RENR PRACTICE TEST 6

1. A nurse is caring for an older adult client who has a new diagnosis of type 2 diabetes mellitus and reports
difficulty following the diet and remembering to take the prescribed medication. Which of the following is NOT
an appropriate action by the nurse?
A. Ask the dietitian to assist with meal planning.
B. Contact the client’s support system.
C. Assess for age-related cognitive awareness.
D. Encourage the use of a daily medication dispenser.

2. A client had a cardiac catheterization for investigation of angina pain. When teaching about home care after the
procedure, the nurse will place importance on
a. A liquid diet for the first 24 hours
b. Maintaining pressure on the site for 3-4 days
c. Having sponge baths only in the first 24 hours
d. Reporting any slight discoloration at the site

3. A nurse is evaluating clients at a health fair for modifiable variables affecting health and wellness. The nurse
identifies which of the following is the LEAST as a modifiable variable?
A. A male who smokes on social occasions
B. A female with a BMI of 28
C. An adult with alopecia
D. An infant with reflux

4. A nurse is caring for a client who was just told she has breast cancer and the nurse evaluates the client’s response.
Which of the following statements by the client reflects a lack of understanding of an illness perspective?
A. “I have no family history of breast cancer.”
B. “I need a second opinion; there is no lump.”
C. “I am glad we live in the city near several large hospitals.”
D. “I will schedule surgery next week, over the holidays.”

5. A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify which of the
following clients?
A. Client who has an ulceration of the right heel whose blood glucose is 300 mg/dL
B. Client who reports right calf pain and shortness of breath
C. Client who has blood on a pressure dressing in the femoral area following a cardiac catheterization
D. Client who has dark red coloration of left toes and absent pedal pulse

6. A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the nurse
plan to take?
i. Induce vomiting.
ii. Instill activated charcoal.
iii. Perform a gastric lavage with aspiration.
iv. Complete a whole-bowel irrigation.
A. i, ii, iii
B. i, ii, iv
C. i, iii, iv
D. ii, iii, iv

7. The senior sister claims to use transformation leadership. Which of the following statements BEST describes
this type of leadership?
a. Uses visioning as the essence of leadership
b. Serves her staff rather than being served
c. Maintains full trust and confidence in subordinates
d. Possesses charisma that makes others feel good in her presence
8. A nurse in the emergency department is assessing a client who is unresponsive. The client’s partner states, “He
was pulling weeds in the yard and dropped to the ground.” Which of the following techniques should the nurse use
to open the client’s airway?
A. Head-tilt, chin-lift
B. Modified jaw thrust
C. Hyperextension of the head
D. Flexion of the head

9. A nurse is reviewing the common emergency management protocol for clients during a cardiac emergency.
Which of the following is an appropriate action by the nurse?
A. Administer IV dobutamine (Dobutrex).
B. Administer IV dopamine (Intropin).
C. Administer IV epinephrine (Adrenaline).
D. Administer IV atropine (Atropair).

10. A nurse is caring for a client post-lumbar puncture who reports a throbbing headache when sitting upright for
meals. Which of the following is NOT an appropriate action by the nurse?
A. Use the Glasgow Coma Scale when assessing the client.
B. Assist client to eat meals while lying flat in bed.
C. Administer an opioid medication.
D. Encourage client to increase fluid intake.

11. A nurse is developing a plan of care for a client who is scheduled for a cerebral angiogram with contrast dye.
Which of the following statements by the client should the nurse NOT report to the provider?
A. “I think I may be pregnant.”
B. “I take Coumadin.”
C. “I take antihypertensive medication.”
D. “I am allergic to shrimp.”

12. A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day.
Which of the following information should the nurse include in the teaching?
A. “Do not wash your hair the morning of the procedure.”
B. “Try to stay awake most of the night prior to the procedure.”
C. “The procedure will take approximately 15 minutes.”
D. “You will need to lie flat for 4 hours after the procedure.”

