycline

dose is 25-50 mg/kg/day. What is the maximum single dose

that can be safely administered to this child?

A. 1 g

B. 500 mg

C. 250 mg

D. 125 mg

90. The nurse is completing an obstetric history of a woman

in labor. Which event in the obstetric history will help the

nurse suspects dysfunctional labor in the current pregnancy?

A. Total time of ruptured membranes was 24 hours with the

second birth.

B. First labor lasting 24 hours.

C. Uterine fibroid noted at time of cesarean delivery.

D. Second birth by cesarean for face presentation.

91. The nurse is planning to talk to the client with an

antisocial personality disorder. What would be the most

therapeutic approach?

A. Provide external controls.

B. Reinforce the client’s self-concept.

C. Give the client opportunities to test reality.

D. Gratify the client’s inner needs.

92. The nurse is teaching a group of women about fertility

awareness, the nurse should emphasize that basal body

temperature:

A. Can be done with a mercury thermometer but no a digital

one.

B. The average temperature taken each morning.

C. Should be recorded each morning before any activity.

D. Has a lower degree of accuracy in predicting ovulation

than the cervical mucus test.

93. The nursing applicant has given the chance to ask

questions during a job interview at a local hospital. What

should be the most important question to ask that can

increase chances of securing a job offer?

A. Begin with questions about client care assignments,advancement opportunities, and continuing education.

B. Decline to ask questions, because that is the

responsibility of the interviewer.

C. Ask as many questions about the facility as possible.

D. Clarify information regarding salary, benefits, and working

hours first, because this will help in deciding whether or not

to take the job.

94. The nurse advised the pregnant woman that smoking

and alcohol should be avoided during pregnancy. The nurse

takes into account that the developing fetus is most

vulnerable to environment teratogens that cause

malformation during:

A. The entire pregnancy.

B. The third trimester.


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C. The first trimester.

D. The second trimester.

95. A male client tells the nurse that there is a big bug in his

bed. The most therapeutic nursing response would be:

A. Silence.

B. “Where’s the bug? I’ll kill it for you.”

C. “I don’t see a bug in your bed, but you seem afraid.”

D. “You must be seeing things.”

96. A pregnant client in late pregnancy is complaining of

groin pain that seems worse on the right side. Which of the

following is the most likely cause of it?

A. Beginning of labor.

B. Bladder infection.

C. Constipation.

D. Tension on the round ligament.

97. The nurse is conducting a lecture to a group of volunteer

nurses. The nurse is correct in imparting the idea that the

Good Samaritan law protects the nurse from a suit for

malpractice when:

A. The nurse stops to render emergency aid and leaves

before the ambulance arrives.

B. The nurse acts in an emergency at his or her place of

employment.

C. The nurse refuses to stop for an emergency outside of the

scope of employment.

D. The nurse is grossly negligent at the scene of an

emergency.

98. A woman is hospitalized with mild preeclampsia. The

nurse is formulating a plan of care for this client, whichnursing care is least likely to be done?

A. Deep-tendon reflexes once per shift.

B. Vital signs and FHR and rhythm q4h while awake.

C. Absolute bed rest.

D. Daily weight.

99. While feeding a newborn with an unrepaired cardiac

defect, the nurse keeps on assessing the condition of the

client. The nurse notes that the newborn’s respiration is 72

breaths per minute. What would be the initial nursing action?

A. Burp the newborn.

B. Stop the feeding.

C. Continue the feeding.

D. Notify the physician.

100. A client who undergone appendectomy 3 days ago is

scheduled for discharge today. The nurse notes that the

client is restless, picking at bedclothes and saying, “I am late

on my appointment,” and calling the nurse by the wrong

name. The nurse suspects:

A. Panic reaction.

B. Medication overdose.

C. Toxic reaction to an antibiotic.

D. Delirium tremens.

[divider] Answers & Rationale

1. A. The oxytocic effect of Pitocin increases the intensity

and durations of contractions; prolonged contractions will

jeopardize the safetyof the fetus and necessitate

discontinuing the drug.

2. B. It is of paramount importance to prevent the client from

hurting himself or herself or others.

3. B. After tonsillectomy, clear, cool liquids should be given.

Citrus, carbonated, and hot or cold liquids should be avoided

because they may irritate the throat. Red liquids should be

avoided because they give the appearance of blood if the

child vomits. Milk and milk products including pudding are

avoided because they coat the throat, cause the child to

clear the throat, and increase the risk of bleeding.

4. A. Phenylephrine, with frequent and continued use, can

cause rebound congestion of mucous membranes.

5. B. The N 95 respirator is a high-particulate filtration mask

that meets the CDC performance criteria for a tuberculosis

respirator.

6. C. The most frequent cause of noncompliance to the

treatment of chronic, or open-angle glaucoma is the miotic

effects of pilocarpine. Pupillary constriction impedes normal

accommodation, making night driving difficult and

hazardous, reducing the client’s ability to read for extended

periods and making participation in games with fast-moving

objects impossible.

7. B. This stops the sucking of air through the tube and

prevents the entry of contaminants. In addition, clampingnear the chest wall provides for some stability and may

prevent the clamp from pulling on the chest tube.

