A client who agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?
  A. Blood relationship.
  B. Sex and size.
  C. Compatible blood and tissue types.
  D. Need.

The nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. She's in her 30s and has two young children. Although she's worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping?
  A. Tell the client's spouse or partner to be supportive while she recovers.
  B. Encourage the client to proceed with the next phase of treatment.
  C. Recommend that the client remain cheerful for the sake of her children.
  D. Refer the client to the American Cancer Society's Reach for Recovery program or another support program.

A 19-year-old primigravida is admitted to the labor and delivery unit in labor. She's 2 cm dilated and 50% effaced, and the fetal head is at 0 station. She's having moderately strong 40-second contractions every 5 minutes. She seems rather anxious and becomes very tense during each contraction. When the client asks for pain relief, what should the nurse do next?
  A. Determine the source of her anxiety and institute interventions to help her relax.
  B. Immediately check the physician's order and give her the analgesic ordered.
  C. Inform her that the neonate's head isn't down far enough just yet but that, as soon as it is, medication will be given.
  D. Tell her that her contractions are only moderately strong and that she should wait until later to take medication.

The nurse is caring for a client admitted to the emergency department after a motor vehicle accident. Under the law, the nurse must obtain informed consent before treatment unless
  A. the client is mentally ill.
  B. the client refuses to give informed consent.
  C. the client is in an emergency situation.
  D. the client asks the nurse to give substituted consent.

The nurse is caring for a client with otosclerosis scheduled to undergo a stapedectomy. The client asks the nurse when her hearing will improve. Which response by the nurse is most appropriate?
  A. Your hearing may not improve but you'll no longer be bothered by tinnitus.
  B. Your hearing may be dramatically improved right after surgery.
  C. You may notice improved hearing within 1 to 2 weeks.
  D. Your hearing may improve 3 to 6 weeks after surgery.

A client's blood glucose level is 45 mg/dL. The nurse should be alert for which signs and symptoms?
  A. Coma, anxiety, confusion, headache, and cool, moist skin.
  B. Kussmaul's respirations, dry skin, hypotension, and bradycardia.
  C. Polyuria, polydipsia, hypotension, and hypernatremia.
  D. Polyuria, polydipsia, polyphagia, and weight loss.

When reporting to the surgeon that a chest tube is malfunctioning, the nurse is ordered to reposition the tube and obtain a chest radiograph. The nurse should
  A. inform the surgeon this isn't within her scope of practice.
  B. report the surgeon to the Ethics Committee.
  C. report the surgeon to the nursing supervisor.
  D. follow the order as requested by the surgeon.

The nurse is providing care to a client with catatonic type of schizophrenia who exhibits extreme negativism. To help the client meet his basic needs, the nurse should
  A. ask the client which activity he would prefer to do first.
  B. negotiate a time when the client will perform activities.
  C. tell the client specifically and concisely what needs to be done.
  D. prepare the client ahead of time for the activity.

A client is admitted for a suspected eating disorder. Which of the following statements would indicate that the client may be suffering from anorexia nervosa?
  A. "I've gained 3 pounds in the last month. "
  B. "I eat loads of spinach and yellow vegetables each day. "
  C. "I'm a perfectionist, and I work hard to get A's. "
  D. "I binge frequently in the morning and feel fat. \

The nurse administers racemic epinephrine to a child. Ten minutes after administration, the nurse should be alert for
  A. respiratory distress.
  B. profound tachycardia.
  C. signs of improved oxygenation.
  D. diminished cyanosis.

A 4-month-old infant is brought to the pediatrician by his parents because they're concerned about his frequent respiratory infections, poor feeding habits, frequent vomiting, and colic. The physician notes that the baby has failed to gain expected weight and recommends that the baby have a sweat test performed to detect possible cystic fibrosis. To prepare the parents for the test, the nurse should explain that
  A. the baby will need to fast before the test.
  B. a sample of blood will be necessary.
  C. a low-sodium diet is necessary for 24 hours before the test.
  D. a low-intensity, painless electrical current is applied to the skin.