13. A nurse is assessing the pain level of a client who has come to the emergency department reporting severe
abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is assessing
which of the following?
A. Presence of associated symptoms
B. Location of the pain
C. Pain quality
D. Aggravating and relieving factors

14. A nurse is assessing a client who is reporting pain despite analgesia. The nurse can best assess the intensity of
the client’s pain by
A. Asking what precipitates the pain.
B. Questioning the client about the location of the pain.
C. Offering the client a pain scale to measure his pain.
D. Using open-ended questions to identify the sensation.

15. A nurse is obtaining a history from a client who has pain. The nurse’s guiding principle throughout this
process should be that
A. Some clients exaggerate their level of pain.
B. Pain must have an identifiable source to justify the use of opioids.
C. Objective data are essential in assessing pain.
D. Pain is whatever the client says it is.
16. A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion
device after abdominal surgery. Which of the following statements indicates that the client knows how to use the
device?
A. “I’ll wait to use the device until it’s absolutely necessary.”
B. “I’ll be careful about pushing the button so I don’t get an overdose.”
C. “I should tell the nurse if the pain doesn’t stop after I use this device.”
D. “I will ask my son to push the dose button when I am sleeping.”

17. A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which
of the following effects should the nurse NOT anticipate?
A. Diarrhea
B. Bradypnea
C. Orthostatic hypotension
D. Nausea

18. A nurse is assessing a client who reports severe headache and a stiff neck. The nurse’s assessment reveals
positive Kernig’s and Brudzinski’s signs. Which of the following actions should the nurse perform first?
A. Administer antibiotics
B. Implement droplet isolation precautions
C. Initiate IV access
D. Decrease bright lights

19. A nurse is assessing for the presence of Brudzinski’s sign in a client who has suspected meningitis. Which of
the following are NOT appropriate actions by the nurse when performing this technique?
A. Place client in supine position.
B. Flex client’s hip and knee.
C. Place hands behind the client’s neck.
D. Bend client’s head toward chest.

20. A nurse is reviewing the health record of a student newly admitted to a university and living in a dormitory.
The health record indicates the student requires follow-up immunizations. Which of the following organisms should
the nurse plan to vaccinate the student against?
A. Streptococcus pneumoniae
B. Neisseria meningitidis
C. Bartonella henselae
D. Rickettsia rickettsii

21. A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP).
Which of the following is an appropriate nursing action?
A. Implement seizure precautions.
B. Perform neurological checks four times a day.
C. Administer morphine for the report of neck and generalized pain.
D. Encourage the client to cough frequently.

22. A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should
NOT be included in the plan of care?
A. Monitor for bradycardia.
B. Provide an emesis basin at the bedside.
C. Administer antipyretic medication as prescribed.
D. Perform a skin assessment.

23. A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure.
Which of the following actions should NOT be implemented by the nurse?
A. Provide privacy.
B. Ease the client to the floor if standing.
C. Move furniture away from the client.
D. Restrain the client.
24. A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should
the nurse perform first?
A. Keep the client in a side-lying position.
B. Monitor the client’s vital signs.
C. Reorient the client to the environment.
D. Check the client for injuries.

25. A nurse is providing discharge instructions to a female client who has a prescription for phenytoin (Dilantin).
Which of the following information should the nurse include?
A. Consider taking oral contraceptives when on this medication.
B. Watch for receding gums when taking the medication.
C. Take the medication at the same time every day.
D. Provide a urine sample to determine therapeutic levels of the medication.

26. A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of
generalized seizures. Which of the following information should the nurse NOT include in this review?
A. Overwhelming fatigue should be avoided.
B. Caffeinated products should be removed from the diet.
C. Looking at flashing lights should be limited.
D. Aerobic exercise may be performed.

27. Which of the following are steps in administering an intramuscular injection?

i. Select an appropriate injection n site
ii. Clean the site with an alcohol prep pad
iii. Insert the needle at a 90 degree angle
iv. Discard used syringe in the bio hazard container
A. i, ii and iii only
B. i, ii and iv only
C. i, ii, iii and iv
D. ii, iii and iv only

28. A nurse is caring for a client who displays signs of stage 3 Parkinson’s disease. Which of the following
actions should the nurse include in the plan of care?
A. Recommend a community support group.
B. Integrate a daily exercise routine.
C. Provide a walker for ambulation.
D. Consultation with a dietitian.

