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Nclex-rn Exam Free Review By Nclex Masters

265 Questions  I  By Rneducator
Nclex-RN Exam FREE Review By Nclex Masters
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1.  The nurse is gathering data from a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. After confirming pregnancy, the nurse calculates the estimated date of delivery (EDD) to be about:
A.
B.
C.
D.
2.  A nurse who works at an extended care facility has just reviewed a new medication order which is not legible. Which statement best reflects assertive communication to the health care provider who wrote the order?
A.
B.
C.
D.
3.  A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?
A.
B.
C.
D.
4.  Which of the followwing entries in the progress notes of a client is the most complete?
A.
B.
C.
D.
5.  A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of these nursing actions should the nurse expect to do first?
A.
B.
C.
D.
6.  A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts "You think you're so perfect and pure and good." The appropriate response for the nurse is:  
A.
B.
C.
D.
7.  Scoliosis a C S curvature of the spine; it cna a temporary or permanent condidtion. At what time would the nurse expect early findings of scoliosis to appear?                                                                                      
A.
B.
C.
D.
8.  After a client has an intestinal feeding tube inserted, the most accurate method for verification of placement is
A.
B.
C.
D.
9.  The nurse is reviewing a handout on infant feeding to be distributed to families visiting the clinic. Which information should be included in the teaching materials?  
A.
B.
C.
D.
10.  A client with heart failure has been instructed by the RN about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?
A.
B.
C.
D.
11.  A 5 years old child has been admitted to the pediatric unit after swallowing a household cleaner. Which of these findings is more commonly associated with the fact that the poison was a corrosive?
A.
B.
C.
D.
12.  The nurse observes a newborn whose Apgar score was 8 and 9. This score would be most closely associated with which of these areas?
A.
B.
C.
D.
13.  The nurse in the delivery room is caringfor the newborn. Which action is the most important and most immediate action for the nurse to take?
A.
B.
C.
D.
14.  Mr. Reynolds, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician, and Mr. Reynolds is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Reynolds complained of a headache before retiring the night before. In addition to the headache and hypertension, which of the following symptoms would you expect Mr. Reynolds to exhibit?
A.
B.
C.
D.
15.  The mother of a two year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The best response of the nurse would be to:    
A.
B.
C.
D.
16.  The nurse is caring for a post-operative client who develops an abdominal wound evisceration. The first nursing intervention should be to
A.
B.
C.
D.
17.  Ms. L. is to go home with her family. The nurse is evaluating that the family members can correctly move Ms. L. from the bed to a chair. Which of the following should be seen?
A.
B.
C.
D.
18.  Mr. T. is a C4 quadriplegic in a nursing home. Which of the following techniques would the nurse use to transfer him from bed to wheelchair?
A.
B.
C.
D.
19.  In addition to handwashing, an appropriate infection control intervention during the care of a newly admitted adult client with a diagnosis of Hepatitis A would be which action?
A.
B.
C.
D.
20.  A client is admitted with severe injuries from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. The initial nursing intervention would be to
A.
B.
C.
D.
21.  Which of the following agents should be avoided by clients on methotrexate therapy?
A.
B.
C.
D.
22.  The parent of a three-year-old child brings the child to the clinic for a well child checkup. Which of these assessment findings made by the nurse is an area of concern and requires further investigation?
A.
B.
C.
D.
23.  Several clients are admitted to an adult medical unit. The nurse would expect airborne precautions for a client with which of the following medical conditions?
A.
B.
C.
D.
24.  In the last 48 hours of life, a hospice client may complain of dry mouth from a poor fluid intake. The nurse should only offer to moisten the mouth because:
A.
B.
C.
D.
25.  The nurse is dangling Ms. S. prior to transferring her from the bed to a wheelchair. Which of the following assessments is essential for the nurse to make before moving the client?
A.
B.
C.
D.
26.  A client with a diagnosis of bipolar disorder has been referred to a local boarding home to be considered for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The nurse should know that the most acceptable is : 
A.
B.
C.
D.
27.  The nurse is caring for a 30-week baby girl who is currently receiving 15 ml of breast milk via oral gastric tube every three hours. As part of the routine assessment the nurse should assess which of the following?
A.
B.
C.
D.
28.  A client tells the nurse, "I have something very important to tell you if you promise not to tell anyone." The appropriate response by the nurse would be
A.
B.
C.
D.
29.  What is the primary nursing intervention to limit transmission of organisms for a client with a salmonella infection?