8. D. Because umbilical cord’s insertion site is born before

the fetal head, the cord may be compressed by the after-

coming head in a breech birth.


12/43

9. B. It is important to externalize the anger away from self.

10. D. Development normally proceeds cephalocaudally; so

the first major developmental milestone that the infant

achieves is the ability to hold the head up within the first 8-12

weeks of life. In hypothyroidism, the infant’s muscle tone

would be poor and the infant would not be able to achieve

this milestone.

11. D. Get a senior nurse who know s the policies, the client,

and the doctor. Generally speaking, a nurse should not

accept telephone orders. However, if it is necessary to take

one, follow the hospital’s policy regarding telephone orders.

Failure to followhospital policy could be considered

negligence. In this case, the nurse was new and did not

know the hospital’s policy concerning telephone orders. The

nurse was also unfamiliar with the doctor and the client.

Therefore the nurse should not take the order unless A. no

one else is available and B. it is an emergency situation.

12. C. The nurse is obligated to inform the nurse manager

about changes in the condition of the client, which may

change the decision made by the nurse manager.

13. A. Perinatal risk factors for the development of Down

syndrome include advanced maternal age, especially with

the first pregnancy.

14. B. Assignments should be based on scope of practice

and expertise.

15. B. The child who is concurrently taking digoxin and

diuretics is at increased risk for digoxin toxicity due to the

loss of potassium. The child and parents should be taught

what foods are high in potassium, and the child should be

encouraged to eat a high-potassium diet. In addition, thechild’s serum potassium level should be carefully monitored.

16. A. The responsible for an accurate informed consent is

the physician. An exception to this answer would be a life-

threatening emergency, but there are no data to support

another response.

17. D. Asking the client to cough and take a deep breath will

help determine if the chest tube is kinked or if the lungs has

reexpanded.

18. B. Every event that exposes a client to harm should be

recorded in an incident report, as well as reported to the

appropriate supervisors in order to resolve the current

problems and permit the institution to prevent the problem

from happening again.

19. D. One of the earliest signs of digoxin toxicity is

Bradycardia. For a toddler, any heart rate that falls below the

norm of about 100-120 bpm would indicate Bradycardia and

would necessitate holding the medication and notifying the

physician.

20. B. This option is least threatening.

21. D. In preparing the client for discharge that is receiving

prednisone, the nurse should caution the client to (A. take

oral preparations after meals; (B. remember that routine

checks of vital signs, weight, and lab studies are critical; (C.

NEVER STOP OR CHANGE THE AMOUNT OF

MEDICATION WITHOUT MEDICAL ADVICE; (D. store the

medication in a light-resistant container.

22. A. Progesterone also reduces smooth muscle motility in

the urinary tract and predisposes the pregnant woman to

urinary tract infections. Women should contact their doctors

if they exhibit signs of infection. Kegel exercise will help

strengthen the perineal muscles; limiting fluids at bedtime

reduces the possibility of being awakened by the necessity of

voiding.

23. B. This is the proper use of anger.

24. C. There are several models of case management, but

the commonality is comprehensive coordination of care to

better predict needs of high-risk clients, decrease

exacerbations and continually monitor progress overtime.

25. A. Phenytoin should be infused or injected into larger

veins to avoid the discoloration know as purple glove

syndrome; infusing into a smaller vein is not appropriate.

26. C. Serum radioimmunoassay (RIA. is accurate within7days of conception. This test is specific for HCG, and

accuracy is not compromised by confusion with LH.

27. D. Surgery and anesthesia can increase mucus

production. Deep breathing and coughing are essential to

prevent atelectasis and pneumonia in the client’s only

remaining lung.

28. B. Newborns can get pneumonia (tachypnea, mild

hypoxia, cough, eosinophiliA. and conjunctivitis from

Chlamydia.

29. D. The client may perceive this as avoidance, but it is

more important to redirect back to the client, especially in

light of the manipulative behavior of drug abusers and

adolescents.


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30. C. It describes a democratic process in which all

members have input in the client’s care.

31. A. Contraction of the milk ducts and let-down reflex occur

under the stimulation of oxytocin released by the posterior

pituitary gland.

32. B. In case management, the nurse assumes total

responsibility for meeting the needs of the client during the

entire time on duty.

33. A. Smoke inhalation affects gas exchange.

34. C. Sperm deposited during intercourse may remain

viable for about 3 days. If ovulation occurs during this period,

conception may result.

35. B. This option shows acceptance (key concept) of this

age-typical sleep pattern (that of waking in the early

morning).

36. D. Taking the mother’s pulse while listening to the FHR

will differentiate between the maternal and fetal heart rates

and rule out fetal Bradycardia.

37. A. Antihistamines cause pupil dilation and should be

avoided with glaucoma.

38. A. This suggests that the level of consciousness is

decreasing.

39. D. An advance directive is a form of informed consent,

and only a competent adult or the holder of a durable power

of attorney has the right to consent or refuse treatment. If the

spouse does not hold the power of attorney, the decisions of

the holder, even if opposed by the spouse, are enforced.

