Multiple Choice
Identify the
choice that best completes the statement or answers the question.
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1.
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A nurse is providing discharge instructions to a
Chinese client regarding prescribed dietary modifications. During the teaching session the client
continually turns away from the nurse. Which of the following nursing actions is most
appropriate?
a. | Continue with the instructions, verifying client
understanding. | b. | Identify the
importance of the instructions for the maintenance of health care. | c. | Walk around the client so that the nurse continually faces the
client. | d. | Give the client a dietary booklet and return later to
continue with the instructions. |
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2.
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A nurse is assisting in preparing a plan of care
for a client who is a Jehovah’s Witness. The client has been told that surgery is necessary.
Considering the client’s religious preferences, the nurse documents that:
a. | Surgery is prohibited in this religious
group. | b. | The administration of blood and blood products is
forbidden. | c. | Medication
administration is not allowed. | d. | Faith healing is
primarily practiced. |
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3.
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A nurse is preparing to deliver a food tray to a
client whose religion is Judaism. The nurse checks the food on the tray and notes that the client has
received a roast beef dinner with whole milk as a beverage. Which of the following actions will the
nurse take?
a. | Deliver the food tray to the
client. | b. | Call the dietary department and ask for a new meal
tray. | c. | Replace the whole milk with fat-free
milk. | d. | Ask the dietary department to replace the roast beef
with pork. |
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4.
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A nurse educator is describing the yin and yang
theory of the ancient Chinese philosophy of Tao to a group of nursing students. The nurse explains
that foods are classified as hot and cold in this theory and are transformed into yin and yang energy
when metabolized by the body. The nursing student understands this theory when the student verbalizes
that a client who practices this belief:
a. | Consumes cold foods when a “hot” illness is
present | b. | Consumes hot foods when a “hot” illness is
present | c. | Believes that yin foods are hot
foods | d. | Believes that yang foods are cold
foods |
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5.
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A nurse is planning to instruct the
Hispanic-American client about nutrition and dietary restrictions. When developing the plan for the
instructions, the nurse is aware that this ethnic group:
a. | Enjoys foods that lack color, flavor, and
texture | b. | Primarily eats raw fish | c. | Enjoys eating red meat | d. | Views food as a
primary form of socialization |
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6.
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A nursing student is discussing cultural issues in
a clinical conference. The nursing instructor asks the student to describe ethnocentrism. Which of
the following if stated by the student indicates a lack of understanding of the issue of
ethnocentrism?
a. | “It is a tendency to view one’s own ways as
best.” | b. | “It is
acting in a manner that is superior to other cultures.” | c. | “It is believing that one’s own ways are the only acceptable
way.” | d. | “It is
imposing one’s beliefs on individuals from another
culture.” |
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7.
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A nurse is assigned to collect data from a
Hispanic-American client during the hospital admission. On initial meeting of the client, the nurse
should plan to:
a. | Greet the client with a
handshake. | b. | Avoid touching the
client. | c. | Avoid any affirmative nods during the conversations with
the client. | d. | Smile and use
humor throughout the entire admission process. |
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8.
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A nurse is providing care to a Cuban-American
client who is terminally ill. Numerous family members are present most of the time, and many of the
family members are very emotional. The most appropriate nursing plan is to:
a. | Restrict the number of family members visiting at one
time. | b. | Inform the family that emotional outbursts are to be
avoided. | c. | Request permission to move the client to a private room,
and allow the family members to visit. | d. | Contact the
physician to speak to the family regarding their behavior. |
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9.
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A nurse is instructing a Native-American client
regarding the procedure for collecting a urine sample. The nurse observes that the client continually
stares at the floor during the instructional session. The nurse interprets this behavior
as:
a. | Rude | b. | Disinterest | c. | Embarrassment | d. | Indicative that
the client is paying close attention |
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10.
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A nurse who works on the night shift enters the
medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker
is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital
area. The appropriate initial action by the nurse is which of the following?
a. | Call the police. | b. | Call security. | c. | Lock the co-worker
in the medication room until help is obtained. | d. | Call the nursing
supervisor. |
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11.
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A licensed practical nurse (LPN) is providing
instructions to a nursing assistant who is preparing to care for a deceased client whose eyes will be
donated. The nurse intervenes if the nursing assistant does which of the following?
a. | Elevates the head of the bed | b. | Closes the client’s eyes | c. | Places wet saline gauze pads and an ice pack on the
eyes | d. | Closes the client’s eyes and places a dry sterile
dressing over the eyes |
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12.
