801 - 900 Solved NCLEX Styled Practical MCQ Test Questions Bank

801. A client tells the nurse that she takes St. John’s wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:
A. St. John’s wort seldom relieves depression.
B. She should avoid eating aged cheese.
C. Skin reactions increase with the use of sunscreen.
D. The herbal is safe to use with other antidepressants.

802. The physician has ordered a low-purine diet for a client with gout. Which protein source is high in purine?
A. Dried beans
B. Nuts
C. Cheese
D. Eggs

803. The nurse is observing the ambulation of a client recently fitted for crutches. Which observation requires nursing intervention?
A. Two finger widths are noted between the axilla and the top of the crutch.
B. The client bears weight on his hands when ambulating.
C. The crutches and the client’s feet move alternately.
D. The client bears weight on his axilla when standing.

804. During the change of shift report, a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift, the notes are found by the client’s daughter. The nurse could be sued for:
A. Libel
B. Slander
C. Malpractice
D. Negligence

805. The nurse is caring for an adolescent with a five-year history of bulimia. A common clinical finding in the client with bulimia is:
A. Extreme weight loss
B. Dental caries
C. Hair loss
D. Decreased temperature

806. A client hospitalized for treatment of congestive heart failure is to be discharged with a prescription for Digitek (digoxin) 0.25mg daily. Which of the following statements indicates that the client needs further teaching?
A. I will need to take the medication at the same time each day.
B. I can prevent stomach upset by taking the medication with an antacid.
C. I can help prevent drug toxicity by eating foods containing fiber.
D. I will need to report visual changes to my doctor.

807. A client with paranoid schizophrenia has an order for Thorazine (chlorpromazine) 400mg orally twice daily. Which of the following symptoms should be reported to the physician immediately?
A. Fever, sore throat, weakness
B. Dry mouth, constipation, blurred vision
C. Lethargy, slurred speech, thirst
D. Fatigue, drowsiness, photosensitivity

808. When caring for a client with an anterior cervical discectomy, the nurse should give priority to assessing for post-operative bleeding. The nurse should pay particular attention to:
A. Drainage on the surgical dressing
B. Complaints of neck pain
C. Bleeding from the mouth
D. Swelling in the posterior neck

809. The initial assessment of a newborn reveals a chest circumference of 34cm and an abdominal circumference of 31cm. The chest is asymmetrical and breath sounds are diminished on the left side. The nurse should give priority to:
A. Providing supplemental oxygen by a ventilated mask
B. Performing auscultation of the abdomen for the presence of active bowel sounds
C. Inserting a nasogastric tube to check for esophageal patency
D. Positioning on the left side with head and chest elevated

810. The physician has ordered Eskalith (lithium carbonate) 500mg three times a day and Risperdal (risperidone) 2mg twice daily for a client admitted with bipolar disorder, acute manic episodes. The best explanation for the client’s medication regimen is:
A. The client’s symptoms of acute mania are typical of undiagnosed schizophrenia.
B. Antipsychotic medication is used to manage behavioral excitement until mood stabilization occurs.
C. The client will be more compliant with a medication that allows some feelings of hypomania.
D. Antipsychotic medication prevents psychotic symptoms commonly associated with the use of mood stabilizers.

811. During a unit card game, a client with acute mania begins to sing loudly as she starts to undress. The nurse should:
A. Ignore the client’s behavior.
B. Exchange the cards for a checker board.
C. Send the other clients to their rooms.
D. Cover the client and walk her to her room.

