Q. 1. The nurse is assessing the reflexes of a newborn. The nurse assesses which of the following reflexes by placing a finger in the newborn’s mouth?
A. Moro reflex
B. Sucking reflex
C. Rooting reflex
D. Babinski reflex
Answer: B
Q. 2.The nurse is preparing to administer an I.M. injection in a client with a spinal cord injury that has resulted in paraplegia. Which of the following muscles is best site for the injection in this case?
A. Deltoid.
B. Dorsal gluteal.
C. Vastus lateralis.
D. Ventral gluteal.
Answer: A
Q. 3.The primary goal of therapy for a client with pulmonary edema and heart failure?
A Enhance comfort
B Improve respiratory status
C Peripheral edema decreased
D Increase cardiac output
Answer: D
Q. 4.A client says to the nurse "I know that I'm going to die." Which of the following responses by the nurse would be best?
A. "We have special equipment to monitor you and your problem."
B. "Don't worry. We know what we're doing and you aren't going to die."
C. "Why do you think you're going to die?"
D. "Oh no, you're doing quite well considering your condition."
Q. 5. The nurse is to collect a sputum specimen from a client. The best time to collect this specimen is:
A. early in the evening.
B. anytime during the day.
C. in the morning, as soon as the client awakens.
D. before bedtime.
Answer: C Because sputum accumulates in the lungs during sleep, the nurse should collect a sputum specimen in the morning, as soon as the client awakens and before he eats or drinks. This specimen will be concentrated, increasing the likelihood of an accurate culture
Q. 6. Which type of nursing intervention does the nurse perform when she administers oral care to a client?
A. Psychomotor.
B. Educational.
C. Maintenance.
D. Supervisory.
Answer:c
Q. 7. On her 3rd postpartum day, a client complains of chills and aches. Her chart shows that she has had a temperature of 100.6° F (38.1° C) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What do these findings suggest?
A. Lochia alba
B. Lochia serosa
C. Localized infection
D. Cervical laceration
Q. 8. What is the term used for normal respiratory rhythm and depth in a client?
A. Eupnea
B. Apnea
C. Bradypnea
D. Tachypnea
Q. 9. An obese client has returned to the unit after receiving sedation and electroconvulsive therapy. The nurse requests assistance moving the client from the stretcher to the bed. There are 2 people available to assist. Which of the following is the best method of transfer for this patient?
A. Carry lift.
B. Sliding board.
C. Lift sheet transfer.
D. Hydraulic lift.
Answer:B
Q. 10. A client receives a painkiller. Thirty minutes
later , The nurse asks the client if the pain is
relieved. Which step of nursing process the
nurse is using?
A. Assessment
B. Nursing diagnosis
C. Implementation
D. Evaluation
Q. 11. A dull percussion is noted over the symphysis pubis , it may indicate
A. Pelvic inflammatory disease
B. Prostatitis
C. Peritonitis
D. Distended Bladder
Answer: D
Q. 12. A nurse is assessing a group of clients. The nurse knows that which of the following clients is at risk for fluid volume deficit?(DHA)
a) Client diagnosed with liver cirrhosis.
b) Client with diminished kidney function.
c) Client diagnosed with congestive heart failure.
d) Client attached to a colostomy bag.
Answer: D
Q.13. Best time to check IOP?
A. Early morning
B. After noon
C. Late evening
D. At noon
Answer: A
Q14. The physician teaches a client about the need to increase her intake of calcium. At a follow-up appointment, the nurse asks the client which foods she has been consuming to increase her calcium intake. Which answer suggests that teaching about calcium-rich foods was effective?
A. Broccoli and nuts
B. Yogurt and kale
C. Bread and shrimp
D. Beans and potatoes
Answer: B
Q15. The nurse is caring for a client diagnosed with a stroke. Because of the stroke, the client has dysphagia (difficulty swallowing). Which intervention by the nurse is best for preventing aspiration?
