NCLEX-PN FINAL NEW *Questions And Answers (A grade)

NCLEX-PN EXAM - 1. A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse? A. Taking the vital signs B. Obtaining t he permit C. Explaining ...

NCLEX-PN EXAM - 1. A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse? A. Taking the vital signs B. Obtaining t he permit C. Explaining the procedure D. Checking the lab work 2. The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority? A. Starting an IV B. Applying oxygen C. Obtaining blood gases D. Medicating the client for pain 3. The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client? A. Rest in bed after taking the medication for at least 30 minutes B. Avoid rapid movements after taking the medication C. Take the medication with water only D. Allow at least 1 hour between taking the medicine and taking other medications 4. The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside? A. A pair of forceps B. A torque wrench C. A pair of wire cutters D. A screwdriver 5. An infant weighs 7 pounds at birth. The expected weight by 1 year should be: A. 10 pounds B. 12 pounds C. 18 pounds D. 21 pounds 6. A client is admitted with a Ewing’s sarcoma. Which symptoms would be expected due to this tumor’s location? A. Hemiplegia B. Aphasia C. Nausea D. Bone pain 7. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug? A. Uric acid of 5mg/dL B. Hematocrit of 33% C. WBC 2,000 per cubic millimeter D. Platelets 150,000 per cubic millimeter 8. A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? A. “Tell me about his pain.” B. “What does his vomit look like?” C. “Describe his usual diet.” D. “Have you noticed changes in his abdominal size?” 9. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided? A. Bran B. Fresh peaches C. Cucumber salad D. Yeast rolls 10. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? A. Teaching how to irrigate the illeostomy B. Stopping electrolyte loss in the incisional area C. Encouraging a high-fiber diet D. Facilitating perineal wound drainage 11. The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet? A. Roasted chicken B. Noodles C. Cooked broccoli D. Custard 12. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: A. Trendelenburg position B. Ice to the entire extremity C. Buck’s traction D. An abduction pillow 13. A client with cancer is to undergo an intravenous pyelogram. The nurse should: A. Force fluids 24 hours before the procedure B. Ask the client to void immediately before the study C. Hold medication that affects the central nervous system for 12 hours pre- and post-test D. Cover the client’s reproductive organs with an x-ray shield 14. The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor: A. That cannot be assessed B. That is in situ C. With increasing lymph node involvement D. With distant metastasis 15. A client is 2 days post-operative colon resection. After a coughing episode, the client’s wound eviscerates. Which nursing action is most appropriate? A. Reinsert the protruding organ and cover with 4×4s B. Cover the wound with a sterile 4×4 and ABD dressing C. Cover the wound with a sterile saline-soaked dressing D. Apply an abdominal binder and manual pressure to the wound 16. The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery? A. Hearing aid B. Contact lenses C. Wedding ring D. Artificial eye 17. The nurse on the 3–11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action? A. Call the surgeon and ask him or her to see the client to clarify the information B. Explain the procedure and complications to the client C. Check in the physician’s progress notes to see if understanding has been documented D. Check with the client’s family to see if they understand the procedure fully 18. The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client’s ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge? A. “I live by myself.” B. “I have trouble seeing.” C. “I have a cat in the house with me.” D. “I usually drive myself to the doctor.” 19. The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while the client is receiving TPN? A. Hemoglobin B. Creatinine C. Blood glucose D. White blood cell count 20. The client with a myocardial infarction comes to the nurse’s station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using? A. Rationalization B. Denial C. Projection D. Conversion reaction 21. Which laboratory test would be the least effective in making the diagnosis of a myocardial infarction? A. AST B. Troponin C. CK-MB D. Myoglobin 22. The licensed practical nurse assigned to the post-partal unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam? A. A gravida IV para 3 that is Rh negative with an Rh-positive baby B. A gravida I para 1 that is Rh negative with an Rh-positive baby C. A gravida II para 0 that is Rh negative admitted after a stillbirth delivery D. A gravida IV para 2 that is Rh negative with an Rh-negative baby 23. The first exercise that should be performed by the client who had a mastectomy is: A. Walking the hand up the wall B. Sweeping the floor C. Combing her hair D. Squeezing a ball 24. The client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test? A. Atropine sulfate B. Furosemide C. Prostigmin D. Promethazine 25. The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam? A. “You will need to lay flat during the exam.” B. “You need to empty your bladder before the procedure.” C. “You will be asleep during the procedure.” D. “The doctor will inject a medication to treat your illness during the procedure.” 26. To ensure safety while administering a nitroglycerine patch, the nurse should: A. Wear gloves B. Shave the area where the patch will be applied C. Wash the area thoroughly with soap and rinse with hot water D. Apply the patch to the buttocks 27. The physician has prescribed tranylcypromine sulfate (Parnate) 10mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause: A. Hypertension B. Hyperthermia C. Melanoma D. Urinary retention 28. The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient’s mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy? A. “She is very irritable lately.” B. “She sleeps quite a bit of the time.” C. “Her gums look too big for her teeth.” D. “She has gained about 10 pounds in the last 6 months.” 29. A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery? A. Decreased appetite B. A low-grade fever C. Chest congestion D. Constant swallowing 30. A 6-year-old with cerebral palsy functions at the level of an 18-month- old. Which finding would support that assessment? A. She dresses herself. B. She pulls a toy behind her. C. She can build a tower of eight blocks. D. She can copy a horizontal or vertical line. 31. Which information obtained from the mother of a child with cerebral palsy most likely correlates to the diagnosis? A. She was born at 42 weeks gestation. B. She had meningitis when she was 6 months old. C. She had physiologic jaundice after delivery. D. She has frequent sore throats. 