1. A client is scheduled for insertion of an inferior vena 8. A client has undergone right pneumonectomy.

When
cava (IVC) filter. Nurse Patricia consults turning the client, the nurse should plan to position the
the physician about withholding which regularly scheduled client either:
medication on the day before the surgery?
a. Right side-lying position or supine
a. Potassium Chloride
b. High Fowler’s position
b. Warfarin Sodium
c. Right or left side lying position
c. Furosemide
d. Low Fowler’s position
d. Docusate
9. Nurse Jenny should caution a female client who is
2. A nurse is planning to assess the corneal reflex on sexually active in taking Isoniazid (INH) because the drug
unconscious client. Which of the following is the safest has which of the following side effects?
stimulus to touch the client’s cornea?
a. Prevents ovulation
a. Cotton buds
b. Has a mutagenic effect on ova
b. Sterile glove
c. Decreases the effectiveness of oral contraceptives
c. Sterile tongue depressor
d. Increases the risk of vaginal infection
d. Wisp of cotton
10. A client has undergone gastrectomy. Nurse Jovy is
3. A female client develops an infection at aware that the best position for the client is:
the catheter insertion site. The nurse in charge uses the
term “iatrogenic” when describing the infection because it a. Left side lying
resulted from:
b. Low fowler’s
a. Client’s developmental level
c. Prone
b. Therapeutic procedure
d. Supine
c. Poor hygiene
11. During the initial postoperative period of the client’s
d. Inadequate dietary patterns stoma. The nurse evaluates which of the following
observations should be reported immediately to the
4. Nurse Carol is assessing a client with Parkinson’s physician?
disease. The nurse recognize bradykinesia when the client
exhibits: a. Stoma is dark red to purple

a. Intentional tremor b. Stoma is oozes a small amount of blood

b. Paralysis of limbs c. Stoma is slightly edematous

c. Muscle spasm d. Stoma does not expel stool

d. Lack of spontaneous movement 12. Kate which has diagnosed with ulcerative colitis is
following physician’s order for bed rest with bathroom
5. A client who suffered from automobile privileges. What is the rationale for this activity
accident complains of seeing frequent flashes of light. The restriction?
nurse should expect:
a. Prevent injury
a. Myopia
b. Promote rest and comfort
b. Detached retina
c. Reduce intestinal peristalsis
c. Glaucoma
d. Conserve energy
d. Scleroderma

6. Kate with severe head injury is being monitored by the

nurse for increasing intracranial pressure (ICP). Which 13. Nurse KC should regularly assess the client’s ability to
finding should be most indicative sign of increasing metabolize the total parenteral nutrition (TPN) solution
intracranial pressure? adequately by monitoring the client for which of the
following signs:
a. Intermittent tachycardia
a. Hyperglycemia
b. Polydipsia
b. Hypoglycemia
c. Tachypnea
c. Hypertension
d. Increased restlessness
d. Elevate blood urea nitrogen concentration
7. A hospitalized client had a tonic-clonic seizure while
walking in the hall. During the seizure the nurse priority 14. A female client has an acute pancreatitis. Which of the
should be: following signs and symptoms the nurse would expect to
see?
a. Hold the clients arms and leg firmly
a. Constipation
b. Place the client immediately to soft surface
b. Hypertension
c. Protects the client’s head from injury
c. Ascites
d. Attempt to insert a tongue depressor between the client’s
teeth d. Jaundice
15. A client is suspected to develop tetany after a subtotal a. Deviation of the trachea towards the involved side
thyroidectomy. Which of the following symptoms might
indicate tetany? b. Reduced or absent of breath sounds at the base of the lung

a. Tingling in the fingers c. Moist crackles at the posterior of the lungs

b. Pain in hands and feet d. Increased resonance with percussion of the involved area

c. Tension on the suture lines 23. A client admitted with newly diagnosed with Hodgkin’s
disease. Which of the following would the nurse expect the
d. Bleeding on the back of the dressing client to report?