A. Placing the client in high Fowler's position to eat.
B. Offering liquids and solids together.
C. Keeping liquids thinned.
D. Placing food on the affected side of the mouth.
Answer: A
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A. Moro reflexB. Sucking reflex
C. Rooting reflex
D. Babinski reflex
Answer: B
Q. 2.The nurse is preparing to administer an I.M. injection in a client with a spinal cord injury that has resulted in paraplegia. Which of the following muscles is best site for the injection in this case?
A. Deltoid.
B. Dorsal gluteal.
C. Vastus lateralis.
D. Ventral gluteal.
Answer: A
Q. 3.The primary goal of therapy for a client with pulmonary edema and heart failure?
A Enhance comfort
B Improve respiratory status
C Peripheral edema decreased
D Increase cardiac output
Answer: D
Q. 4.A client says to the nurse "I know that I'm going to die." Which of the following responses by the nurse would be best?
A. "We have special equipment to monitor you and your problem."
B. "Don't worry. We know what we're doing and you aren't going to die."
C. "Why do you think you're going to die?"
D. "Oh no, you're doing quite well considering your condition."
Q. 5. The nurse is to collect a sputum specimen from a client. The best time to collect this specimen is:
A. early in the evening.
B. anytime during the day.
C. in the morning, as soon as the client awakens.
D. before bedtime.
Answer: C Because sputum accumulates in the lungs during sleep, the nurse should collect a sputum specimen in the morning, as soon as the client awakens and before he eats or drinks. This specimen will be concentrated, increasing the likelihood of an accurate culture
Q. 6. Which type of nursing intervention does the nurse perform when she administers oral care to a client?
A. Psychomotor.
B. Educational.
C. Maintenance.
D. Supervisory.
Answer:c
Q. 7. On her 3rd postpartum day, a client complains of chills and aches. Her chart shows that she has had a temperature of 100.6° F (38.1° C) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What do these findings suggest?
A. Lochia alba
B. Lochia serosa
C. Localized infection
D. Cervical laceration
Q. 8. What is the term used for normal respiratory rhythm and depth in a client?
A. Eupnea
B. Apnea
C. Bradypnea
D. Tachypnea
Q. 9. An obese client has returned to the unit after receiving sedation and electroconvulsive therapy. The nurse requests assistance moving the client from the stretcher to the bed. There are 2 people available to assist. Which of the following is the best method of transfer for this patient?
A. Carry lift.
B. Sliding board.
C. Lift sheet transfer.
D. Hydraulic lift.
Answer:B
Q. 10. A client receives a painkiller. Thirty minutes
later , The nurse asks the client if the pain is
relieved. Which step of nursing process the
nurse is using?
A. Assessment
B. Nursing diagnosis
C. Implementation
D. Evaluation
Q. 11. A dull percussion is noted over the symphysis pubis , it may indicate
A. Pelvic inflammatory disease
B. Prostatitis
C. Peritonitis
D. Distended Bladder
Answer: D
Q. 12. A nurse is assessing a group of clients. The nurse knows that which of the following clients is at risk for fluid volume deficit?(DHA)
a) Client diagnosed with liver cirrhosis.
b) Client with diminished kidney function.
c) Client diagnosed with congestive heart failure.
d) Client attached to a colostomy bag.
Answer: D
Q.13. Best time to check IOP?
A. Early morning
B. After noon
C. Late evening
D. At noon
Answer: A
Q14. The physician teaches a client about the need to increase her intake of calcium. At a follow-up appointment, the nurse asks the client which foods she has been consuming to increase her calcium intake. Which answer suggests that teaching about calcium-rich foods was effective?
A. Broccoli and nuts
B. Yogurt and kale
C. Bread and shrimp
D. Beans and potatoes
Answer: B
Q15. The nurse is caring for a client diagnosed with a stroke. Because of the stroke, the client has dysphagia (difficulty swallowing). Which intervention by the nurse is best for preventing aspiration?
A. Placing the client in high Fowler's position to eat.
B. Offering liquids and solids together.
C. Keeping liquids thinned.
D. Placing food on the affected side of the mouth.
Answer: A
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