1. Which intervention is an example of primary 9. Nurse Margareth is revising a client’s care plan.

prevention? During which step of the nursing process does such

A. Administering digoxin (Lanoxicaps) to a patient revision take place?
with heart failure A. Assessment
B. Administering a measles, mumps, and rubella B. Planning
immunization to an infant C. Implementation
C. Obtaining a Papanicolaou smear to screen for D. Evaluation
cervical cancer 10. A 65-year-old female who has diabetes mellitus and
D. Using occupational therapy to help a patient has sustained a large laceration on her left wrist asks the
cope with arthritis nurse, “How long will it take for my scars to disappear?”
2. The nurse in charge is assessing a patient’s abdomen. which statement would be the nurse’s best response?
Which examination technique should the nurse use first? A. “The contraction phase of wound healing can
A. Auscultation take 2 to 3 years.”
B. Inspection B. “Wound healing is very individual but within 4
C. Percussion months the scar should fade.”
D. Palpation C. “With your history and the type of location of
3. Which statement regarding heart sounds is correct? the injury, it’s hard to say.”
A. S1 and S2 sound equally loud over the entire D. “If you don’t develop an infection, the wound
cardiac area. should heal any time between 1 and 3 years from
B. S1 and S2 sound fainter at the apex now.”
C. S1 and S2 sound fainter at the base 11. One aspect of implementation related to drug therapy
D. S1 is loudest at the apex, and S2 is loudest at the is:
base A. Developing a content outline
4. The nurse in charge identifies a patient’s responses to B. Documenting drugs given
actual or potential health problems during which step of C. Establishing outcome criteria
the nursing process? D. Setting realistic client goals
A. Assessment 12. A female client is readmitted to the facility with a
B. Nursing diagnosis warm, tender, reddened area on her right calf. Which
C. Planning contributing factor would the nurse recognize as most
D. Evaluation important?
5. A female patient is receiving furosemide (Lasix), 40 A. A history of increased aspirin use
mg P.O. b.i.d. in the plan of care, the nurse should B. Recent pelvic surgery
emphasize teaching the patient about the importance of C. An active daily walking program
consuming: D. A history of diabetes
A. Fresh, green vegetables 13. Which intervention should the nurse in charge try
B. Bananas and oranges first for a client that exhibits signs of sleep disturbance?
C. Lean red meat A. Administer sleeping medication before bedtime
D. Creamed corn B. Ask the client each morning to describe the
6. The nurse in charge must monitor a patient receiving quantity of sleep during the previous night
chloramphenicol for adverse drug reaction. What is the C. Teach the client relaxation techniques, such as
most toxic reaction to chloramphenicol? guided imagery, medication, and progressive
A. Lethal arrhythmias muscle relaxation
B. Malignant hypertension D. Provide the client with normal sleep aids, such
C. Status epilepticus as pillows, back rubs, and snacks
D. Bone marrow suppression 14. While examining a client’s leg, the nurse notes an
7. A female patient is diagnosed with deep-vein open ulceration with visible granulation tissue in the
thrombosis. Which nursing diagnosis should receive wound. Until a wound specialist can be contacted, which
highest priority at this time? type of dressings is most appropriate for the nurse in
A. Impaired gas exchanges related to increased charge to apply?
blood flow A. Dry sterile dressing
B. Fluid volume excess related to peripheral B. Sterile petroleum gauze
vascular disease C. Moist, sterile saline gauze
C. Risk for injury related to edema D. Povidone-iodine-soaked gauze
D. Altered peripheral tissue perfusion related to 15. A male client in a behavioral-health facility receives
venous congestion a 30-minute psychotherapy session, and provider uses a
8. When positioned properly, the tip of a central venous current procedure terminology (CPT) code that bills for
catheter should lie in the: a 50-minute session. Under the False Claims Act, such
A. Superior vena cava illegal behavior is known as:
B. Basilica vein A. Unbundling
C. Jugular vein B. Overbilling
D. Subclavian vein C. Upcoding
D. Misrepresentation
16. A nurse assigned to care for a postoperative male 23. Nurse Danny has been teaching a client about a high-
client who has diabetes mellitus. During the assessment protein diet. The teaching is successful if the client
interview, the client reports that he’s impotent and says identifies which meal as high in protein?