40. C. Gentle but firm guidance and nonverbal direction is

needed to intervene when a client with schizophrenic

symptoms is being disruptive.

41. C. Suctioning is only done for 10 seconds, intermittently,

as the catheter is being withdrawn.

42. D. The priority for this client is being able to establish an

airway.

43. A. Signs of placental separation include a change in the

shape of the uterus from ovoid to globular.

44. B. This could indicate intracranial bleeding. Alteplase is a

thrombolytic enzyme that lyses thrombi and emboli. Bleeding

is an adverse effect. Monitor clotting times and signs of any

gastrointestinal or internal bleeding.

45. D. Because flank incision in nephrectomy is directly

below the diaphragm, deep breathing is painful. Additionally,

there is a greater incisional pull each time the person moves

than there is with abdominal surgery. Incisional pain

following nephrectomy generally requires analgesics

administration every 3-4 hours for 24-48 hours after surgery.

Therefore, turning, coughing and deep-breathing exercises

should be planned to maximize the analgesic effects.

46. B. Under high estrogen levels, during the period

surrounding ovulation, the cervical mucus becomes thin,

clear, and elastic (spinnbarkeit), facilitating sperm passage.

47. D. After surgery for a ruptured appendix, the client

should be placed in a semi-Fowler’s position to promote

drainage and to prevent possible complications.

48. C. Directing and evaluation of staff is a major

responsibility of a nursing manager.

49. A. The recommended procedure for administering

eyedrops to any client calls for the drops to be placed in the

middle of the lower conjunctival sac.

50. B. Thirst and restlessness indicate hypovolemia and

hypoxemia. Internal bleeding is difficult to recognized and

evaluate because it is not apparent.

51. C. Erythema toxicum is the normal, nonpathological

macular newborn rash.

52. D. The family needs to understand what brain death is

before talking about organ donation. They need time toaccept the death of their family member. An environment

conducive to discussing an emotional issue is needed.

53. A. Bending from the waist in pregnancy tends to make

backache worse.

54. B. Support and limit setting decrease anxiety and provide

external control.

55. C. The stoma drainage bag is applied in the operating

room. Drainage from the ileostomy contains secretions that

are rich in digestive enzymes and highly irritating to the skin.

Protection of the skin from the effects of these enzymes is

begun at once. Skin exposed to these enzymes even for a

short time becomes reddened, painful and excoriated.


14/43

56. B. It is the most accurate statement of physiological facts

for a 28-day menstrual cycle: ovulation at day 14, egg life

span 24 hours, sperm life span of 72 hours. Fertilization

could occur from sperm deposited before ovulation.

57. C. An advocate role encourage freedom of choice,

includes speaking out for the client, and supports the client’s

best interests.

58. A. Abstinence will eliminate any unnecessary pain during

intercourse and will reduce the possibility of transmitting

infection to one’s sexual partner.

59. B. Anxiety is generated by group therapy at 9:00 AM.

The ritualistic behavioral defense of hand washing

decreases anxiety by avoiding group therapy.

60. D. Denial is a very strong defense mechanism used to

allay the emotional effects of discovering a potential threat.

Although denial has been found to be an effective

mechanism for survival in some instances, such as during

natural disasters, it may in greater pathology in a woman

with potential breast carcinoma.

61. B. The registered nurse cannot delegate the

responsibility for assessment and evaluation of clients. The

status of the client in restraint requires further assessment to

determine if there are additional causes for the behavior.

62. C. The client with chest pain may be having a myocardial

infarction, and immediate assessment and intervention is a

priority.

63. B. Is correct because semen analysis requires that a

freshly masturbated specimen be obtained after a rest

(abstinence) period of 48-72 hours.

64. C. Betamethasone, a form of cortisone, acts on the fetal

lungs to produce surfactant.

65. A. Secretions may have pooled above the tracheostomy

cuff. If these are not suctioned before deflation, the

secretions may be aspirated.

66. C. Proper handling of sputum is essential to allay droplet

transference of bacilli in the air. Clients need to be taught to

cover their nose and mouth with tissues when sneezing or

coughing. Chemotherapy generally renders the client

noninfectious within days to a few weeks, usually before

cultures for tubercle bacilli are negative. Until chemical

isolation is established, many institutions require the client to

wear a mask when visitors are in the room or when the nurse

is in attendance. Client should be in a well-ventilated room,

without air recirculation, to prevent air contamination.

67. A. It is best to establish baseline information first.

68. B. Listening is probably the most effective response of

the four choices.

69. A. Urine flow is continuous. The pouch has an outlet

valve for easy drainage every 3-4 hours. (the pouch should

be changed every 3-5 days, or sooner if the adhesive is

loose).

70. C. A high fever accompanied by a body rash could

indicate that the child has a communicable disease and

would have exposed other students to the infection. The

school nurse would want to investigate this telephone call

immediately so that plans could be instituted to control the

spread of such infection.

71. A. Severe abdominal pain may indicate complications of

pregnancy such as abortion, ectopic pregnancy, or abruption

placenta; fluid discharge from the vagina may indicate

premature rupture of the membrane.

72. D. Gentle aspiration of mucus helps maintain a patent

airway, required for effective gas exchange.

