(MCQ) 1. The nurse is assessing a postpartum patient and notes the…

(MCQ)
1. The nurse is assessing a postpartum patient and notes the peri-pad has whitish-yellow discharge. The nurse would correctly document this vaginal discharge as which of the following?
A. Lochia alba.
B. Lochiarubra.
C. Lochiaserosa.
D. Postpartal bleeding.
2. A client begins to have a seizure during your assessment. Which of the following interventions should be initiated first?
A. Place protective pads on the bed.
B. Protect the client from injuring himself.
C. Turn the client onto his side.
D. Monitor seizure and give appropriate medication.
3. A client with congestive heart failure is receiving spironolactone (Aldactone) 25 mg orally each day. Which of the following is essential for the nurse to assess in order to monitor the client for symptoms of potassium imbalance?
A.Hypotension and hyperglycemia.
B.Nausea, vomiting, and diarrhea.
C.Increased respirations and decreasing level of consciousness.
D.Increased urine output.
4. The nurse is caring for a client who has been experiencing nausea and vomiting for several client is at risk for developing which of these imbalances?
A.Respiratoryalkalosis.
B.Metabolic acidosis.
C.Metabolic alkalosis.
D.Respiratoryacidosis.
5. The nurse is assisting the obstetrician during a vaginal examination. The obstetrician notes has a bluish-purple color. The nurse would recognize this condition as _____
A.Chadwick’s sign.
B.leukorrhea.
C.Goodell’s sign.
D.mucus plug.
6. The patient is experiencing the effects of a recent cerebrovascular accident and is unable to hear out of the left ear. Which of the following cranial nerves was most likely affected?
A. Cranial nerve VIII.
B. Cranial nerve XII.
C. Cranial nerve VII.
D. Cranial nerve I.
7. Blood work done to identify risk factors for coronary heart disease reveals a client has elevated cholesterol and low density lipid (LDL) levels. The nurse should make the following suggestions for changes in dietary habits _____
A. Eliminate all red meat from the diet.
B. Eliminate all simple sugars from the diet.
C. Avoid eating eggs or any foods prepared with eggs.
D. Switch from whole milk to skim milk.
8. The nurse is preparing to administer influenza immunizations to a group of clients. The nurse should not administer the immunization to clients who are _____
A. immunosuppressed.
B. not exposed to the influenza virus.
C. naturallyimmune.
D. elderly.
9. The nurse The nurse is developing a plan of care for a client with an Avoidant Personality Disorder. decides an appropriate goal would be for the client to _____
A.make a decision about their care.
B.refrain from harming others.
C.improve social skills.
D.be free from self-harm.
10. A postoperative laryngectomy and radical neck dissection client has a nursing diagnosis of Impaired Verbal Communication. Which of the following interventions should be included in the care plan?
A. Provide the client with a pen and paper for writing.
B. Instruct the client to speak softly when talking.
C. Teach the client to read lips.
D. Provide uninterrupted time for the client to attempt communication with the nurse
and health care team.
11. The nurse is caring for a patient who was admitted to the medical unit. The physician states that the patient’s Romberg test was positive. As the nurse plans to meet the patient’s elimination needs, the nurse would implement which of the following interventions?
A. Obtain a bedside commode.
B. Allow the patient to walk independently.
C. Limit fluid intake.
D. Obtain an order for a catheter.
12. Following a hypophysectomy for a pituitary tumor, the client is monitored for the presence of diabetes insipidus. Which finding by the nurse indicates this condition?
A. Large amount of dilute urine.
B. Fluid retention and dependent edema.
C. Rise in blood pressure.
D. Hyponatremia.
13. While eating in a restaurant, a nurse observes a woman in the late stage of pregnancy coughing and holding her throat. When asked by the nurse if she is choking, she nods “yes.” What is the most correct placement of hands should the nurse need to perform the Heimlich maneuver?
A. Above the naval and below the xiphoid process.
B. In the same place as for CPR.
C. Over the xiphoid process of the sternum.
D. Over the upper two-thirds of the sternum.
14. A student nurse had a needle-stick injury and had not been immunized for hepatitis B. The infection control nurse advises the student nurse to get which of the following treatments?
A. Evaluation of liver function tests in 10 days.
B. Hepatitis B immune globulin(HBIG).
C. Hepatitis B vaccine.
D. Hepatitis B vaccine and hepatitis B immune globulin(HBIG).