16. A 58 year old woman has newly diagnosed with a. Lymph node pain
hypothyroidism. The nurse is aware that the signs and
symptoms of hypothyroidism include: b. Weight gain

a. Diarrhea c. Night sweats

b. Vomiting d. Headache

c. Tachycardia 24. A client has suffered from fall and sustained a leg
injury. Which appropriate question would the nurse ask
d. Weight gain the client to help determine if the injury caused fracture?

17. A client has undergone for an ileal conduit, the nurse in a. “Is the pain sharp and continuous?”
charge should closely monitor the client for occurrence of
which of the following complications related to pelvic b. “Is the pain dull ache?”
surgery?
c. “Does the discomfort feel like a cramp?”
a. Ascites
d. “Does the pain feel like the muscle was stretched?”
b. Thrombophlebitis
25. The Nurse is assessing the client’s casted extremity for
c. Inguinal hernia signs of infection. Which of the following findings is
indicative of infection?
d. Peritonitis
a. Edema
18. Dr. Marquez is about to defibrillate a client in
ventricular fibrillation and says in a loud voice “clear”. b. Weak distal pulse
What should be the action of the nurse?
c. Coolness of the skin
a. Places conductive gel pads for defibrillation on the client’s
d. Presence of “hot spot” on the cast
chest
26. Nurse Rhia is performing an otoscopic examination on
b. Turn off the mechanical ventilator
a female client with a suspected diagnosis of mastoiditis.
c. Shuts off the client’s IV infusion Nurse Rhia would expect to note which of the following if
this disorder is present?
d. Steps away from the bed and make sure all others have done
the same a. Transparent tympanic membrane

19. A client has been diagnosed with glomerulonephritis b. Thick and immobile tympanic membrane
complains of thirst. The nurse should offer:
c. Pearly colored tympanic membrane
a. Juice
d. Mobile tympanic membrane
b. Ginger ale
27. Nurse Jocelyn is caring for a client with nasogastric
c. Milk shake tube that is attached to low suction. Nurse Jocelyn assesses
the client for symptoms of which acid-base disorder?
d. Hard candy
a. Respiratory alkalosis
20. A client with acute renal failure is aware that the most
serious complication of this condition is: b. Respiratory acidosis

a. Constipation c. Metabolic acidosis

b. Anemia d. Metabolic alkalosis

c. Infection 28. A male adult client has undergone a lumbar puncture

to obtain cerebrospinal fluid (CSF) for analysis. Which of
d. Platelet dysfunction the following values should be negative if the CSF is
normal?
21. Nurse Karen is caring for clients in the OR. The nurse
is aware that the last physiologic function that the client a. Red blood cells
loss during the induction of anesthesia is:
b. White blood cells
a. Consciousness
c. Insulin
b. Gag reflex
d. Protein
c. Respiratory movement
29. A client is suspected of developing diabetes insipidus.
d. Corneal reflex Which of the following is the most effective assessment?

22. The nurse is assessing a client with pleural effusion. a. Taking vital signs every 4 hours
The nurse expect to find:
b. Monitoring blood glucose
c. Assessing ABG values every other day

d. Measuring urine output hourly 37. A client has undergone surgery for retinal detachment.
Which of the following goal should be prioritized?
30. A 58 year old client is suffering from acute phase of
rheumatoid arthritis. Which of the following would the a. Prevent an increase intraocular pressure
nurse in charge identify as the lowest priority of the plan
of care? b. Alleviate pain

a. Prevent joint deformity c. Maintain darkened room

b. Maintaining usual ways of accomplishing task d. Promote low-sodium diet

c. Relieving pain 38. A Client with glaucoma has been prescribed with
miotics. The nurse is aware that miotics is for:
d. Preserving joint function
a. Constricting pupil
31. Among the following, which client is autotransfusion
possible? b. Relaxing ciliary muscle

a. Client with AIDS c. Constricting intraocular vessel

b. Client with ruptured bowel d. Paralyzing ciliary muscle

c. Client who is in danger of cardiac arrest 39. When suctioning an unconscious client, which nursing
intervention should the nurse prioritize in maintaining
d. Client with wound infection cerebral perfusion?