812. A child with Down syndrome has a developmental age of four years. According to the Denver Developmental Assessment, the four-year-old should be able to:
A. Draw a man in six parts
B. Give his first and last name
C. Dress without supervision
D. Define a list of words

813. A client with paranoid schizophrenia is brought to the hospital by her elderly parents. During the assessment, the client’s mother states, “Sometimes she is more than we can manage.” Based on the mother’s statement, the most appropriate nursing diagnosis is:
A. Ineffective family coping related to parental role conflict
B. Care-giver role strain related to chronic situational stress
C. Altered family process related to impaired social interaction
D. Altered parenting related to impaired growth and development

814. An adolescent client hospitalized with anorexia nervosa is described by her parents as “the perfect child.” When planning care for the client, the nurse should:
A. Allow her to choose what foods she will eat
B. Provide activities to foster her self-identity
C. Encourage her to participate in morning exercise
D. Provide a private room near the nurse’s station

815. The nurse is assigning staff to care for a number of clients with emotional disorders. Which facet of care is suitable to the skills of the nursing assistant?
A. Obtaining the vital signs of a client admitted for alcohol withdrawal
B. Helping a client with depression with bathing and grooming
C. Monitoring a client who is receiving electroconvulsive therapy
D. Sitting with a client with mania who is in seclusion

816. A client with angina is being discharged with a prescription for Transderm Nitro (nitroglycerin) patches. The nurse should tell the client to:
A. Shave the area before applying the patch
B. Remove the old patch and clean the skin with alcohol
C. Cover the patch with plastic wrap and tape it in place
D. Avoid cutting the patch because it will alter the dose

817. A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:
A. Decreased blood pressure and constricted pupils
B. Increased heart rate and increased respirations
C. Increased respirations and increased blood pressure
D. Anoxia and absence of the cough reflex

818. The nurse is providing dietary teaching for a client with hypertension. Which food should be avoided by the client on a sodium-restricted diet?
A. Dried beans
B. Swiss cheese
C. Peanut butter
D. Colby cheese

819. A client is admitted to the emergency room with partial-thickness burns to his right arm and full-thickness burns to his trunk. According to the Rule of Nines, the nurse calculates that the total body surface area (TBSA) involved is:
A. 20%
B. 35%
C. 45%
D. 60%

820. The physician has ordered a paracentesis for a client with severe abdominal ascites. Before the procedure, the nurse should:
A. Provide the client with a urinal
B. Prep the area by shaving the abdomen
C. Encourage the client to drink extra fluids
D. Request an ultrasound of the abdomen

821. Which of the following combinations of foods is appropriate for an eight-month-old infant?
A. Cocoa-flavored cereal, orange juice, and strained meat
B. Graham crackers, strained prunes, and pudding
C. Rice cereal, bananas, and strained carrots
D. Mashed potatoes, strained beets, and whole milk

822. The mother of a nine-year-old with asthma has brought an electric CD player for her son to listen to while he is receiving oxygen therapy. The nurse should:
A. Explain that he does not need the added stimulation.
B. Allow the CD player, but ask him to wear earphones.
C. Tell the mother that he cannot have items from home.
D. Ask the mother to bring a battery-operated CD instead.

823. Which one of the following situations represents a maturational crisis for the family?
A. A four-year-old entering nursery school
B. Development of preeclampsia during pregnancy
C. Loss of employment and health benefits
D. Hospitalization of a grandfather with a stroke

824. A client with a history of phenylketonuria is seen at the local family planning clinic. After completing the client’s intake history, the nurse provides literature for a healthy pregnancy. Which statement indicates that the client needs further teaching?
A. I can help control my weight by switching from sugar to Nutrasweet.
B. I need to resume my old diet before becoming pregnant.
C. Fresh fruits and raw vegetables will make excellent between-meal snacks.
D. I need to eliminate most sources of phenylalanine from my diet.

825. Parents of a toddler are dismayed when they learn that their child has Duchenne’s muscular dystrophy. Which statement describes the inheritance pattern of the disorder?
A. An affected gene is located on one of the 21 pairs of autosomes.
B. The disorder is caused by an over-replication of the X chromosome in males.
C. The affected gene is located on the Y chromosome of the father.
D. The affected gene is located on the X chromosome of the mother.