29. A nurse is developing a plan of care for the nutritional needs of a client who has stage 4 Parkinson’s disease.
Which actions should the nurse NOT include in the plan of care?
A. Provide three large balanced meals daily.
B. Record diet and fluid intake daily.
C. Add thickener to liquids.
D. Offer nutritional supplements between meals.

30. A nurse is reinforcing teaching with a client who has Parkinson’s disease and has received a prescription for
bromocriptine (Parlodel). Which of the following instructions should the nurse include in the teaching?
A. Rise slowly when standing.
B. Increase carbohydrate intake.
C. Limit exposure to heat.
D. Report any skin discoloration.

31. A nurse is assessing a client for manifestations of Parkinson’s disease. Which of the following are NOT
expected findings?
A. Decreased vision
B. Pill-rolling tremor of the fingers
C. Shuffling gait
D. Drooling
32. A nurse is caring for a client who has Parkinson’s disease and displays signs of bradykinesia. Which of the
following is an appropriate action by the nurse?
A. Allow client extra time for verbal responses to questions.
B. Complete passive range-of-motion exercises.
C. Provide an alternate form of communication.
D. Assist with hygiene as needed.

33. A nurse is providing teaching to the partner of an older adult client who has Alzheimer’s disease and has a
new prescription for donepezil (Aricept). Which of the following statements by the partner indicates the teaching
is effective?
A. “This medication should increase my husband’s appetite.”
B. “This medication should help my husband sleep better.”
C. “This medication should help my husband’s daily function.”
D. “This medication should increase my husband’s energy level.”

34. A nurse is making a home visit to a client who has Alzheimer’s Disease. The client’s partner states that the
client is often disoriented to time and place, is unsteady on his feet, and has a history of wandering. Which of the
following safety measures should the nurse NOT review with the partner?
A. Remove floor rugs.
B. Have door locks that can be easily opened.
C. Provide increased lighting in stairwells.
D. Install handrails in the bathroom.

35. A nurse is caring for a client who has Alzheimer’s Disease and falls frequently. Which of the following actions
should the nurse take first to keep the client safe?
A. Keep the call light near the client.
B. Place the client in a room close to the nurses’ station.
C. Encourage the client to ask for assistance.
D. Remind the client to walk with someone for support.

36. A nurse working in a long-term care facility is planning care for a client in stage 5 of Alzheimer’s disease.
Which of the following interventions should be included in the plan of care?
A. Use a gait belt for ambulation.
B. Thicken all liquids.
C. Provide protective undergarments.
D. Assist with ADLs.

37. A nurse is caring for a client who has Alzheimer’s disease. A family member of the client asks the nurse about
risk factors for the disease. Which of the following should be included in the nurse’s response?
A. Exposure to metal waste products
B. Sustained use of vitamin E
C. Previous head injury
D. History of herpes infection

38. A nurse is caring for a client who is having surgery for the removal of an encapsulated acoustic tumor. Which
of the following potential complications should the nurse monitor for postoperatively?
i. Increased intracranial pressure
ii. Hemorrhagic shock
iii. Hydrocephalus
iv. Hypoglycemia
A. i and ii
B. i and iii
C. ii and iii
D. iii and iv
39. A nurse is caring for a client who has just undergone a craniotomy for a supratentorial tumor. Which of the
following postoperative prescriptions should the nurse clarify with the provider?
A. Dexamethasone (Decadron) 30 mg IV bolus BID
B. Morphine sulfate 2 mg IV bolus PRN every 2 hr for pain
C. Ondansetron (Zofran) 4 mg IV bolus PRN every 4 to 6 hr for nausea
D. Phenytoin (Dilantin) 100 mg IV bolus TID

40. A nurse is completing an assessment of a client who has increased intracranial pressure. Which of the
following is NOT an expected finding?
A. Disoriented to time and place
B. Restlessness and irritability
C. Unequal pupils
D. ICP 15 mm/Hg

41. A nurse is reviewing a prescription for dexamethasone (Decadron) with a client who has an expanding brain
tumor. Which of the following are NOT appropriate statements by the nurse?
A. “It is given to reduce swelling of the brain.”
B. “You may notice weight gain.”
C. “Tumor growth will be delayed.”
D. “It can cause you to retain fluids.”