A 24-year-old client on the labor unit is being coached in the Lamaze method by her husband. On assessment, the nurse finds the client to be 5 cm dilated, 90% effaced, at +1 station with contractions coming every 2 to 3 minutes and lasting 35 to 40 seconds. The client has asked for pain relief. What's the nurse's best action?
  A. Check maternal blood pressure and pulse and fetal heart rate in response to contractions.
  B. Realize that it's too early to give pain medication, and encourage the husband to continue with the Lamaze coaching.
  C. Arrange for a sonogram to determine fetal position.
  D. Perform a vaginal examination to determine dilation, effacement, and station.

Which finding is considered normal in a neonate during the first few days after birth?
  A. Weight loss of 25%.
  B. Birth weight of 2,000 to 2,500 g.
  C. Weight loss then return to birth weight.
  D. Weight gain of 25%.

The nurse is assigned to care for a postoperative client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says that he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to
  A. encourage the client to ask questions about personal sexuality.
  B. provide time for privacy.
  C. provide support for the spouse or significant other.
  D. suggest referral to a sex counselor or other appropriate professional.

The nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find
  A. hypotension.
  B. thick, coarse skin.
  C. deposits of adipose tissue in the trunk and dorsocervical area.
  D. weight gain in arms and legs.

A client with coronary artery disease reports intermittent chest pain that occurs with exertion. The physician prescribes sublingual nitroglycerin. When teaching the client about nitroglycerin administration, the nurse should include which instruction?
  A. "Be careful after taking nitroglycerin because it may cause dizziness. "
  B. "Make sure you replace your nitroglycerin tablets every 6 months to ensure potency. "
  C. "A burning sensation after taking nitroglycerin indicates medication potency. "
  D. "When you experience chest pain, take one tablet every 30 minutes until the pain is relieved. \

The nurse is caring for a -year-old male client with tetralogy of Fallot. Which assessment findings should the nurse expect?
  A. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy.
  B. Pulmonary artery stenosis, intraventricular septal defect, overriding aorta, right ventricular hypertrophy.
  C. Pulmonary artery stenosis, patent ductus arteriosus, overriding aorta, right ventricular hypertrophy.
  D. Transposition of the great vessels, intraventricular septal defect, right ventricular hypertrophy, patent ductus arteriosus.

The nurse is caring for a neonate with congenital clubfoot. After the final cast has been removed, which member of the health care team will most likely help the neonate with leg and ankle exercises and provide his parents with a home exercise regimen?
  A. Occupational therapist.
  B. Physical therapist.
  C. Recreational therapist.
  D. Speech therapist.

A client at term arrives at the labor room experiencing contractions every 4 minutes. After a brief assessment, she's admitted and an electronic fetal monitor is applied. Which of the following would alert the nurse to an increased potential for fetal distress?
  A. Weight gain of 30 lb (13.6 kg).
  B. Maternal age of 32 years.
  C. Blood pressure of 146/90 mmHg.
  D. Treatment for syphilis at 15 weeks' gestation.

Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI), a client reports midsternal chest pain radiating down the left arm. The nurse notices that the client is restless and slightly diaphoretic, and measures a temperature of 99. 6°F (37.6℃), a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90mmHg. Which nursing diagnosis takes highest priority?
 A. Risk for imbalanced body temperature.
 B. Decreased cardiac output.
 C. Anxiety.
 D. Acute pain.

A client with paranoid type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse should
  A. tell him that she'll leave for now but will return soon.
  B. ask him if it's okay if she sits quietly with him.
  C. ask him why he wants to be left alone.
  D. tell him that she won't let anything happen to him.

A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely evidence of ineffective individual coping?
  A. Inability to make choices and decisions without advice.
  B. Showing interest only in solitary activities.
  C. Avoiding developing relationships.
  D. Recurrent self-destructive behavior with history of depression.

When prioritizing a client's care plan based on Maslow's hierarchy of needs, the nurse's first priority would be
   A. allowing the family to see a newly admitted client.
   B. ambulating the client in the hallway.
   C. administering pain medication.
   D. placing wrist restraints on the client.

When inserting a urinary catheter, the nurse can facilitate the insertion by asking the client to
  A. initiate a stream of urine.
  B. breathe deeply.
  C. turn to the side.
  D. hold the labia or shaft of penis.

A 2-month-old neonate with diarrhea and vomiting has been receiving IV fluids for the past 24 hours. The specific gravity of the neonate's urine is 1.012. What should the nurse do next?
  A. Check the neonate's blood pressure.
  B. Check the specific gravity again as soon as possible.
  C. Notify the physician.
  D. Continue the ordered IV flow rate.

