Multiple Choice
Identify the
choice that best completes the statement or answers the question.
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1.
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A licensed practical nurse (LPN) is a certified
basic life support (BLS) instructor. The LPN is conducting a BLS recertification class and is
discussing automated external defibrillation. A member of the class asks the LPN to identify the
correct location for the placement of conductive gel pads to treat ventricular fibrillation. The LPN
tells the class that the conductive gel pads are placed in which of the following locations on the
client’s chest?
a. | Bilaterally under the right and left
clavicles | b. | Parallel between the umbilicus and the left
nipple | c. | Centered on the upper and lower half of the
sternum | d. | Under the right clavicle and to the left of the
precordium |
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2.
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A nurse is initiating one-rescuer cardiopulmonary
resuscitation on an adult client. After ventilating the client, the nurse places the hands in which
of the following positions to begin chest compressions?
a. | On the upper third of the
sternum | b. | On the lower half of the
sternum | c. | On the lower third of the
sternum | d. | On the upper half of the
sternum |
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3.
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A nurse walking in a downtown business area sees a
worker fall from a ladder while working on a sign above the door to a store. The nurse rushes to the
victim, who is unresponsive. The nurse then uses which of the following most appropriate methods to
open the victim’s airway?
a. | Head tilt–jaw thrust | b. | Jaw thrust maneuver | c. | Head
tilt–chin lift | d. | Neutral or
sniffing position |
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4.
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A nurse notes that a 5-year-old child is choking
but is awake and alert at this time. As the nurse rushes to aid the child, the nurse plans to place
the hands between which of the following landmarks to remove the foreign body?
a. | The umbilicus and xiphoid
process | b. | The lower abdomen and chest | c. | The umbilicus and the groin | d. | The groin and the xiphoid process |
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5.
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A nurse employed in the pediatric unit working on
the 11:00 PM to 7:00 AM shift finds an infant unresponsive and without respiration or a pulse. After
opening the airway and initiating ventilation, the nurse plans to deliver chest compressions at a
rate of at least:
a. | 140 times per minute | b. | 100 times per minute | c. | 80 times per
minute | d. | 60 times per
minute |
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6.
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A nurse arrives at the scene of a code and begins
to assist in performing cardiopulmonary resuscitation (CPR) on an adult client. After determining
proper hand placement, the nurse begins delivering compressions by pushing down on the chest to a
depth of:
a. | 1 to 2 inches | b. | 2 to 3 inches | c. | 1/2 to 1
inch | d. | 1/4 to 1/2 inch |
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7.
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An automatic external defibrillator (AED) is
available to treat a client who goes into cardiac arrest. The nurse uses this equipment to determine
cardiac rhythm by doing which of the following?
a. | Applying the adhesive patch electrodes to the skin and
moving away from the client | b. | Connecting
standard electrocardiographic (ECG) electrodes to a transtelephonic monitoring
device | c. | Applying standard ECG monitoring leads to the client and
observing the rhythm | d. | Holding the
defibrillator paddles firmly against the chest |
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8.
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An automatic external defibrillator (AED)
interprets that the rhythm of a pulseless client is ventricular fibrillation. The nurse takes which
of the following actions next?
a. | Charges the machine and immediately pushes the discharge
buttons on the console | b. | Administers rescue
breathing during the defibrillation | c. | Orders personnel
away from the client, charges the machine, and depresses the discharge
buttons | d. | Performs cardiopulmonary resuscitation for 1 minute
before defibrillating |
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9.
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A nurse witnesses a person starting to choke in the
hospital cafeteria. Before performing abdominal thrusts, the nurse should first:
a. | Ask the client, “Are you
choking?” | b. | Begin rescue
breathing. | c. | Place the arms
around the victim’s waist. | d. | Look for pallor or
cyanosis. |
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10.
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A nurse has completed five cycles of compressions
after beginning cardiopulmonary resuscitation (CPR) on a hospitalized adult client. At this time, the
nurse should:
a. | Prepare for defibrillation. | b. | Reassess the client. | c. | Prepare for the
administration of bicarbonate. | d. | Stop
CPR. |
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11.
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A client with a perforated gastric ulcer is
scheduled for emergency surgery. The client cannot sign the operative consent form because he has
been sedated with opioid analgesics. The nurse should take which of the following actions in the care
of this client?
a. | Obtain a telephone consent from the family member
witnessed by two persons. | b. | Obtain a court
order for the surgery. | c. | Send the client to
surgery without the consent form being signed. | d. | Have the hospital
chaplain sign the informed consent immediately. |
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12.