826. A client with obsessive compulsive personality disorder annoys his co-workers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:
A. Helping the client develop a plan for changing his behavior
B. Contracting with him for the time he spends on a task
C. Avoiding a discussion of his annoying behavior because it will only make him worse
D. Encouraging him to set a time schedule and deadlines for himself

827. The mother of a child with chickenpox wants to know if there is a medication that will shorten the course of the illness. Which medication is sometimes used to speed healing of the lesions and shorten the duration of fever and itching?
A. Zovirax (acyclovir)
B. Varivax (varicella vaccine)
C. VZIG (varicella-zoster immune globulin)
D. Periactin (cyproheptadine)

828. One of the most important criteria for the diagnosis of physical abuse is inconsistency between the appearance of the injury and the history of how the injury occurred. Which one of the following situations should alert the nurse to the possibility of abuse?
A. An 18-month-old with sock and mitten burns from a fall into the bathtub
B. A six-year-old with a fractured clavicle following a fall from her bike
C. An eight-year-old with a concussion from a skateboarding accident
D. A two-year-old with burns to the scalp and face from a grease spill

829. A patient refuses to take his dose of oral medication. The nurse tells the patient that if he does not take the medication that she will administer it by injection. The nurse’s comments can result in a charge of:
A. Malpractice
B. Assault
C. Negligence
D. Battery

830. During morning assessments, the nurse finds that a client’s nephrostomy tube has been clamped. The nurse’s first action should be to:
A. Assess the drainage bag.
B. Check for bladder distention.
C. Unclamp the tubing.
D. Irrigate the tubing.

831. The nurse caring for a client with closed chest drainage notes that the collection chamber is full.
A. Add more water to the suction-control chamber.
B. Remove the drainage using a 60mL syringe.
C. Milk the tubing to facilitate drainage.
D. Prepare a new unit for continuing collection.

832. A client with severe anemia is to receive a unit of packed red blood cells. In the event of a transfusion reaction, the first action by the nurse should be to:
A. Notify the physician and the nursing supervisor.
B. Stop the transfusion and maintain an IV of normal saline.
C. Call the lab for verification of type and cross match.
D. Prepare an injection of Benadryl (diphenhydramine).

833. A new mother tells the nurse that she is getting a new microwave so that her husband can help prepare the baby’s feedings. The nurse should:
A. Explain that a microwave should never be used to warm the baby’s bottles.
B. Tell the mother that microwaving is the best way to prevent bacteria in the formula.
C. Tell the mother to shake the bottle vigorously for one minute after warming in the microwave.
D. Instruct the parents to always leave the top of the bottle open while microwaving so heat can escape.

834. A client with HELLP syndrome is admitted to the labor and delivery unit for observation. The nurse knows that the client will have elevated:
A. Serum glucose levels
B. Liver enzymes
C. Pancreatic enzymes
D. Plasma protein levels

835. To reduce the possibility of having a baby with a neural tube defect, the client should be told to increase her intake of folic acid. Dietary sources of folic acid include:
A. Meat, liver, eggs
B. Pork, fish, chicken
C. Spinach, beets, cantaloupe
D. Dried beans, sweet potatoes, Brussels sprouts

836. The nurse is making room assignments for four obstetrical clients. If only one private room is available, it should be assigned to:
A. A multigravida with diabetes mellitus
B. A primigravida with preeclampsia
C. A multigravida with preterm labor
D. A primigravida with hyperemesis gravidarum

837. A client has a tentative diagnosis of myasthenia gravis. The nurse recognizes that myasthenia gravis involves:
A. Loss of the myelin sheath in portions of the brain and spinal cord
B. An interruption in the transmission of impulses from nerve endings to muscles
C. Progressive weakness and loss of sensation that begins in the lower extremities
D. Loss of coordination and stiff “cogwheel” rigidity

838. The physician has ordered an infusion of Osmitrol (mannitol) for a client with increased intracranial pressure. Which finding indicates the direct effectiveness of the drug?
A. Increased pulse rate
B. Increased urinary output
C. Decreased diastolic blood pressure
D. Increased pupil size

839. The nurse has just received the change of shift report. Which client should the nurse assess first?
A. A client with a supratentorial tumor awaiting surgery
B. A client admitted with a suspected subdural hematoma
C. A client recently diagnosed with akinetic seizures
D. A client transferring to the neuro rehabilitation unit