Which phrase is used to describe the volume of air inspired and expired with a normal breath?
  A. Total lung capacity.
  B. Forced vital capacity.
  C. Tidal volume.
  D. Residual volume.

A child with rheumatic fever complains of painful joints. What nonpharmacologic measures should the nurse use to reduce the child's pain?
  A. Performing gentle passive range-of-motion (ROM) exercises.
  B. Gently massaging the painful joints.
  C. Using a bed cradle to keep linens off the joints.
  D. Encouraging position changes in bed every 2 hours.

A 56-year-old male has a blood pressure reading of 146/96mmHg. Upon hearing the reading, he exclaims, "My pressure has never been this high. Will I need to take medication to reduce it?" Which of the following responses by the nurse would be best?
  A. "Yes. Hypertension is prevalent among males; it's fortunate we caught this during your routine examination. "
  B. "We'll need to reevaluate your blood pressure because your age places you at high risk for hypertension. "
  C. "A single elevated blood pressure doesn't confirm hypertension. You'll need to have your blood pressure reassessed several times before a diagnosis can be made. "
  D. "You have no need to worry. Your pressure is probably elevated because you're in the doctor's office. \

The nurse is developing a teaching plan for a client diagnosed with diabetes insipidus. The nurse should include information about which hormone, commonly lacking in clients with diabetes insipidus?
  A. Antidiuretic hormone (ADH).
  B. Thyroid-stimulating hormone (TSH).
  C. Follicle-stimulating hormone (FSH).
  D. Luteinizing hormone (LH).

The nurse is providing care for a postoperative client who has undergone a small bowel resection. The nurse may use an epidural catheter for which of the following?
  A. Antibiotic therapy.
  B. Pain management.
  C. Blood transfusion.
  D. Anticoagulation.

The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Which nursing diagnosis should receive the highest priority?
  A. Risk for self- or other-directed violence.
  B. Imbalanced nutrition.
  C. Ineffective coping.
  D. Impaired verbal communication.

A pregnant client is taking folic acid. During prenatal teaching, which of the following foods would the nurse recommend as high in folic acid?
  A. Egg yolks.
  B. Fruit.
  C. Bread.
  D. Milk.

The physician prescribes a monoamine oxidase (MAO) inhibitor for a client. Which of the following nursing diagnostic categories would be most appropriate to focus on during client teaching?
  A. Risk for injury.
  B. Disturbed thought processes.
  C. Deficient fluid volume.
  D. Disturbed sleep pattern.

The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?
  A. Avoiding the use of recreational drugs and alcohol.
  B. Refraining from telling anyone about the diagnosis.
  C. Following safer-sex practices.
  D. Telling potential sex partners about the diagnosis, as required by law.

A nurse needs assistance transferring an elderly, confused client to bed. The nurse leaves the client to find someone to assist her with the transfer. While the nurse is gone, the client falls and hurts herself. The nurse is at fault because she hasn't
  A. properly educated this client about safety measures.
  B. restrained the client.
  C. documented that she left the client.
   D. arranged for continual care of the client.

A 58-year-old client on a mental health unit has lost control, despite having been properly medicated, and is threatening to harm himself and others. He has been placed in four- point restraints. Which nursing measure should be taken next?
  A. Release one restraint every 15 minutes.
  B. Have a staff member stay with the client at all times.
  C. Leave the client alone to reduce his sensory stimulation and allow him to regain control.
  D. Restrict fluids until the restraint period is over.

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?
  A. 9%.
  B. 18%.
  C. 27%.
  D. 36%.

The mother of a hospitalized 3-year-old girl expresses concern because her daughter is wetting the bed. What should the nurse tell her?
  A. "It's common for a child to exhibit regressive behavior when anxious or stressed. "
  B. "Your child is probably angry about being hospitalized. This is her way of acting out. "
  C. "Don't worry. It's common for a 3-year-olcl child to not be fully toilet-trained. "
  D. "The nurses probably haven't been answering the call light soon enough. They will try to respond more quickly. \

The nurse is developing a teaching plan for a client with genital herpes. She should include information about
   A. acyclovir (Zovirax).
   B. penicillin.
   C. doxycycline.
   D. tetracycline.