32. A 10-year-old is being treated for asthma. Before administering Theodur, the nurse should check the: A. Urinary output B. Blood pressure C. Pulse D. Temperature 33. An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals and cloudiness in the IV medication? A. Discard the solution and order a new bag B. Warm the solution C. Continue the infusion and document the finding D. Discontinue the medication 34. The client is diagnosed with multiple myoloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client? A. “Walk about a mile a day to prevent calcium loss.” B. “Increase the fiber in your diet.” C. “Report nausea to the doctor immediately.” D. “Drink at least eight large glasses of water a day.” 35. The client is taking rifampin 600mg po daily to treat his tuberculosis. Which action by the nurse indicates understanding of the medication? A. Telling the client that the medication will need to be taken with juice B. Telling the client that the medication will change the color of the urine C. Telling the client to take the medication before going to bed at night D. Telling the client to take the medication if night sweats occur 36. The client is taking prednisone 7.5mg po each morning to treat his systemic lupus errythymatosis. Which statement best explains the reason for taking the prednisone in the morning? A. There is less chance of forgetting the medication if taken in the morning. B. There will be less fluid retention if taken in the morning. C. Prednisone is absorbed best with the breakfast meal. D. Morning administration mimics the body’s natural secretion of corticosteroid. 37. A 20-year-old female has a prescription for tetracycline. While teaching the client how to take her medicine, the nurse learns that the client is also taking Ortho-Novum oral contraceptive pills. Which instructions should be included in the teaching plan? A. The oral contraceptives will decrease the effectiveness of the tetracycline. B. Nausea often results from taking oral contraceptives and antibiotics. C. Toxicity can result when taking these two medications together. D. Antibiotics can decrease the effectiveness of oral contraceptives, so the client should use an alternate method of birth control. 38. A 60-year-old diabetic is taking glyburide (Diabeta) 1.25mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching? A. “I will keep candy with me just in case my blood sugar drops.” B. “I need to stay out of the sun as much as possible.” C. “I often skip dinner because I don’t feel hungry.” D. “I always wear my medical identification.” 39. The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to exert an effect: A. In 5–10 minutes B. In 10–20 minutes C. In 30–60 minutes D. In 60–120 minutes 40. Vitamin K (aquamephyton) is administered to a newborn shortly after birth for which of the following reasons? A. To prevent dehydration B. To treat infection C. To replace electrolytes D. To facilitate clotting 41. The client with an ileostomy is being discharged. Which teaching should be included in the plan of care? A. Use Karaya powder to seal the bag. B. Irrigate the ileostomy daily. C. Stomahesive is the best skin protector. D. Neosporin ointment can be used to protect the skin. 42. The client has an order for FeSo4 liquid. Which method of administration would be best? A. Administer the medication with milk B. Administer the medication with a meal C. Administer the medication with orange juice D. Administer the medication undiluted 43. The client arrives in the emergency room with a hyphema. Which action by the nurse would be best? A. Elevate the head of the bed and apply ice to the eye B. Place the client in a supine position and apply heat to the knee C. Insert a Foley catheter and measure the intake and output D. Perform a vaginal exam and check for a discharge 44. The nurse is making assignments for the day. Which client should be assigned to the nursing assistant? A. The 18-year-old with a fracture to two cervical vertebrae B. The infant with meningitis C. The elderly client with a thyroidectomy 4 days ago D. The client with a thoracotomy 2 days ago 45. The client arrives in the emergency room with a “bull’s eye” rash. Which question would be most appropriate for the nurse to ask the client? A. “Have you found any ticks on your body?” B. “Have you had any nausea in the last 24 hours?” C. “Have you been outside the country in the last 6 months?” D. “Have you had any fever for the past few days?” 46. Which of the following is the best indicator of the diagnosis of HIV? A. White blood cell count B. ELISA C. Western Blot D. Complete blood count 47. The nurse is evaluating nutritional outcomes for an elderly client with anorexia. Which data best indicates that the plan of care is effective? A. The client selects a balanced diet from the menu. B. The client’s hematocrit improves. C. The client’s tissue turgor improves. D. The client gains weight. 48. The client is admitted following repair of a fractured femur with cast application. Which nursing assessment should be reported to the doctor? A. Pain B. Warm toes C. Pedal pulses rapid D. Paresthesia of the toes 49. Which would be an expected finding during injection of dye with a cardiac catheterization? A. Cold extremity distant to the injection site B. Warmth in the extremity C. Extreme chest pain D. Itching in the extremities 50. Which action by the healthcare worker indicates a need for further teaching? A. The nursing assistant wears gloves while giving the client a bath. B. The nurse wears goggles while drawing blood from the client. C. The doctor washes his hands before examining the client. D. The nurse wears gloves to take the client’s vital signs. 51. The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective? A. The client loses consciousness. B. The client vomits. C. The client’s ECG indicates tachycardia. D. The client has a grand mal seizure. 52. A 5-year-old is being tested for pinworms. To collect a specimen for assessment of pinworms, the nurse should teach the mother to: A. Examine the perianal area with a flashlight 2–3 hours after the child is asleep and to collect any eggs on a clear tape B. Scrape the skin with a piece of cardboard and bring it to the clinic C. Obtain a stool specimen in the afternoon D. Bring a hair sample to the clinic for evaluation 53. Which instruction should be given regarding the medication used to treat enterobiasis (pinworms)? A. Treatment is not recommended for children less than 10 years of age. B. The entire family should be treated. C. Medication therapy will continue for 1 year. D. Intravenous antibiotic therapy will be ordered. 