840. The physician has ordered an IV bolus of Solu-Medrol (methylprednisolone sodium succinate) in normal saline for a client admitted with a spinal cord injury. Solu-Medrol has been shown to be effective in:
A. Preventing spasticity associated with cord injury
B. Decreasing the need for mechanical ventilation
C. Improving motor and sensory functioning
D. Treating post injury urinary tract infections

841. The physician has ordered a lumbar puncture for a client with suspected Guillain-Barre syndrome. The spinal fluid of a client with Guillain-Barre syndrome typically shows:
A. Decreased protein concentration with a normal cell count
B. Increased protein concentration with a normal cell count
C. Increased protein concentration with an abnormal cell count
D. Decreased protein concentration with an abnormal cell count

842. An 18-month-old is admitted to the hospital with acute laryngotracheobronchitis. When assessing the respiratory status, the nurse should expect to find:
A. Inspiratory stridor and harsh cough
B. Strident cough and drooling
C. Wheezing and intercostal retractions
D. Expiratory wheezing and nonproductive cough

843. The school nurse is assessing an elementary student with hemophilia who fell during recess. Which symptoms indicate hemarthrosis?
A. Pain, coolness, and blue discoloration in the affected joint
B. Tingling and pain without loss of movement in the affected joint
C. Warmth, redness, and decreased movement in the affected joint
D. Stiffness, aching, and decreased movement in the affected joint

844. The physician has ordered aerosol treatments, chest percussion, and postural drainage for a client with cystic fibrosis. The nurse recognizes that the combination of therapies is to:
A. Decrease respiratory effort and mucous production
B. Increase efficiency of the diaphragm and gas exchange
C. Dilate the bronchioles and help remove secretions
D. Stimulate coughing and oxygen consumption

845. The nurse is assessing a six-year-old following a tonsillectomy. Which one of the following signs is an early indication of hemorrhage?
A. Drooling of bright red secretions
B. Pulse rate of 90
C. Vomiting of dark brown liquid
D. Infrequent swallowing while sleeping

846. A client is admitted for suspected bladder cancer. Which one of the following factors is most significant in the client’s diagnosis?
A. Smoking a pack of cigarettes a day for 30 years
B. Use of nonsteroidal anti-inflammatories
C. Eating foods with preservatives
D. Past employment involving asbestos

847. The nurse is teaching a client with peritoneal dialysis how to manage exchanges at home. The nurse should tell the client to notify the doctor immediately if:
A. The dialysate returns become cloudy in appearance.
B. The return of the dialysate is slower than usual.
C. A “tugging” sensation is noted as the dialysate drains.
D. A feeling of fullness is felt when the dialysate is instilled.

848. The physician has prescribed nitroglycerin sublingual tablets as needed for a client with angina. The nurse should tell the client to take the medication:
A. After engaging in strenuous activity
B. Every four hours to prevent chest pain
C. As soon as he notices signs of chest pain
D. At bedtime to prevent nocturnal angina

849. The nurse is caring for a client following a myocardial infarction. Which of the following enzymes are specific to cardiac damage?
A. SGOT and LDH
B. SGOT and CK BB
C. LDH and CK MB
D. LDH and CK BB

850. Which of the following characterizes peer group relationships in eight- and nine-year-olds?
A. Activities organized around competitive games
B. Loyalty and strong same-sex friendships
C. Informal socialization between boys and girls
D. Shared activities with one best friend

851. If the school-age child is not given the opportunity to engage in tasks and activities he can carry through to completion, he is likely to develop feelings of:
A. Guilt
B. Shame
C. Stagnation
D. Inferiority

852. The physician has ordered two units of whole blood for a client following surgery. To provide for client safety, the nurse should:
A. Obtain a signed permit for each unit of blood.
B. Use a new administration set for each unit transfused.
C. Administer the blood using a Y connector.
D. Check the blood type and Rh factor three times before initiating the transfusion.