A.
B.
C.
D.
30.  A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving Aminophylline, 25mg/hour. Which finding by the nurse would require immediate intervention?
A.
B.
C.
D.
31.  The nurse is to open a sterile package from central supply. Which is the correct direction to open the first flap?
A.
B.
C.
D.
32.  The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is appropriate?
A.
B.
C.
D.
33.  The nurse is to apply a dressing to a stage II pressure ulcer. Which of the following dressings is best?
A.
B.
C.
D.
34.  A client is receiving a nitroglycerin (NTG) infusion for unstable angina. What would be a priority for monitoring the effects of this medication?
A.
B.
C.
D.
35.  While giving nursing care to a hospitalized adolescent, the nurse should be aware that the major threat felt by the hospitalized adolescent is :
A.
B.
C.
D.
36.  If a nurse is uncertain about whether he or she is licensed to perform certain tasks, they should first check information in which of these resources?
A.
B.
C.
D.
37.  The nurse is collecting data on a client with a stage 2 skin ulcer. Which treatment is considered most effective to promote healing?
A.
B.
C.
D.
38.  A school nurse plans to reinforce information about the most effective methods to prevent the spread of head lice in school age children at a teacher's conference . The most appropriate information to give would be that
A.
B.
C.
D.
39.  The nurse is gathering data from a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. After confirming pregnancy, the nurse calculates the estimated date of delivery (EDD) to be about:
A.
B.
C.
D.
40.  A nurse has been named in a lawsuit. The best evidence a nurse can use for self- protection in a court of law is which of these items?
A.
B.
C.
D.
41.  A 52 year-old post menopausal woman asks the nurse how frequently she should have a mammogram. The nurse's best response is:
A.
B.
C.
D.
42.  The nurse is assessing a six-month-old infant during a well child visit. The nurse makes all of the following observations. Which of the following assessments made by the nurse is an area of concern indicating a need for further evaluation?
A.
B.
C.
D.
43.  Ms. P. is transferred to a skilled nursing facility from the hospital because she is unable to ambulate due to a left femoral fracture. The nurse knows Ms. P.'s greatest risk factor for developing a pressure ulcer is that she
A.
B.
C.
D.
44.  The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?
A.
B.
C.
D.
45.  When reinforcing teaching to a depressed client about a new prescription for nortriptyline (Pamelor), the nurse must emphasize
A.
B.
C.
D.
46.  The hospice nurse is visiting a 75 year-old client with end-stage cancer. For chronic malignant pain management in this client the nurse understands that:
A.
B.
C.
D.
47.  Pediatric Nursing The nurse is testing reflexes in a four-month­old infant as part of the neurologic asse,ssment. Which of the following findings would indicate an abnormal reflex pattern and an area of concern in a four-month-old -infant?
A.
B.
C.
D.
48.  A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove her dentures prior to leaving the unit for the operating room. The most appropriate intervention by the nurse is:
A.
B.
C.
D.
49.  The nurse is assisting with teaching a group of college students about breast self-examination. A woman asks when to perform the monthly exam. The appropriate reply by the nurse would be which of these?
A.
B.
C.
D.
50.  Ms. W. has a draining pressure ulcer on her sacrum and is to be discharged to her daughter's care. The nurse has taught Ms. W.'s daughter to perform dressing changes. Which observation by the nurse indicates the daughter's technique is done correctly? The daughter
A.
B.
C.
D.
51.  A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to
A.
B.
C.
D.
52.  In taking the history of a pregnant woman, which factor would the nurse recognize as the primary contraindication for breast feeding?
A.
B.
C.
D.
53.  The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. The nurse should be sure to include which information?
A.
B.
C.
D.
54.  Which of these actions is the first priority in the prevention of infections, whether in the hospital or home setting?
A.
B.
C.
D.
55.  A client has been taking Procardia for Raynaud's disease and hypertension. Which finding would indicate that the client may be having a side effect of the medication?
A.
B.
C.
D.
56.  Miss Peters is found wandering on campus after a fraternity party. She is disheveled and does not know who she is. She has no recollection of the evening. She is diagnosed with dissociative amnesia subsequent to a rape. The most appropriate nursing diagnosis for the nurse to formulate is :
A.
B.
C.
D.
57.  The nurse will administer liquid medicine to a nine month-old child. Which method is appropriate?
A.
B.
C.
D.