that he’s concerned about its effect on his marriage. In A. Baked beans, hamburger, and milk
planning this client’s care, the most appropriate B. Spaghetti with cream sauce, broccoli, and tea
intervention would be to: C. Bouillon, spinach, and soda
A. Encourage the client to ask questions about D. Chicken cutlet, spinach, and soda
personal sexuality 24. A male client is admitted to the hospital with blunt
B. Provide time for privacy chest trauma after a motor vehicle accident. The first
C. Provide support for the spouse or significant nursing priority for this client would be to:
other A. Assess the client’s airway
D. Suggest referral to a sex counselor or other B. Provide pain relief
appropriate professional C. Encourage deep breathing and coughing
17. Using Abraham Maslow’s hierarchy of human D. Splint the chest wall with a pillow
needs, a nurse assigns highest priority to which client 25. A newly hired charge nurse assesses the staff nurses
need? as competent individually but ineffective and
A. Security nonproductive as a team. In addressing her concern, the
B. Elimination charge nurse should understand that the usual reason for
C. Safety such a situation is:
D. Belonging A. Unhappiness about the charge in leadership
18. A male client is on prolonged bed rest has developed B. Unexpected feeling and emotions among the
a pressure ulcer. The wound shows no signs of healing staff
even though the client has received skin care and has C. Fatigue from overwork and understaffing
been turned every 2 hours. Which factor is most likely D. Failure to incorporate staff in decision making
responsible for the failure to heal? 26. A male client blood test results are as follows: white
A. Inadequate vitamin D intake blood cell (WBC) count, 100ul; hemoglobin (Hb) level,
B. Inadequate protein intake 14 g/dl; hematocrit (HCT), 40%. Which goal would be
C. Inadequate massaging of the affected area most important for this client?
D. Low calcium level A. Promote fluid balance
19. A female client who received general anesthesia B. Prevent infection
returns from surgery. Postoperatively, which nursing C. Promote rest
diagnosis takes highest priority for this client? D. Prevent injury
A. Acute pain related to surgery 27. Following a tonsillectomy, a female client returns to
B. Deficient fluid volume related to blood and fluid the medical-surgical unit. The client is lethargic and
loss from surgery reports having a sore throat. Which position would be
C. Impaired physical mobility related to surgery most therapeutic for this client?
D. Risk for aspiration related to anesthesia A. Semi-Fowler’s
20. Nurse Cay inspects a client’s back and notices small B. Supine
hemorrhagic spots. The nurse documents that the client C. High-Fowler’s
has: D. Side-lying
A. Extravasation 28. Nurse Berri inspects a client’s pupil size and
B. Osteomalacia determines that it’s 2 mm in the left eye and 3 mm in the
C. Petechiae right eye. Unequal pupils are known as:
D. Uremia A. Anisocoria
21. Which document addresses the client’s right to B. Ataxia
information, informed consent, and treatment refusal? C. Cataract
A. Standard of Nursing Practice D. Diplopia
B. Patient’s Bill of Rights 29. The nurse in charge is caring for an Italian client.
C. Nurse Practice Act He’s complaining of pain, but he falls asleep right after
D. Code for Nurses his complaint and before the nurse can assess his pain.
22. If a blood pressure cuff is too small for a client, The nurse concludes that:
blood pressure readings taken with such a cuff may do A. He may have a low threshold for pain
which of the following? B. He was faking pain
A. Fail to show changes in blood pressure C. Someone else gave him medication
B. Produce a false-high measurement D. The pain went away
C. Cause sciatic nerve damage
D. Produce a false-low measurement
30. A female client is admitted to the emergency Option C may be warranted but is secondary to
department with complaints of chest pain shortness of altered tissue perfusion.
