1.

for NLE - How longafter amitriptyline (Elavil) therapy begins can the nurse
expect the client toshow improved psychological symptoms?
a. 2 to 4 days
b. 4 to 6 days
c. 6 to 8 days
d. 10 to 14 days
Answer:D Rationale;Because tricyclic antidepressants have long half-lives, a
noticeable response may not occur for 10 to 14 days; a full response may
take up to 30 days.
2.Your clientis taking clozapine (Clozaril) and complains of a sore throat. This
symptom maybe an indication of which of the following adverse reactions?
a. extrapyramidal reaction
b. tardive dyskinesia
c. reye's syndrome
d. agranulocytosis
Answer:D Rationale;The complaint of a sore throat may indicate an infection
caused by agranulocytosis, a depletion in white blood cells. Although
extrapyramidal reaction and tardive dyskinesia may occur, a sore throat isn't
an indication of these conditions. Reye's syndrome is caused by a virus
unrelated to clozapine.
3.A clientasks the nurse, "Do you think I should leave my husband?" The
nurseresponds, "You aren't sure if you should leave your husband?" Thenurse
is using which therapeutic technique?
a. restating
b. reframing
c. reflecting
d. offering a general lead
Answer:C Rationale;Reflecting is correct because the nurse is referring
feelings back to the client to explore. When restating, the nurse simply
restates what the client said. Reframing is offering a new way to look at a
situation. The nurse's response is specific; it isn't offering a general lead.
4.Touching other people without their permission, reading someone else's
mail, and using personal possessions without asking permission are all
examples of:
a. antisocial behavior.

b. manipulation.
c. poor boundaries.
d. passive-aggressive.
Answer:C Rationale;The described behaviors indicate poor personal
boundaries, which is the inability to differentiate between self and others.
Poor boundaries are symptoms of antisocial and passive-aggressive behavior.
Manipulation is an attempt to control another person.
5.The nurse is caring for a client with a serumpotassium level of 3.5 mEq/L.
The client is placed on a cardiac monitor andreceives 40 mEq KCL in 1000 ml
of 5% dextrose in water IV. Which of thefollowing EKG patterns indicates to
the nurse that the infusions should bediscontinued?
a. QRS complex
b. s...hort "PR" interval
c. tall peaked T waves
d. "U" waves
Answer:C Rationale;A tall peaked T wave is a sign of hyperkalemia. The
health care provider should be notified regarding discontinuing the
medication.
6. A nurseprepares to care for a 4 year-old newly admitted for
rhabdomyosarcoma. The nurse should alert the staff to pay more attention to
the function of whicharea of the body?
a. the muscles
b. the cerebellum
c. the kidneys
d. the leg bones
Answer:A Rationale;Rhabdomyosarcoma is the most common children''s soft
tissue sarcoma. It originates in striated (skeletal) muscles and can be found
anywhere in the body. The clue is in the middle of the word and is myo
which typically means muscle.
7. Whichcomplication of cardiac catheterization should the nurse monitor for
in theinitial 24 hours after the procedure?
a. angina at rest
b. thrombus formation
c. dizziness
d. falling blood pressure

Answer:B Rationale;Thrombus formation in the coronary arteries is a

potential problem in the initial 24 hours after a cardiac catheterization. A
falling BP occurs along with hemorrhage of the insertion site which is
associated with the first 12 hours after the procedure.
8. A clienthas been taking furosemide (Lasix) for the past week. The nurse
recognizeswhich finding may indicate the client is experiencing a negative
side effectfrom the medication?
a. Weight gain of 5 pounds
b. Edema of the ankles
c. Gastric irritability
d. Decreased appetite
Answer:D Rationale;Lasix causes a loss of potassium if a supplement is not
taken. Signs and symptoms of hypokalemia include anorexia, fatigue,
nausea, decreased GI motility, muscle weakness, dysrhythmias.
9.A nurseenters a client's room to discover that the client has no pulse
orrespirations. After calling for help, the firstaction the nurse should take is:
a. start a peripheral IV
b. initiate closed-chest massage
c. establish an airway
d. obtain the crash cart
Answer:C Rationale;Establishing an airway is always the primary objective in
a cardiopulmonary arrest.
10. A clienthas a Swan-Ganz catheter in place. The nurse understands that
this is intendedto measure:
a. right heart function
b. left heart function
c. renal tubule function
d. carotid artery function
Answer:B Rationale;The Swan-Ganz catheter is placed in the pulmonary
artery to obtain information about the left side of the heart. The pressure
readings are inferred from pressure measurements obtained on the right side
of the circulation. Right-sided heart function is assessed through the
evaluation of the central venous pressures (CVP).
11. The nurseanticipates that for a family who practices Chinese medicine
the priority goal would be to:
a. achieve harmony