73. A. Somatoform disorders provide a way of coping with

conflicts.

74. C. Immunization should never be mixed together in a

syringe, thus necessitating three separate injections in three

sites. Note: some manufacturers make a premixed

combination of immunization that is safe and effective.

75. A. Clients with radioactive implants should be positioned

flat in bed to prevent dislodgement of the vaginal packing.

The client may roll to the side for meals but the upper body

should not be raised more than 20 degrees.

76. A. Syrup of ipecac is not administered when the ingested

substances is corrosive in nature. Toilet bowl cleaners, as a

collective whole, are highly corrosive substances. If the

ingested substance “burned” the esophagus going down, it

will “burn” the esophagus coming back up when the child

begins to vomit after administration of syrup of ipecac.

77. B. Inability to open eyelids on operative side is seen with

cranial nerve III damage.


15/43

78. A. Assessment of physical injuries (like bruises,

lacerations, bleeding and fractures) is the first priority.

79. C. The nurse who is supervising others has a legal

obligation to determine that they are competent to perform

the assignment, as well as legal obligation to provide

adequate supervision.

80. D. Increasing hydrostatic pressure in the urinary tract will

facilitate passage of the calculi.

81. A. Infertility is not diagnosed until atleast 12months of

unprotected intercourse has failed to produce a pregnancy.

Older couples will experience a longer time to get pregnant.

82. B. Determining how well the kidneys filter wastes states

the purpose of a Creatinine clearance test.

83. A. Acknowledging a feeling tone is the most therapeutic

response and provides a broad opening for the client to

elaborate feelings.

84. C. The behavior should be stopped. The first is to remind

the staff that confidentiality maybe violated.

85. C. With a right-sided cerebrovascular accident the client

would have left-sided hemiplegia or weakness. The client’s

good side should be closest to the bed to facilitate the

transfer.

86. D. Legos are small plastic building blocks that could

easily slip under the child’s cast and lead to a break in skin

integrity and even infection. Pencils, backscratchers, and

marbles are some other narrow or small items that could

easily slip under the child’s cast and lead to a break in skin

integrity and infection.

87. D. Oxytocin (Pitocin) is used to maintain uterine tone.

88. B. The submission of reports about incidents that expose

clients to harm does not remove the obligation to report

ongoing behavior as long as the risk to the client continues.

89. C. The recommended dosage of tetracycline is 25-

50mg/kg/day. If the child weighs 20kg and the maximum

dose is 50mg/kg, this would indicate a total daily dose of

1000mg of tetracycline. In this case, the child is being given

this medication four times a day. Therefore the maximum

single dose that can be given is 250mg (1000 mg of

tetracycline divided by four doses.)

90. C. An abnormality in the uterine muscle could reduce the

effectiveness of uterine contractions and lengthen the

duration of subsequent labors.

91. A. Personality disorders stem from a weak superego,

implying a lack of adequate controls.

92. C. The basal body temperature is the lowest body

temperature of a healthy person that is taken immediately

after waking and before getting out of bed. The BBT usually

varies from 36.2 ºC to 36.3ºC during menses and for about

5-7 days afterward. About the time of ovulation, a slight drop

in temperature may be seen, after ovulation in concert with

the increasing progesterone levels of the early luteal phase,

the BBT rises 0.2-0.4 ºC. This elevation remains until 2-3

days before menstruation, or if pregnancy has occurred.

93. A. This choice implies concern for client care and self-

improvement.

94. C. The first trimester is the period of organogenesis, that

is, cell differentiation into the various organs, tissues, and

structures.

95. C. This response does not contradict the client’s

perception, is honest, and shows empathy.

96. D. Tension on round ligament occurs because of the

erect human posture and pressure exerted by the growing

fetus.

97. D. The Good Samaritan Law does not impose a duty to

stop at the scene of an emergency outside of the scope of

employment, therefore nurses who do not stop are not liable

for suit.

98. C. Although reducing environment stimuli and activity is

necessary for a woman with mild preeclampsia, she will

most probably have bathroom privileges.

99. B. A normal respiratory rate for a newborn is 30-40

breaths per minute.

100. D. The behavior described is likely to be symptoms of

delirium tremens, or alcohol withdrawal (often unsuspected

on a surgical unit.)


16/43

1. A 10 year old who has sustained a head injury is brought

to the emergency department by his mother. A diagnosis of a

mild concussion is made. At the time of discharge, nurse

Ron should instruct the mother to:

A. Withhold food and fluids for 24 hours.

B. Allow him to play outdoors with his friends.

C. Arrange for a follow up visit with the child’s primary care

provider in one week.

C. Check for any change in responsiveness every two hours

until the follow-up visit.

2. A male client has suffered a motor accident and is now

suffering from hypovolemic shock. Nurse Helen should

frequency assess the client’s vital signs during the

compensatory stage of shock, because:

A. Arteriolar constriction occurs

B. The cardiac workload decreases

C. Decreased contractility of the heart occurs

D. The parasympathetic nervous system is triggered

3. A paranoid male client with schizophrenia is losing weight,

reluctant to eat, and voicing concerns about being poisoned.