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A hospitalized client tells the nurse that a living
will is being prepared and that the lawyer will be bringing the will to the hospital today for
witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The
appropriate response to the client is which of the following?
a. | “I will sign as a witness to your
signature.” | b. | “You will
need to find a witness on your own.” | c. | “I will call
the nursing supervisor to seek assistance regarding your request.” | d. | “Whoever is available at the time will sign as a witness for
you.” |
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13.
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A nurse is assigned to care for a newly admitted
client and is reviewing the physician’s orders. The nurse notes that the physician has
prescribed a medication dose that is twice the amount that the client reports taking prior to
admission. The appropriate nursing action is to:
a. | Question the client regarding the accuracy of the
reported dosage. | b. | Consult with the
registered nurse (RN). | c. | Administer the
medication as prescribed. | d. | Administer half of
the prescribed dose and then notify the RN. |
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14.
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A nurse is caring for a client with severe cardiac
disease. While the nurse is caring for the client, the client states, “If anything should
happen to me, please make sure that the doctors do not try to push on my chest and revive me.”
The appropriate nursing action is to:
a. | Tell the client that this procedure cannot legally be
refused by a client if the physician feels that it is necessary to save the client’s
life. | b. | Tell the client that it is necessary to notify the
physician of the client’s request. | c. | Tell the client
that the family must agree with the request. | d. | Plan a client
conference with the nursing staff to share the client’s
request. |
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15.
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An adult client is brought to the emergency
department by the emergency medical services team after being hit by a car. The name of the client is
not known. The client has sustained a severe head injury and multiple fractures and is unconscious.
An emergency craniotomy is required. In regard to informed consent for the surgical procedure, which
of the following is the best initial action?
a. | Call the police to identify the client and locate the
family. | b. | Obtain a court order for the surgical
procedure. | c. | Ask the emergency
medical services team to sign the informed consent. | d. | Transport the victim to the operating room for
surgery. |
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16.
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A client brought to the emergency department is
dead on arrival (DOA). The family of the client tells the physician that the client had terminal
cancer. The emergency department physician examines the client and asks the nurse to contact the
medical examiner regarding an autopsy. The family of the client tells the nurse that they do not want
an autopsy performed. Which response to the family is appropriate?
a. | “It is required by federal law. Why don’t we
talk about it, and why don’t you tell me how you feel?” | b. | “The decision is made by the medical
examiner.” | c. | “I will
contact the medical examiner regarding your request.” | d. | “An autopsy is mandatory for any client who is
DOA.” |
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17.
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A nurse witnesses an accident on a highway and
stops to provide assistance to the victim. The nurse notes that the client sustained a head injury
and a compound fracture to the left leg. The nurse provides the appropriate care prior to transport
of the victim to the hospital by ambulance. The client develops a severe bone infection at the site
of the fracture that requires amputation of the leg and files suit against the nurse who provided
care at the scene of the accident. Which of the following is accurate regarding the nurse’s
immunity from this suit?
a. | A Good Samaritan law will protect the
nurse. | b. | A Good Samaritan law will not protect the
nurse. | c. | A Good Samaritan law will provide immunity from suit
even if the nurse accepted compensation for the care provided. | d. | A Good Samaritan law protects laypersons and not professional health care
providers. |
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18.
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A licensed practical nurse (LPN) has been assigned
to assist a community nurse, who is the leader of a task force, to identify interventions for
teenagers from a local community who are abusing drugs. At the first meeting of the task force, the
group members express concern that more information is needed to determine appropriate measures for
the target teenagers. The LPN suggests which of the following to the community nurse to direct the
group most effectively?
a. | Prepare a survey that can be distributed to community
members to determine their understanding of the drug abuse problem. | b. | Initiate a drug abuse program in all of the
schools. | c. | Seek out the teenage drug abusers and refer them to drug
abuse centers. | d. | Prepare posters
that can be distributed to the schools. |
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19.
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A licensed practical nurse (LPN) is planning the
client assignments for the day. Which of the following is an appropriate assignment for the nursing
assistant?
a. | A client with difficulty swallowing food and
fluids | b. | A client who requires a 24-hour urine
collection | c. | A client requiring
a colostomy irrigation | d. | A client receiving
continuous tube feedings |
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20.
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A nursing instructor asks a nursing student to
identify situations that indicate a secondary level of prevention in health care. Which statement, if
made by the student, would indicate a need for further study of the levels of
prevention?
a. | Teaching a stroke client how to use a
walker | b. | Encouraging a client to take antihypertensive
medications as prescribed | c. | Screening for
hypertension in a community | d. | Encouraging a
woman older than age 40 to obtain periodic mammograms |
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21.