b. maintain a balance of energy

c. respect life
d. restore yin and yang
Answer:D Rationale;For followers of Chinese medicine, health is maintained
through balance between the forces of yin and yang.
12.Whenpreparing a client for bronchoscopy, the nurse should instruct the
client notto:
a. walk.
b. cough.
c. talk.
d. eat.
Answer:D Rationale;Bronchoscopy involves visualization of the trachea and
bronchial tree. To prevent aspiration of stomach contents into the lungs, the
nurse should instruct the client not to eat or drink anything for approximately
6 hours before the procedure. It's not necessary for the client to avoid
walking, talking, or coughing.
13. When preparing a client with a draining vertical incision for ambulation,
whereshould the nurse apply the thickest portion of a dressing?
a. at the top of the wound
b. in the middle of the wound
c. at the base of the wound
d. over the total wound
Answer:C Rationale: When a client is ambulating, gravity causes the drainage
to flow downward. Covering the base of the wound with extra dressing will
contain the drainage. Applying the thickest portion of the dressing at the top,
in the middle, or over the total wound won't contain the drainage
14. When should the nurse check a client for rebound tenderness?
a. near the beginning of the examination
b. before doing anything else
c. anytime during the examination
d. at the end of the examination
Answer:D Rationale: If a client complains of abdominal pain, the nurse should
check for rebound tenderness. Because this maneuver can be painful, the
nurse should perform it at the end of the abdominal assessment.

15. Whenassessing the facial lacerations of a middle-aged client admitted to

thefacility 1 week ago, the nurse observes scabs around the lacerations.
Scabsindicate which phase of wound healing?
a. contraction
b. fibrinoplastic
c. lag
d. inflammation
Answer: C Rationale: At the end of the lag phase, the fibrin network dries out
and forms a scab. The fibrinoplastic phase concludes with a scar, and the
contraction phase is demonstrated by sloughing and shrinking of the scar.
Inflammation is the first stage of wound healing and includes hemostasis,
edema, and drawing of leukocytes to the wound area.
16.The nursemust monitor a client receiving chloramphenicol for adverse
drug reactions.What is the most toxic reaction to chloramphenicol?
a. lethal arrhythmias
b. malignant hypertension
c. status epilepticus
d. bone marrow suppression
Answer: D Rationale: The most toxic reaction to chloramphenicol is bone
marrow suppression. Chloramphenicol isn't known to cause lethal
arrhythmias, malignant hypertension, or status epilepticus.
17. Whichclinical characteristic affects client compliance?
a. drug knowledge
b. psychosocial factors
c. the nurse-client relationship
d. disease duration and severity
Answer: C Rationale: Two major clinical characteristics affect client
compliance: the nurse-client relationship and the therapeutic regimen. The
client's drug knowledge, psychosocial factors, and disease duration and
severity are client characteristics, not clinical ones.
18. The nurseis preparing to help a client with weakness in his right leg get
out of bed toa chair. Where should the nurse place the chair?
a. parallel to the bed on the right side
b. perpendicular to the bed on the right side
c. parallel to the bed on the left side
d. parallel to the bed on either ...