42. A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if he can expect this
same type of tumor to occur in other areas of his body. Which of the following is an appropriate response by the
nurse?
A. “It can spread to breasts and kidneys.”
B. “It can develop in your gastrointestinal tract.”
C. “It is limited to brain tissue.”
D. “It probably started in another area of your body and spread to your brain.”

43. A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a
positive Romberg sign. Which of the following actions should the nurse take to assess for this sign?
A. Stroke the lateral aspect of the sole of the foot.
B. Ask the client to blink his eyes.
C. Observe for facial drooping.
D. Have the client stand erect with eyes closed.

44. Which nursing intervention best assists a bedridden client to keep skin intact?
a. Apply talcum powder to the perineal area.
b. Turn the client every 2 to 4 hours.
c. Use a foam mattress pad.
d. Use a lift sheet to move the client in bed.

45. The nurse explains that acute leukemia is caused by

a. accumulation of immature blast cells.
b. excessively rapid mitosis of leukemic cells.
c. proliferation of neutrophils.
d. undifferentiated blast cells entering bone marrow.

46. A nurse is caring for a client who has myasthenia gravis (MG) and has developed drooping eyelids. Which of
the following actions should the nurse take?
i. Apply lubricating eye drops.
ii. Encourage use of sunglasses.
iii. Support the head with pillows.
iv. Tape eyes closed at night.
A. i and ii
B. ii and iii
C. i and iv
D. iii and iv
47. A nurse instructs a client who has MG about home care and the risk factors that can exacerbate the disease.
Which of the following client statements indicates a need for further teaching?
A. “I should take my medication 45 min before meals.”
B. “I have suction equipment at home in case I start to choke.”
C. “I will soak in a warm bath every day.”
D. “I ordered a medical identification bracelet to wear.”

48. A nurse is caring for an older adult client who has diabetes mellitus. The client reports loss of peripheral
vision. For which of the following is the client at risk?
A. Cataracts
B. Open-angle glaucoma
C. Macular degeneration
D. Angle-closure glaucoma

49. A nurse is caring for a client following a trabeculectomy. Which of the following statements should the nurse
include in the teaching?
A. “You may resume playing golf.”
B. “You need to tilt your head back when washing your hair.”
C. “You may continue driving to and from work.”
D. “You need to limit your housekeeping activities.”

50. A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of the following
is NOT a risk factor associated with this disease?
A. Gender
B. Genetic predisposition
C. Hypertension
D. Age

51. A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following clinical
manifestations should the nurse expect to find?
i. Eye pain
ii. Floating spots
iii. Blurred vision
iv. White pupils
A. i and ii
B. ii only
C. ii and iv
D. iii and iv

52. A nurse is assessing a client following cataract surgery. The client reports nausea and severe eye pain. Which
of the following actions should the nurse take?
A. Notify the provider.
B. Administer an analgesic.
C. Administer an antiemetic.
D. Turn the client onto the operative side.

53. A nurse is caring for a client who was recently admitted to the emergency department following a head-on
motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and a laceration on his
forehead that is bleeding. Which of the following is the priority nursing action at this time?
A. Keep neck stabilized.
B. Insert nasogastric tube.
C. Monitor pulse and blood pressure frequently.
D. Establish IV access and start fluid replacement.
54. A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural
hematoma. Which of the following is the priority assessment?
A. Glasgow Coma Scale
B. Cranial nerve function
C. Oxygen saturation
D. Pupillary response

55. A nursing is caring for a client who has a closed-head injury with ICP readings range from 16 to 22 mm Hg.
Which of the following action should NOT be taken to decrease the potential for raising the client’s ICP?
A. Suction the endotracheal tube.
B. Hyperventilate the client.
C. Elevate the client’s head on two pillows.
D. Administer a stool softener.