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A licensed practical nurse (LPN) employed in a
long-term care facility is asked to assist in planning implementation of a change in the method of
documentation system in the nursing unit. Many problems have occurred as a result of the present
documentation system, and the nurse manager determines that a change is required. The LPN understands
that the initial step in the process of change is which of the following?
a. | Plan strategies to implement the
change. | b. | Identify potential solutions and strategies for the
change process. | c. | Set goals and
priorities regarding the change process. | d. | Identify the
inefficiency that needs improvement or correction. |
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22.
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A nursing instructor asks a nursing student to
identify the priorities of care for an assigned client. The student correctly identifies the client
needs that are the priority by telling the nursing instructor that:
a. | Actual or life-threatening concerns are the
priority. | b. | Time constraints related to the client’s needs are
the priority. | c. | Obtaining needed
supplies to care for the client is the priority. | d. | Completing care in a reasonable time frame is the
priority. |
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23.
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A licensed practical nurse (LPN) employed in a
long-term care facility is planning assignments for the clients on a nursing unit. The LPN needs to
assign four clients and has another LPN and three nursing assistants on a nursing team. Which of the
following clients should the nurse assign the LPN?
a. | The client requiring a 24-hour urine
collection | b. | An older adult
client requiring assistance with a bed bath | c. | A client requiring
frequent ambulation | d. | A client with an
abdominal wound requiring wound irrigations and dressing changes every 3
hours |
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24.
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A licensed practical nurse (LPN) has received the
assignment for the day shift. After making initial rounds and checking all of the assigned clients,
which client will the LPN plan to care for first?
a. | A client who is ambulatory | b. | A client with a fever who is diaphoretic and
restless | c. | A client scheduled for physical therapy at 1:00
PM | d. | A postoperative client who has just received pain
medication |
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25.
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A nursing instructor asks a nursing student to
define a critical path. Which of the following statements, if made by the student, indicates a need
for further understanding regarding critical paths?
a. | “They are developed through the collaborative
efforts of all members of the health care team.” | b. | “They provide an effective way to monitor care and for reducing or
controlling the length of hospital stay for the client.” | c. | “They are developed based on appropriate standards of
care.” | d. | “They are
nursing care plans and use the steps of the nursing
process.” |
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26.
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A registered nurse (RN) is discussing the overall
fluid balance of an assigned client. The RN calculates that the client’s insensible fluid loss
is approximately 500 mL/day. The licensed practical nurse (LPN) recalls that the RN is referring to
fluid losses occurring through which of the following areas?
a. | Nasogastric tube and wound
drain | b. | Foley catheter and nasogastric
tube | c. | Wound drain and skin | d. | Skin and lungs |
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27.
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A nurse is assisting in the care of a group of
clients on the nursing unit. The nurse determines that a client with which of the following diagnoses
is the one who has the least amount of risk for developing third-spacing of body fluid?
a. | Laënnec’s
cirrhosis | b. | Ischemic stroke | c. | Major burn | d. | Renal
failure |
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28.
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A nurse is assisting in the care of a group of
clients on the clinical nursing unit. The nurse monitors the fluid balance of a client who has which
of the following diagnoses and is most at risk for fluid volume deficit?
a. | Ileostomy | b. | Hypertension | c. | Congestive heart
failure | d. | Acute renal
failure |
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29.
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An older adult client is admitted with a diagnosis
of pneumonia and dehydration. The nurse monitors the client for which of the following manifestations
that correlates with this client’s fluid imbalance?
a. | Flat neck veins | b. | Lung crackles | c. | Increased blood
pressure | d. | Decreased pulse |
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30.
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A nurse is administering a dose of a prescribed
diuretic to an assigned client. The nurse would plan to monitor the client for hypokalemia as a side
effect of therapy if the client were receiving which of the following medications?
a. | Spironolactone (Aldactone) | b. | Bumetanide (Bumex) | c. | Triamterene
(Dyrenium) | d. | Amiloride HCl
(Midamor) |
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31.
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A nurse is assisting in the care of a client who is
at risk for hyponatremia. The nurse would monitor this client for which of the following
manifestations of this electrolyte imbalance?
a. | Slow pulse rate | b. | High blood pressure | c. | Flaccid
muscles | d. | Abdominal
cramping |
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32.
