D) Every hour
The correct answer is B: Continuously
82. The nurse is teaching an 87 year-old client methods for maintaining regular bowelmovements. The nurse
would caution the client to AVOID
A) Glycerine suppositories
B) Fiber supplementsC)
Laxatives
D) Stool softeners
The correct answer is C: Laxatives
83. A client with diarrhea should avoid which of the following?A) Orange juice
B) Tuna
C) Eggs
D) Macaroni
The correct answer is A: Orange juice
84. Which statement best describes the effects of immobility in children?
A) Immobility prevents the progression of language and fine motor developmentB) Immobility in
children has similar physical effects to those found in adults
C) Children are more susceptible to the effects of immobility than are adults
D) Children are likely to have prolonged immobility with subsequent complications The correct answer is
B: Immobility in children has similar physical effects to thosefound in adults
85. A nurse is providing care to a 63 year-old client with pneumonia. Which interventionpromotes the client’s
comfort?
A) Increase oral fluid intake
B) Encourage visits from family and friendsC) Keep
conversations short
D) Monitor vital signs frequently
The correct answer is C: Keep conversations short
86. After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client
about the diet, which meal plan would be the most appropriate
A) 3 oz. broiled fish, 1 baked potato, . cup canned beets, 1 orange, and milk
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B) 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
C) A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange The correct answer is D: 3
oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
87. The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findingsinclude moderate
edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are
most appropriate?
A) Decreased carbohydrates and fat
B) Decreased sodium and potassium
C) Increased potassium and proteinD) Increased
sodium and fluids
The correct answer is B: Decreased sodium and potassium
88. What nursing assessment of a paralyzed client would indicate the probable presenceof a fecal impaction?
A) Presence of blood in stoolsB) Oozing
liquid stool
C) Continuous rumbling flatulence
D) Absence of bowel movements
The correct answer is B: Oozing liquid stool
89. 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) have the client identify coping methods
B) get the description of the location and intensity of the painC) accept the client’s
report of pain
D) determine the client’s status of pain
The correct answer is C: Accept the client''s report of pain
90. An 85 year-old client complains of generalized muscle aches and pains. The firstaction by the nurse
should be
A) Assess the severity and location of the pain
B) Obtain an order for an analgesic
C) Reassure him that this is not unusual for his age
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D) Encourage him to increase his activity
The correct answer is A: Assess the severity and location of the pain
91. A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home
from the hospital. The client is to keep the affected leg elevatedand is on contact
precautions. The client wants to know if visitors can come. The appropriate responsefrom the home health nurse
is that:
A) Visitors must wear a mask and a gown
B) There are no special requirements for visitors of clients on contact precautionsC) Visitors should wash
their hands before and after touching the client
D) Visitors
The correct answer is C:Visitors should wash their hands before and after touching theclient
92. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcalmeningitis. Which
admission orders should the nurse do first?
A) Institute seizure precautions
B) Monitor neurologic status every hour
C) Place in respiratory/secretion precautions
D) Cefotaxime IV 50 mg/kg/day divided q6h
The correct answer is C: Place in respiratory/secretion precautions
93. Which of these nursing diagnoses of 4 elderly clients would place 1 client at thegreatest risk for falls?
A) Sensory perceptual alterations related to decreased vision
B) Alteration in mobility related to fatigue
C) Impaired gas exchange related to retained secretions
D) Altered patterns of urinary elimination related to nocturia
The correct answer is D: Altered patterns of urinary elimination related to nocturia
94. A nurse who is reassigned to the emergency department needs to understand thatgastric lavage is a
priority in which situation?
A) An infant who has been identified to have botulism
B) A toddler who ate a number of ibuprofen tablets
C) A preschooler who swallowed powdered plant food
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