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A preoperative client expresses anxiety to the
nurse about the upcoming surgery. Which of the following responses by the nurse is most likely to
stimulate further discussion between the client and the nurse?
a. | “I will be happy to explain the entire surgical
procedure to you.” | b. | “Let me tell
you about the care you’ll receive after surgery and the amount of pain you can
anticipate.” | c. | “If
it’s any help, everyone is nervous before surgery.” | d. | “Can you share with me what you’ve been told about your
surgery?” |
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13.
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A nurse is teaching a client about the use of an
incentive spirometer in the postoperative period. The nurse should include which of the following
pieces of information in discussions with the client?
a. | Keep a loose seal between the lips and the
mouthpiece. | b. | Inhale as rapidly
as possible. | c. | After maximum
inspiration, hold the breath for 10 seconds and exhale. | d. | The best results are achieved when sitting at least halfway or fully
upright. |
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14.
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A nurse is preparing the client for transfer to the
operating room (OR). The nurse should take which of the following actions in the care of this client
at this time?
a. | Administer all the daily
medications. | b. | Ensure that the
client has voided. | c. | Verify that the
client has not eaten for the last 24 hours. | d. | Practice
postoperative breathing exercises. |
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15.
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A nurse is assigned to assist in caring for a
client who recently returned from the operating room. On data collection, the nurse notes that the
client’s vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per
minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74
beats per minute, respirations 20 breaths per minute. Which of the following actions should the nurse
plan to take first?
a. | Recheck the vital signs in 15
minutes. | b. | Call the surgeon immediately. | c. | Cover the client with a warm blanket. | d. | Shake gently to arouse. |
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16.
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A nurse just reassessed the condition of a
postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to most
carefully monitor which of the following parameters during the next hour?
a. | Serous drainage on the surgical
dressing | b. | Blood pressure of 100/70 mm
Hg | c. | Urinary output of 20 mL/hour | d. | Temperature of 99.6° F (37.6°
C) |
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17.
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A client is admitted to the surgical unit
postoperatively with a wound drain (Hemovac) in place. Which of the following nursing actions would
the nurse avoid in the care of the drain?
a. | Check the drain for patency. | b. | Curl the drain tightly and tape it firmly to the
body. | c. | Maintain aseptic technique when
emptying. | d. | Observe for bright red bloody
drainage. |
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18.
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When performing a surgical dressing change of a
client’s abdominal dressing, a nurse notes an increase in the amount of drainage and separation
of the incision line. The underlying tissue is visible to the nurse. The nurse should plan to do
which of the following in the initial care of this wound?
a. | Leave the incision open to the air to dry the
area. | b. | Apply a povidone-iodine–soaked sterile
dressing. | c. | Irrigate the wound and apply a dry sterile
dressing. | d. | Apply a sterile dressing soaked with normal
saline. |
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19.
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A nurse is monitoring the status of the
postoperative client. The nurse would become most concerned with which of the following signs, which
could indicate an evolving complication?
a. | Blood pressure of 110/70 mm Hg with a pulse of 86 beats
per minute | b. | Increasing
restlessness | c. | Hypoactive bowel
sounds in all four quadrants | d. | A negative
Homans’ sign |
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20.
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A nurse is reviewing the physician’s order
sheet for the preoperative client, which states that the client must be on nothing per mouth (NPO)
status after midnight. The nurse would clarify whether which of the following medications should be
given to the client and not withheld?
a. | Conjugated estrogen
(Premarin) | b. | Atenolol
(Tenormin) | c. | Cyclobenzaprine
(Flexeril) | d. | Ferrous
sulfate |
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21.
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A client has just returned from the cardiac
catheterization laboratory. The left femoral vessel was used as the access site. After returning the
client to bed and collecting initial data, the nurse places a sign above the bed stating that the
client should remain on bedrest:
a. | With the foot of the bed elevated as much as tolerated
by the client | b. | In
semi-Fowler’s position | c. | With the head of
the bed elevated 45 degrees | d. | With the head of
the bed elevated no more than 15 degrees |
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22.
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A nurse is providing instructions to a client and
family regarding home care following cataract removal from the left eye. The nurse would provide the
client with which of the following pieces of information about positioning in the postoperative
period?
a. | Lower the head between the knees three times a
day. | b. | Bend below the waist as frequently as
able. | c. | Do not sleep on the left
side. | d. | Sleep only on the left
side. |
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23.
