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1. Which of the following connective tissue disorders is characterized by insoluble collagen

being formed and accumulating excessively in the tissues?

A Rheumatoid arthritis

B Scleroderma

C Systemic lupus erythematosus

D Polymyalgia rheumatic

2. Helen, a client with myasthenia gravis, begins to experience increased difficulty in

swallowing. To prevent aspiration of food, the nursing action that would be most

effective would be to:

A Assess her respiratory status before and after meals

B Change her diet order from soft foods to clear liquids

C Coordinate her meal schedule with the peak effect of her medication

D Place an emergency tracheostomy set in her room

3. After Billroth II Surgery, the client developed dumping syndrome. Which of the

following should the nurse exclude in the plan of care?

A Reduce the amount of simple carbohydrate in the diet

B Sit upright for at least 30 minutes after meals

C Eat small meals every 2-3 hours

D Take only sips of H2O between bites of solid food

4. After the acute phase of congestive heart failure, the nurse should expect the dietary

management of the client to include the restriction of:

A Potassium

B Sodium

C Calcium

D Magnesium

5.

A Sengstaken-Blakemore tube is inserted in the effort to stop the bleeding esophageal

varices in a patient with complicated liver cirrhosis. Upon insertion of the tube, the client

complains of difficulty of breathing. The first action of the nurse is to:

A Notify the MD

B Monitor VS

C Encourage him to take deep breaths

D Deflate the esophageal balloon

6.

The nurse is attending a bridal shower for a friend when another guest, who happens tobe a diabetic, starts to tremble and complains of dizziness. The next best action for the

nurse to take is to:

A Encourage the guest to eat some baked macaroni

B Offer the guest a cup of coffee

C Give the guest a glass of orange juice

D Call the guests personal physician

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7. Included in the plan of care for the immediate post-gastroscopy period will be:

A Assess for pain and medicate as ordered

B Assess gag reflex prior to administration of fluids

C Maintain NGT to intermittent suction

D Measure abdominal girth every 4 hours

8.

A client has Gastroesophageal Reflux Disease (GERD). The nurse should teach the client

that after every meals, the client should

A Rest in sitting position

B Lie down at least 30 minutes

C Drink plenty of water

D Take a short walk

9. Mr. Alzawar is in continuous pain from cancer that has metastasized to the bone. Pain

medication provides little relief and he refuses to move. The nurse should plan to:

A Complete A.M. care quickly as possible when necessary

B Reassure him that the nurses will not hurt him

C Let him perform his own activities of daily living

D Handle him gently when assisting with required care

10.After surgery, Gihan returns from the Post-anesthesia Care Unit (Recovery Room) with a

nasogastric tube in place following a gall bladder surgery. She continues to complain of

nausea. Which action would the nurse take?

A Change the patients position.

B Check the patency of the NGT for any obstruction

C Administer the prescribed antiemetic.

D Call the physician immediately

11.

Mr. Kalifa a client with CHF, has been receiving a cardiac glycoside, a diuretic, and a

vasodilator drug. His apical pulse rate is 44 and he is on bed rest. The nurse concludes

that his pulse rate is most likely the result of the:

A Bed-rest regimen

B Cardiac glycoside

C Diuretic

D Vasodilator

12.A client with leukemia is undergoing radiation therapy to the brain and spinal cord. In

planning care for this client, the nurse would include which nursing intervention?A A dandruff shampoo twice daily

B Not allowing the client to use a hat or scarf

C Avoiding washing off the target's marks

D A scalp ointment to prevent dryness

13.A 60 year old male client comes into the emergency department with complaints of

crushing substernal chest pain that radiates to his shoulder and left arm. The admitting

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diagnosis is acute myocardial infarction (MI). Immediate admission orders include

oxygen by nasal cannula at 4L/minute, blood work, a chest radiograph, a 12-lead

electrocardiogram (ECG) and 2 mg of morphine sulfate given intravenously. The nurse

should first:

A obtain a blood work

B administer the morphine

C order the chest radiograph

D obtain a 12 lead ECG

14.Nurse Jamela is assigned to care for a client who has returned to the nursing unit after

left nephrectomy. Nurse Jamelas highest priority would be

A Temperature

B Hourly urine output

C Able to sips clear liquid

D Able to turn side to side

15.