56. A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to
the head. Which of the following assessment findings are NOT indicative of increased ICP?
A. Headache
B. Dilated pupils
C. Tachycardia
D. Decorticate posturing

57. A nurse is caring for a client who has increased ICP and a new prescription for mannitol (Osmitrol). For
which of the following adverse effects should the nurse monitor?
A. Hyperglycemia
B. Hyponatremia
C. Hypervolemia
D. Oliguria

58. A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are
NOT an expected finding?
A. Impulse control difficulty
B. Left hemiplegia
C. Loss of depth perception
D. Aphasia

59. A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an
appropriate nursing intervention?
A. Teach the client to scan to the right to see objects on the right side of her body.
B. Place the client’s bedside table on the right side of the bed.
C. Orient the client to the food on her plate using the clock method.
D. Place the client’s wheelchair on her left side.

60. A nurse is planning care for a client who has dysphagia and has a new dietary prescription. Which of the
following should the nurse NOT include in the plan of care?
A. Have suction equipment available for use.
B. Use thickened liquids.
C. Place food on the client’s unaffected side of her mouth.
D. Assign assistive personnel to feed the client slowly.

61. A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following
should the nurse NOT include in the client’s plan of care?
A. Speak to the client at a slower rate.
B. Look directly at the client when speaking.
C. Allow extra time for the client to answer.
D. Complete sentences that the client cannot finish.
62. A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an
expected finding?
A. Impulse control difficulty
B. Poor judgment
C. Inability to recognize familiar objects
D. Loss of depth perception

63. A nurse is planning care for a client who suffered a spinal cord injury (SCI) involving a T12 fracture 1 week
ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the
nurse’s highest priority?
A. Prevention of further damage to the spinal cord
B. Prevention of contractures of the lower extremities
C. Prevention of skin breakdown of areas that lack sensation
D. Prevention of postural hypotension when placing the client in a wheelchair

64. A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating
profusely. Vital signs include BP of 220/110 mm Hg, with an apical heart rate of 54/min. Which of the following
actions should the nurse take first?
A. Notify the provider.
B. Sit the client upright in bed.
C. Check the client’s urinary catheter for blockage.
D. Administer antihypertensive medication.

65. A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse
recognize the client as being at the greatest risk for?
A. Neurogenic shock
B. Paralytic ileus
C. Stress ulcer
D. Respiratory compromise

66. A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following types
of prescribed medications should the nurse clarify with the provider?
A. Glucocorticoids
B. Plasma expanders
C. H2 antagonists
D. Muscle relaxants

67. A nurse is caring for a client who experienced a cervical spine injury 3 months ago. Which of the following
types of bladder management methods should the nurse use for this client?
A. Condom catheter
B. Intermittent urinary catheterization
C. Credé’s method
D. Indwelling urinary catheter

68. A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the
following actions should the nurse take?
A. Position the client in an upright position, leaning over the bedside table.
B. Explain the procedure to the client.
C. Obtain ABGs from the client.
D. Administer benzocaine spray to the client.
69. A nurse is assessing a client who is in respiratory distress. The nurse should recognize that which of the
following can cause a low pulse oximetry reading?
i. Nail polish
ii. Inadequate peripheral circulation
iii. Hyperthermia
iv. Increased Hgb level
A. i and ii
B. ii and iii
C. iii and iv
D. i, ii and iv

70. A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse
report to the doctor?
A. Blood-tinged sputum
B. Dry, nonproductive cough
C. Sore throat
D. Bronchospasms

71. A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the
nurse LEAST ensure is in the client’s room?
A. Oxygen equipment
B. Incentive spirometer
C. Pulse oximeter
D. Sterile dressing

72. A nurse is caring for a client following a thoracentesis. Which of the following clinical manifestations should
the nurse LEAST recognize as risks for complications?
A. Dyspnea
B. Localized bloody drainage on the dressing
C. Fever
D. Report of pain at the puncture site

73. A nurse is preparing to care for a client following chest tube placement. Which of the following items should
NOT be available in the client’s room?
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
D. Indwelling urinary catheter

74. A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the
client’s chest tube was accidentally removed. Which of the following actions should the nurse take first?
A. Place the tubing in sterile water to restore the water seal.
B. Apply sterile gauze to the insertion site.
C. Place tape around the insertion site.
D. Assess the client’s respiratory status.