15. Many hospitals are no longer allowing the use of the letter “Q” as an abbreviation either alone or in combination (such as QID, or QS). What is the primary reason for this action?
A. Errors are reduced when fewer abbreviations are used in orders and in communicating information.
B. Not all nurses know that “Q” means “quaque” in Latin.
C. A hospital may not have computerized ordering and physicians’ handwriting is often hard to read.
D. It is more accurate to write “every” instead of “Q”.
16. A 78-year-old client is admitted with a diagnosis of left-sided congestive heart failure. When assessing the client, what signs and symptoms can the nurse expect to find?
A. Dyspnea, orthopnea, and cough.
B. Enlarged liver, venous congestion, and distended neck veins.
C. Peripheral dependent edema and bradycardia.
D. Signs of fluid volume deficit, hypokalemia, and hypernatremia.
17. A client has been treated with a cardiac glycoside and diuretics for congestive heart failure (CHF). The nurse determines the treatment has been successful when the client experiences _____
A. improved level of consciousness.
B. clear lung sounds.
C. weight loss.
D. an increase in energy level.
18. A client has just been diagnosed with a pulmonary embolism. The nurse anticipates the physician will order which of the following medication therapies?
A. Nitroglycerin therapy.
B. Heparin therapy.
C. Bronchodilator and nebulizer treatments. D. Antibiotic therapy.
19. The client diagnosed with endometriosis asks the nurse to explain what it is. The nurse provides the following explanation _____
A. “It is inflammation of the inside of your uterus.”
B. “It is an infection of the tissue that connects your intestines.”
C. “It is inflammation of the outside lining of your uterus.”
D. “It is a condition in which the tissue found inside the uterus grows outside the
uterus.”
20. A nurse is assigned to a client who is returning from the recovery room after a right pneumonectomy. What is the best position to facilitate chest and lung expansion postoperatively for this client?
A. Left side-lying.
B. Supine.
C. Semi-Fowler’s.
D. Right side-lying.
21. Family members are upset and frightened over a client’s use of profane language and verbal abusive behavior. The nurse explains that the behavior is related to the location of the client’s brain tumor in the _____
A. temporal lobe.
B. parietal lobe.
C. frontal lobe.
D. occipital lobe.

22. A client who has just had a heart attack reports experiencing intense pain in the left shoulder.
The nurse explains this type of pain is called———
A.acute pain.
B.phantompain.
C.referred pain.
D.chronic pain.

23. The nurse is interviewing a female patient who reports no menstrual periods for 2 months and breast soreness The nurse would document this data as which classification of signs of
pregnancy?
A. Objective.
B. Positive.
C. Presumptive.
D. Probable.

24. A client who has experienced a severe blood loss becomes hypotensive and loses consciousness. The nurse suspects the client is experiencing _____
A. cardiogenic shock.
B. hypovolemic shock.
C. neurogenic shock.
D. anaphylactic shock.
25. According accurate?
to the GTPAL system of recording prenatal histories, which statement is most
A. Multiple-gestation births increase the number of the G parameter.
B. Elective abortions are not considered in the A parameter.
C. Preterm birth (P parameter) occurs at 18 weeks of gestational age.
D. The notation of L parameter may be different than the stated amount of G and P
parameters following the birth.