The nurse is teaching the client with right leg fracture regarding the physicians order

for partial weight bearing status. The client understands the health teaching if he

verbalizes:

A

I am allowed to put 40 of my weight on my right leg

B I am allowed to put 10% of my actual weight on my right leg

C I am not allowed to let my fractured leg touch the floor

D I should not bear weight on my fractured leg

16.Which of the following signs and symptoms would Nurse Maureen include in teaching

plan as an early manifestation of laryngeal cancer?

A Airway obstruction

B Dysphagia

C Stomatitis

D Hoarseness

17.Noor is ordered laboratory tests after she is admitted to the hospital for angina. The

isoenzyme test that is the most reliable early indicator of myocardial insult is:

A CK-MB

B LDH

C AST

D SGPT18.The emergency room nurse admits a child who experienced a seizure at school. The

father comments that this is the first occurrence, and denies any family history of

epilepsy. What is the best response by the nurse?

A Since this was the first convulsion, it may not happen again.

B Long term treatment will prevent future seizures

C The seizure may or may not mean your child has epilepsy.

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D Do not worry. Epilepsy can be treated with medications

19.A female client is experiencing painful and rigid abdomen and is diagnosed with

perforated peptic ulcer. A surgery has been scheduled and a nasogastric tube is inserted.

The nurse should place the client before surgery in

A Supine position

B Semi-fowlers position

C Dorsal recumbent position

D Sims position

20.Amir who has undergone thoracic surgery has chest tube connected to a water-seal

drainage system attached to suction. Presence of excessive bubbling is identified in water-

seal chamber, the nurse should

A Recognize the system is functioning correctly

B Check the system for air leaks

C Strip the chest tube catheter

D Decrease the amount of suction pressure

21.Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The

nurse understands that this therapy is effective because it:

A Decreases the production of auto antibodies that attack the acetylcholine

receptors.

B Promotes the removal of antibodies that impair the transmission of impulses

C Inhibits the breakdown of acetylcholine at the neuromuscular junction.

D Stimulates the production of acetylcholine at the neuromuscular junction.

22.Which of the following statements reflect nursing interventions in the care of the patient

with osteoarthritis?

A Provide an analgesic after exercise.

B Encourage weight loss and an increase in aerobic activity.

C Avoid the use of topical analgesics.

D Assess for the gastrointestinal complications associated with COX-2 inhibitors

23.A client has suffered from fall and sustained a leg injury. Which appropriate question

would the nurse ask the client to help determine if the injury caused fracture?

A Does the pain feel like the muscle was stretched?

B Is the pain dull ache?

C Does the discomfort feel like a cramp?D Is the pain sharp and continuous?

24.The laboratory of a male patient with Peptic ulcer revealed an elevated titer of

Helicobacter pylori. Which of the following statements indicate an understanding of this

data?

A Surgical treatment is necessary

B No treatment is necessary at this time

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C This result indicates gastric cancer caused by the organism

D Treatment will include Ranitidine and Antibiotics

25.A student nurse is assigned to a client who has a diagnosis of thrombophlebitis. Which

action by this team member is most appropriate?

A Apply a heating pad to the involved site.

B Provide active range-of-motion exercises to both legs at least twice every shift.

C Elevate the clients legs 90 degrees.

D Instruct the client about the need for bed rest.

26.The husband of a client asks the nurse about the protein-restricted diet ordered because

of advanced liver disease. What statement by the nurse would best explain the purpose of

the diet?

A Most people have too much protein in their diets. The amount of this diet is

better forliver healing.

B Because of portal hyperemesis, the blood flows around the liver and ammonia

made from protein collects in the brain causing hallucinations.

C The liver heals better with a high carbohydrates diet rather than protein.

D The liver cannot rid the body of ammonia that is made by the breakdown of

protein in the digestive system.