breath. The nurse’s assessment reveals jugular vein 8. Answer A. When the central venous catheter is
distention. The nurse knows that when a client has positioned correctly, its tip lies in the superior
jugular vein distension, it’s typically due to: vena cava, inferior vena cava, or the right atrium
A. A neck tumor —that is, in central venous circulation. Blood
B. An electrolyte imbalance flows unimpeded around the tip, allowing the
C. Dehydration rapid infusion of large amounts of fluid directly
D. Fluid overload into circulation. The basilica, jugular, and
Answers and Rationales subclavian veins are common insertion sites for
1. Answer B. Immunizing an infant is an example central venous catheters.
of primary prevention, which aims to prevent 9. Answer D. During the evaluation step of the
health problems. Administering digoxin to treat nursing process the nurse determines whether
heart failure and obtaining a smear for a the goals established in the care plan have been
screening test are examples for secondary achieved, and evaluates the success of the plan.
prevention, which promotes early detection and If a goal is unmet or partially met the nurse
treatment of disease. Using occupational therapy reexamines the data and revises the plan.
to help a patient cope with arthritis is an Assessment involves data collection. Planning
example of tertiary prevention, which aims to involves setting priorities, establishing goals,
help a patient deal with the residual and selecting appropriate interventions.
consequences of a problem or to prevent the 10. Answer C. Wound healing in a client with
problem from recurring. diabetes will be delayed. Providing the client
2. Answer B. Inspection always comes first when with a time frame could give the client false
performing a physical examination. Percussion information.
and palpation of the abdomen may affect bowel 11. Answer B. Although documentation isn’t a step
motility and therefore should follow in the nursing process, the nurse is legally
auscultation. required to document activities related to drug
3. Answer D. The S1 sound—the “lub” sound—is therapy, including the time of administration, the
loudest at the apex of the heart. It sounds longer, quantity, and the client’s reaction. Developing a
lower, and louder there than the S2 sounds. The content outline, establishing outcome criteria,
S2—the “dub” sound—is loudest at the base. It and setting realistic client goals are part of
sounds shorter, sharper, higher, and louder there planning rather than implementation.
than S1. 12. Answer B. The client shows signs of deep vein
4. Answer B. The nurse identifies human responses thrombosis (DVT). The pelvic area is rich in
to actual or potential health problems during the blood supply, and thrombophlebitis of the deep
nursing diagnosis step of the nursing process. vein is associated with pelvic surgery. Aspirin,
During the assessment step, the nurse an antiplatelet agent, and an active walking
systematically collects data about the patient or program help decrease the client’s risk of DVT.
family. During the planning step, the nurse In general, diabetes is a contributing factor
develops strategies to resolve or decrease the associated with peripheral vascular disease.
patient’s problem. During the evaluation step, 13. Answer D. The nurse should begin with the
the nurse determines the effectiveness of the simplest interventions, such as pillows or
plan of care. snacks, before interventions that require greater
5. Answer B. Because furosemide is a potassium- skill such as relaxation techniques. Sleep
wasting diuretic, the nurse should plan to teach medication should be avoided whenever
the patient to increase intake of potassium-rich possible. At some point, the nurse should do a
foods, such as bananas and oranges. Fresh, green thorough sleep assessment, especially if
vegetables; lean red meat; and creamed corn are common sense interventions fail.
not good sources of potassium. 14. Answer C. Moist, sterile saline dressings support
6. Answer D. The most toxic reaction to would heal and are cost-effective. Dry sterile
chloramphenicol is bone marrow suppression. dressings adhere to the wound and debride the
Chloramphenicol is not known to cause lethal tissue when removed. Petroleum supports
arrhythmias, malignant hypertension, or status healing but is expensive. Povidone-iodine can
epilepticus. irritate epithelial cells, so it shouldn’t be left on
7. Answer D. Altered peripheral tissue perfusion an open wound.
related to venous congestion” takes highest 15. Answer C. Upcoding is the practice of using a
priority because venous inflammation and clot CPT code that’s reimbursed at a higher rate than
formation impede blood flow in a patient with the code for the service actually provided.
deep-vein thrombosis. Option A is incorrect Unbundling, overbilling, and misrepresentation
because impaired gas exchange is related to aren’t the terms used for this illegal practice.