58.  The nurse would anticipate that an eight month-old would be able to  do one or more of the following:
A.
B.
C.
D.
59.  A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and beccomes lost when she leaves home. Which statement would provide the best reality orientation for this client?
A.
B.
C.
D.
60.  A client is admitted with a diagnosis of schizophrenia. The client states "I don't need medication. It makes me sleepy." The client insists that the nurse explain the use and side effects of the medication. The nurse should understand that the best intervention is:
A.
B.
C.
D.
61.  9.    Miss Rodriguez is an 88-year-old client at a long-term care facility. Prior to administering any medication or treatment to this client the nurse must confirm identity by asking the client if she is Miss Rodriguez
A.
B.
C.
D.
62.  Ms. O'Brien is bedridden. The nurse is evaluating whether the family members understand how to position the client correctly. Which of the following should the nurse observe?
A.
B.
C.
D.
63.  Mr. Reynolds, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician, and Mr. Reynolds is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Reynolds complained of a headache before retiring the night before. Unresponsive patients like Mr. Reynolds may develop a drying of the cornea, which is usually caused by
A.
B.
C.
D.
64.  Mrs. F. has remained close to the nurse all day. When the nurse talked with other clients during dinner, Mrs. F. tried to regain the nurse's attention and then began to shout "You're just like my mother. You pay attention to everyone but me!" The best interpretation of this behavior is that
A.
B.
C.
D.
65.  A school nurse plans to reinforce information about the most effective methods to prevent the spread of head lice in school age children at a teacher's conference . The most appropriate information to give would be that
A.
B.
C.
D.
66.  A nurse is part of a community task force on teenage suicide. The task force is considering all of the following steps in an effort to reduce teen suicide. Which action represents primary prevention?
A.
B.
C.
D.
67.  After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can't do anything that pleases him. I'm not going in there again." The nurse's appropriate response should be
A.
B.
C.
D.
68.  The mother of an infant who is being treated for pesticide poisoning asks why activated charcoal is the treatment. What is the nurse's best response?
A.
B.
C.
D.
69.  A client was just taken off the ventilator following surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client?
A.
B.
C.
D.
70.  Which one of these tasks for a 69 year-old client with a diagnosis of hyperglycemia could the nurse assign to the unlicensed assistive personnel (UAP)?
A.
B.
C.
D.
71.  An elderly male client is transferred to a skilled nursing facility from the hospital because he is unable to ambulate due to a left femoral fracture. When doing a skin assessment, the nurse notices a 3-cm, round area partial thickness skin loss that looks like a blister on the client's sacrum. The nurse knows this is a
A.
B.
C.
D.
72.  A two month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate postoperative period for a cleft lip repair, which of these nursing actions should be the priority?
A.
B.
C.
D.
73.  A client is admitted for Lithium (Lithane) toxicity. Which finding should the nurse report immediately to the health care provider?
A.
B.
C.
D.
74.  The visiting nurse makes a postpartum home visit to a married female client. Upon arrival, the nurse observes that the client has a black eye and numerous bruises on her arms and legs. The next nursing intervention would be to
A.
B.
C.
D.
75.  A nurse arranges for an interpreter to assist with communication between the health care team and a non-English speaking client. To promote therapeutic communication when working with an interpreter, the utmost thing for the nurse to remember is to :
A.
B.
C.
D.
76.  A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking the lips alternately with grinding of the teeth. The nurse assesses this as
A.
B.
C.
D.
77.  Mr. C. has just been admitted for acute asthma exacerbation and placed in a high Fowler's position. The nurse knows this position is best because it
A.
B.
C.
D.
78.  A 14 month-old child ingested half a bottle of aspirin tablets. Which finding would the nurse expect to see in the child?
A.
B.
C.
D.
79.  A young man was arrested by the police for indecent exposure, loitering, and disturbing the peace. He became hyperactive, stripped off his clothes, and terrorized people living in the area near the house. He was then admitted to the psychiatric unit. Upon admission he was speaking very rapidly, and moved quickly around the unit, never sitting. He refused to eat or drink. The nursing diagnosis that would most appropriately describe the behavior that is of greatest concern is :
A.
B.
C.
D.
80.  A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking the lips alternately with grinding of the teeth. The nurse assesses this as
A.
B.
C.
D.
81.  Privacy and confidentiality of client information is legally protected. In which of these situations would the nurse make an exception to this practice?
A.
B.
C.
D.