54. Which client should be assigned to the pregnant licensed practical nurse? A. The client who just returned after receiving linear accelerator radiation therapy for lung cancer B. The client with a radium implant for cervical cancer C. The client who has just been administered soluble brachytherapy for thyroid cancer D. The client who has returned from placement of iridium seeds for prostate cancer 55. Which client should be assigned to a private room if only one is available? A. The client with Cushing’s syndrome B. The client with diabetes C. The client with acromegaly D. The client with myxedema 56. The nurse caring for a client on the pediatric unit administers adult- strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with: A. Negligence B. Tort C. Assault D. Malpractice 57. Which assignment should not be performed by the licensed practical nurse? A. Inserting a Foley catheter B. Discontinuing a nasogastric tube C. Obtaining a sputum specimen D. Initiating a blood transfusion 58. A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when: A. Estrogen levels are low. B. Lutenizing hormone is high. C. The endometrial lining is thin. D. The progesterone level is low. 59. A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the: A. Age of the client B. Frequency of intercourse C. Regularity of the menses D. Range of the client’s temperature 60. A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes? A. Intrauterine device B. Oral contraceptives C. Diaphragm D. Contraceptive sponge 61. The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy? A. Painless vaginal bleeding B. Abdominal cramping C. Throbbing pain in the upper quadrant D. Sudden, stabbing pain in the lower quadrant 62. The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client? A. Hamburger pattie, green beans, French fries, and iced tea B. Roast beef sandwich, potato chips, baked beans, and cola C. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea D. Fish sandwich, gelatin with fruit, and coffee 63. The client with hyperemesis gravidarum is at risk for developing: A. Respiratory alkalosis without dehydration B. Metabolic acidosis with dehydration C. Respiratory acidosis without dehydration D. Metabolic alkalosis with dehydration 64. A client with a fractured hip has been placed in traction. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction: A. Utilizes a pin through bones B. Requires that both legs be secured C. Utilizes Kirschner wires D. Is used primarily to heal the fractured hips 65. The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the client for: A. Hypovolemia B. Pain C. Nutritional status D. Immobilizer 66. Which statement made by the family member caring for the client with a percutaneous gastrotomy tube indicates understanding of the nurse’s teaching? A. “I must flush the tube with water after feedings and clamp the tube.” B. “I must check placement four times per day.” C. “I will report to the doctor any signs of indigestion.” D. “If my father is unable to swallow, I will discontinue the feeding and call the clinic.” 67. The nurse is assessing the client with a total knee replacement 2 hours post-operative. Which information requires notification of the doctor? A. Bleeding on the dressing is 2cm in diameter. B. The client has a low-grade temperature. C. The client’s hemoglobin is 6g/dL. D. The client voids after surgery. 68. The nurse is caring for the client with a 5-year-old diagnosed with plumbism. Which information in the health history is most likely related to the development of plumbism? A. The client has traveled out of the country in the last 6 months. B. The client’s parents are skilled stained-glass artists. C. The client lives in a house built in 1990. D. The client has several brothers and sisters. 69. A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with prevention of dislocation of the prosthesis? A. An abduction pillow B. A straight chair C. A pair of crutches D. A soft mattress 70. The client with a joint replacement is scheduled to receive Lovenox (enoxaparin). Which lab value should be reported to the doctor? A. PT of 20 seconds B. PTT of 300 seconds C. Protime of 30 seconds D. INR 3 71. The nurse is responsible for performing a neonatal assessment on a full- term infant. At 1 minute, the nurse could expect to find: A. An apical pulse of 100 B. Absence of tonus C. Cyanosis of the feet and hands D. Jaundice of the skin and sclera 72. A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client’s need for: A. Supplemental oxygen B. Fluid restriction C. Blood transfusion D. Delivery by Caesarean section 73. A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes: A. Increasing fluid intake B. Limiting ambulation C. Administering an enema D. Withholding food for 8 hours 74. An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year? A. 14 pounds B. 16 pounds C. 18 pounds D. 24 pounds 75. A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test: A. Determines the lung maturity of the fetus B. Measures the activity of the fetus C. Shows the effect of contractions on the fetal heart rate D. Measures the neurological well-being of the fetus 76. A full-term male has hypospadias. Which statement describes hypospadias? A. The urethral opening is absent. B. The urethra opens on the dorsal side of the penis. C. The penis is shorter than usual. D. The urethra opens on the ventral side of the penis. 77. A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8cm dilated withcomplete effacement. The priority nursing diagnosis at this time is: A. Alteration in coping related to pain B. Potential for injury related to precipitate delivery C. Alteration in elimination related to anesthesia D. Potential for fluid volume deficit related to NPO status 78. The client with varicella will most likely have an order for which category of medication? A. Antibiotics B. Antipyretics C. Antivirals D. Anticoagulants 79. A client is admitted with complaints of chest pain. Which of the following drug orders should the nurse question? A. Nitroglycerin B. Ampicillin C. Propranolol D. Verapamil 80. Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis? A. Avoid exercise because it fatigues the joints. B. Take prescribed anti-inflammatory medications with meals. C. Alternate hot and cold packs to affected joints. D. Avoid weight-bearing activity. 