decreased, not increased, blood flow. Option B 16. Answer D. The nurse should refer this client to a
is inappropriate because no evidence suggest sex counselor or other professional. Making
that this patient has a fluid volume excess. appropriate referrals is a valid part of planning
 the client’s care. The nurse doesn’t normally splinting are important for the client’s comfort,
provide sex counseling. Therefore, providing but would come after airway assessment.
time for privacy and providing support for the Coughing and deep breathing may be
spouse or significant other are important, but not contraindicated if the client has internal bleeding
as important as referring the client to a sex and other injuries.
counselor. 25. Answer B. The usual or most prevalent reason
17. Answer B. According to Maslow, elimination is for lack of productivity in a group of competent
a first-level or physiological need, and therefore nurses is inadequate communication or a
takes priority over all other needs. Security and situation in which the nurses have unexpected
safety are second-level needs; belonging is a feeling and emotions. Although the other
third-level need. Second- and third-level needs options could be contributing to the problematic
can be met only after a client’s first-level needs situation, they’re less likely to be the cause.
have been satisfied. 26. Answer B. The client is at risk for infection
18. Answer B. A client on bed rest suffers from a because WBC count is dangerously low. Hb
lack of movement and a negative nitrogen level and HCT are within normal limits;
balance. Therefore, inadequate protein intake therefore, fluid balance, rest, and prevention of
impairs wound healing. Inadequate vitamin D injury are inappropriate.
intake and low calcium levels aren’t factors in 27. Answer D. Because of lethargy, the post
poor healing for this client. A pressure ulcer tonsillectomy client is at risk for aspirating
should never be massaged. blood from the surgical wound. Therefore,
19. Answer D. Risk for aspiration related to placing the client in the side-lying position until
anesthesia takes priority for thins client because he awake is best. The semi-Fowler’s, supine,
general anesthesia may impair the gag and and high-Fowler’s position don’t allow for
swallowing reflexes, possibly leading to adequate oral drainage in a lethargic post
aspiration. The other options, although tonsillectomy client, and increase the risk of
important, are secondary. blood aspiration.
20. Answer C. Petechiae are small hemorrhagic 28. Answer A. Unequal pupils are called anisocoria.
spots. Extravasation is the leakage of fluid in the Ataxia is uncoordinated actions of involuntary
interstitial space. Osteomalacia is the softening muscle use. A cataract is an opacity of the eye’s
of bone tissue. Uremia is an excess of urea and lens. Diplopia is double vision.
other nitrogen products in the blood. 29. Answer A. People of Italian heritage tend to
21. Answer B. The Patient’s Bill of Rights addresses verbalize discomfort and pain. The pain was real
the client’s right to information, informed to the client, and he may need medication when
consent, timely responses to requests for he wakes up.
services, and treatment refusal. A legal 30. Answer D. Fluid overload causes the volume of
document, it serves as a guideline for the nurse’s blood within the vascular system to increase.
decision making. Standards of Nursing Practice, This increase causes the vein to distend, which
the Nurse Practice Act, and the Code for Nurses can be seen most obviously in the neck veins. A
contain nursing practice parameters and neck tumor doesn’t typically cause jugular vein
primarily describe the use of the nursing process distention. An electrolyte imbalance may result
in providing care. in fluid overload, but it doesn’t directly
22. Answer B. Using an undersized blood pressure contribute to jugular vein distention.
cuff produces a falsely elevated blood pressure
because the cuff can’t record brachial artery
measurements unless it’s excessively inflated.
The sciatic nerve wouldn’t be damaged by
hyperinflation of the blood pressure cuff because
the sciatic nerve is located in the lower
extremity.
23. Answer A. Baked beans, hamburger, and milk
are all excellent sources of protein. The
spaghetti-broccoli-tea choice is high in
carbohydrates. The bouillon-spinach-soda
choice provides liquid and sodium as well as
some iron, vitamins, and carbohydrates. Chicken
provides protein but the chicken-spinach-soda
combination provides less protein than the baked
beans-hamburger-milk selection.
24. Answer A. The first priority is to evaluate
airway patency before assessing for signs of
obstruction, sternal retraction, stridor, or
wheezing. Airway management is always the
nurse’s first priority. Pain management and