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A nurse has assisted the physician with a liver
biopsy, which was done at the bedside. Upon completion of the procedure, the nurse assists the client
into which of the following positions?
a. | Left side-lying with a small pillow or towel under the
puncture site | b. | Right side-lying
with a small pillow or towel under the puncture site | c. | Left side-lying with the right arm elevated above the
head | d. | Right side-lying with the left arm elevated above the
head |
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24.
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A client with right pleural effusion by chest x-ray
is being prepared for a thoracentesis. The client experiences dizziness when sitting upright. The
nurse assists the client to which of the following positions for the procedure?
a. | Prone with the head turned to the side supported by a
pillow | b. | Sims’ position with the head of the bed
flat | c. | Right side-lying with the head of the bed elevated 45
degrees | d. | Left side-lying with the head of the bed elevated 45
degrees |
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25.
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A nurse is caring for a client following craniotomy
who has a supratentorial incision. The nurse reviews the client’s plan of care, expecting to
note that the client should be maintained in which of the following positions?
a. | Semi-Fowler’s position | b. | Dorsal recumbent position | c. | Prone position | d. | Supine
position |
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26.
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A nurse is teaching a client with chronic airflow
limitation (CAL) about positions that help breathing during dyspneic episodes. The nurse instructs
the client to avoid which of the following positions because it will aggravate
breathing?
a. | Sitting up with elbows resting on
knees | b. | Standing and leaning against a
wall | c. | Lying on his or her back in low Fowler’s
position | d. | Sitting up and leaning on a
table |
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27.
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A client is about to undergo a lumbar puncture
(LP). The nurse tells the client that which of the following positions will be used during the
procedure?
a. | Side-lying with the legs pulled up and the head bent
down onto the chest | b. | Side-lying with a
pillow under the hip | c. | Prone with a
pillow under the abdomen | d. | Prone in slight
Trendelenburg’s position |
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28.
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A nurse has admitted a client to the clinical
nursing unit following a right mastectomy. The nurse plans to place the right arm in which of the
following positions?
a. | Elevated above shoulder level | b. | Elevated on one or two pillows | c. | Level with the right atrium | d. | Dependent to the right atrium |
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29.
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A client has undergone a right pneumonectomy. The
nurse positioning this client following admission from the postanesthesia care unit avoids placing
the client in which harmful position?
a. | Right lateral | b. | Low Fowler’s position | c. | Semi-Fowler’s position | d. | High Fowler’s position |
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30.
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A nurse is assisting a physician with the insertion
of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the
tube is inserted. Based on this observation, the nurse plans to take which appropriate
action?
a. | Document the accurate functioning of the
tube. | b. | Reinforce the occlusive
dressing. | c. | Ensure that suction is turned
on. | d. | Encourage the client to deep
breathe. |
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31.
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A nurse is caring for a client with a chest tube
who accidentally disconnects the tube from the drainage system when trying to get out of bed. The
nurse should take which action first?
a. | Replace the chest tube
system. | b. | Place a sterile dressing over the end of the chest
tube. | c. | Place the client in a prone
position. | d. | Immerse the end of the tube in sterile
saline. |
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32.
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A physician is about to remove a chest tube from a
client. Once the dressing is removed and the sutures have been cut, the nurse assisting the physician
asks the client to:
a. | Exhale immediately. | b. | Perform the Valsalva maneuver. | c. | Breathe deeply and rapidly. | d. | Breathe in and out rapidly. |
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33.
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A nurse is assisting in caring for the client
immediately after removal of the endotracheal tube following radical neck dissection. The nurse
interprets that which of the following signs experienced by the client should be reported immediately
to the registered nurse (RN)?
a. | Respiratory rate of 26 breaths per
minute | b. | Lung congestion | c. | Stridor | d. | Occasional
pink-tinged sputum |
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34.
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A nurse is assigned to assist in caring for a
client who has a pneumothorax. The nurse notes continuous bubbling in the water seal chamber of the
client’s closed-chest drainage system. The nurse determines that which of the following is
occurring?
a. | The system must have a crack in
it. | b. | The suction to the system is shut
off. | c. | There is an air leak somewhere in the
system. | d. | The pneumothorax is
resolving. |
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35.