75. A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are
expected findings?
i. Continuous bubbling in the water seal chamber
ii. Gentle constant bubbling in the suction control chamber
iii. Rise and fall in the level of water in the water seal chamber with inspiration and expiration
iv. Exposed sutures without dressing
A. i and iii
B. ii and iii
C. ii and iv
D. iii and iv
76. A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse
instruct the client to do?
A. Lie on his left side.
B. Use the incentive spirometer.
C. Cough at regular intervals.
D. Perform the Valsalva maneuver.

77. A 30 year old female with sudden abdominal pain is rushed to the emergency room. On examination, her skin
is cold and clammy, she is in obvious painful distress and she says that she expected her period two weeks ago.
What would be your IMMEDIATE nursing management for this client?

A. Prepare the client for surgery

B. Inform the charge nurse on duty
C. Check her vital signs, including a blood glucose check
D. Inform the doctor on duty immediately of the client’s condition

78. A nurse is caring for a client who is experiencing respiratory distress. Which of the following are early clinical
manifestations of hypoxemia?
A. Confusion
B. Pale skin
C. Bradycardia
D. Hypotension

79. An eight month old baby is brought to the Accident and Emergency Department with high fever, vomiting and
diarrhea for 48 hours. Which of the following should the nurse assess LAST in this baby?
A. Skin turgor
B. Dryness of skin
C. Status of fontanelle
D. Status of the mucous membranes

80. A nurse is caring for a client who has dyspnea and is to receive oxygen continuously. Which of the following
oxygen devices should the nurse use to deliver a precise amount of oxygen to the client?
A. Nonrebreather mask
B. Venturi mask
C. Nasal cannula
D. Simple face mask

81. Which of the following has NO risk of sexual transmission?

A. Zika
B. Chikungunya
C. Ebola
D. Heptatitis C

82. Which of the following clients have the LEAST increased risk for developing pneumonia?
A. Client who has AIDS
B. Client who was vaccinated for pneumococcus and influenza 6 months ago
C. Client who has a closed head injury and is receiving ventilation
D. Client who has myasthenia gravis

83. A nurse in a clinic is caring for a client who was brought to the clinic by her partner. The partner states the
client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and
chest pain that is worse upon inspiration. Which of the following is the priority nursing action?
A. Obtain baseline vital signs and oxygen saturation.
B. Obtain a sputum culture.
C. Obtain a complete history from the client.
D. Provide a pneumococcal vaccination.
84. A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8° C (100° F),
respirations 30/min, BP 130/76, heart rate 100/min, and SaO2 91% on room air. Using a scale of 1 to 4, with 1
being the highest priority, which nursing intervention should be given the HIGHEST priority?
A. Administer antibiotics as prescribed.
B. Administer oxygen therapy.
C. Perform a sputum culture.
D. Administer an antipyretic medication to promote client comfort.

85. A nurse in a clinic is caring for a client who has sinusitis. Which of the following techniques should the nurse
use to identify clinical manifestations of this disorder?
A. Percussion of posterior lobes of lungs
B. Auscultation of the trachea
C. Inspection of the conjunctiva
D. Palpation of the orbital areas

86. A nurse is teaching a group of clients about influenza. Which of the following statements by a client requires
clarification?
A. “I should wash my hands after blowing my nose to prevent spreading the virus.”
B. “I need to avoid drinking fluids if I develop symptoms.”
C. “I need a flu shot every year because of the different flu strains.”
D. “I should sneeze into my elbow rather than my hands.”