32. Which of the following is not a sign of a. Administer diuretics

thromboembolism?
b. Administer analgesics
a. Edema
c. Provide hygiene
b. Swelling
d. Hyperoxygenate before and after suctioning
c. Redness
40. When discussing breathing exercises with a
d. Coolness postoperative client, Nurse Hazel should include which of
the following teaching?
33. Nurse Becky is caring for client who begins to
experience seizure while in bed. Which action should the a. Short frequent breaths
nurse implement to prevent aspiration?
b. Exhale with mouth open
a. Position the client on the side with head flexed forward
c. Exercise twice a day
b. Elevate the head
d. Place hand on the abdomen and feel it rise
c. Use tongue depressor between teeth
41. Louie, with burns over 35% of the body, complains of
d. Loosen restrictive clothing chilling. In promoting the client’s comfort, the nurse
should:
34. A client has undergone bone biopsy. Which nursing
action should the nurse provide after the procedure? a. Maintain room humidity below 40%

a. Administer analgesics via IM b. Place top sheet on the client

b. Monitor vital signs c. Limit the occurrence of drafts

c. Monitor the site for bleeding, swelling and hematoma d. Keep room temperature at 80 degrees
formation
42. Nurse Trish is aware that temporary heterograft (pig
d. Keep area in neutral position skin) is used to treat burns because this graft will:

35. A client is suffering from low back pain. Which of the a. Relieve pain and promote rapid epithelialization
following exercises will strengthen the lower back
muscle of the client? b. Be sutured in place for better adherence

a. Tennis c. Debride necrotic epithelium

b. Basketball d. Concurrently used with topical antimicrobials

c. Diving

d. Swimming

36. A client with peptic ulcer is being assessed by the nurse

for gastrointestinal perforation. The nurse should monitor
43. Mark has multiple abrasions and a laceration to the
for:
trunk and all four extremities says, “I can’t eat all this
a. (+) guaiac stool test food”. The food that the nurse should suggest to be eaten
first should be:
b. Slow, strong pulse
a. Meat loaf and coffee
c. Sudden, severe abdominal pain
b. Meat loaf and strawberries
d. Increased bowel sounds
c. Tomato soup and apple pie

d. Tomato soup and buttered bread

44. Tony returns from surgery with permanent colostomy.
During the first 24 hours the colostomy does not
drain. The nurse should be aware that:

a. Proper functioning of nasogastric suction

b. Presurgical decrease in fluid intake

c. Absence of gastrointestinal motility

d. Intestinal edema following surgery

45. When teaching a client about the signs of colorectal

cancer, Nurse Trish stresses that the most common
complaint of persons with colorectal cancer is:

a. Abdominal pain

b. Hemorrhoids

c. Change in caliber of stools

d. Change in bowel habits

46. Louis develops peritonitis and sepsis after surgical

repair of ruptures diverticulum. The nurse in charge
should expect an assessment of the client to reveal:

a. Tachycardia

b. Abdominal rigidity

c. Bradycardia

d. Increased bowel sounds

47. Immediately after liver biopsy, the client is placed on

the right side, the nurse is aware that that this position
should be maintained because it will:

a. Help stop bleeding if any occurs

b. Reduce the fluid trapped in the biliary ducts

c. Position with greatest comfort

d. Promote circulating blood volume

48. Tony has diagnosed with hepatitis A. The information

from the health history that is most likely linked to
hepatitis A is:

a. Exposed with arsenic compounds at work

b. Working as local plumber

c. Working at hemodialysis clinic

d. Dish washer in restaurants

49. Nurse Trish is aware that the laboratory test result that
most likely would indicate acute pancreatitis is an
elevated:

a. Serum bilirubin level

b. Serum amylase level

c. Potassium level

d. Sodium level

50. Dr. Marquez orders serum electrolytes. To determine

the effect of persistent vomiting, Nurse Trish should be
most concerned with monitoring the:

a. Chloride and sodium levels

b. Phosphate and calcium levels

c. Protein and magnesium levels

d. Sulfate and bicarbonate levels

Answers and Rationale

 B.) With an increase in activity the body will utilize more
carbohydrates; therefore more insulin will be required.
1.) A client is receiving NPH insulin 20 units subq at 7:00
AM daily, at 3 PM how would the nurse finds if the client C.) The increase in activity results in an increase in the
were having a hypoglycemic reaction? utilization of insulin; therefore the client should decrease
his/her carbohydrate intake
A.) Feel the client and bed for dampness
D.) Exercise will improve pancreatic circulation and
B.) Observe client kussmaul respirations stimulate the islet of Langerhans to increase the production
C.) Smell client's breathe for acetone odor of intrinsic insulin