27.Nurse Perry is evaluating the renal function of a male client. After documenting urine

volume and characteristics, Nurse Perry assesses which signs as the best indicator of

renal function.

A Pulse rate

B Blood pressure

C Consciousness

D Distension of the bladder

28.

Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the

parents remark: We just dont know how he caught the disease! The nurse's response is

based on an understanding that

A The illness is usually associated with chronic respiratory infections

B The disease is easily transmissible in schools and camps

C It is not caught but is a response to a previous B-hemolytic strep infection

D AGN is a streptococcal infection that involves the kidney tubules

29.

The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the following actions would be most appropriate?

A Administer analgesic therapy as ordered

B Fluid restriction 1000cc per day

C Encourage increased caloric intake

D Ambulate in hallway 4 times a day

30.Which description of pain would be most characteristic of a duodenal ulcer?

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C Morphine

D Meperidine

37.Days after abdominal surgery, the clients wound dehisces. The safest nursing

intervention when this occurs is to

A Approximate the wound edges with tapes

B Cover the wound with sterile, moist saline dressing

C Irrigate the wound with sterile saline

D Hold the abdominal contents in place with a sterile gloved hand

38.A client with multiple injuries following a vehicular accident is transferred to the critical

care unit. He begins to complain of increased abdominal pain in the left upper quadrant.

A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. In

preparing the client for surgery, the nurse should emphasize in his teaching plan the:

A Risk of the procedure with his other injuries

B Presence of abdominal drains for several days after surgery

C Complete safety of the procedure

D Expectation of postoperative bleeding

39.A 3 year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the

nurse should

A Use a heat lamp to reduce the drying time

B Expose the cast to air and turn the child frequently

C Turn the child as little as possible

D Handle the cast with the abductor bar

40.What would be the primary goal of therapy for a client with pulmonary edema and heart

failure?

A Enhance comfort

B Improve respiratory status

C Peripheral edema decreased

D Increase cardiac output

41.A nurse wants to assess if the clients brachial plexus was compromised after undergoing

shoulder arthroplasty due to rheumatoid arthritis. To assess the cutaneous nerve status

which of the following would the nurse perform?

A Ask the client move his thumb toward the palm and back to the neutral position

B Let the client raise his forearm and monitor for flexion of the biceps

C Have the client spread all the fingers wide and resist pressure.

D Have the client grasp the nurses hand while noting the clients strength of the

first and second fingers

42.At a senior citizens meeting a nurse talks with a client who has diabetes mellitus Type 1.

Which statement by the client during the conversation is most predictive of a potential

for impaired skin integrity?

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A "I give my insulin to myself in my thighs."

B "Here are my up and down glucose readings that I wrote on my calendar."

C Sometimes when I put my shoes on I don't know where my toes are.

D "If I bathe more than once a week my skin feels too dry.

43.

A newborn has been diagnosed with hypothyroidism. In discussing the condition and

treatment with the family, the nurse should emphasize

A Administration of thyroid hormone will prevent problems

B Physical growth/development will be delayed

C They can expect the child will be mentally retarded

D This rare problem is always hereditary

44.To promote continued improvement in the respiratory status of a client following chest

tube removal after a chest surgery for multiple rib fracture, the nurse should:

A Encourage bed rest with active and passive range of motion exercises

B Continue observing for dyspnea and crepitus

C Encourage frequent coughing and deep breathing

D Turn him from side to side at least every 2 hours

45.The client underwent Billroth surgery for gastric ulcer. Post-operatively, the drainage

from his NGT is thick and the volume of secretions has dramatically reduced in the last

2 hours and the client feels like vomiting. The most appropriate nursing action is to:

A Irrigate the NGT with 50 cc of sterile

B Discontinue the low-intermittent suction

C Notify the MD of your findings

D Reposition the NGT by advancing it gently NSS

46.

A child in the Emergency Room is diagnosed with an acute episode of Croup (Acute

laryngotracheo - bronchitis). During the initial assessment, which of the following

finding would the nurse expect to find?