Answer: A Rationale: The client can maintain his weight and pivot with his
left foot if the chair is placed on his right side parallel to the bed. The nurse
shouldn't place the chair on his left side or perpendicular to the bed because
the client won't be able to support his weight on his right leg.
19. The nurseadministers racemic epinephrine to an 8-year-old boy. Ten
minutes after administration, the nurse should be alert for:
a. respiratory distress.
b. respiratory distress.
c. signs of improved oxygenation.
d. diminished cyanosis.
Answer: A Rationale: A rebound effect from racemic epinephrine can occur
up to 4 hours after treatment with signs of respiratory distress (tachypnea,
restlessness, and cyanosis). Tachycardia may initially follow treatment with
racemic epinephrine as well as improvement in client status (improved
oxygenation and improved color).
20.Which ofthe following is the most common source of airway obstruction in
an unconsciousvictim?
a. a foreign object
b. saliva or mucus
c. the tongue
d. edema
Answer: C Rationale: In many cases, the muscles controlling the tongue
relax, causing the tongue to obstruct the airway. When this occurs, the nurse
should use the head-tilt, chin-lift maneuver to cause the tongue to fall back
in place. If a neck injury is suspected, the jaw-thrust maneuver must be
performed.
21. The nurseis developing a drug therapy regimen that won't interfere with
the client's lifestyle. When doing this, the nurse must consider the drug's:
a. adverse effects.
b. route of excretion.
c. peak concentration time.
d. steady-state duration of action.
Answer: A Rationale: When developing a drug therapy regimen that won't
interfere with a client's lifestyle, the nurse must consider the drug's adverse
effects because these
22. The nurseis caring for a geriatric client with a pressure ulcer on the
sacrum. When teaching the client about dietary intake, which foods should
the nurse plan to emphasize?
a. legumes and cheese

b. whole grain products

c. fruits and vegetables
d. lean meats and low-fat milk
Answer: D Rationale: Although the client should eat a balanced diet with
foods from all food groups, the diet should emphasize foods that supply
complete protein, such as lean meats and low-fat milk, because protein helps
build and repair body tissue, which promotes healing. Legumes provide
incomplete protein. Cheese contains complete protein,
23. Whenassessing a client with cellulitis of the right leg, which of the
following would the nurse expect to find?
a. painful skin that is swollen and pale in color
b. cold, red skin
c. small, localized blackened area of skin
d. red, swollen skin with inflammation spreading to surrounding ...tissues
Answer: D Rationale: Cellulitis is an inflammation of soft tissues that can
extend to surrounding tissues. The skin becomes reddened, warm, swollen,
and sometimes painful. The skin wouldn't be cold, pale, or necrotic.
24. When givingan I.M. injection, the nurse should insert the needle into the
muscle at an angle of:
a. 15 degrees.
b. 30 degrees.
c. 45 degrees.
d. 90 degrees.
Answer: D Rationale: When giving an I.M. injection, the nurse inserts the
needle into the muscle at a 90-degree angle, using a quick, dartlike motion.
A 15-degree angle is appropriate when administering an intradermal
injection. A 30-degree angle isn't used for any type of injection. A 45- or 90degree angle can be used when giving a subcutaneous injection
25. To evaluatea client's chief complaint, the nurse performs deep palpation.
The purpose of deep palpation is to assess which of the following?
a. skin turgor
b. hydration
c. organs
d. temperature
Answer: C Rationale: The purpose of deep palpation, in which the nurse
indents the client's skin approximately 1" (3.8 cm), is to assess underlying
organs and structures, such as the kidneys and spleen. Skin turgor,

hydration, and temperature can be assessed by using light touch or light

palpation
26.On daily cleaning of a tracheostomy, theclient coughs and displaces the
tracheostomy tube. The nurse could have avoided this by:
a. placing an obturator at the clients bedside
b. having another nurse assist with the procedure
c. fastening clean tracheostomy ties before removing... old ties
d. withdraw catheter in a circular motion
Answer:C Rationale;Fastening clean tracheostomy ties before removing old
ones will ensure that the tracheostomy is secured during the entire cleaning
procedure. The obturator is useful to keep the airway open only after the
tracheostomy outer tube is coughed out. A second nurse is not needed.
Changing the position may not prevent a dislodged tracheostomy.
27. A 78 year-old client with pneumonia has aproductive cough but is
confused. Restraints havebeen ordered for this client. How can the nurse
prevent aspiration?
a. suction the client frequently while restrained
b. secure all 4 restraints to 1 side of bed
c. obtain a sitter for the... client while restrained
d. request an order for a suppressant
Answer; C Rationale; The plan to use safety devices (restraints) should be
rethought. Restraints are used to protect the client from harm caused by
removing tubes or getting out of bed. In the event that this restricted
movement could cause more harm, such as aspiration, then a sitter should
be ... See Morerequested. These are to be provided by the facility in the
event the family cannot do so. This client needs to cough and be watched
rather than restricted. Suctioning will not prevent aspiration in this situation.
Cough suppressants should be avoided for this client.
28. Which nursing observation would suggest that a client has developed an
Addisonian crisis?
a. Muscular weakness and fatigue.
b. Restlessness and rapid, weak pulse.
c. Dark pigmentation of the skin.
d. Gastrointestinal disturbances and anorexia.
Strategy: Determine how each answer relates to Addison's.
(a) signs and symptoms of Addison's disease, but do not indicate a crisis