81. A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should the nurse question? A. Meperidine B. Mylanta C. Cimetadine D. Morphine 82. The primary reason for rapid continuous rewarming of the area affected by frostbite is to: A. Lessen the amount of cellular damage B. Prevent the formation of blisters C. Promote movement D. Prevent pain and discomfort 83. A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse’s response is based on the knowledge that hemodialysis works by: A. Passing water through the dialyzing membrane B. Eliminating plasma proteins from the blood C. Lowering the pH by removing nonvolatile acids D. Filtering waste through a dialyzing membrane 84. During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate? A. Administering an antibiotic B. Contacting the physician for an order for immune globulin C. Administering an antiviral D. Telling the client that he should remain in isolation for 2 weeks 85. A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact? A. The client should be placed in a room with negative pressure. B. Infection requires close contact; therefore, the door may remain open. C. Transmission is highly likely, so the client should wear a mask at all times. D. Infection requires skin-to-skin contact and is prevented by handwashing, gloves, and a gown. 86. A client with an above-the-knee amputation is being taught methods to prevent hipflexion deformities. Which instruction should be given to the client? A. “Lie supine with the head elevated on two pillows.” B. “Lie prone every 4 hours during the day for 30 minutes.” C. “Lie on your side with your head elevated.” D. “Lie flat during the day.” 87. A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that, during the Whipple procedure, the doctor will remove the: A. Head of the pancreas B. Proximal third section of the small intestines C. Stomach and duodenum D. Esophagus and jejunum 88. The physician has ordered a minimal bacteria diet for a client with neutropenia. The client should be taught to avoid eating: A. Fruits B. Salt C. Pepper D. Ketchup 89. A client is discharged home with a prescription for Coumadin (warfarin sodium). The client should be instructed to: A. Have a Protime done monthly B. Eat more fruits and vegetables C. Drink more liquids D. Avoid crowds 90. The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to: A. Perform the Valsalva maneuver as the catheter is advanced B. Turn his head to the left side and hyperextend the neck C. Take slow, deep breaths as the catheter is removed D. Turn his head to the right while maintaining a sniffing position 91. A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for: A. Allergies to pineapples and bananas B. A history of streptococcal infections C. Prior therapy with phenytoin D. A history of alcohol abuse 92. The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid: A. Using oil- or cream-based soaps B. Flossing between the teeth C. The intake of salt D. Using an electric razor 93. A client hospitalized with severe depression and suicidal ideation refuses to talk with the nurse. The nurse recognizes that the suicidal client has difficulty: A. Expressing feelings of low self-worth B. Discussing remorse and guilt for actions C. Displaying dependence on others D. Expressing anger toward others 94. A client receiving HydroDIURIL (hydrochlorothiazide) is instructed to increase her dietary intake of potassium. The best snack for the client requiring increased potassium is: A. Pear B. Apple C. Orange D. Banana 95. The nurse is caring for a client following removal of the thyroid. Immediately post-op, the nurse should: A. Maintain the client in a semi-Fowler’s position with the head and neck supported by pillows B. Encourage the client to turn her head side to side, to promote drainage of oral secretions C. Maintain the client in a supine position with sandbags placed on either side of the head and neck D. Encourage the client to cough and breathe deeply every 2 hours, with the neck in a flexed position 96. A client hospitalized with chronic dyspepsia is diagnosed with gastric cancer. Which of the following is associated with an increased incidence of gastric cancer? A. Dairy products B. Carbonated beverages C. Refined sugars D. Luncheon meats 97. A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing the client’s record, the nurse could expect to find: A. A history of consistent employment B. A below-average intelligence C. A history of cruelty to animals D. An expression of remorse for his actions 98. The licensed vocational nurse may not assume the primary care for a client: A. In the fourth stage of labor B. Two days post-appendectomy C. With a venous access device D. With bipolar disorder 99. The physician has ordered dressings with mafenide acetate (Sulfamylon) cream for a client with full-thickness burns of the hands and arms. Before dressing changes, the nurse should give priority to: A. Administering pain medication B. Checking the adequacy of urinary output C. Requesting a daily complete blood count D. Obtaining a blood glucose by finger stick 100. The nurse is teaching a group of parents about gross motor development of the toddler. Which behavior is an example of the normal gross motor skill of a toddler? A. She can pull a toy behind her. B. She can copy a horizontal line. C. She can build a tower of eight blocks. D. She can broad-jump. 101. A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible? A. Wire cutters B. Oral airway C. Pliers D. Tracheostomy set 102. The nurse is to administer digoxin (Lanoxin) elixir to a 6-month-old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100. The nurse should: A. Record the heart rate and call the physician B. Record the heart rate and administer the medication C. Administer the medication and recheck the heart rate in 15 minutes D. Hold the medication and recheck the heart rate in 30 minutes 103. A mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain the treatment for her daughter. The nurse’s explanation is based on the knowledge that lead poisoning is treated with: A. Gastric lavage B. Chelating agents C. Antiemetics D. Activated charcoal 104. An 18-month-old is scheduled for a cleft palate repair. The usual type of restraints for the child with a cleft palate repair are: A. Elbow restraints B. Full arm restraints C. Wrist restraints D. Mummy restraints 105. A client with glaucoma has been prescribed Timoptic (timolol) eyedrops. Timoptic should be used with caution in the client with a history of: A. Diabetes B. Gastric ulcers C. Emphysema D. Pancreatitis 106. An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client’s confusion by: A. Assigning a nursing assistant to sit with him until he falls asleep B. Allowing the client to room with another elderly client C. Administering a bedtime sedative D. Leaving a nightlight on during the