A Inspiratory stridor with a brassy cough

B Shallow respirations

C Decreased aeration in lung fields

D Diffuse expiratory wheezing

47.A nurse at the weight loss clinic assesses a client who has a large abdomen and a

rounded face. Which additional assessment finding would lead the nurse to suspect that

the client has Cushings syndrome rather than obesity?A abdominal striae and ankle enlargement

B large thighs and upper arms

C posterior neck fat pad and thin extremities

D pendulous abdomen and large hips

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48.A newly admitted client is diagnosed with Hodgkins disease undergoes an excisional

cervical lymph node biopsy under local anesthesia. What does the nurse assess first after

the procedure?

A Incision site

B Airway

C Level of consciousness

D Vital sign

49.A homeless individual is brought to the Emergency Room after having been out in

subfreezing temperatures for three to four days. The toes of the patient's right foot

appear hard and cold with mottling, and are unresponsive to touch. Which of the

following would NOT be included in the initial management of this patient by the

Emergency Room nurse?

A Place sterile gauze between the affected digits

B Wrap the affected extremity in a blanket and apply moist heat

C Rewarm the extremity with controlled and rapid rewarming until the injured part

flushes

D Elevate the affected extremity

50.Which type of jaundice in adults is the result of increased destruction of red blood cells?

A Non-obstructive

B Hemolytic

C Hepatocellular

D Obstructive

51.Abu Salem is a 46 year-old radio technician who is admitted because of mild chest pain.

He is 5 feet, 8 inches tall and weighs 190 pounds. He is diagnosed with a myocardial

infarct. Morphine sulfate, Diazepam (Valium) and Lidocaine are prescribed. The

physician orders 8 mg of Morphine Sulfate to be given IV. The vial on hand is labeled 1

ml/ 10 mg. The nurse should administer:

A 12 minims

B 8 minims

C 15 minims

D 10 minims

52.Which of the following stage the carcinogen is irreversible?

A Initiation stageB Progression stage

C Promotion stage

D Regression stage

53.The physician orders non-weight bearing with crutches for Joy, who had surgery for a

fractured hip. The most important activity to facilitate walking with crutches before

ambulation begun is:

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A Using the trapeze frequently for pull-ups to strengthen the biceps muscles

B Sitting up at the edge of the bed to help strengthen back muscles

C Doing isometric exercises on the unaffected leg

D Exercising the triceps, finger flexors, and elbow extensors

54.

Mrs. Mantesh a 78 year old client is admitted with the diagnosis of mild chronic heart

failure. The nurse expects to hear when listening to clients lungs indicative of chronic

heart failure would be:

A Friction rubs

B Wheezes

C Crackles

D Stridor

55.14 year old girl has been hospitalized with Sickle Cell Anemia in vasoocclusive crisis.

Which of these nursing diagnoses should receive priority in the nursing plan of care:

A Alteration in tissue perfusion

B Impaired social interaction

C Pain

D Alteration in body image

56.Osteoporosis is characterized by change in bone density or mass and fragile bones that

lead to fractures. A nurse is conducting a health screening clinic for osteoporosis. The

nurse determines that this client seen in the clinic is at the greatest risk of developing

the disorder.

A A sedentary 65 year old female who smokes cigarettes

B A 25 year old female who jogs

C A 36 year old male who has asthma

D A 70 year old male who consumes excess alcohol

57.

A nurse is caring for a client who had a closed reduction of a fractured right wrist

followed by the application of a fiberglass cast 12 hours ago. Which finding requires the

nurses immediate attention?

A Skin warm to touch and normally colored

B Slight swelling of fingers of right hand

C Client reports prickling sensation in the right hand

D Capillary refill of fingers on right hand is 3 seconds

58.

