, CHAP TER 1 ONE
Practice Exam 1 and
Rationales
i
Quick Answer: 58
1. A client with a renal failure is prescribed a low potassium diet.
Detailed Answer: 61
Which food choice would be best for this client?
❍ A. 1 cup beef broth
❍ B. 1 baked potato with the skin
❍ C. 1/2 cup raisins
❍ D. 1 cup rice
2. An appropriate nursing intervention for the client with borderline Quick Answer: 58
personality disorder is: Detailed Answer: 61
❍ A. Observing the client for signs of depression or suicidal
thinking
❍ B. Allowing the client to lead unit group sessions
❍ C. Restricting the client’s activity to the assigned unit of
care throughout hospitalization
❍ D. Allowing the client to select a primary caregiver
3. Which of the following is an expected finding in the assessment of Quick Answer: 58
a client with bulimia nervosa? Detailed Answer: 61
❍ A. Extreme weight loss
❍ B. Presence of lanugo over body
❍ C. Erosion of tooth enamel
❍ D. Muscle wasting
4. Assuming that all have achieved normal cognitive and emotional
Quick Answer: 58
development, which of the following children is at greatest risk for
accidental poisoning? Detailed Answer: 61
❍ A. One-year-old
❍ B. Four-year-old
❍ C. Eight-year-old
❍ D. Twelve-year-old
,6 Chapter 1
✓
Quick Check
5. Which term describes the play activity of the preschool Quick Answer: 58
aged child? Detailed Answer: 61
❍ A. Cooperative
❍ B. Associative
❍ C. Parallel
❍ D. Solitary
6. The nurse is ready to begin an exam on a nine-month-old infant Quick Answer: 58
who is sitting quietly on his mother’s lap. Which should the nurse Detailed Answer: 61
do first?
❍ A. Check the Babinski reflex
❍ B. Listen to the heart and lung sounds
❍ C. Palpate the abdomen
❍ D. Check tympanic membranes
7. In terms of cognitive development, a three-year-old would be
Quick Answer: 58
expected to:
Detailed Answer: 61
❍ A. Think abstractly
❍ B. Use magical thinking
❍ C. Understand conservation of matter
❍ D. See things from the perspective of others
8. Which of the following describes the language development of a
two-year-old? Quick Answer: 58
Detailed Answer: 61
❍ A. Doesn’t understand yes and no
❍ B. Understands the meaning of all words
❍ C. Can combine three or four words
❍ D. Repeatedly asks “why?”
9. A client who has been receiving Urokinase (uPA) for deep vein
thrombosis is noted to have dark brown urine in the urine collec- Quick Answer: 58
tion bag. Which action should the nurse take immediately? Detailed Answer: 61
❍ A. Prepare an injection of vitamin K
❍ B. Irrigate the urinary catheter with 50 mL of normal
saline
❍ C. Offer the client additional oral fluids
❍ D. Withhold the medication and notify the physician
, Practice Exam 1 and Rationales 7
✓
Quick Check
10. Which of the following can occur with the frequent use of calcium- Quick Answer: 58
based antacids? Detailed Answer: 62
❍ A. Constipation
❍ B. Hyperperistalsis
❍ C. Delayed gastric emptying
❍ D. Diarrhea
11. Which statement made by the student nurse indicates the need for Quick Answer: 58
further teaching regarding the administration of heparin? Detailed Answer: 62
❍ A. “I will administer the medication 1–2 inches away
from the umbilicus.”
❍ B. “I will not massage the injection site after administer-
ing the heparin.”
❍ C. “I will check the PTT before administering the
heparin.”
❍ D. “I will need to gently aspirate when I give the heparin.”
12. To correctly assess the oxygen saturation level of an adult client,
Quick Answer: 58
the pulse oximeter should not be placed on the:
Detailed Answer: 62
❍ A. Finger
❍ B. Earlobe
❍ C. Extremity with noninvasive BP cuff
❍ D. Nose
13. While caring for an elderly patient with hypertension, the nurse
notes the following vital signs: BP of 140/40, pulse 120, respira- Quick Answer: 58
tions 36. The nurse’s initial action should be to: Detailed Answer: 62
❍ A. Report the findings to the physician
❍ B. Recheck the vital signs in one hour
❍ C. Ask the patient if he is in pain
❍ D. Compare the current vital signs with those on
admission
14. The nurse is preparing a client with an axillopopliteal bypass graft
for discharge. The client should be taught to avoid: Quick Answer: 58
Detailed Answer: 62
❍ A. Using a recliner to rest
❍ B. Resting in supine position
❍ C. Sitting in a straight chair
❍ D. Sleeping in right Sim’s position
Practice Exam 1 and
Rationales
i
Quick Answer: 58
1. A client with a renal failure is prescribed a low potassium diet.
Detailed Answer: 61
Which food choice would be best for this client?