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A nurse must ambulate a client who has a
nephrostomy tube attached to a drainage bag. The nurse plans to do this most safely and effectively
by:
a. | Asking the client to hold the drainage bag lower than
the level of the bladder | b. | Changing the
drainage bag to a leg collection bag | c. | Tying the drainage
bag to the client’s waist while ambulating | d. | Hanging the drainage bag from a walker while
ambulating |
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36.
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A licensed practical nurse (LPN) is assisting in
insertion of a nasogastric (NG) tube for an adult client. The LPN helps determine the correct length
to insert the tube by measuring:
a. | A 30-inch length on the tube | b. | An 18-inch length on the tube | c. | From the tip of the client’s nose to the earlobe and then down to the
xiphoid process | d. | From the tip of
the client’s nose to the earlobe and then down to the top of the
sternum |
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37.
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A postoperative client has regained bowel sounds
and is ready to start a clear liquid diet. The nurse is told that the physician has written an order
to remove the nasogastric (NG) tube. The nurse assists in the procedure and asks the client to do
which of the following during tube removal?
a. | Exhale until the tube is out. | b. | Inhale until the tube is out. | c. | Perform the Valsalva maneuver. | d. | Hold the breath to the count of five. |
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38.
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A nurse has an order to give 30 mL of an antacid to
a client through a nasogastric (NG) tube that is connected to wall suction. The nurse would do which
of the following to perform this procedure correctly?
a. | Adjust the suction to low-intermittent setting for an
hour after medication administration. | b. | Aspirate the NG
tube following medication administration to maintain patency. | c. | Position the client supine to assist in medication
absorption. | d. | Clamp the NG tube
for 30 minutes following administration of the medication. |
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39.
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A nurse is caring for a client with esophageal
varices who is going to have a Sengstaken-Blakemore tube inserted. The nurse brings which priority
item to the bedside so that it is available at all times?
a. | A Kelly clamp | b. | An obturator | c. | An irrigation
set | d. | A pair of
scissors |
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40.
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A licensed practical nurse (LPN) is assisting a
high school nurse in conducting a session with female adolescents regarding the menstrual cycle. The
LPN tells the adolescents that the normal duration of the menstrual cycle is about:
a. | 14 days | b. | 28 days | c. | 30
days | d. | 45 days |
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41.
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A nurse-midwife is conducting a session on the
process of fertilization with a group of nursing students. The nurse-midwife asks a nursing student
to identify the structure in which fertilization of an ovum takes place. The student answers
correctly by identifying which location?
a. | Fallopian tube | b. | Fundus of the uterus | c. | Ovary | d. | Corpus of the
uterus |
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42.
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A nurse is collecting data from a female client who
is suspected of having mittelschmerz. Which of the following would the nurse expect to note on data
collection of the client?
a. | Pain at the beginning of
menstruation | b. | Profuse vaginal
bleeding | c. | Sharp pain located on the right side of the
pelvis | d. | Pain that occurs during
intercourse |
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43.
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A client calls the physician’s office to
schedule an appointment because a home pregnancy test was performed and the results were positive.
The nurse determines that the home pregnancy test identified the presence of which of the following
in the urine?
a. | Estrogen | b. | Progesterone | c. | Human chorionic
gonadotropin (hCG) | d. | Follicle-stimulating hormone |
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44.
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A nurse is teaching a pregnant woman about the
physiological effects and hormone changes that occur in pregnancy. The woman asks the nurse about the
purpose of estrogen. The nurse bases the response on which of the following purposes of
estrogen?
a. | It maintains the uterine lining for
implantation. | b. | It stimulates
metabolism of glucose and converts the glucose to fat. | c. | It prevents the involution of the corpus luteum and maintains the production
of progesterone until the placenta is formed. | d. | It stimulates
uterine development to provide an environment for the fetus and stimulates the breasts to prepare for
lactation. |
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45.
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A nurse is reviewing the record of a pregnant
client and notes that the physician has documented the presence of Chadwick’s sign. The nurse
determines that the hormone responsible for the development of this sign is which of the
following?
a. | Human chorionic gonadotropin | b. | Estrogen | c. | Progesterone | d. | Prolactin |
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46.
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A nurse is reviewing the health care record of a
pregnant client at 16 weeks’ gestation. The nurse would expect documentation that the fundus of
the uterus is noted at which of the following areas?
a. | Midway between the symphysis pubis and the
umbilicus | b. | At the umbilicus | c. | Just above the symphysis pubis | d. | At the level of the xiphoid process |
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