82.  After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can't do anything that pleases him. I'm not going in there again." The nurse's appropriate response should be
A.
B.
C.
D.
83.  A two month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate postoperative period for a cleft lip repair, which of these nursing actions should be the priority?
A.
B.
C.
D.
84.  The mother of an infant who is being treated for pesticide poisoning asks why activated charcoal is the treatment. What is the nurse's best response?
A.
B.
C.
D.
85.  The nurse is caring for a four year-old two hours after tonsillectomy and adenoidectomy. Which observation must be reported immediately?
A.
B.
C.
D.
86.  Which cognitive skill would the nurse expect a six-year-old child to be in the process of developing?
A.
B.
C.
D.
87.  Before administering digoxin (Lanoxin) to a client, which nursing action is a priority?
A.
B.
C.
D.
88.  While giving nursing care to a hospitalized adolescent, the nurse should be aware that the major threat felt by the hospitalized adolescent is :
A.
B.
C.
D.
89.  The mother of a three-month-old infant asks the nurse when she can start feeding her baby solid food. Which of the following should the nurse include in teaching this mother about the nutritional needs of infants?
A.
B.
C.
D.
90.  Marty Cole, 7 years old, is admitted to the pediatric service with a diagnosis of juvenile diabetes mellitus. He has not been under treatment previously. When counseling Marty about his diabetes and its treatment, you would advise against eating
A.
B.
C.
D.
91.  The health care provider has written "Morphine sulfate 2 mgs IV every three-to-four hours prn for pain" on the chart of an elderly client in an extended care facility. The PN has no other licensed persons working that shift. The initial action by the PN should be to
A.
B.
C.
D.
92.  Which one of these tasks for a 69 year-old client with a diagnosis of hyperglycemia could the nurse assign to the unlicensed assistive personnel (UAP)?
A.
B.
C.
D.
93.  The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?
A.
B.
C.
D.
94.  Which of the followwing entries in the progress notes of a client is the most complete?
A.
B.
C.
D.
95.  The nurse uses a wide stance when moving a heavy box of supplies. Which of the following is the best reason the nurse would do this? Because it
A.
B.
C.
D.
96.  A client is admitted with a diagnosis of schizophrenia. The client states "I don't need medication. It makes me sleepy." The client insists that the nurse explain the use and side effects of the medication. The nurse should understand that the best intervention is:
A.
B.
C.
D.
97.  A three year-old child is treated in the emergency room after ingestion of an ounce from a liquid narcotic bottle. What action should the nurse take first?
A.
B.
C.
D.
98.  The partner of a client with Alzheimer's disease expresses concern about the burden of caregiving. Which action by the nurse should be a priority?
A.
B.
C.
D.
99.  A client calls the evening health clinic to state "I know I have a severely low sugar since the Lantus insulin was given three hours ago and it peaks in two hours." What should be the nurse's initial response to the client?
A.
B.
C.
D.
100.  X-RN A client with a diagnosis of methicillin resistant staphylococcus aureus (MRSA) has died. Which type of transmission-based precautions is the appropriate type to use when performing postmortem care?
A.
B.
C.
D.
101.  When a client is diagnosed with tuberculosis, the public health department is to be notified for what reason?
A.
B.
C.
D.
102.  The nurse is preparing to administer lithium (Eskalith) to a client with bipolar disorder. The client complains of nausea and muscle weakness, and his speech is slurred. His lithium level is 1.6 mEq/L. The best action for the nurse to take is to
A.
B.
C.
D.
103.  The nurse monitors a client after the treatment of bradycardia with intravenous atropine sulfate. Which of these findings should be reported to the health care provider immediately?
A.
B.
C.
D.
104.  A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?
A.
B.
C.
D.
105.  The health care provider order reads "aspirate nasogastric feeding (NG) tube every four hours and check pH of aspirate". The pH of the aspirate is 10. Which action should the nurse take?
A.
B.
C.
D.
106.  19.    The nurse is caring for a 48-hour full-term infant whose mother abused cocaine and heroin throughout pregnancy. The mother does not wish to go into rehabilitation at this time. The nursing care plan should include which of the following?            
A.
B.
C.
D.
107.  The nurse is assisting with teaching a group of college students about breast self-examination. A woman asks when to perform the monthly exam. The appropriate reply by the nurse would be which of these?
A.
B.
C.
D.
108.  Which of the following is least likely to influence the potential for patient to comply with lithium therapy after discharge?
A.