26. When providing client instruction, the nurse must incorporate all three domains of learning to promote the success if the teaching. A client is to be instructed in giving heparin by self- injection. Which aspect of the teaching involves the psychomotor domain of the client’s learning?
A. The nurse discusses with the client how he feels about giving himself injections.
B. The client is educated about the reasons he is taking heparin.
C. The client provides a return demonstration of the procedure for subcutaneous
injection to the nurse.
D. The client is given a list of side effects that need to be reported to the physician.
27. A nurse has ambulated a 2-day postoperative adult client as ordered and assists the client to return to bed. The nurse determines that the client did not physically tolerate the ambulation when the client _____
A. has a systolic blood pressure of 104 mmHg.
B. has a radial pulse of 140 beats per minute.
C. complains of feeling weak and tired.
D. expresses feeling nauseous.
28. A client is brought in with a gunshot wound to the chest. The nurse assesses for tension pneumothorax. What signs and symptoms of tension pneumothorax can the nurse expect to find?
A. Wheezes in all lung fields.
B. Audible sucking sounds on inspiration.
C. Deviated trachea.
D. High blood pressure.
29. The nurse is checking the laboratory results on a client suspected of having a myocardial infarction (MI). Which of the following would provide the most specific information for this diagnosis?
A. C-reactive protein.
B. Low density lipids (LDLs).
C. AST and ALT.
D. CK-MB.
30. The nurse is monitoring vital signs on a client receiving a blood transfusion. If a transfusion febrile reaction occurs, the client experiences chills and fever usually within _____
A. 3 hours.
B. 2 hours.
C. 60 minutes.
D. 15 minutes.
31. The nurse should watch for which of the following side effects when clients are receiving NSAIDs, nonsteroidal anti-inflammatory drugs, for pain?
A. Vertigo and syncope.
B. Diarrhea and vomiting.
C. Confusion and memory loss.
D. Tarry black stools and epigastric pain.
32. The nurse evaluates the effectiveness of a client’s intravenous injection of morphine sulfate, 15 mg, given for pain. How soon can the nurse expect the client to begin to get some relief?
A. 1 to 5 minutes.
B. 10 to 15 minutes.
C. 20 to 30 minutes.
D. 1 to 2 hours.
33. The nurse caring for a client admitted with a diagnosis of suspected lung cancer might expect to find which of the following on assessment?
A. Dysphagia.
B. Night sweats.
C. Cyanosis.
D. Hemoptysis.
34. A physician’s order has been written for a pediatric client in skeletal traction to be weighed daily because of recent anorexia, vomiting, and diarrhea. The nurse who is caring for the client should plan to first _____
A. weigh the client every day at the same time, using the same scale.
B. discuss the order with the physician before implementing it.
C. tell the client and the parents about the new order.
D. remove the traction apparatus to facilitate weighing the client.
35. A client suffers from claustrophobia, the fear of being in enclosed places. The nurse knows that the client may have difficulty with the following test _____
A.CT scan.
B.X-rayimaging.
C.MRI.
D.Ultrasonography.
36. The nurse is caring for a patient who denies having pain. The nurse has noticed the patient grimacing and clenching his teeth when moving. The patient’s spouse has asked the nurse why some people deny obvious pain. What response by the nurse is most appropriate?
A.Some people feel reporting their pain is a sign of weakness.”
B. “You should try to find out why your husband is denying the pain.”
C.”Have you talked to the physician about this?”
D.”Maybe we are wrong and pain is not really bad.”
37. Which nursing action is indicated when performing the Romberg test?
A. Instruct the patient to keep the eyes open.
B. Strike the tuning fork prior to beginning the test.
C. Instruct the patient to occlude the ear canal of the untested ear.
D. Stand close to the patient.
38. A nurse in a same-day surgery center is reinforcing discharge instructions to a client who has had a removal of a cataract and implanting of an intraocular lens in the right eye. Which of the following is the least correct nursing instruction for the client?
A. Deep-breathe and cough every 1 to 2 hours.
B. Sleep on the left side.
C. Refrain from removing the right eye patch.
D. Call the surgery center or the physician’s office if any eye pain is present.
39. The nurse monitors a client with suspected nasal bone fractures for cerebrospinal fluid leakage by _____
A. gently palpating nose for presence of crepitus.