D.) Check client's pupils for dilation 8.) The nurse is caring for a client who has exophthalmos
associated with her thyroid disease. What is the cause of
2.) Postoperative thyroidectomy nursing care includes exophthalmos?
which measures?
A.) Fluid edema in the retro-orbital tissues which force the
A.) Have the client speak every 5-10 mins if hoarseness is eyes to protrude
present
B.) Impaired vision, which causes the client to squint in
B.) Provide a low calcium diet to prevent hypercalcemia order to see

C.) Check the dressing all the back of the neck for bleeding C.) Increased eye lubrication, which makes the client blink
less
D.) Apply a soft cervical collar to restrict neck movement
D.) Decrease in extraocular eye movements, which results in
3.) What would the nurse note as typical findings on the the "thyroid stare."
assessment of a client with acute pancreatitis?
9.) What is characteristic symptom of hypoglycemia that
should alert nurse to an early insulin reaction?
A.) Steatorrhea, abdominal pain, fever
A.) Diaphoresis
B.) Fever, hypoglycemia, DHN
B.) Drowsiness
C.) Melena, persistent vomiting, hyperactive bowel sounds
C.) Severe thirst
D.) Hypoactive bowel sounds, decreased amylase and lipase
levels D.) Coma

4.) A client is found to be comatose and hypoglycemic 10.) A client is scheduled for routine glycosylated
with a blood sugar level 50 mg/dl. What nursing action is hemoglobin (HbA1c) test. What is important for the
implemented first? nurse to tell the client before this test?

A.) Infuse 1000 ml of D5W over a 12-hour period A.) Drink only water after midnight and come to the clinic
early in the morning
B.) Administer 50% glucose IV
B.) Eat a normal breakfast and be at the clinic 2 hours
C.) Check the client's urine for the presence of sugar and because of the multiple blood draws
acetone
C.) Expect to be at the clinic for several hours because of the
D.) Encourage the client to drink orange juice with added multiple blood draws
sugar
D.) Come to the clinic at the earliest convenience to have
5.) Which medication will the nurse have available for the blood drawn
emergency treatment of tetany in the client who has had
a thyroidectomy? 11.) A client has been inhalation vasopressin therapy.
What will the nurse evaluate to determine the
A.) Calcium chloride therapeutic response to this medication?
B.) Potassium chloride A.) Urine specific gravity
C.) Magnesium sulfate B.) Blood glucose
D.) Sodium bicarbonate C.) Vital signs
6.) What is the primary action of insulin in the body? D.) Oxygen saturation levels
A.) Enhances the transport of glucose across cell walls 12.) A client with diagnosis of type 2 diabetes has been
ordered a course of prednisone for her severe arthritic
B.) Aids in the process of gluconeogenesis
pain. An expected change that requires close monitoring
C.) Stimulates the pancreatic beta cells by the nurse is;

D.) Decreases the intestinal absorption of glucose A.) Increased blood glucose level

7.) What will the nurse teach the diabetic client regarding B.) Increased platelet aggregation
exercise in his /her treatment program?
C.) Increased creatinine clearance
A.) During exercise the body will use carbohydrates for
D.) Increased ketone level in urine
energy production, which in turn will decrease the need for
insulin
13.) The nurse performing an assessment on a client who
has been receiving long-term steroid therapy would
expect to find:

A.) Jaundice

B.) Flank pain

C.) Bulging eyes 20.) A client is prescribed levothyroxine (Synthroid)

daily. The most important instruction to give the client
D.) Central obesity for administration of this drug is:

14.) A diabetic client receives a combination of regular A.) Taper dose and discontinue if mental and emotional
and NPH insulin at 0700 hours. The nurse teaches the statuses stabilize
client to be alert for signs of hypoglycemia at
B.) Take it at bedtime to avoid the side effects of nausea and
A.) 1200 and 1300 hours flatus

B.) 1100 and 1700 hours C.) Call the M.D. immediately at the onset of palpitations or
nervousness
C.) 1000 and 2200 hours
D.) Decrease intake of juices and fruits with high potassium
D.) 0800 and 1100 hours and calcium contents
15.) It is important for the nurse to teach the client that 21.) The nurse would question which medication order
metformin (Glucophage): for a client with acute-angled glaucoma?
A.) May cause nocturia A.) Atropine (Sal-tropine) 1-2 drops in each eye now
B.) Should be taken at night B.) Hydrochloride (Diuril) 25 mg PO daily
C.) Should be taken with meals C.) Propranolol (Inderal) 20 mg PO 2 times a day
D.) May increase the effects of aspirin D.) Carbanyl choline (Isopto carbachol) eye drops; 1 drop 2
times a day
16.) A nurse assessing a client with SIADH would expect
to find laboratory values of: 22.) A client tells you she has heard that glaucoma may
be a hereditary problem and she is concerned about her
A.) Serum Na= 150 mEq/L and low urine osmolality
adult children. What is the best response?
B.) Serum K= 5 mEq/L and low serum osmolality
A.) "There is no need for concern; glaucoma is not hereditary
C.) Serum Na=120 mEq/L and low serum osmolality order."

D.) Serum K= 3 mEq/L and high serum osmolality B.) "Screening for glaucoma should be included in an annual
eye exam for everyones over 50."
17.) A priority nursing diagnosis for a client admitted to
the hospital with a diagnosis of diabetes insipidus is: C.) "There may be a genetic factor with glaucoma and your
children over 30 y/o should be screened yearly."
A.) Sleep pattern deprivation related nocturia
D.) "Are your grandchildren complaining of any eye
B.) Activity intolerance r/t muscle weakness problems? Glaucoma generally skips a generation."
C.) Fluid volume excess r/t intake greater that output 23.) What will be important to include in the nursing care
for the client with angle-closure glaucoma?
D.) Risk for impaired skin integrity r/t generalized edema
A.) Evaluation of medications to determine if any of them
18.) A client admitted with a pheochromocytoma returns
cause an increase in IOP is a side effect.
from the operating room after adrenalectomy. The nurse
should carefully assess this client for: B.) Observation for an increase in loss of vision; it can be
reversed if promptly identified.
A.) Hypokalemia
C.) Control BP to decrease the client's potential
B.) Hyperglycemia
loss of peripheral vision.
C.) Marked Na and water intake
D.) Assessment for a level of discomfort; the client may
D.) Marked fluctuations in BP
experience considerable pain until the optic nerve atrophies
19.) When caring for client in thyroid crisis, the nurse
24.) A child is scheduled for a myringotomy. What goal of
would question an order for:
this procedure will the nurse discuss with the parents?
A.) IV fluid
A.) Promote drainage from the ear
B.) Propranolol (Inderal)
B.) Irrigate the Eustachian tube
C.) Propylthiouracil
C.) Correct a malformation in the inner ear
D.) A hyperthermia blanket
D.) Equalize pressure on the tympanic membrane
25.) After a client's eye has been anesthetized, what D.) Assess if the occurrence is vertigo or dizziness
instructions will be important for the nurse to give the
client? 31.) Which client is at highest risk for retinal
detachment?
A.) Do not watch TV for at least one day
A.) 4-year old with amblyopia
B.) Do not rub the eye for 15-20 minutes
B.) 17 y/o who plays physical contact
C.) Irrigate the eye every hour to prevent dryness
C.) 33 y/o with severe ptosis and diplopia
D.) Wear sunglasses when in direct sunlight for the next 6
hours D.) 72 y/o with nystagmus and Bell's palsy

26.) A child diagnosed with conjunctivitis. Which 32.) To promote and maintain safety for a client after a
statement reflects that the child understood the nurse's stapedectomy. What would be included in the nursing
teaching? care plan?