B.
C.
D.
109.  When evaluating a client with a pressure ulcer, the nurse understands that the best response to treatment of the sacral pressure ulcer on a client with a hip fracture would be indicated by
A.
B.
C.
D.
110.  Which one of the following statements best describes the effects of immobility in children?
A.
B.
C.
D.
111.  The nurse is working in a high risk antepartal clinic. A 40 year-old woman in the first trimester gives a thorough health history. Which of the following collected data should receive priority attention by the nurse?
A.
B.
C.
D.
112.  Mr. Lowell is brought in after a motor vehicle accident. He has suffered a head injury and possible spinal injury. When moving him from the stretcher to the bed, the nurse should do the following
A.
B.
C.
D.
113.  The nurse observes a newborn whose Apgar score was 8 and 9. This score would be most closely associated with which of these areas?
A.
B.
C.
D.
114.  The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. The nurse should be sure to include which information?
A.
B.
C.
D.
115.  An important goal in the development of a therapeutic inpatient milieu is providing a A) businesslike atmosphere where clients can work on individual goals forum in which clients deB) group cide on unit rules, regulations, and policies
A.
B.
C.
D.
116.  A nurse arranges for an interpreter to assist with communication between the health care team and a non-English speaking client. To promote therapeutic communication when working with an interpreter, the utmost thing for the nurse to remember is to :
A.
B.
C.
D.
117.  A client states, "People think I'm no good, you know what I mean?" Which nursing response would be most therapeutic for this client?
A.
B.
C.
D.
118.  Which one of these tasks could be assigned to the certified nursing assistant (cna)? 
A.
B.
C.
D.
119.  A client with a panic disorder has a new prescription for Xanax (alpazolam). When reinforcing teaching to the client about the drug's actions and side effects, which item should the nurse emphasize?
A.
B.
C.
D.
120.  What is the primary nursing intervention to limit transmission of organisms for a client with a salmonella infection?
A.
B.
C.
D.
121.  Ms. Jordan is bedridden and positioned on her right side. There is a pillow beneath her head. Her right arm is extended near her hip. Her left leg is extended and parallel with the right leg. Which of the following is correct?
A.
B.
C.
D.
E.
122.  A 14 years child goes into seizures. Which nursing action is a priority for a client during a seizure
A.
B.
C.
D.
123.  The nurse should be informed about cultural issues related to the client's background because one of the following:
A.
B.
C.
D.
124.  The nurse is beginning to establish a nurse­client relationship with Ms. E. who was referred for help in managing her children. Ms. E. arrives late for appointments and focuses on her busy schedule, the difficulty in parking, and other reasons for being late. The nurse best interprets this behavior as
A.
B.
C.
D.
125.  During the focused assessment of a client with major depression, the nurse may ask which of the following questions?
A.
B.
C.
D.
126.  The nurse should be informed about cultural issues related to the client's background because one of the following:
A.
B.
C.
D.
127.  A client was just taken off the ventilator following surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client?
A.
B.
C.
D.
128.  Which newly admitted client would be most appropriate to assign to the unlicensed assistive personnel (UAP)?
A.
B.
C.
D.
129.  Marty Cole, 7 years old, is admitted to the pediatric service with a diagnosis of juvenile diabetes mellitus. He has not been under treatment previously. As a practical nurse, you would expect Marty to exhibit all of the following symptoms EXCEPT
A.
B.
C.
D.
130.  The best action to establish correct placement of a gastric tube is for the nurse to
A.
B.
C.
D.
131.  The nurse finds, during the initial assessment of the star player on the basketball team, that he is not concerned about the sudden paralysis of his "shooting arm." This behavior is known as :
A.
B.
C.
D.
132.  The community health nurse is making a newborn follow-up home visit. During the visit the two-year-old sibling has a temper tantrum. The parent asks the nurse for guidance in dealing with the toddler's temper tantrums. Which of the following is the most appropriate nursing action?
A.
B.
C.
D.
133.  Mr. A. has sprained his ankle. The physician would order cold applied to the injured area to
A.
B.
C.
D.
134.  If a nurse is uncertain about whether he or she is licensed to perform certain tasks, they should first check information in which of these resources?
A.
B.
C.
D.
135.  Mr. S. is to have a tepid sponge bath to lower his fever. What temperature should the nurse make the water?
A.
B.
C.
D.