87. A nurse in the emergency department is caring for a client who was admitted with an acute asthma attack.
Which of the following is NOT an indication that the client’s respiratory status is declining?
A. SaO2 95%
B. Wheezing
C. Retraction of sternal muscles
E. Premature ventricular complexes (PVCs)

88. A nurse working on a medical-surgical unit admits a client. Two hours after admission, the client’s SaO2 is
91% and he is exhibiting audible wheezes and use of his accessory muscles. Which of the following medications
should the nurse expect to administer?
A. Antibiotic
B. Beta-blocker
C. Antiviral
D. Beta2 agonist

89. A nurse is completing discharge teaching with a client who has a new prescription for prednisone (Deltasone)
for asthma. Which of the following client statements indicates a need for further teaching?
A. “I will drink plenty of fluids while taking this medication.”
B. “I will tell the doctor if I have black, tarry stools.”
C. “I will take my medication on an empty stomach.”
D. “I will monitor my mouth for canker sores.”

90. A nurse is assessing a client with asthma. Which of the following is a risk factor associated with this disease?
A. Gender
B. Environmental allergies
C. Alcohol use
D. Race

91. A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following
statements by the client indicates the teaching was effective?
A. “This medication can decrease my immune response.”
B. “I take this medication to prevent asthma attacks.”
C. “I need to take this medication with food.”
D. “This medication has a slow onset to treat my symptoms.”
92. A nurse is providing discharge teaching to a client who has COPD and has a new prescription for albuterol
(Proventil). Which of the following statements made by the client indicates an understanding of the teaching?
A. “This medication can increase my blood sugar levels.”
B. “This medication can decrease my immune response.”
C. “I can have an increase in my heart rate while taking this medication.”
D. “I can have mouth sores while taking this medication.”

93. A nurse is preparing to administer a new prescription prednisone (Deltasone) to a client who has COPD. Which
of the following should the nurse LEAST monitor for?
A. Monitor the client or hypokalemia.
B. Monitor the client for tachycardia.
C. Observe the client for fluid retention.
D. Advise the client to report black, tarry stools.

94. A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements made
by the client indicates an understanding of the teaching?
A. “I will place the adapter on my finger to read my blood oxygen saturation level.”
B. “I will lie on my back with my knees bent.”
C. “I will rest my hand over my abdomen to create resistance.”
D. “I will take in a deep breath and hold it before exhaling.”

95. A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be
able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by
the nurse?
A. “There are portable oxygen delivery systems that you can take with you.”
B. “When you go out, you can remove the oxygen and then reapply it when you get home.”
C. “You probably will not be able to go out as much as you used to.”
D. “Home health services will come to you so you will not need to get out.”

96. A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following should
the nurse include in the plan of care?
A. Take quick breaths upon inhalation.
B. Place your hand over your stomach.
C. Take a deep breath in through your nose.
D. Puff your checks upon exhalation.

97. A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following
medication regimen: isoniazid (Nydrazid) 250 mg PO daily, rifampin (Rifadin) 500 mg PO daily, pyrazinamide
750 mg PO daily, and ethambutol (Myambutol) 1 mg PO daily. Which of the following client statements indicate
understanding of the teaching?
i. “I can substitute one medication for another if I run out because they all fight infection.”
ii. “I will wash my hands each time I cough.”
iii. “I will wear a mask when I am in a public area.”
iv. “I am glad I don’t have to have any more sputum specimens.”
A. i and ii
B. i and iii
C. ii and iii
D. i, iii and iv

98. A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include
in the teaching?
A. “You will need continue to take the multimedication regimen for 4 months.”
B. “You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication.”
C. “You will need to remain hospitalized for treatment.”
D. “You will need to wear a mask at all times.”
99. A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multimedication
regimen. Which of the following instructions should the nurse give the client related to the medication ethambutol
(Myambutol)?
A. “Your urine may turn a dark orange.”
B. “Watch for a change in the sclera of your eyes.”
C. “Watch for any changes in vision.”
D. “Take vitamin B6 daily.”

100. A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis.
Which of the following is an appropriate statement by the nurse about this medication?
A. “You may notice yellowing of your skin.”
B. “You may experience pain in your joints.”
C. “You may notice tingling of your hands.”
D. “You may experience a loss of appetite.”