evening and night shifts 107. Which of the following is a common complaint of the client with end- stage renal failure? A. Weight loss B. Itching C. Ringing in the ears D. Bruising 108. A client with AIDS is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract? A. Thoroughly cooking all foods B. Offering yogurt and buttermilk between meals C. Forcing fluids D. Providing small, frequent meals 109. The treatment protocol for a client with acute lymphocytic leukemia includes prednisone, methotrexate, and cimetadine. The purpose of the cimetadine is to: A. Decrease the secretion of pancreatic enzymes B. Enhance the effectiveness of methotrexate C. Promote peristalsis D. Prevent a common side effect of prednisone 110. Which of the following meal choices is suitable for a 6-month-old infant? A. Egg white, formula, and orange juice B. Apple juice, carrots, whole milk C. Rice cereal, apple juice, formula D. Melba toast, egg yolk, whole milk 111. The LPN is preparing to administer an injection of vitamin K to the newborn. The nurse should administer the injection in the: A. Rectus femoris muscle B. Vastus lateralis muscle C. Deltoid muscle D. Dorsogluteal muscle 112. The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephotic syndrome. The nurse should: A. Encourage the client to drink extra fluids B. Request a low-protein diet for the client C. Bathe the client using only mild soap and water D. Provide additional warmth for swollen, inflamed joints 113. The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal? A. Antabuse (disulfiram) B. Romazicon (flumazenil) C. Dolophine (methodone) D. Ativan (lorazepam) 114. A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at: A. 8 a.m. B. 10 a.m. C. 3 p.m. D. 5 a.m. 115. The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority? A. Alteration in comfort B. Alteration in mobility C. Alteration in skin integrity D. Alteration in O2 perfusion 116. The primary purpose for using a CPM machine for the client with a total knee repair is to help: A. Prevent contractures B. Promote flexion of the artificial joint C. Decrease the pain associated with early ambulation D. Alleviate lactic acid production in the leg muscles 117. Which of the following statements reflects Kohlberg’s theory of the moral development of the preschool-age child? A. Obeying adults is seen as correct behavior. B. Showing respect for parents is seen as important. C. Pleasing others is viewed as good behavior. D. Behavior is determined by consequences. 118. A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to: A. Determine whether the ear infection has affected her hearing B. Make sure that she has taken all the antibiotic C. Document that the infection has completely cleared D. Obtain a new prescription in case the infection recurs 119. Before administering a client’s morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to: A. Record the pulse rate and administer the medication B. Administer the medication and monitor the heart rate C. Withhold the medication and notify the doctor D. Withhold the medication until the heart rate increases 120. What information should the nurse give a new mother regarding the introduction of solid foods for her infant? A. Solid foods should not be given until the extrusion reflex disappears, at 8– 10 months of age. B. Solid foods should be introduced one at a time, with 4- to 7-day intervals. C. Solid foods can be mixed in a bottle or infant feeder to make feeding easier. D. Solid foods should begin with fruits and vegetables. 121. A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to: A. Withholding all morning medications B. Ordering a CBC and CPK C. Administering prescribed anti-Parkinsonian medication D. Transferring the client to a medical unit 122. A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid: A. Calcium-rich foods B. Canned or frozen vegetables C. Processed meat D. Raw fruits and vegetables 123. A 4-year-old is admitted with acute leukemia. It will be most important to monitor the child for: A. Abdominal pain and anorexia B. Fatigue and bruising C. Bleeding and pallor D. Petechiae and mucosal ulcers 124. A 5-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on: A. Preventing infection B. Administering antipyretics C. Keeping the skin free of moisture D. Limiting oral fluid intake 125. The nurse is caring for a client with a history of diverticulitis. The client complains of abdominal pain, fever, and diarrhea. Which food was responsible for the client’s symptoms? A. Mashed potatoes B. Steamed carrots C. Baked fish D. Whole-grain cereal 126. The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client’s cancer is located in: A. The tail of the pancreas B. The head of the pancreas C. The body of the pancreas D. The entire pancreas 127. A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is: A. Weight gain B. Hair loss C. Sore throat D. Brittle nails 128. The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is to: A. Prevent addiction B. Alleviate pain C. Facilitate mobility D. Prevent nausea 129. Which finding is the best indication that a client with ineffective airway clearance needs suctioning? A. Oxygen saturation B. Respiratory rate C. Breath sounds D. Arterial blood gases 130. An obstetrical client calls the clinic with complaints of morning sickness. The nurse should tell the client to: A. Keep crackers at the bedside for eating before she arises B. Drink a glass of whole milk before going to sleep at night C. Skip breakfast but eat a larger lunch and dinner D. Drink a glass of orange juice after adding a couple of teaspoons of sugar 131. The nurse has taken the blood pressure of a client hospitalized with methicillin-resistant staphylococcus aureus. Which action by the nurse indicates an understanding regarding the care of clients with MRSA? A. The nurse leaves the stethoscope in the client’s room for future use. B. The nurse cleans the stethoscope with alcohol and returns it to the exam room. C. The nurse uses the stethoscope to assess the blood pressure of other assigned clients. D. The nurse cleans the stethoscope with water, dries it, and returns it to the nurse’s station. 132. The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician’s teaching by telling the parents that: A. The medication will be needed only during times of rapid growth. B. The medication will be needed throughout the child’s lifetime. C. The medication schedule can be arranged to allow for drug holidays. D. The medication is given one time daily every other day. 133. The LPN is reviewing the lab results of an elderly client when she notes a specific gravity of 1.025. The nurse recognizes that: A. The client has impaired renal function. B. The client has a normal specific gravity. C. The client has mild to moderate dehydration. D. The client has diluted urine from fluid overload. 