(b) correctmay be signs of shock related to an Addisonian crisis... See More

(c) signs and symptoms of Addison's disease, but do not indicate a crisis
(d) signs and symptoms of Addison's disease, but do not indicate a crisis
29. The nurse recognizes which of the following as early signs of lithium
toxicity?
a. restlessness, shuffling gait,involuntary muscle movements
b. ataxia, confusion, seizures.
c. fine tremors, nausea, vomiting,diarrhea.
d. elevated white blood cell count, orthostatic hypotension.
Strategy: Think about each answer.
(a) indicative of side effects associated with antipsychotic agents, not lithium
(b) indicative of severe lithium toxicity, which requires prompt medical
management... See More
(c) correctnurse should be alert to early signs/symptoms of lithium toxicity;
include fine tremors of
fingers, wrists, and hands, and nausea, vomiting, and diarrhea
(d) indicative of side effects associated with antipsychotic agents, not lithium
30. The client is admitted with cerebrovascular
accident (CVA) and has facial paralysis. Nursing care should be planned
to prevent which of the following complications?
a. inability to talk.
...b. Inability to swallow caused by loss of the gag reflex.
c. Inability to open the affected eye.
d. Corneal abrasion.
Strategy:
(a) may occur, but nursing care cannot prevent it
(b) may occur, but nursing care cannot prevent it
(c) may occur, but nursing care cannot prevent it... See More
(d) correctclient will be unable to close eye voluntarily; when facial nerve
(cranial nerve VII) is affected, the lacrimal gland will no longer supply
secretions that protect eye

31. The nurseis teaching a client who will be discharged soon how to change
a sterile dressing on the right leg. During the teaching session, the nurse
noticesredness, swelling, and induration at the wound site. What do these
signs suggest? a. infection
b. dehiscence
c. hemorrhage
d. evisceration
Answer: A Rationale: Infection produces such signs as redness, swelling,
induration, warmth, and possibly drainage. Dehiscence, which refers to the
separation of a wound, may cause unexplained fever and tachycardia,
unusual wound pain, and prolonged paralytic ileus. Hemorrhage can result in
increased pulse and respiratory rate, decreased blood pressure, restlessness,
thirst, and cold, clammy skin. Evisceration produces visible protrusion of
organs, usually through an incision.
32. The nurse administers furosemide (Lasix) to treat a client with heart
failure. Which adverse effect must the nurse watch for most carefully?
a. increase in blood pressure
b. increase in blood volume
c. low serum potassium level
d. high serum sodium level
Answer: C Rationale: Furosemide is a potassium-wasting diuretic. The nurse
must monitor the serum potassium level and assess for signs of low
potassium. As water and sodium are lost in the urine, blood pressure
decreases, blood volume decreases, and urine output increases.
33. The nurseshould be prepared to manage complications after abdominal
aortic aneurysm resection. Which of the following complications is most
common postoperatively?
a. renal failure
b. hemorrhage and shock
c. graft occlusion
d. enteric fistula
Answer: B Rationale: Hemorrhage and shock are the most common
complications after abdominal aortic aneurysm resection. Renal failure can
occur as a result of shock or from injury to the renal arteries during surgery.
Graft occlusion and enteric fistula formation are rare complications of
abdominal aortic aneurysm repair.
34. The nurse would teach a client with Raynaud's phenomenon that it is
most important to:
a. stop smoking