Nurse Trish is aware that temporary heterograft (pig skin) is used to treat burns becausethis graft will:

A Relieve pain and promote rapid epithelialization

B Concurrently used with topical antimicrobials

C Debride necrotic epithelium

D Be sutured in place for better adherence

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59.A client with burns on the chest has periodic episodes of dyspnea. The position that

would provide for the greatest respiratory capacity would be the:

A Orthopneic position

B Supine position

C Sims position

D Semi-fowlers position

60.The observation that indicates a desired response to thoracostomy drainage of a client

with chest injury is:

A Increased respiratory rate

B Increased breath sounds

C Constant bubbling in the drainage chamber

D Crepitus detected on palpation of chest

61.Faida with a history of chronic infection of the urinary system complains of urinary

frequency and burning sensation. To figure out whether the current problem is in renal

origin, the nurse should assess whether the client has discomfort or pain in the

A Urinary meatus

B Pain in the Labium

C Suprapubic area

D Right or left costovertebral angle

62.After gastroscopy, an adaptation that indicates major complication would be:

A Abdominal distention

B Nausea and vomiting

C Difficulty in swallowing

D Increased GI motility

63.

A chest tube with water seal drainage is inserted to a client following a multiple chest

injury. A few hours later, the clients chest tube seems to be obstructed. The most

appropriate nursing action would be to

A Milk the tube toward the collection container as ordered

B Arrange for a stat Chest x-ray film.

C Prepare for chest tube removal

D Clamp the tube immediately

64.Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure

recognizes an adequate amount of high-biologic-value protein when the food the clientselected from the menu was:

A Cottage cheese

B Raw carrots

C Apple juice

D Whole wheat bread

65.An early finding in the EKG of a client with an infarcted myocardium would be:

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A Elevated ST segments

B Disappearance of Q waves

C Absence of P wave

D Flattened T waves

66.

A 57 year-old male client has hemoglobin of 10 mg/dl and a hematocrit of 32%. What

would be the most appropriate follow-up by the home care nurse?

A Tell the client to schedule an appointment with a hematologist

B Tell the client to call an ambulance and go to the emergency department

immediately

C Schedule a repeat Hemoglobin and Hematocrit in 1 month

D Ask the client if he has noticed any bleeding or dark stools

67.A nurse prepares discharge instructions for a patient with chronic syndrome of

inappropriate antidiuretic hormone (SIADH). Which statement indicates that the patient

understands these instructions?

A I will use a refractometer to check the specific gravity of my urine. If the result

gradually rises, I will consult my physician.

B I will weigh everyday and I will log it in a notebook. I will call my physician

whenever I gain 2 lbs or more in a day without changing my eating habits.

C Ill check my pulse every morning and will contactmy doctor if its rapid or

irregular.

D I have to avoid too much sodium intake. I will read all food labels to make sure I

dont get too much of it in my diet.

68.Which client is at highest risk for developing a pressure ulcer?

A 23 year-old in traction for fractured femur

B 72 year-old with peripheral vascular disease, who is unable to walk without

assistance

C 30 year-old who is comatose following a ruptured aneurysm0

D 75 year-old with left sided paresthesia and is incontinent of urine and stool

69.A client is prescribed an inhaler. How should the nurse instruct the client to breathe in

the medication?

A As quickly as possible

B Deeply for 3-4 seconds

C As slowly as possibleD Until hearing whistling by the spacer

70.A chemotherapeutic agent 5FU is ordered as an adjunct measure to surgery. Which of

the ff. statements about chemotherapy is true?

A it affects both normal and tumor cells

B it is a local treatment affecting only tumor cells

C it has been proven as a complete cure for cancer

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D it is often used as a palliative measure

71.Mr. Dibagulun is admitted to the hospital with a diagnosis of Left-sided CHF. In the

assessment, the nurse should expect to find:

A Extensive peripheral edema

B Crushing chest pain

C Jugular vein distention

D Dyspnea on exertion

72.The nurse is assessing an infant with developmental dysplasia of the hip. Which finding

would the nurse anticipate?

A Limited adduction

B Symmetrical gluteal folds

C Unequal leg length

D Diminished femoral pulses

73.Most skin conditions related to HIV disease may be helped primarily by:

A improvement of the patient's nutritional status.

B highly active antiretroviral therapy (HAART).