853. A client with B positive blood is scheduled for a transfusion of whole blood. Which finding requires nursing intervention?
A. The available blood has been banked for two weeks.
B. The blood available for transfusion is Rh negative.
C. The client has a peripheral IV of D5 1/2 normal saline.
D. The blood available for transfusion is type O positive.

854. The nurse is reviewing the lab results of a client’s arterial blood gases. The PaCO2 indicates effective functioning of the:
A. Kidneys
B. Pancreas
C. Lungs
D. Liver

855. The autopsy results in SIDS-related death will show the following consistent findings:
A. Abnormal central nervous system development
B. Abnormal cardiovascular development
C. Intraventricular hemorrhage and cerebral edema
D. Pulmonary edema and intrathoracic hemorrhages

856. The nurse is caring for a newborn who is on strict intake and output. The used diaper weighs 73.5gm. The diaper’s dry weight was 62gm. The newborn’s urine output is:
A. 10mL
B. 11.5mL
C. 10gm
D. 12gm

857. The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should explain the need for:
A. Additional calcium in the infant’s diet
B. Careful handling to prevent fractures
C. Providing extra sensorimotor stimulation
D. Frequent testing of visual function

858. A newborn is diagnosed with respiratory distress syndrome (RDS). Which position is best for maintaining an open airway?
A. Prone, with his head turned to one side
B. Side-lying, with a towel beneath his shoulders
C. Supine, with his neck slightly flexed
D. Supine, with his neck slightly extended

859. A client with bipolar disorder is discharged with a prescription for Depakote (divalproex sodium). The nurse should remind the client of the need for:
A. Frequent dental visits
B. Frequent lab work
C. Additional fluids
D. Additional sodium

860. The physician’s notes state that a client with cocaine addiction has formication. The nurse recognizes that the client has:
A. Tactile hallucinations
B. Irregular heart rate
C. Paranoid delusions
D. Methadone tolerance

861. The nurse is preparing a client with gastroesophageal reflux disease (GERD) for discharge. The nurse should tell the client to:
A. Eat a small snack before bedtime
B. Sleep on his right side
C. Avoid carbonated beverages
D. Increase his intake of citrus fruits

862. A client with a C3 spinal cord injury experiences autonomic hyperreflexia. After placing the client in high Fowler’s position, the nurse’s next action should be to:
A. Notify the physician
B. Make sure the catheter is patent
C. Administer an antihypertensive
D. Provide supplemental oxygen

863. A client is to receive Dilantin (phenytoin) via a nasogastric (NG) tube. When giving the medication, the nurse should:
A. Flush the NG tube with 2–4mL of water before giving the medication
B. Administer the medication, flush with 5mL of water, and clamp the NG tube
C. Flush the NG tube with 5mL of normal saline and administer the medication
D. Flush the NG tube with 2–4oz of water before and after giving the medication

864. When assessing the client with acute arterial occlusion, the nurse would expect to find:
A. Peripheral edema in the affected extremity
B. Minute blackened areas on the toes
C. Pain above the level of occlusion
D. Redness and warmth over the affected area

865. The nurse is assessing a client following the removal of a pituitary tumor. The nurse notes that the urinary output has increased and that the urine is very dilute. The nurse should give priority to:
A. Notifying the doctor immediately
B. Documenting the finding in the chart
C. Decreasing the rate of IV fluids
D. Administering vasopressive medication

866. The physician has ordered Coumadin (sodium warfarin) for a client with a history of clots. The nurse should tell the client to avoid which of the following vegetables?
A. Lettuce
B. Cauliflower
C. Beets
D. Carrots

867. The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should:
A. Use a small hand-held hair dryer set on medium heat.
B. Place a small heater near the child’s bed.
C. Turn the child at least every two hours.
D. Allow one side to dry before changing positions.