A.) "It's okay for me to let my friends use my sunglasses A.) Implement fall precautions
while we are playing together."
B.) Prevent aspirations
B.) "It's okay for me to softly rub my eye, as long as I use the
C.) Begin oxygen 2-4L/min via nasal cannula
back of my hand."
D.) Change inner ear dressing when saturated
C.) "I can pick the crusty stuff out of my eyelashes with my
fingers when I wake up in the morning." 33.) The nurse would question the administration of
which eye drop in a patient with increased ICP?
D.) "I will use my own washrag and towel while my eyes are
sick." A.) Artificial tears
27.) What medication would the nurse anticipate giving a B.) Betaxolol (Betoptic)
client with Meniere's disease?
C.) Acetazolamide (Diamox)
A.) Nifedipine
D.) Epinephrine HCL (Epirate)
B.) Amoxicillin
34.) A client is being admitted for problems with
C.) Propranolol Meniere's disease. What is most important to the nurse
to assess?
D.) Hydrochloride (Hydro DIURIL)
A.) Diet history
28.) When teaching a family and a client about the use of
a hearing aid, the nurse will base the teaching on what B.) Screening hearing test
information regarding the hearing aid?
C.) Effect on client's activities of daily living (ADLs)
A.) Provides mechanical transmission for damaged part of
the ear D.) Frequency and severity

B.) Stimulates the neural network of the inner ear to amplify 35.) A client calls the nurse regarding an accident that
sound just occurred during which an unknown chemical was
splashed in his eyes. What is the most important for the
C.) Amplifies sound but does not improve the ability to hear nurse to tell the client to do immediately?
D.) Tunes out extraneous noise in the lower-frequency A.) Rinse the eye with large amount of water or saline
sound spectrum solution

B.) Put a pad soaked in the sterile saline solution over the
eye

C.) Go to the closest emergency room

29.) What statement by the client recovering from
cataract surgery would indicate to the nurse need for D.) Have a co-worker visually checks the eye for a foreign
additional teaching? body
A.) "I'll call if I have a significant amount of pain."

B.) "I'll continue to take my Metamucil for another week."

C.) "I'll just do some laundry this afternoon instead of going

to work."

D.) "I'll take my acetazolamide (Diamox) drops with my

other morning medications 36.) A 25- year old woman comes to the clinic
complaining of dizziness, weakness and palpitations.
30.) A client is walking down the hall and begins to What will be important for the nurse to initially evaluate
experience vertigo. What is the most important nursing when obtaining the health history?
action when this occurs?
A.) Activity and exercise patterns
A.) Have the client sit in a chair and lower his head
B.) Nutritional patterns
B.) Administer meclizine (Antivert) PO
C.) Family health status
C.) Assist the client to sit or lie down
D.) Coping and stress tolerance
37.) A child with leukemia is being discharged after D.) Hydration, oxygenation, electrolyte balance
beginning chemotherapy. What instructions will the
nurse include in the teaching plan for the parents of this 43.) A client in the ICU has been diagnosed with DIC. The
child? nurse will anticipate administering which of the
following fluids?
A.) Provide a diet low in protein and high in carbohydrates
A.) Packed RBC
B.) Avoid fresh vegetables that are not cooked or peeled
B.) Fresh Frozen plasma (FFP)
C.) Notify the M.D. if the child's temperature exceeds 101F
(39C) C.) Volume expanders, such as D10W

D.) Increase the use of humidifiers throughout the house D.) Whole blood

38.) Which client is most likely to have iron deficiency 44.) The nurse is assessing a client who has been given a
anemia? diagnosis of polycythemia vera. What characteristics will
the nurse anticipate finding when assessing this client?
A.) A client with cancer receiving radiation therapy twice a
week A.) Increased fatigue and bleeding tendencies

B.) A toddler whose primary nutritional intake is milk B.) Hemoglobin below 13 mg/dl

C.) A client with peptic ulcer who had surgery 6 weeks ago C.) Headaches, dyspnea, claudication

D.) A 15-year old client in sickle cell crisis D.) Back pain, ecchymosis, and joint tenderness

39.) A client has an order for one unit of whole blood.