C low potency topical corticosteroid therapy.

D symptomatic therapies

74.A client experiences post partum hemorrhage eight hours after the birth of twins.

Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and

hematocrit are within normal limits. She asks the nurse whether she should continue to

breast feed the infants. Which of the following is based on sound rationale?

A "Breastfeeding twins will take too much energy after the hemorrhage."

B "Lactation should be delayed until the "real milk" is secreted."

C Nursing will help contract the uterus and reduce your risk of bleeding.

D "The blood transfusion may increase the risks to you and the babies.

75. A client is for discharge post TURP. What is the most important teaching a nurse should

take:

A. Instruct the client to massage the bladder with fist in a rolling motion during

urination.

B. Report signs of foul odor urine, difficulty of starting urination and fever.

C. Instruct the client to perform perennial exercise by contracting and relaxing the

perineum.

76. Which of the following is a characteristic sign of SLE?

A. Rash on the face across the bridge of the nose and cheeks

B. Fatigue

C. Fever

D. Elevated rbc count

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77. A child is scheduled for tonsillectomy. Which of the following presents the highest risk

of aspiration during surgery?

A. Difficulty swallowing

B.

Presence of loose teeth

C.

Bleeding during surgery

D.

Exudate in the throat area

78. The chief clinical manifestation that the nurse would expect in the early stages of

cataract formation is:

A. Eye pain

B. Floating spots

C. Blurred vision

D. Diplopia

80. The nurse is performing an admission assessment on a client with bladder CA. which of

the following would the nurse most likely to expect?

A.

Hematuria

B. Burning

C. Urgency

D. Frequency

81. A client is admitted to the hospital and has a diagnosis of early stage of CRF. Which of

the following does the nurse expect to note on assessment?

A.

Polyuria

B. Edema

C. Oliguria

D.

Anuria

82. A client has developed atrial fibrillation with a ventricular rate of 150 per minute. The

nurse assesses the client for

a. Hypotension and dizziness

b. Nausea and vomiting

c. Hypertension and headache

d. Flat neck veins

2. When assessing a client with ulcerative colitis, which of the following findings would the

nurse report to the physician?

a.

Bloody diarrhea

b. Hypotension

c. A hemoglobin level of 12 mg/dL

d. Rebound tenderness

3. Which of the following is a characteristic sign of Lyme Disease Stage I?

a. Signs of neurological disorders

b. Enlarged and inflamed joints

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c. Arthalgias

d. Flu-like symptoms

4. Which of the following is not a sign of testicular cancer?

a.

Painless testicular swelling

b.

Heavy sensation in the scrotum

c.

Alopecia

d. Back pain

5. Which of the following data is a sign of paralytic ileus in a patient with acute pancreatitis

and a history of alcoholism?

a. Firm, nontender mass palpable at the lower right costa margin

b. Severe constant pain with rapid onset

c. Inability to pass flatus

d. Loss of anal sphincter control

6. A client is receiving external radiation to the neck for cancer of the larynx. The most

likely side effect to be expected is

a. Constipation

b. Dyspnea

c. Sore throat

d. Diarrhea

7.

The client has experienced pulmonary embolism. The nurse assesses for which of the

following symptoms most commonly reported?

a. Dyspnea noted when deep breaths are taken

b.

Hot, flushed feeling

c.

Chest pain that occurs suddenly

d.

Sudden chills and fevers

The nurse is caring for an elderly client with a suspected diagnosis of pneumonia who has just been admitted to the hospital. The

client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to

the unlicensed assistant? Select all that apply.

A. Obtaining vital signs

B. Initiating oxygen therapy as needed

C. Applying anti-embolic stockings

D. Assessing the clients chief complaint

A nursing assistant is assigned to care for a client with hemiparesis of the right arm and leg. With regards to morning care, the nurseinstructs the nursing assistant to place personal articles

A. Within the clients reach on the left side.

B. Within the clients reach on the right side.

C. Just out of the clients reach on the right side.

D. Just out of the clients reach on the left side.

Glycosylated hemoglobin of a diabetic client is 4%. What is the nurses correct interpretation?