134. A client with acute pancreatitis has requested pain medication. Which pain medication is indicated for the client with acute pancreatitis? A. Demerol (meperidine) B. Toradol (ketorolac) C. Morphine (morphine sulfate) D. Codeine (codeine) 135. A client with a hiatal hernia has been taking magnesium hydroxide for relief of heartburn. Overuse of magnesium-based antacids can cause the client to have: A. Constipation B. Weight gain C. Anorexia D. Diarrhea 136. When performing a newborn assessment, the nurse measures the circumference of the neonate’s head and chest. Which assessment finding is expected in the normal newborn? A. The head and chest circumference are the same. B. The head is 2cm larger than the chest. C. The head is 3cm smaller than the chest. D. The head is 4cm larger than the chest. 137. A client with a history of clots is receiving Lovenox (enoxaparin). Which drug is given to counteract the effects of enoxaparin? A. Calcium gluconate B. Aquamephyton C. Methergine D. Protamine sulfate 138. The nurse is formulating a plan of care for a client with a cognitive disorder. Which activity is most appropriate for the client with confusion and short attention span? A. Taking part in a reality-orientation group B. Participating in unit community goal setting C. Going on a field trip with a group of clients D. Meeting with an assertiveness training group 139. The nurse is providing dietary teaching regarding low-sodium diets for a client with hypertension. Which food should be avoided by the client on a low-sodium diet? A. Dried beans B. Swiss cheese C. Peanut butter D. American cheese 140. A client is admitted to the emergency room with partial-thickness burns of his head and both arms. According to the Rule of Nines, the nurse calculates that the TBSA (total body surface area) involved is: A. 20% B. 27% C. 35% D. 50% 141. The physician has ordered a paracentesis for a client with severe ascites. Before the procedure, the nurse should: A. Instruct the client to void B. Shave the abdomen C. Encourage extra fluids D. Request an abdominal x-ray 142. The mother of a child with chickenpox wants to know if there is a medication that will shorten the course of the illness. Which medication is sometimes used to speed healing of the lesions and shorten the duration of fever and itching? A. Zovirax (acyclovir) B. Varivax (varicella vaccine) C. VZIG (varicella-zoster immune globulin) D. Periactin (cyproheptadine) 143. Which of the following clients is most likely to be a victim of elder abuse? A. A 62-year-old female with diverticulitis B. A 76-year-old female with right-sided hemiplegia C. A 65-year-old male with a hip replacement D. A 72-year-old male with diabetes mellitus 144. A hospitalized client with severe anemia is to receive a unit of blood. Which facet of care is most appropriate for the newly licensed practical nurse? A. Initiating the IV of normal saline B. Monitoring the client’s vital signs C. Initiating the blood transfusion D. Notifying the physician of a reaction 145. To reduce the possibility of having a baby with a neural tube defect, the client should be told to increase her intake of folic acid. Dietary sources of folic acid include: A. Meat, liver, eggs B. Pork, fish, chicken C. Oranges, cabbage, cantaloupe D. Dried beans, sweet potatoes, Brussels sprouts 146. A client is admitted for suspected bladder cancer. Which one of the following factors is most significant in the client’s diagnosis? A. Smoking a pack of cigarettes a day for 30 years B. Taking hormone-replacement therapy C. Eating foods with preservatives D. Past employment involving asbestos 147. The physician has prescribed nitroglycerin buccal tablets as needed for a client with angina. The nurse should tell the client to take the tablets: A. After engaging in strenuous activity B. Every 4 hours to prevent chest pain C. When he first feels chest discomfort D. At bedtime to prevent nocturnal angina 148. The nurse is caring for an infant who is on strict intake and output. The used diaper weighs 90.5 grams. The diaper’s dry weight was 62 grams. The infant’s urine output was: A. 10mL B. 28.5mL C. 10 grams D. 152.5 grams 149. The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should explain the need for: A. Additional calcium in the infant’s diet B. Careful handling to prevent fractures C. Providing extra sensorimotor stimulation D. Frequent testing of visual function 150. Which snack is best for the child following a tonsillectomy? A. Banana popsicle B. Chocolate milk C. Fruit punch D. Cola 151. The physician has prescribed Xanax (alprazolam) for a client with acute anxiety. The nurse should teach the client to avoid: A. Sun exposure B. Drinking beer C. Eating cheese D. Taking aspirin 152. The nurse is instructing a post-operative client on the use of an incentive spirometer. The nurse knows that the correct use of the incentive spirometer is directly related to: A. Promoting the client’s circulation B. Preparing the client for amubulation C. Strengthening the client’s muscles D. Increasing the client’s respiratory effort 153. The nurse is assisting the physician with the insertion of an esophageal tamponade. Before insertion, the nurse should: A. Inflate and deflate the gastric and esophageal balloons B. Measure from the tip of the client’s nose to the xiphoid process C. Explain to the client that the tube will remain in place for 5–7 days D. Insert a nasogastric tube for gastric suction 154. The physician has ordered Cephulac (lactulose) for a client with increased serum ammonia. The nurse knows the medication is having its desired effect if the client experiences: A. Increased urination B. Diarrhea C. Increased appetite D. Decreased weight 155. The nurse is assessing a client immediately following delivery. The nurse notes that the client’s fundus is boggy. The nurse’s next action should be to: A. Assess for bladder distention B. Notify the physician C. Gently massage the fundus D. Administer pain medication 156. Which breakfast selection is suitable for the client on a high-fiber diet? A. Danish pastry, tomato juice, coffee, and milk B. Oatmeal, grapefruit wedges, coffee, and milk C. Cornflakes, toast and jam, and milk D. Scrambled eggs, bacon, toast, and coffee 157. A male client is admitted with a tentative diagnosis of Hodgkin’s lymphoma. The client with Hodgkin’s lymphoma commonly reports: A. Finding enlarged nodes in the neck while shaving B. Projectile vomiting upon arising C. Petechiae and easy bruising D. Frequent, painless hematuria 158. A