Practice Exam 1 and Rationales
This chapter is from the book
This chapter is from the book
This chapter is from the book
Practice Exam 1 and Rationales
A client with a renal failure is prescribed a low potassium diet. Which food choice would be best for this client?
A. 1 cup beef broth B. 1 baked potato with the skin C. 1/2 cup raisins D. 1 cup riceQuick Answer: 58
Detailed Answer: 61
An appropriate nursing intervention for the client with borderline personality disorder is:
A. Observing the client for signs of depression or suicidal thinking B. Allowing the client to lead unit group sessions C. Restricting the client’s activity to the assigned unit of care throughout hospitalization D. Allowing the client to select a primary caregiverQuick Answer: 58
Detailed Answer: 61
Which of the following is an expected finding in the assessment of a client with bulimia nervosa?
A. Extreme weight loss B. Presence of lanugo over body C. Erosion of tooth enamel D. Muscle wastingQuick Answer: 58
Detailed Answer: 61
Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning?
A. One-year-old B. Four-year-old C. Eight-year-old D. Twelve-year-oldQuick Answer: 58
Detailed Answer: 61
Which term describes the play activity of the preschool aged child?
A. Cooperative B. Associative C. Parallel D. SolitaryQuick Answer: 58
Detailed Answer: 61
The nurse is ready to begin an exam on a nine-month-old infant who is sitting quietly on his mother’s lap. Which should the nurse do first?
A. Check the Babinski reflex B. Listen to the heart and lung sounds C. Palpate the abdomen D. Check tympanic membranesQuick Answer: 58
Detailed Answer: 61
In terms of cognitive development, a three-year-old would be expected to:
A. Think abstractly B. Use magical thinking C. Understand conservation of matter D. See things from the perspective of othersQuick Answer: 58
Detailed Answer: 61
Which of the following describes the language development of a two-year-old?
A. Doesn’t understand yes and no B. Understands the meaning of all words C. Can combine three or four words D. Repeatedly asks “why?”Quick Answer: 58
Detailed Answer: 61
A client who has been receiving Urokinase (uPA) for deep vein thrombosis is noted to have dark brown urine in the urine collection bag. Which action should the nurse take immediately?
A. Prepare an injection of vitamin K B. Irrigate the urinary catheter with 50 mL of normal saline C. Offer the client additional oral fluids D. Withhold the medication and notify the physicianQuick Answer: 58
Detailed Answer: 61
Which of the following can occur with the frequent use of calcium-based antacids?
A. Constipation B. Hyperperistalsis C. Delayed gastric emptying D. DiarrheaQuick Answer: 58
Detailed Answer: 62
Which statement made by the student nurse indicates the need for further teaching regarding the administration of heparin?
A. “I will administer the medication 1–2 inches away from the umbilicus.” B. “I will not massage the injection site after administering the heparin.” C. “I will check the PTT before administering the heparin.” D. “I will need to gently aspirate when I give the heparin.”Quick Answer: 58
Detailed Answer: 62
To correctly assess the oxygen saturation level of an adult client, the pulse oximeter should not be placed on the:
A. Finger B. Earlobe C. Extremity with noninvasive BP cuff D. NoseQuick Answer: 58
Detailed Answer: 62
While caring for an elderly patient with hypertension, the nurse notes the following vital signs: BP of 140/40, pulse 120, respirations 36. The nurse’s initial action should be to:
A. Report the findings to the physician B. Recheck the vital signs in one hour C. Ask the patient if he is in pain D. Compare the current vital signs with those on admissionQuick Answer: 58
Detailed Answer: 62
The nurse is preparing a client with an axillopopliteal bypass graft for discharge. The client should be taught to avoid:
A. Using a recliner to rest B. Resting in supine position C. Sitting in a straight chair D. Sleeping in right Sim’s positionQuick Answer: 58
Detailed Answer: 62
The doctor has ordered antithrombotic stockings to be applied to the legs of a client with peripheral vascular disease. The nurse knows antithrombotic stockings should be applied:
A. Before the client arises in the morning B. With the client in a standing position C. After the client has bathed and applied lotion to the legs D. Before the client retires in the eveningQuick Answer: 58
Detailed Answer: 62
The nurse has just received the change of shift report and is preparing to make rounds. Which client should the nurse assess first?