A. Good control

B. Poor control

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C. Fair control

D. Needs further test

For a client placed in Bucks traction, the nurse can provide for countertraction to reduce shear and friction by

A. Providing an overhead trapeze

B. Using a foot board

C. Slightly elevating the head of the bed

D. Slightly elevating the foot of the bed

A patient with tuberculosis is scheduled for chest x-ray. What will the nurse do?

A. Request a portable x-ray to be brought to the patients room

B. Wear a particulate mask when transporting the patient to the x-ray room

C. Bring the patient to the x-ray room when there is fewer crowds in the hallway

D. Ask the patient to wear surgical mask when being transported to the x-ray room.

A nurse is conducting a health teaching for a client who is about to have an inguinal hernia repair (herniorraphy) tomorrow. The

nurse includes all of the following teaching except:

A. Doing lifting works at home 3 weeks after the surgery.

B. Applying ice pack to scrotal area to relieve edema.

C. Wearing scrotal support while ambulating

D. Increasing fiber in the diet to prevent constipation

Rationale: A.

A nurse obtains an order form the physician to restrain a client. The nurse instructs the nursing assistant to apply restraints to the

client. Which of the following observations indicate improper understanding of the nursing assistant in the use of restrains? Select

all that apply.

A. Removing restraints fro 10m minutes every 2 hours for range-of-motion exercises.

B. Restrain straps are safely secured in the side rails

C. The nursing assistant uses safety knot in securing the restrain straps in the bed frame.

D. Allowing enough space between the restrains and skin for movement.

Which of the following would alert the nurse to the potential for delirium tremors in a client undergoing alcohol withdrawal?

A. Ataxia, hunger, hypotension

B. Muscular rigidity, stupor, agitation

C. Hallucinations, hypertension, changes in the level of consciousness

D. Coarse hand tremors, hypotension, agitation

. A client with a diagnosis of peptic ulcer disease ask the nurse about what causes the disease to develop. The nurses appropriately

respond, that according to research, many peptic ulcers are result of which of the following?

A. Diets high in cholesterol

B. Family history of the disease

C. Stress

D.

elicobacter pylori

infection

The position of the client for colonoscopy is

A. Prone

B. Right lateral

C. lying on the left side with knees drawn to the chest up

D. Left Sims positionBeing weaned from TPN, the client is expected to begin taking solid food today. The ongoing solution rate is has been 100 mL/hour.

A nurse anticipates that which of the following orders regarding the TPN solution will accompany the diet order?A. Discontinue the TPN.

B. Continue current infusion rate orders for TPN.C. Decrease TPN rate to 50 mL/hr.

D. Hang 1 L 0.9% normal saline.

A client is receiving TPN in the home setting gained 5 lb weight in a week. The nurse next assesses the client to detect the presence

of which of the following?

A. Crackles on auscultation of the lungs

B. Thirst

C. Decreased blood pressure

D. Polyuria

The nurse after changing the IV bottle observes that the patient exhibits dyspnea. What will the nurse do first?

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A. Call the physician

B. Put on lateral side and lower down the head

C. Stop the IV

D. Take the vital signs and call the supervisorA client with cirrhosis of the liver is scheduled for a liver biopsy. How will the nurse position the client after the procedure?

A. Trendelenburg positionB. Right side lying

C. Semi-Fowlers

A 50-year-old client is receiving radiation therapy in the chest wall for breast cancer. She calls her health care provider and report

that she has pain while swallowing and burning and tightness in her chest. Which of the following complications of radiation

therapy is most likely responsible for her symptoms?

A. Hiatal hernia

B. Stomatitis

C. Radiation enteritis

D. Esophagitis

A pregnant client has just given birth following a cesareanm delivery. While the client was transported to the recovery room, the

nurse assesses the client and suspects the client of having pulmonary embolism, if which of the following clinical manifestation is

present?

A. Bradypnea

B. Bradycardia

C. Dyspnea

D. Decreased respirations