client with acquired immunodeficiency syndrome has begun treatment with Pentam (pentamidine). The nurse recognizes that the medication will help to prevent: A. Candida albicans B. Pneumocystis carinii C. Cryptosporidiosis D. Cytomegaloretinitis 159. During a well-baby visit, the mother asks the nurse when the “soft spot” on the front of her baby’s head will close. The nurse should tell the mother that the anterior fontanel normally closes by the time the baby is: A. 4–6 months of age B. 7–9 months of age C. 10–12 months of age D. 12–18 months of age 160. An elderly client with anemia has a positive Schilling test. The nurse knows that the client’s anemia is due to: A. Chronically low iron store B. Abnormal shape of the red blood cells C. Lack of intrinsic factor D. Shortened lifespan of the red blood cells 161. A client has returned from having an arteriogram. The nurse should give priority to: A. Checking the radial pulse B. Assessing the site for bleeding C. Offering fluids D. Administering pain medication 162. The physician has ordered Dolophine (methadone) for a client withdrawing from opiates. Which finding is associated with acute methodone toxicity? A. Fever B. Oliguria C. Nasal congestion D. Respiratory depression 163. A client scheduled for surgery has a preoperative order for atropine on call. The nurse should tell the client that the medication will: A. Make him drowsy B. Make his mouth dry C. Help him to relax D. Prevent infection 164. The nurse is assessing a primgravida 12 hours after a Caesarean section. The nurse notes that the client’s fundus is at the umbilicus and is firm. The nurse should: A. Prepare to catheterize the client B. Obtain an order for an oxytocic C. Chart the finding D. Tell the client to remain in bed 165. Which of the following observations in a 4-year-old suggests the possibility of child abuse? A. The presence of “rainbow” bruises B. Sucking the thumb when going to sleep C. Crying during painful procedures D. Eagerness to talk to strangers 166. A client with a history of alcoholism cannot remember the events of the past week even though he has receipts from various places of business. The client’s inability to recall events is known as: A. Alcoholic hallucinosis B. A hangover C. A blackout D. Sunday morning paralysis 167. Which food is the best source of calcium and potassium? A. Broccoli B. Sweet potato C. Spinach D. Avocado 168. The physician has ordered a PSA and acid phosphatase for a client admitted with complaints of dysuria. The nurse knows that a PSA and acid phosphatase are screening tests for: A. Cancer of the bladder B. Cancer of the prostate C. Cancer of the vas deferens D. Cancer of the testes 169. The client’s morning lithium level is 1.2mEq/L. The nurse recognizes that: A. The level is too low to be therapeutic. B. The client can be expected to have signs of toxicity. C. The level is within the therapeutic range. D. The client needs to eat more sodium-rich foods. 170. Which emergency treatment is appropriate for the client who suddenly develops ventricular fibrillations? A. Cardioversion B. Intubation C. Defibrillation D. Anticonvulsant medication 171. The nurse is caring for a client following a stroke that left him with apraxia. The nurse knows that the client will: A. Be unable to communicate through speech B. Have difficulty swallowing C. Have difficulty with voluntary movements D. Be unable to perform previously learned skills 172. The nurse is positioning a client with right hemiplegia. To prevent subluxation of the client’s right shoulder, the nurse should: A. Use a pillow to support the client’s arm when she is sitting in a chair B. Elevate the arm and hand above chest level when she is lying in bed C. Place a pillow under the axilla to elevate the elbow when she is lying in bed D. Use a pillow to support the client’s hand when she is sitting in a chair 173. A client with thrombophlebitis is receiving Lovenox (enoxaparin). Which method is recommended for administering Lovenox? A. Z track in the dorsogluteal muscle B. Intramuscularly in the deltoid muscle C. Subcutaneously in the abdominal tissue D. Orally after breakfast 174. A client with angina is to be discharged with a prescription for nitroglycerin tablets. The client should be instructed to: A. Take one tablet daily with a glass of water B. Leave the medication in a dark-brown bottle C. Replenish the medication supply every year D. Leave the cotton in the bottle to protect the tablets 175. The physician has ordered Parnate (tranylcypromine) for a client with depression. The nurse should tell the client to avoid foods containing tryamine because it can result in: A. Elevations in blood pressure B. Decreased libido C. Elevations in temperature D. Increased depression 176. A client is receiving external radiation for cancer of the larynx. As a result of the treatment, the client will most likely complain of: A. Generalized pruritis B. Dyspnea C. Sore throat D. Bone pain 177. The nurse is caring for a client with a T4 spinal cord injury when he begins to have symptoms of autonomic dysreflexia. After placing the client in high Fowler’s position, the nurse should: A. Administer a prescribed analgesic B. Check for patency of the catheter C. Tell the client to breathe slowly D. Check the temperature 178. A 40-year-old client with a myocardial infarction tells the nurse, “My father died with a heart attack when he was in his forties, and I guess I will, too.” Which response by the nurse is most appropriate? A. “Tell me more about what you are feeling.” B. “Are you thinking you won’t recover from this?” C. “You have an excellent doctor, so I’m sure everything will be fine.” D. “I would think that’s unlikely because we have much better treatment now.” 179. Which nursing action is most appropriate immediately following the removal of a nasogastric tube? A. Providing mouth care B. Auscultating bowel sounds C. Offering fluids D. Checking for abdominal distention 180. An elderly client injured in a fall is admitted with fractures of the ribs and a closed right pneumothorax. The nurse should position the client: A. In modified Trendelenburg position with the lower extremities elevated B. In semi-Fowler’s position tilted toward the right side C. In dorsal recumbent position with the lower extremities flat D. In semi-Fowler’s position tilted toward the left side 181. A client develops cravings while withdrawing from alcohol. Which measure will best help the client maintain sobriety? A. Placing the client in seclusion for 24 hours B. Restricting visits from family and friends C. Gaining support from other recovering alcoholics D. Assigning a staff member to stay until the cravings pass 182. A