A. A client recovering from a stroke with an oxygen saturation rate of 99% B. A client three days post-coronary artery bypass graft with an oral temperature of 100.2°F C. A client admitted one hour ago with rales and shortness of breath D. A client being prepared for discharge following a right colectomyQuick Answer: 58
Detailed Answer: 62
A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with:
A. Hypothyroidism B. Diabetic ulcers C. Gastroenteritis D. Bacterial pneumoniaQuick Answer: 58
Detailed Answer: 62
The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?
A. “I will have blood drawn every month.” B. “I will assess my skin for a rash.” C. “I take aspirin for a headache.” D. “I will use an electric razor to shave.”Quick Answer: 58
Detailed Answer: 62
The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation?
A. Pedal pulses regular B. Urinary output 20mL in the past hour C. Blood pressure 108/50 D. Oxygen saturation 97%Quick Answer: 58
Detailed Answer: 63
The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider?
A. Diet pattern B. Mobility C. Fluid intake D. Sexual functionQuick Answer: 58
Detailed Answer: 63
Which one of the following statements is correct when measuring the client for crutches?
A. A distance of five fingerbreadths should exist between the top of the crutch and the axilla. B. The nurse should measure three inches between the top of the crutch and the axilla. C. The client’s elbows should be flexed at a 10° angle. D. The crutches should be extended 8 to 10 inches from the side of the foot.Quick Answer: 58
Detailed Answer: 63
The nurse is caring for a client following a cerebral vascular accident. Which portion of the brain is responsible for changes in the client’s vision?
A. Temporal lobe B. Frontal lobe C. Occipital lobe D. Parietal lobeQuick Answer: 58
Detailed Answer: 63
A client with a hemorrhagic stroke has a temperature of 103°F. Efforts to reduce the temperature have not been effective. The most likely explanation for the elevated temperature is that damage has occurred to the:
A. Hypothalamus B. Pituitary C. Carotid baroreceptors D. Frontal lobeQuick Answer: 58
Detailed Answer: 63
A client is admitted to the hospital in chronic renal failure. A low protein diet is ordered. The rationale for a low protein diet is that:
A. A low protein diet helps reduce blood urea nitrogen and other wastes excreted by the kidneys. B. A low protein diet increases the sodium and potassium levels. C. A low protein diet increases albumin production. D. A low protein diet increases the calcium and phosphorous levels.Quick Answer: 58
Detailed Answer: 63
The nurse has an order for the administration of intravenous heparin. The medication should be administered using a/an:
A. Metered chamber B. Infusion controller C. Intravenous filter D. Three-way stopcockQuick Answer: 58
Detailed Answer: 63
When assessing the client’s blood pressure, the nurse should use a cuff with a width that is ____% of the circumference of the extremity. (Fill in the blank.)
A. 40 B. 30 C. 20 D. 10Quick Answer: 58
Detailed Answer: 63
Which diet would the nurse expect to see ordered for a patient with nephrotic syndrome?
A. Low carbohydrate potassium B. Moderate protein C. Low calcium D. Increased potassiumQuick Answer: 58
Detailed Answer: 63
A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which finding should be reported to the doctor?
A. A WBC of 14,000 cu.mm B. Auscultation of abdominal bruit C. Complaints of lower back pain D. A platelet count of 175,000 cu.mmQuick Answer: 58
Detailed Answer: 63
When assessing deep tendon reflexes, the nurse grades the client’s patellar reflex as a 3+. This reading indicates that the assessed reflex is:
A. Stronger than normal B. Hypoactive C. Normal D. HyperactiveQuick Answer: 58
Detailed Answer: 64
The physician has ordered atropine sulfate 0.4milligrams IM before surgery. The medication is supplied in 0.8 milligrams per milliliter. How much medication should the nurse prepare to administer?
A. 0.25mL B. 0.5mL C. 1.0mL D. 1.25mLQuick Answer: 58
Detailed Answer: 64