The nurse is teaching a client who is 28 weeks pregnant and has gestational diabetes how to control her blood glucose levels. Diet therapy alone has been unsuccessful in controlling her blood glucose levels, so she has started insulin therapy. The nurse should consider the teaching effective when the client says
  A. "I won't use insulin if I'm sick. "
  B. "I need to use insulin each day. "
  C. "If I give myself an insulin injection, I don't need to watch what I eat. "
  D. "I'll monitor my blood glucose levels twice a week. \

The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to
  A. change his own dressing.
  B. walk in the hallway.
  C. walk from his room to the end of the hall and back before discharge.
  D. eat a special diet.

The parents of a 4-year-old with sickle cell anemia tell the nurse that they would like to have other children, but they're concerned about passing sickle cell anemia on to them. Which health care team member would be the most appropriate person for the nurse to refer them to?
  A. Clergy.
  B. Social worker.
  C. Certified nurse midwife.
  D. Genetic counselor.

A woman in labor shouts to the nurse, "My baby is coming right now! I feel like I have to push!" An immediate nursing assessment reveals that the head of the fetus is crowning. After asking another staff member to notify the physician and setting up for delivery, which nursing intervention is most appropriate?
  A. Gently pulling at the neonate's head as it's delivered.
  B. Holding the neonate's head back until the physician arrives.
   C. Applying gentle pressure to the neonate's head as it's delivered.
  D. Placing the mother in a Trendelenburg position until the physician arrives.

A client is 22 weeks pregnant with her first child. Her weight gain is normal, but she complains of constipation. What's the most effective recommendation the nurse can make?
  A. "Take a mild laxative daily. "
  B. "Increase intake of fluids and high-fiber foods. "
  C. "Relax when trying to move the bowels. "
  D. "Start a strenuous exercise program. \

The nurse is caring for a bedridden, elderly adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan?
  A. Turn and reposition the client a minimum of every 8 hours.
  B. Vigorously massage lotion into bony prominences.
  C. Post a turning schedule at the client's bedside.
  D. Slide the client, rather than lift, when turning.

The nurse is teaching breast self-examination (BSE) to a college student. The nurse knows that the client understands the best time to examine her breasts when she says:
  A. "I'll examine my breasts 1 week after my period starts. "
  B. "I'll perform a BSE just before my period starts. "
  C. "I must examine my breasts the same time each day. "
  D. "Every time I shower I'll do a breast examination. \

The nurse is teaching a female client with osteoporosis about her prescribed diet. Which of the following foods is the best source of calcium?
  A. 1 cup of low-fat yogurt.
  B. 1 cup of skim milk.
  C. 1 oz of cheddar cheese.
  D. 1 cup of ice cream.

The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover
  A. cancerous lumps.
  B. areas of thickness or fullness.
  C. changes from previous self-examinations.
  D. fibrocystic masses.

The mother of a 1B-year-old girl calls the emergency department, suspecting her daughter's abdominal pain may be appendicitis. In addition to pain, her daughter has a fever of 100°F (37.8℃) and has vomited twice. What should the nurse tell the mother?
  A. Give the daughter a laxative to rule out the possibility that constipation is causing the pain.
  B. Gently press on the left lower quadrant of her daughter's abdomen to test for rebound tenderness.
  C. It's most likely the flu because her daughter is too young to have appendicitis.
  D. Immediately bring her daughter into the emergency department before the appendix has a chance to rupture.

Two family members are arguing in a child's room. They start to hit each other and the child is crying. What's the most appropriate nursing action?
  A. Call security to come and intervene.
  B. Remove the child from the room.
  C. Ask one of the family members to leave the room.
  D. Try to reason with both family members.

A mother complains to the nurse that her 4-year-old son often lies. What's the nurse's best response?
  A. Let the child know that he'll be punished for lying.
  B. Ask him why he isn't telling the truth.
  C. It's probably due to his vivid imagination and creativity.
  D. Acknowledge him by saying, "That's a pretend story. \

A psychiatric client who was voluntarily admitted now wishes to be discharged from the hospital, against medical advice. What's the most important assessment the nurse should make of the client?
   A. Ability to care for himself.
  B. Degree of danger to self and others.
  C. Level of psychosis.
  D. Intended compliance with aftercare.

A neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is
  A. peripheral acrocyanosis.
  B. bradycardia.
  C. lethargy.
  D. jaundice.