136.  Four-year-old Amy has been blind since birth. She has been attending a nursery program for the visually impaired. To continue independence in her activities of daily living, when her lunch tray arrives, the nurse will
A.
B.
C.
D.
137.  When a client is diagnosed with tuberculosis, the public health department is to be notified for what reason?
A.
B.
C.
D.
138.  Dorreen an adolescent female is newly diagnosed with bulimia. The nurse is reinforcing instructions to the client and her parents about the theraputic benefits of Tofranil. Which statement demonstrates an understanding by the client?
A.
B.
C.
D.
139.  The nurse knows which of the following is the proper technique for medical asepsis selecting:
A.
B.
C.
D.
140.  While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the following actions is appropriate for the nurse to perform?
A.
B.
C.
D.
141.  In taking the history of a pregnant woman, which factor would the nurse recognize as the primary contraindication for breast feeding?
A.
B.
C.
D.
142.  PharmacologyAn antibiotic (intramuscular) IM injection for a two year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to
A.
B.
C.
D.
143.  A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to
A.
B.
C.
D.
144.  The nurse is reinforcing instructions for a client with asthma. Which item should be stressed for the client to monitor on a daily basis?
A.
B.
C.
D.
145.  Which of these protocols would be essential for the nurse to implement during the care of a client with active tuberculosis?
A.
B.
C.
D.
146.  Ms. F. suffered a stroke and has right-sided hemiparesis. The nurse is going to transfer her from bed to wheelchair. Which of the following is the best method?
A.
B.
C.
D.
147.  Randy, age 8, is admitted with rheumatic fever. Which clinical finding indicates to the nurse that Randy needs to continue taking the salicylates he had received at home?
A.
B.
C.
D.
148.  A three year-old child is treated in the emergency room after ingestion of an ounce from a liquid narcotic bottle. What action should the nurse take first?
A.
B.
C.
D.
149.  A 52 year-old post menopausal woman asks the nurse how frequently she should have a mammogram. The nurse's best response is:
A.
B.
C.
D.
150.  The nurse would reinforce the need to take alendronate (Fosamax) as prescribed by the physician,
A.
B.
C.
D.
151.  A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland." The nurse reviews this data and determines that this client is experiencing a speech pattern commonly seen in manic episodes called
A.
B.
C.
D.
152.  A 5 years old child has been admitted to the pediatric unit after swallowing a household cleaner. Which of these findings is more commonly associated with the fact that the poison was a corrosive?
A.
B.
C.
D.
153.  A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my companion will never come near me." The nurse's best response would be "Are you:
A.
B.
C.
D.
154.  A client tells the nurse, "I have something very important to tell you if you promise not to tell anyone." The appropriate response by the nurse would be
A.
B.
C.
D.
155.  Which of these actions best describes the application of time management strategies for the role of the PN charge nurse?
A.
B.
C.
D.
156.  Which of these actions is the first priority in the prevention of infections, whether in the hospital or home setting?
A.
B.
C.
D.
157.  Which action would be the best strategy for the nurse to use when reinforcing insulin injection techniques to a newly diagnosed adult client with diabetes mellitus?
A.
B.
C.
D.
158.  Several clients are admitted to an adult medical unit. The nurse would expect airborne precautions for a client with which of the following medical conditions?
A.
B.
C.
D.
159.  Mr. D. has a disorder of the hypothalamus and is on a hypothermia blanket. The nurse should make which of the following assessments?
A.
B.
C.
D.
160.  A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my companion will never come near me." The nurse's best response would be "Are you:
A.
B.
C.
D.
161.  A young adult is involuntarily admitted to the psychiatric unit in a manic state. Upon arrival on the unit he is unable to sit, and it is very difficult to follow what he is saying because of the rate and content of speech. He is very provocative and refuses to eat or drink. The area of disturbance that poses the greatest physical danger to this client is
A.
B.
C.
D.
162.  A ten year-old child has a history of tonic-clonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the most important action during the seizure activity would be to
A.
B.
C.
D.
163.  Which action would be the best strategy for the nurse to use when reinforcing insulin injection techniques to a newly diagnosed adult client with diabetes mellitus?
A.
B.
C.
D.
164.  Which of the following nursing diagnoses would be most appropriate for a client who is diagnosed as bipolar I disorder, single manic episode and is intrusive, argumentative, and severely critical of peers?
A.
B.
C.
D.
165.  A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts "You think you're so perfect and pure and good." The appropriate response for the nurse is:  
A.
B.
C.
D.