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A nurse is planning to reinforce dietary teaching
about foods that are low in potassium to a client receiving a potassium-sparing diuretic. The nurse
would be sure to include which of the following on a list of foods that have a low potassium
content?
a. | Spinach | b. | Avocado | c. | Fresh
pork | d. | White bread |
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33.
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A nurse is obtaining the intershift report for a
group of assigned clients. The nurse plans to monitor which client for signs of hyperkalemia because
of the physiology associated with the health problem?
a. | A client with a new burn
injury | b. | A client with Cushing’s
syndrome | c. | A client with ulcerative
colitis | d. | A client who has a history of long-term laxative
abuse |
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34.
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A nurse is monitoring a client for hypercalcemia.
Which of the following would the nurse note in hypercalcemia?
a. | Slight muscle weakness | b. | Tingling sensations | c. | Hyperactive
reflexes | d. | Muscle cramps |
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35.
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A nurse is caring for a client with Paget’s
disease who has an elevated serum calcium level of 12.3 mEq/L. The nurse checks to see that which of
the following medications is available in the stock medication supply area for possible use to
reverse this elevation?
a. | Calcium gluconate | b. | Calcium chloride | c. | Calcitonin
(Calcimar) | d. | Vitamin
D |
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36.
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A client with diabetes mellitus has a blood glucose
on admission of 596 mg/dL. The nurse anticipates that this client would be experiencing which of the
following types of acid-base imbalance?
a. | Metabolic acidosis | b. | Metabolic alkalosis | c. | Respiratory
acidosis | d. | Respiratory
alkalosis |
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37.
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A nurse is assisting to admit a client with a
diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe enough, the
client will be at risk for which of the following acid-base imbalances?
a. | Metabolic acidosis | b. | Metabolic alkalosis | c. | Respiratory
acidosis | d. | Respiratory
alkalosis |
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38.
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A client is determined to be in respiratory
alkalosis by blood gas analysis. The nurse would monitor this client for signs of which of the
following electrolyte disorders that could accompany the acid-base imbalance?
a. | Hypercalcemia | b. | Hypochloremia | c. | Hypernatremia | d. | Hypokalemia |
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39.
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A nurse is caring for a client who is nervous and
is hyperventilating. The nurse would monitor the client for signs of which of the following acid-base
imbalances?
a. | Respiratory acidosis | b. | Respiratory alkalosis | c. | Metabolic
alkalosis | d. | Metabolic
acidosis |
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40.
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A nurse is assisting in the care of a client for
whom an arterial blood gas (ABG) must be drawn. The nurse notes that the person who draws the blood
sample from the radial artery performs Allen’s test first. The nurse understands that this is
being done to determine the adequacy of the:
a. | Carotid circulation | b. | Ulnar circulation | c. | Femoral
circulation | d. | Brachial
circulation |
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41.
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A nurse is assisting in the care of a client who
had an ileostomy created a few days ago. Owing to the normally high output of drainage from this type
of ostomy, the nurse monitors the client for signs of:
a. | Metabolic acidosis | b. | Metabolic alkalosis | c. | Respiratory
acidosis | d. | Respiratory
alkalosis |
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42.
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A client with a chronic airflow limitation is
experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the
client’s respiratory status would avoid doing which of the following?
a. | Keeping the head of the bed
elevated | b. | Monitoring the flow rate of supplemental
oxygen | c. | Assisting the client to turn, cough, and deep
breathe | d. | Encouraging the client to breathe slowly and
shallowly |
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43.
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An anxious client is experiencing respiratory
alkalosis from hyperventilation due to anxiety. The nurse would do which of the following to help the
client experiencing this acid-base disorder?
a. | Withhold all sedative or antianxiety
medications. | b. | Provide emotional
support and reassurance. | c. | Tell the client to
breathe very deeply but more slowly. | d. | Put the client in
a supine position. |
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44.
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A client is being treated for metabolic acidosis
with medication therapy and other measures. The nurse would plan to most carefully note the levels of
which of the following electrolytes, which could dramatically decline with effective treatment of the
acidosis?
a. | Sodium | b. | Potassium | c. | Magnesium | d. | Phosphorus |
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45.
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A licensed practical nurse (LPN) is assisting in
the care of a client who overdosed on aspirin 24 hours ago. The LPN would report to the registered
nurse (RN) which of the following findings associated with an anticipated acid-base
disturbance?
a. | Drowsiness, headache, and
tachypnea | b. | Decreased respiratory rate and depth, cardiac
irregularities | c. | Disorientation and
dyspnea | d. | Tachypnea, dizziness, and
paresthesias |
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