❍ A. 1 cup beef broth
❍ B. 1 baked potato with the skin
❍ C. 1/2 cup raisins
❍ D. 1 cup rice
2. An appropriate nursing intervention for the client with borderline Quick Answer: 58
personality disorder is: Detailed Answer: 61
❍ A. Observing the client for signs of depression or suicidal
thinking
❍ B. Allowing the client to lead unit group sessions
❍ C. Restricting the client’s activity to the assigned unit of
care throughout hospitalization
❍ D. Allowing the client to select a primary caregiver
3. Which of the following is an expected finding in the assessment of Quick Answer: 58
a client with bulimia nervosa? Detailed Answer: 61
❍ A. Extreme weight loss
❍ B. Presence of lanugo over body
❍ C. Erosion of tooth enamel
❍ D. Muscle wasting
4. Assuming that all have achieved normal cognitive and emotional
Quick Answer: 58
development, which of the following children is at greatest risk for
accidental poisoning? Detailed Answer: 61
❍ A. One-year-old
❍ B. Four-year-old
❍ C. Eight-year-old
❍ D. Twelve-year-old
,6 Chapter 1
✓
Quick Check
5. Which term describes the play activity of the preschool Quick Answer: 58
aged child? Detailed Answer: 61
❍ A. Cooperative
❍ B. Associative
❍ C. Parallel
❍ D. Solitary
6. The nurse is ready to begin an exam on a nine-month-old infant Quick Answer: 58
who is sitting quietly on his mother’s lap. Which should the nurse Detailed Answer: 61
do first?
❍ A. Check the Babinski reflex
❍ B. Listen to the heart and lung sounds
❍ C. Palpate the abdomen
❍ D. Check tympanic membranes
7. In terms of cognitive development, a three-year-old would be
Quick Answer: 58
expected to:
Detailed Answer: 61
❍ A. Think abstractly
❍ B. Use magical thinking
❍ C. Understand conservation of matter
❍ D. See things from the perspective of others
8. Which of the following describes the language development of a
two-year-old? Quick Answer: 58
Detailed Answer: 61
❍ A. Doesn’t understand yes and no
❍ B. Understands the meaning of all words
❍ C. Can combine three or four words
❍ D. Repeatedly asks “why?”
9. A client who has been receiving Urokinase (uPA) for deep vein
thrombosis is noted to have dark brown urine in the urine collec- Quick Answer: 58
tion bag. Which action should the nurse take immediately? Detailed Answer: 61
❍ A. Prepare an injection of vitamin K
❍ B. Irrigate the urinary catheter with 50 mL of normal
saline
❍ C. Offer the client additional oral fluids
❍ D. Withhold the medication and notify the physician
, Practice Exam 1 and Rationales 7
✓
Quick Check
10. Which of the following can occur with the frequent use of calcium- Quick Answer: 58
based antacids? Detailed Answer: 62
❍ A. Constipation
❍ B. Hyperperistalsis
❍ C. Delayed gastric emptying
❍ D. Diarrhea
11. Which statement made by the student nurse indicates the need for Quick Answer: 58
further teaching regarding the administration of heparin? Detailed Answer: 62
❍ A. “I will administer the medication 1–2 inches away
from the umbilicus.”
❍ B. “I will not massage the injection site after administer-
ing the heparin.”
❍ C. “I will check the PTT before administering the
heparin.”
❍ D. “I will need to gently aspirate when I give the heparin.”
12. To correctly assess the oxygen saturation level of an adult client,
Quick Answer: 58
the pulse oximeter should not be placed on the:
Detailed Answer: 62
❍ A. Finger
❍ B. Earlobe
❍ C. Extremity with noninvasive BP cuff
❍ D. Nose
13. While caring for an elderly patient with hypertension, the nurse
notes the following vital signs: BP of 140/40, pulse 120, respira- Quick Answer: 58
tions 36. The nurse’s initial action should be to: Detailed Answer: 62
❍ A. Report the findings to the physician
❍ B. Recheck the vital signs in one hour
❍ C. Ask the patient if he is in pain
❍ D. Compare the current vital signs with those on
admission
14. The nurse is preparing a client with an axillopopliteal bypass graft
for discharge. The client should be taught to avoid: Quick Answer: 58
Detailed Answer: 62
❍ A. Using a recliner to rest
❍ B. Resting in supine position
❍ C. Sitting in a straight chair
❍ D. Sleeping in right Sim’s position