B. checking nasal or ear drainage for glucose.
C. determining the amount of postnasal drainage.
D. checking the nasal drainage for blood.
40. A client admitted with a diagnosis of anorexia nervosa has all of the following nursing diagnoses. Which diagnosis will take priority in planning nursing care?
A. Imbalanced Nutrition: less than body requirements.
B. Risk for Impaired Tissue Integrity.
C. Chronic Low Self-Esteem.
D. Disturbed Body Image.
41. The nurse notes that a client has a diagnosis of post-traumatic stress syndrome (PTSD). When developing a plan of care, the nurse anticipates the client may have the following nursing diagnosis _____
A. Disturbed Body Image related to trauma of imprisonment.
B. Self-Care Deficit related to refusal to bathe self.
C. Anxiety related to flashbacks of torture.
D. Acute Pain related to nerve damage secondary to torture.
42. The nurse is performing an otoscopic examination on an adult patient and is unable to visualize the tympanic membrane. The nurse should perform which of the following steps to better visualize this structure?
A. Tell the patient to move away from the speculum if they experience any pain as the otoscope is advanced.
B. Pull the pinna down and back, then reinsert the otoscope.
C. Pull the pinna up and back, then reinsert the otoscope.
D. Reinsert the otoscope quickly and press against both sides of the inner auditory
canal.
43. An intravenous infusion site in the left hand has become infiltrated and the nurse is choosing another site to restart the infusion. The most appropriate site for the nurse to consider next for venipuncture is a site _____
A. at least 3 inches distal to the previous site in the left hand.
B. at least 3 inches proximal to the previous site in the left hand.
C. in the most distal appropriate vein in the right hand.
D. in the most proximal appropriate vein in the right hand.
44. The nurse is caring for a pregnant patient who wishes to know the estimated date of birth (EDB) for the baby. The patient reports the last menstrual period (LMP) was April 10. Using Nagele’s formula, the nurse would correctly calculate the EDB as which of the following?
A. May24.
B. January17.
C. February1.
D. May17.
45. The nurse is conducting a hearing assessment on an older adult patient with impacted cerumen noted in the right ear canal. When performing the Weber test, the nurse would expect which finding?
A. Bone conduction is longer than air conduction.
B. Air conduction is longer than bone conduction.
C. Sound is lateralized to the right ear.
D. The patient is unable to maintain balance while standing.
46. A client is receiving cancer chemotherapy treatment for cancer of the colon. All of the following side effects of the medications used for the chemotherapy are experienced by the client. Which side effect is of most concern to the nurse at this time?
A. Photosensitivity.
B. Bone marrow depression.
C. Alopecia.
D. Nausea and vomiting.
47. A nurse has obtained a blood pressure reading of 110/70. The client asks what the number 70
means. The nurse should tell the client that this number _____
A. reflects the pressure of the left ventricle of the heart when it is contracting.
B. is abnormally high.
C. represents the pressure present at all times within the arteries.
D. is the pulse pressure.
48. A client is scheduled to have a right eye cataract extraction and is having a pre-surgery appointment with the nurse to receive the preoperative instructions. The client asks the nurse how a cataract extraction is done. What is the most appropriate initial response by the nurse?
A. “What has the doctor told you about how it will be done?”
B. “What do you know about the procedure?”
C. “We have a video that shows a cataract extraction. Would you like to watch it?”
D. “Do you have concerns about the cataract surgery?”
49. A client with left-side congestive heart failure is being treated with digoxin (Lanoxin) and furosemide (Lasix). Which observation of the client indicates a desired effect of the medications on the client’s respiratory system?
A.Gurgling sounds are heard on auscultation of the lower lobes of the lungs bilaterally.
B.The client experiences some dyspnea after ambulation.
C.The client is sitting in the orthopneic position, and respirations are even and non- labored.
D.The client is resting in a low-Fowler’s position, and respirations are even and non- labored.
50. The nurse performs frequent neurovascular assessments for clients with musculoskeletal trauma in order to prevent _____
A. fat embolus.
B. DVT.
C. compartment syndrome.
D. CVA.

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