b. keep feet dry

c. reduce stress
d. avoid caffeine
Answer: A Rationale: The most important teaching for this client is to stop
smoking. The question is asking what is the most important teaching. The
others tend to be done less frequently than smoking and are less of a threat.
35. A client has been admitted for meningitis. Inreviewing the laboratory
analysis of cerebrospinal fluid (CSF), the nurse would expect to note
a. high protein
b. clear color
c. elevated sedimentation rate
d. increased glucose
Answer: A: Rationale:High protein A positive CSF for meningitis would include
presence of protein, a positive blood culture, decreased glucose, cloudy color
with an increased opening pressure, and an elevated white blood cell count.
36. For a client with a head injury whose neck has been stabilized, the
preferred bed
position is:
a. trendelenburg's
b. 30-degree head elevation
c. flat
d. side-lying
Answer: B Rationale: For clients with increased intracranial pressure (ICP),
the head of the bed is elevated to promote venous outflow. Trendelenburg's
position is contraindicated because it can raise ICP. Flat or neutral positioning
is indicated when elevating the head of the bed would increase the risk of
neck injury or airway obstruction. Side-lying isn't specifically a therapeutic
treatment for increased ICP.
37. A client complains of vertigo. The nurse anticipates that the client may
have a problem with which portion of the ear?
a. external ear
b. middle ear
c. inner ear
d. tympanic membrane
Answer: C Rationale: A client with vertigo experiences problems with the
inner ear. The inner ear is responsible for maintaining equilibrium. The

external ear collects sound; the middle ear conducts sound. The tympanic
membrane (eardrum) vibrates in response to sound stimulation....
38. The nurse is caring for a client who requires intracranial pressure (ICP)
monitoring. The nurse should be alert for what major complication of ICP
monitoring?
a. coma
b. infection
c. high blood pressure
d. apnea
Answer: B Rationale: The catheter for measuring ICP is inserted through a
burr hole into a lateral ventricle of the cerebrum, thereby creating a risk of
infection. Coma, high blood pressure, and apnea are late signs of increased
ICP.
39. The nurse is removing a fecal impaction on a75 year-old client. It is most
important that the nurse remember that:
a. the procedure be done prior to the bath
b. family members should be taught the procedure
c. cardiac dysrhythmias can result during the process
d. increased dietary fiber can minimize such problems
Answer: C Rationale: Cardiac dysrhythmias such as severe bradycardia can
result from vagal nerve stimulation during fecal impaction removal in the
elderly or in cardiac patients. Options 1, 2 and 4 are appropriate though are
not the most important considerations.
40. An elderly client with tuberculosis has difficulty coughing up secretions
for a sputum specimen. Which nursing action is appropriate?
a. spray the oropharynx with saline
b. ask the client to drink a warm liquid
c. force fluids for the next 8 hours
d. raise the head of the bed to at least 45 degree...
Answer: C Rationale: Cardiac dysrhythmias such as severe bradycardia can
result from vagal nerve stimulation during fecal impaction removal in the
elderly or in cardiac patients. Options 1, 2 and 4 are appropriate though are
not the most important considerations.
41. To evaluate a client's chief complaint, the nurse performs deep palpation.
The purpose of deep palpation is to assess which of the following?
a. skin turgor

b. hydration
c. organs
d. temperature
Answer: CRationale: The purpose of deep palpation, in which the nurse
indents the client's skin approximately 1" (3.8 cm), is to assess underlying
organs and structures, such as the kidneys and spleen. Skin turgor,
hydration, and temperature can be assessed by using light touch or light
palpation...
42 A client is
diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH).
The
nurse should anticipate which laboratory test result?
a. Decreased serum sodium level
b. Decreased serum creatinine level
c. Increased hematocrit
d. Increased blood urea nitrogen (BUN)
level
Rationale In SIADH, the posterior pituitary gland produces
excess antidiuretic hormone (vasopressin), which decreases water excretion
by
the kidneys. This, in turn, reduces the serum sodium level, causing
hyponatremia. In SIADH, the serum creatinine level isn't affected by the
client's fluid status and re...
43. Wheninstructing the client diagnosed with hyperparathyroidism about
diet, the nurse
should stress the importance of which of the following?
a. Restricting fluids
b. Restricting sodium
c. Forcing fluids
d. Restricting potassium
Answer: C Rationale:The client should be encouraged to force fluids
to prevent renal calculi formation. Sodium should be encouraged to replace
losses in urine. Restricting potassium isn't necessary in hyperparathyroidism.