166.  An adult is admitted to the hospital to undergo a stapedectomy for the treatment of otosclerosis. Which findings elicited during physical assessment are most indicative of otosclerosis?
A.
B.
C.
D.
167.  A ten year-old child has a history of tonic-clonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the most important action during the seizure activity would be to
A.
B.
C.
D.
168.  The parents of a four year-old hospitalized child tell the nurse they will leave for a time and return at 6 PM. When the child asks when the parents will come again, the nurse can best respond by saying:
A.
B.
C.
D.
169.  The nurse is caring for a client who is four days post-op for a transverse colostomy. The client is ready for discharge and asks the nurse to empty the colostomy pouch. The nurse's best response to the client is:
A.
B.
C.
D.
170.  The client is receiving an intravenous piggyback infusion of penicillin. Which client statement would require the nurse's immediate attention?
A.
B.
C.
D.
171.  X-RN A client with a diagnosis of methicillin resistant staphylococcus aureus (MRSA) has died. Which type of transmission-based precautions is the appropriate type to use when performing postmortem care?
A.
B.
C.
D.
172.  A victim of a motor vehicle accident is brought to the emergency room via ambulance in hypovolemic shock. When placing the client in a modified Trendelenburg position, the nurse should place the client
A.
B.
C.
D.
173.  The nurse is assisting in the assessment of a client's home in preparation for discharge. Which focus should be given priority consideration?
A.
B.
C.
D.
174.  A 14 month-old child ingested half a bottle of aspirin tablets. Which finding would the nurse expect to see in the child?
A.
B.
C.
D.
175.  A client who has just joined a health maintenance organization (HMO) asks for information about the payment obligations with this plan. The most accurate description of health care costs is that the client will be charged
A.
B.
C.
D.
176.  A nurse who works at an extended care facility has just reviewed a new medication order which is not legible. Which statement best reflects assertive communication to the health care provider who wrote the order?
A.
B.
C.
D.
177.  An adult is in an acute manic phase of bipolar disorder. He talks and paces incessantly, frequently shouting and threatening other clients. The nurse expects the client's care plan to include which of the following?
A.
B.
C.
D.
178.  The nurse is checking a woman in early labor. While positioning for a vaginal exam, she complains of dizziness and nausea and appears pale. Her blood pressure has dropped slightly. What is the appropriate initial nursing action?
A.
B.
C.
D.
179.  Scoliosis a C S curvature of the spine; it cna a temporary or permanent condidtion. At what time would the nurse expect early findings of scoliosis to appear?                                                                                      
A.
B.
C.
D.
180.  While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the following actions is appropriate for the nurse to perform?
A.
B.
C.
D.
181.  A client with a diagnosis of bipolar disorder has been referred to a local boarding home to be considered for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The nurse should know that the most acceptable is : 
A.
B.
C.
D.
182.  In addition to handwashing, an appropriate infection control intervention during the care of a newly admitted adult client with a diagnosis of Hepatitis A would be which action?
A.
B.
C.
D.
183.  12.    A young woman with a history of bipolar disorder is admitted to the psychiatric unit. She is talking excitedly and walking rapidly around the unit. During the initial period of hospitalization, the nurse would most likely encourage the client to participate in group and therapeutic activities.
A.
B.
C.
D.
184.  The parents of a four year-old hospitalized child tell the nurse they will leave for a time and return at 6 PM. When the child asks when the parents will come again, the nurse can best respond by saying:
A.
B.
C.
D.
185.  A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?
A.
B.
C.
D.
186.  A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove her dentures prior to leaving the unit for the operating room. The most appropriate intervention by the nurse is:
A.
B.
C.
D.
187.  Which of these actions best describes the application of time management strategies for the role of the PN charge nurse?
A.
B.
C.
D.
188.  The nurse should begin considering discharge concerns for a hospitalized client considering one fo of the following:
A.
B.
C.
D.
189.  7.    Bumping into a crib, the nurse notices that the newborn infant demonstrates the Moro (startle) reflex. This is seen as the following:
A.
B.
C.
D.
190.  Privacy and confidentiality of client information is legally protected. In which of these situations would the nurse make an exception to this practice?
A.
B.
C.
D.
191.  A client is admitted to the emergency room following an acute asthma attack. Which of the following findings would be most important to report?
A.
B.
C.
D.
192.  The nurse is caring for a two month-old infant with a congenital heart defect. Which of the following is a priority nursing action?