What is a correct nursing action?
45.) A client has been diagnosed with pernicious anemia
A.) Initiate an IV with 5% dextrose in water (D5W) to what will the nurse teach this client regarding
maintain a patent access site medication he will need to take after he goes home?

B.) Initiate the transfusion within 30 minutes of receiving the A.) Monthly Vit. B12 injections will be necessary
blood
B.) Ferrous sulfate PO daily will be prescribed
C.) Monitor the client's vital signs for the first 5 minutes
C.) Coagulation studies are important to evaluate
D.) Monitor V/S every 2 hours during the transfusion medications

40.) The nurse is caring for a client who is receiving a D.) Decrease intake of leafy green vegetables because of
blood transfusion. The transfusion was started 30 mins increased Vit. K
ago at a rate of 100 ml/hr. The client begins to complain
46.) First postop day after a right lower lobe (RLL)
of low back pain and headache and is increasing restless,
lobectomy, the client breathes and coughs but has
what is the first nursing action?
difficulty raising mucus. What indicates that the client is
A.) Slow the infusion and evaluate the V/S and client's not adequately clearing secretions?
history of transfusion reaction
A.) Chest x-ray film shows right sided pleural fluid
B.) Stop the transfusion, disconnect the blood tubing and
B.) A few scattered crackles on RLL on auscultation
begin a primary infusion of normal saline solution
C.) PCO2 increases from 35-45 mmHg
C.) Stop the infusion of blood and begin infusion of NSS from
the Y connector D.) Decrease in forced vital capacity
D.) Recheck the unit of blood for correct identification 47.) What nursing observations indicate that the cuff on
numbers and cross-match information an endotracheal tube is leaking?
41.) The nurse is preparing to start an IV infusion before A.) An increase in peak pressure on the ventilator
the administration of a unit of packed red blood cells,
what fluid will the nurse select to maintain the infusion B.) Client is able to speak
before hanging the unit of blood?
C.) Increased swallowing efforts by client
A.) D5W
D.) Increased crackles (rales) over left lung field
B.) D5W/0.45 NaCl

C.) LR solution

D.) .9% Na Cl
48.) The client with COPD is to be discharged home while
42.) A client in sickle cell crisis is admitted to the receiving continuous oxygen at a rate of 2 L/min via
emergency department what are the priorities of care? cannula. What information does the nurse provide to the
client and his wife regarding the use of oxygen at home?
A.) Nutrition, hydration, electrolyte balance
A.) Because of his need for oxygen, the client will have to
B.) Hydration, pain management, electrolyte balance limit activity at home
C.) Hydration, oxygenation, pain management
B.) The use of oxygen will eliminate the client's shortness of
breath

C.) Precautions are necessary because oxygen can

spontaneously ignite and explode

D.) Use oxygen during activity to relieve the strain on the

client's heart

49.) The wife of a client with COPD is worried about

caring for her husband at home. Which statement by the
nurse provides the most valid information?

A.) "You should avoid emotional situations that increase his

shortness of breathe."

B.) "Help your husband arrange activities so that he does as

little walking as possible."

C.) "Arrange a schedule so your husband does all necessary

activities before noon; then he can rest during the afternoon
and evening."

D.) "Your husband will be no more short of breath when he

walks but that will not hurt him."

50.) Which statement correctly describes suctioning

through an endotracheal tube

A.) The catheter is inserted into the endotracheal tube;

intermittent suction is applied until no further secretions are
retrieved; the catheter is then withdrawn.

B.) The catheter is inserted through the nose, and the upper
airway is suctioned; the catheter is then removed from the
upper airway and inserted into the endotracheal tube to
suction the lower airway

C.) With suction applied, the catheter is inserted into the

endotracheal tube; when resistance is met, the catheter is
slowly withdrawn

D.) The catheter is inserted into the endotracheal tube to a

point of resistance, and intermittent suction is applied
during withdrawal.