client with Addison’s disease has a diagnosis of fluid volume deficit related to inadequate adrenal hormone secretion. Which fluids are most appropriate for the client with Addison’s disease? A. Milk and diet soda B. Water and tea C. Bouillon and juice D. Coffee and juice 183. The nurse is preparing to administer a DTP, Hib, and hepatitis B immunizations to an infant. The nurse should: A. Administer all the immunizations in one site B. Administer the DTP in one leg, and the Hib and the hepatitis B in the other leg C. Administer the DTP in the leg, the Hib in the other leg, and the hepatitis B in the arm D. Administer the DTP and Hib in one leg, and the hepatitis B in the arm 184. Lab results indicate that a client receiving heparin has a prolonged bleeding time. Which medication is the antidote for heparin? A. Aquamephyton (phytonadione) B. Ticlid (ticlopidine) C. Protamine sulfate (protamine sulfate) D. Amicar (aminocaproic acid) 185. A newborn of 32 weeks gestation is diagnosed with respiratory distress syndrome 3 hours after birth. An assessment finding in the newborn with respiratory distress syndrome is: A. Feeding difficulties B. Nasal flaring C. Increased blood pressure D. Temperature instability 186. To reduce the risk of SIDS (sudden infant death syndrome), the nurse should tell parents to place the infant: A. Prone while he is sleeping B. Side-lying while he is awake C. On his back while he is sleeping D. Prone while he is awake 187. Which of the following play activities is most developmentally appropriate for the toddler? A. Watching cartoons B. Pulling a toy wagon C. Watching a mobile D. Coloring with crayons in a coloring book 188. The physician has discharged a client with diverticulitis with a prescription for Metamucil (psyllium). When teaching the client how to prepare the medication, the nurse should tell the client to: A. Dissolve the medication in gelatin or applesauce B. Mix the medication with water and drink it immediately C. Sprinkle the medication on ice cream or sherbet D. Take the medication with an ounce of antacid 189. A client with end stage cirrhosis can sometimes develop mental changes. What is the most likely cause? A. Elevated blood ammonia B. Decreased serum proteins C. Leukocytosis D. Hyperglycemia 190. The nurse is caring for a client after a liver biopsy. The nurse should carefully monitor the client for the development of which of the following? A. Respiratory alkalosis B. Metabolic acidosis C. Pneumothorax D. Cardiac tamponade 191. The LPN/LVN is assisting a client immediately after a paracentesis. Which of the following actions is the priority? A. Obtaining vital signs B. Positioning the client for comfort C. Detailed documentation of the procedure D. Reporting the amount removed to the client 192. A client has received platelet infusions. Which finding would indicate the most therapeutic effect from the transfusions? A. Hgb level increase from 8.9 to 10.6 B. Temperature reading of 99.4°F C. White blood cell count of 11,000 D. Decrease in oozing of blood from IV site 193. A client is admitted with Parkinson’s disease. The client has been taking Carbidopa/levodopa (Sinemet) for 1 year. Which clinical manifestation would be most important to report? A. Dryness of the mouth B. Spasmodic eye winking C. Dark urine D. Dizziness 194. The nurse who is caring for a client with cancer notes a WBC of 1,000. Which intervention would be most appropriate to include when caring for this client? A. Assess temperature every 4 hours, due to risk for hypothermia B. Instruct the client to avoid large crowds and people who are sick C. Instruct in the use of a soft toothbrush D. Assess for hematuria 195. A client is admitted with possible paralytic illeus. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? A. “Tell me about your pain.” B. “What does your vomit look like?” C. “Describe your usual diet.” D. “Have you noticed an increase in abdominal size?” 196. A client is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a side effect of this drug? A. BUN 10mg/dL B. Hemoglobin 13.0gm/dL C. WBC 4,000/mm3 D. Platelets 200,000/mm3 197. A client has received damage to the parietal lobe. Which symptom would be expected due to this tumor’s location? A. Hemiplegia B. Aphasia C. Paresthesia D. Nausea 198. A client weighing 120 pounds has received burns over 40% of his body at 1200 hours. Using the Parkland formula, calculate the expected amount of fluid that the client should receive by 2000 hours as fluid-replacement therapy? A. 2160 B. 4320 C. 6480 D. 8640 199. Diphenoxylate hydrochloride and atropine sulfate (Lomotil) is prescribed for the client with ulcerative colitis. The nurse realizes that the medication is having a therapeutic effect when which of the following is noted? A. There is an absence of peristalasis. B. The number of diarrhea stools decreases. C. Cramping in the abdomen has increased. D. Abdominal girth size increases. 200. The physician is about to remove a chest tube. Which client instruction is appropriate? A. Take a deep breath, exhale, and bear down B. Hold the breath for 2 minutes and exhale slowly C. Exhale upon actual removal of the tube D. Continually breathe deeply in and out during removal 201. A client with severe anxiety has been prescribed haloperidol (Haldol). What clinical manifestation suggests that the client is experiencing side effects from this medication? A. Cough B. Tremors C. Diarrhea D. Pitting edema 202. A client with a femur fracture is exhibiting shortness of breath, pain upon deep breathing, and a cough that produces blood-tinged sputum. The nurse would determine that these clinical manifestations are indicative of which of the following? A. Congestive heart failure B. Pulmonary embolus C. Adult respiratory distress syndrome D. Tension pneumothorax 203. A client with Alzheimer’s disease has been prescribed donepezil (Aricept). Which information should the nurse include when explaining about Aricept? A. “Take the medication with meals.” B. “The medicine can cause dizziness, so rise slowly.” C. “If a dose is skipped, take two the next time.” D. “The pill can cause an increase in heart rate.” 204. A client who had an abdominal aortic aneurysm repair is having delayed healing of the wound. Which laboratory test result would most closely correlate to this problem? A. Decreased albumin B. Decreased creatinine C. Increased calcium D. Increased sodium 205. A client is admitted to the chemical dependency unit due to cocaine addiction. The client states, “I don’t know why you are all so worried. I am in control. I don’t have a problem.” Which defense mechanism is being utilized? A. Rationalization B. Projection C. Dissociation D. Denial