The best intervention by nurse Dina would be to:

A. Allow the client to open canned or pre-packaged food

B. Restrict the client to his room until 2 lbs are gained

C. Have a staff member personally taste all of the client’s

food

D. Tell the client the food has been x-rayed by the staff and is

safe

4. One day the mother of a young adult confides to nurse

Frida that she is very troubled by he child’s emotional illness.

The nurse’s most therapeutic initial response would be:

A. “You may be able to lessen your feelings of guilt by

seeking counseling”

B. “It would be helpful if you become involved in volunteer

work at this time”

C. “I recognize it’s hard to deal with this, but try to remember

that this too shall pass”

D. “Joining a support group of parents who are coping with

this problem can be quite helpful.

5. To check for wound hemorrhage after a client has had a

surgery for the removal of a tumor in the neck, nurse grace

should:

A. Loosen an edge of the dressing and lift it to see the

wound

B. Observe the dressing at the back of the neck for the

presence of blood

C. Outline the blood as it appears on the dressing to observe

any progression

D. Press gently around the incision to express accumulated

blood from the wound

6. A 16-year-old primigravida arrives at the labor and birthing

unit in her 38th week of gestation and states that she is

labor. To verify that the client is in true labor nurse Trina

should:

A. Obtain sides for a fern test

B. Time any uterine contractions

C. Prepare her for a pelvic examination

D. Apply nitrazine paper to moist vaginal tissue

7. As part of the diagnostic workup for pulmonic stenosis, a

child has cardiac catheterization. Nurse Julius is aware that

children with pulmonic stenosis have increased pressure:

A. In the pulmonary vein

B. In the pulmonary artery

C. On the left side of the heart

D. On the right side of the heart

8. An obese client asks nurse Julius how to lose weight.

Before answering, the nurse should remember that long-term

weight loss occurs best when:

A. Eating patterns are altered

B. Fats are limited in the diet

C. Carbohydrates are regulated

D. Exercise is a major component

9. As a very anxious female client is talking to the nurse May,

she starts crying. She appears to be upset that she cannot

control her crying. The most appropriate response by the

nurse would be:

A. “Is talking about your problem upsetting you?”

B. “It is Ok to cry; I’ll just stay with you for now”

C. “You look upset; lets talk about why you are crying.”

D. “Sometimes it helps to get it out of your system.”

10. A patient has partial-thickness burns to both legs and

portions of his trunk. Which of the following I.V. fluids is given

first?

A. Albumin

B. D5W

C. Lactated Ringer’s solution

D. 0.9% sodium chloride solution with 2 mEq of potassium

per 100 ml


17/43

11. During the first 48 hours after a severe burn of 40% of

the clients body surface, the nurse’s assessment should

include observations for water intoxication. Associated

adaptations include:

A. Sooty-colored sputum

B. Frothy pink-tinged sputum

C. Twitching and disorientation

D. Urine output below 30ml per hour

12. After a muscle biopsy, nurse Willy should teach the client

to:

A. Change the dressing as needed

B. Resume the usual diet as soon as desired

C. Bathe or shower according to preference

D. Expect a rise in body temperature for 48 hours

13. Before a client whose left hand has been amputated can

be fitted for a prosthesis, nurse Joy is aware that:

A. Arm and shoulder muscles must be developed

B. Shrinkage of the residual limb must be completed

C. Dexterity in the other extremity must be achieved

D. Full adjustment to the altered body image must have

occurred

14. Nurse Cathy applies a fetal monitor to the abdomen of a

client in active labor. When the client has contractions, the

nurse notes a 15 beat per minute deceleration of the fetal

heart rate below the baseline lasting 15 seconds. Nurse

Cathy should:

A. Change the maternal position

B. Prepare for an immediate birth

C. Call the physician immediately

D. Obtain the client’s blood pressure

15. A male client receiving prolonged steroid therapy

complains of always being thirsty and urinating frequently.

The best initial action by the nurse would be to:

A. Perform a finger stick to test the client’s blood glucose

level

B. Have the physician assess the client for an enlarged

prostate

C. Obtain a urine specimen from the client for screening

purposes

D. Assess the client’s lower extremities for the presence of

pitting edema

16. Nurse Bea recognizes that a pacemaker is indicated

when a client is experiencing:

A. Angina

B. Chest pain

C. Heart block

D. Tachycardia

17. When administering pancrelipase (Pancreases capsules)

to child with cystic fibrosis, nurse Faith knows they should be

given:

A. With meals and snacks

B. Every three hours while awake

C. On awakening, following meals, and at bedtime

C. After each bowel movement and after postural draianage

18. A preterm neonate is receiving oxygen by an overhead

hood. During the time the infant is under the hood, it would

be appropriate for nurse Gian to:

A. Hydrate the infant q15 min

B. Put a hat on the infant’s head

C. Keep the oxygen concentration consistent

D. Remove the infant q15 min for stimulation

19. A client’s sputum smears for acid fast bacilli (AFB) are

positive, and transmission-based airborne precautions are

ordered. Nurse Kyle should instruct visitors to:

A.Limit contact with non-exposed family members

B. Avoid contact with any objects present in the client’s room

C. Wear an Ultra-Filter mask when they are in the client’s

room

D. Put on a gown and gloves before going into the client’s

room

20. A client with a head injury has a fixed, dilated right pupil;

responds only to painful stimuli; and exhibits decorticate

posturing. Nurse Kate should recognize that these are signs

of:

A. Meningeal irritation

B. Subdural hemorrhage

C. Medullary compression

D. Cerebral cortex compression

21. After a lateral crushing chest injury, obvious right-sided

paradoxic motion of the client’s chest demonstrates multiple

rib fraactures, resulting in a flail chest. The complication the

nurse should carefully observe for would be:

A. Mediastinal shift

B. Tracheal laceration

C. Open pneumothorax

D. Pericardial tamponade


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22. When planning care for a client at 30-weeks gestation,

admitted to the hospital after vaginal bleeding secondary to

placenta previa, the nurse’s primary objective would be:

A. Provide a calm, quiet environment

B. Prepare the client for an immediate cesarean birth

C. Prevent situations that may stimulate the cervix or uterus

D. Ensure that the client has regular cervical examinations

assess for labor

23. When planning discharge teaching for a young female

client who has had a pneumothorax, it is important that the

nurse include the signs and symptoms of a pneumothorax

and teach the client to seek medical assistance if she

experiences:

A. Substernal chest pain

B. Episodes of palpitation

C. Severe shortness of breath

D. Dizziness when standing up

24. After a laryngectomy, the most important equipment to

place at the client’s bedside would be:

A. Suction equipment

B. Humidified oxygen

C. A nonelectric call bell

D. A cold-stream vaporizer

25. Nurse Oliver interviews a young female client with

anorexia nervosa to obtain information for the nursing

history. The client’s history is likely to reveal a:

A. Strong desire to improve her body image

B. Close, supportive mother-daughter relationship

C. Satisfaction with and desire to maintain her present

weight

D. Low level of achievement in school, with little concerns for

grades

26. Nurse Bea should plan to assist a client with an

obsessive-compulsive disorder to control the use of ritualistic

behavior by:

A. Providing repetitive activities that require little thought

B. Attempting to reduce or limit situations that increase

anxiety

C. Getting the client involved with activities that will provide

distraction

D. Suggesting that the client perform menial tasks to expiate

feelings of guilt

27. A 2 ½ year old child undergoes a ventriculoperitoneal

shunt revision. Before discharge, nurse John, knowing the

expected developmental behaviors for this age group, should

tell the parents to call the physician if the child:

A. Tries to copy all the father’s mannerisms

B. Talks incessantly regardless of the presence of others

C. Becomes fussy when frustrated and displays a shortened

attention span

D. Frequently starts arguments with playmates by claiming

all toys are “mine”

28. A urinary tract infection is a potential danger with an

indwelling catheter. Nurse Gina can best plan to avoid this

complication by:

A. Assessing urine specific gravity

B. Maintaining the ordered hydration

C. Collecting a weekly urine specimen

D. Emptying the drainage bag frequently

29. A client has sustained a fractured right femur in a fall on

stairs. Nurse Troy with the emergency response team assess

for signs of circulatory impairment by:

A. Turning the client to side lying position

B. Asking the client to cough and deep breathe

C. Taking the client’s pedal pulse in the affected limb

D. Instructing the client to wiggle the toes of the right foot

30. To assess orientation to place in a client suspected of

having dementia of the alzheimers type, nurse Chris should

ask:

A. “Where are you?”

B. “Who brought you here?”

C. “Do you know where you are?”

D. “How long have you been there?”

31. Nurse Mary assesses a postpartum client who had an

abruption placentae and suspects that disseminated

intravascular coagulation (DIC) is occurring when

assessments demonstrate:

A. A boggy uterus

B. Multiple vaginal clots

C. Hypotension and tachycardia

D. Bleeding from the venipuncture site

32. When a client on labor experiences the urge to push a

9cm dilation, the breathing pattern that nurse Rhea should

instruct the client to use is the:


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A. Expulsion pattern

B. Slow paced pattern

C. Shallow chest pattern

D. blowing pattern

33. Nurse Ronald should explain that the most beneficial

between-meal snack for a client who is recovering from the

full-thickness burns would be a:

A. Cheeseburger and a malted

B. Piece of blueberry pie and milk

C. Bacon and tomato sandwich and tea

D. Chicken salad sandwich and soft drink

34. Nurse Wilma recognizes that failure of a newborn to

make the appropriate adaptation to extrauterine life would be

indicated by:

A. flexed extremities

B. Cyanotic lips and face

C. A heart rate of 130 beats per minute

D. A respiratory rate of 40 breath per minute

35. The laboratory calls to state that a client’s lithium level is

1.9 mEq/L after 10 days of lithium therapy. Nurse Reese

should:

A. Notify the physician of the findings because the level is

dangerously high

B. Monitor the client closely because the level of lithium in

the blood is slightly elevated

C. Continue to administer the medication as ordered

because the level is within the therapeutic range

D. Report the findings to the physician so the dosage can be

increased because the level is below therapeutic range

36. A client has a regular 30-day menstrual cycles. When

teaching about the rhythm method, Which the client and her

husband have chosen to use for family planning, nurse

Dianne should emphasize that the client’s most fertile days

are:

A. Days 9 to 11

B. Days 12 to 14

C. Days 15 to 17

D. Days 18 to 20

37. Before an amniocentesis, nurse Alexandra should:

A. Initiate the intravenous therapy as ordered by the

physiscian

B. Inform the client that the procedure could precipitate an

infection

C. Assure that informed consent has been obtained from the

client

D. Perform a vaginal examination on the client to assess

cervical dilation

38. While a client is on intravenous magnesium sulfate

therapy for preeclampsia, it is essential for nurse Amy to

monitor the client’s deep tendon reflexes to:

A. Determine her level of consciousness

B. Evaluate the mobility of the extremities

C. Determine her response to painful stimuli

D. Prevent development of respiratory distress

39. A preschooler is admitted to the hospital with a diagnosis

of acute glomerulonephritis. The child’s history reveals a 5-

pound weight gain in one week and peritoneal edema. For

the most accurate information on the status of the child’s

edema, nursing intervention should include:

A. Obtaining the child’s daily weight

B. Doing a visual inspection of the child

C. Measuring the child’s intake and output

D. Monitoring the child’s electrolyte values

40. Nurse Mickey is administering dexamethasome

(Decadron) for the early management of a client’s cerebral

edema. This treatment is effective because:

A. Acts as hyperosmotic diuretic

B. Increases tissue resistance to infection

C. Reduces the inflammatory response of tissues

D. Decreases the information of cerebrospinal fluid

41. During newborn nursing assessment, a positive

Ortolani’s sign would be indicated by:

A. A unilateral droop of hip

B. A broadening of the perineum

C. An apparent shortening of one leg

D. An audible click on hip manipulation

42. When caring for a dying client who is in the denial stage

of grief, the best nursing approach would be to:

A. Agree and encourage the client’s denial

B. Allow the denial but be available to discuss death

C. Reassure the client that everything will be OK

D. Leave the client alone to confront the feelings of

impending loss

43. To decrease the symptoms of gastroesophageal reflux

disease (GERD), the physician orders dietary and


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medication management. Nurse Helen should teach the

client that the meal alteration that would be most appropriate

would be:

A. Ingest foods while they are hot

B. Divide food into four to six meals a day

C.Eat the last of three meals daily by 8pm

D. Suck a peppermint candy after each meal

44. After a mastectomy or hysterectomy, clients may feel

incomplete as women. The statement that should alert nurse

Gina to this feeling would be:

A. “I can’t wait to see all my friends again”

B. “I feel washed out; there isn’t much left”

C. “I can’t wait to get home to see my grandchild”

D. “My husband plans for me to recuperate at our daughter’s

home”

45. A client with obstruction of the common bile duct may

show a prolonged bleeding and clotting time because:

A. Vitamin K is not absorbed

B. The ionized calcium levels falls

C. The extrinsic factor is not absorbed

D. Bilirubin accumulates in the plasma

46. Realizing that the hypokalemia is a side effect of steroid

therapy, nurse Monette should monitor a client taking steroid

medication for:

A. Hyperactive reflexes

B. An increased pulse rate

C. Nausea, vomiting, and diarrhea

D. Leg weakness with muscle cramps

47. When assessing a newborn suspected of having Down

syndrome, nurse Rey would expect to observe:

A. long thin fingers

B. Large, protruding ears

C. Hypertonic neck muscles

D. Simian lines on the hands

48. A 10 year old girl is admitted to the pediatric unit for

recurrent pain and swelling of her joints, particularly her

knees and ankles. Her diagnosis is juvenile rheumatoid

arthritis. Nurse Janah recognizes that besides joint

inflammation, a unique manifestation of the rheumatoid

process involves the:

A. Ears

B. Eyes

C. Liver

D. Brain

49. A disturbed client is scheduled to begin group therapy.

The client refuses to attend. Nurse Lolit should:

A. Accept the client’s decision without discussion

B. Have another client to ask the client to consider

C. Tell the client that attendance at the meeting is required

D. Insist that the client join the group to help the socialization

process

50. Because a severely depressed client has not responded

to any of the antidepressant medications, the psychiatrist

decides to try electroconvulsive therapy (ECT). Before the

treatment the nurse should:

A. Have the client speak with other clients receiving ECT

B. Give the client a detailed explanation of the entire

procedure

C. Limit the client’s intake to a light breakfast on the days of

the treatment

D. Provide a simple explanation of the procedure and

continue to reassure the client

51. Nurse Vicky is aware that teaching about colostomy care

is understood when the client states, “I will contact my

physician and report ____”:

A. If I notice a loss of sensation to touch in the stoma tissue”

B. When mucus is passed from the stoma between

irrigations”

C. The expulsion of flatus while the irrigating fluid is running

out”

D. If I have difficulty in inserting the irrigating tube into the

stoma”

52. The client’s history that alerts nurse Henry to assess

closely for signs of postpartum infection would be:

A. Three spontaneous abortions

B. negative maternal blood type

C. Blood loss of 850 ml after a vaginal birth

D. Maternal temperature of 99.9° F 12 hours after delivery

53. A client is experiencing stomatitis as a result of

chemotherapy. An appropriate nursing intervention related to

this condition would be to:

A. Provide frequent saline mouthwashes

B. Use karaya powder to decrease irritation

C. Increase fluid intake to compensate for the diarrhea


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D. Provide meticulous skin care of the abdomen with

Betadine

54. During a group therapy session, one of the clients ask a

male client with the diagnosis of antisocial personality

disorder why he is in the hospital. Considering this client’s

type of personality disorder, the nurse might expect him to

respond:

A. “I need a lot of help with my troubles”

B. “Society makes people react in old ways”

C. “I decided that it’s time I own up to my problems”

D. “My life needs straightening out and this might help”

55. A child visits the clinic for a 6-week checkup after a

tonsillectomy and adenoidectomy. In addition to assessing

hearing, the nurse should include an assessment of the

child’s:

A. Taste and smell

B. Taste and speech

C. Swallowing and smell

D. Swallowing and speech

56. A client is diagnosed with cancer of the jaw. A course of

radiation therapy is to be followed by surgery. The client is

concerned about the side effects related to the radiation

treaments. Nurse Ria should explain that the major side

effects that will experienced is:

A. Fatigue

B. Alopecia

C. Vomiting

D. Leucopenia

57. Nurse Katrina prepares an older-adult client for sleep,

actions are taken to help reduce the likelihood of a fall during

the night. Targeting the most frequent cause of falls, the

nurse should:

A. Offer the client assistance to the bathroom

B. Move the bedside table closer to the client’s bed

C. Encourage the client to take an available sedative

D. Assist the client to telephone the spouse to say

“goodnight”

58. When evaluating a growth and development of a 6 month

old infant, nurse Patty would expect the infant to be able to:

A. Sit alone, display pincer grasp, wave bye bye

B. Pull self to a standing position, release a toy by choice,

play peek-a-boo

C. Crawl, transfer toy from one hand to the other, display of

fear of strangers

D. Turn completely over, sit momentarily without support,

reach to be picked up

59. A breastfeeding mother asks the nurse what she can do

to ease the discomfort caused by a cracked nipple. Nurse

Tina should instruct the client to:

A. Manually express milk and feed it to the baby in a bottle

B. Stop breastfeeding for two days to allow the nipple to heal

C. Use a breast shield to keep the baby from direct contact

with the nipple

D. Feed the baby on the unaffected breast first until the

affected breast heals

60. Nurse Sandy observes that there is blood coming from

the client’s ear after head injury. Nurse Sandy should:

A. Turn the client to the unaffected side

B. Cleanse the client’s ear with sterile gauze

C. Test the drainage from the client’s ear with Dextrostix

D. Place sterile cotton loosely in the external ear of the client

61. Nurse Gio plans a long term care for parents of children

with sickle-cell anemia, which includes periodic group

conferences. Some of the discussions should be directed

towards:

A. Finding special school facilities for the child

B. Making plans for moving to a more therapeutic climate

C. Choosing a means of birth control to avoid future

pregnancies

D. Airing their feelings regarding the transmission of the

disease to the child

62. The central problem the nurse might face with a

disturbed schizophrenic client is the client’s:

A. Suspicious feelings

B. Continuous pacing

C. Relationship with the family

D. Concern about working with others

63. When planning care with a client during the

postoperative recovery period following an abdominal

hysterectomy and bilateral salpingo-oophorectomy, nurse

Frida should include the explanation that:

A. Surgical menopause will occur

B. Urinary retention is a common problem

C. Weight gain is expected, and dietary plan are needed

D. Depression is normal and should be expected


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64. An adolescent client with anorexia nervosa refuses to

eat, stating, “I’ll get too fat.” Nurse Andrea can best respond

to this behavior initially by:

A. Not talking about the fact that the client is not eating

B. Stopping all of the client’s privileges until food is eaten

C. Telling the client that tube feeding will eventually be

necessary

D. Pointing out to the client that death can occur with

malnutrition.

65. A pain scale is used to assess the degree of pain. The

client rates the pain as an 8 on a scale of 10 before

medication and a 7 on a scale of 10 after being medicated.

Nurse Glenda determines that the:

A. Client has a low pain tolerance

B. Medication is not adequately effective

C. Medication has sufficiently decreased the pain level

D. Client needs more education about the use of the pain

scale

66. To enhance a neonate’s behavioral development,

therapeutic nursing measures should include:

A. Keeping the baby awake for longer periods of time before

each feeding

B. Assisting the parents to stimulate their baby through

touch, sound, and sight.

C. Encouraging parental contact for at least one 15-minute

period every four hours.

D. Touching and talking to the baby at least hourly, beginning

within two to four hours after birth

67. Before formulating a plan of care for a 6 year old boy with

attention deficit hyperactivity disorder (ADHD), nurse Kyla is

aware that the initial aim of therapy is to help the client to:

A. Develop language skills

B. Avoid his own regressive behavior

C. Mainstream into a regular class in school

NLE practice exam with answers

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