868. The local health clinic recommends vaccination against influenza for all its employees. The influenza vaccine is usually given annually in:
A. November
B. December
C. January
D. February

869. A client is admitted with suspected Hodgkin’s lymphoma. The diagnosis is confirmed by the:
A. Overproliferation of immature white cells
B. Presence of Reed-Sternberg cells
C. Increased incidence of microcytosis
D. Reduction in the number of platelets

870. The nurse is caring for a client following a laryngectomy. The nurse can best help the client with communication by:
A. Providing a pad and pencil
B. Checking on him every 30 minutes
C. Telling him to use the call light
D. Teaching the client simple sign language

871. A client has recently been diagnosed with primary open-angle glaucoma. The nurse should tell the client to avoid taking:
A. Aleve (naprosyn)
B. Benadryl (diphenhydramine)
C. Tylenol (acetaminophen)
D. Robitussin (guaifenesin)

872. The nurse is caring for a client with an endemic goiter. The nurse recognizes that the client’s condition is related to:
A. Living in an area where the soil is depleted of iodine
B. Eating foods that decrease the thyroxine level
C. Using aluminum cookware to prepare the family’s meals
D. Taking medications that decrease the thyroxine level

873. A client with a history of schizophrenia is seen in the local health clinic for medication follow-up. To maintain a therapeutic level of medication, the nurse should tell the client to avoid:
A. Taking over-the-counter allergy medication
B. Eating cheese and pickled foods
C. Eating salty foods
D. Taking over-the-counter pain relievers

874. The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is:
A. Body image disturbance related to enlargement of the neck
B. Activity intolerance related to fatigue
C. Nutrition imbalance, less than body requirements, related to increased metabolism
D. Risk for ineffective airway clearance related to pressure of goiter on the trachea

875. Upon arrival to the nursery, Ilotycin (erythromycin) eyedrops are instilled in the newborn’s eyes. The nurse understands that the medication will:
A. Make the eyes less sensitive to light
B. Help prevent neonatal blindness
C. Strengthen the muscles of the eyes
D. Improve accommodation to near objects

876. A client has a diagnosis of discoid lupus erythematosus (DLE). The nurse recognizes that discoid lupus differs from systemic lupus erythematosus because it:
A. Produces changes in the kidneys
B. Is confined to changes in the skin
C. Results in damage to the heart and lungs
D. Affects both joints and muscles

877. A client sustained a severe head injury to the occipital lobe. The nurse should carefully assess the client for:
A. Changes in vision
B. Difficulty in speaking
C. Impaired judgment
D. Hearing impairment

878. The nurse observes a group of toddlers at daycare. Which of the following play situations exhibits the characteristics of parallel play?
A. Lindie and Laura sharing clay to make cookies
B. Nick and Matt playing beside each other with trucks
C. Adrienne working a puzzle with Meredith and Ryan
D. Ashley playing with a busy box while sitting in her crib

879. Which of the following statements is true regarding language development of young children?
A. Infants can discriminate speech from other patterns of sound.
B. Boys are more advanced in language development than girls of the same age.
C. Second-born children develop language earlier than first-born or only children.
D. Using single words for an entire sentence suggests delayed speech development.

880. A mother tells the nurse that her daughter has become quite a collector, filling her room with Beanie babies, dolls, and stuffed animals. The nurse recognizes that the child is developing:
A. Object permanence
B. Post-conventional thinking
C. Concrete operational thinking
D. Pre-operational thinking

881. According to Erikson, the developmental task of the infant is to establish trust. Parents and caregivers foster a sense of trust by:
A. Holding the infant during feedings
B. Speaking quietly to the infant
C. Providing sensory stimulation
D. Consistently responding to needs

882. The nurse is preparing to walk the postpartum client for the first time since delivery. Before walking the client, the nurse should:
A. Give the client pain medication.
B. Assist the client in dangling her legs.
C. Have the client breathe deeply.
D. Provide the client additional fluids.

883. To minimize confusion in the elderly hospitalized client, the nurse should:
A. Provide sensory stimulation by varying the daily routine.
B. Keep the room brightly lit and the television on to provide orientation to time.
C. Encourage visitors to limit visitation to phone calls to avoid overstimulation.
D. Provide explanations in a calm, caring manner to minimize anxiety.

884. A client diagnosed with tuberculosis asks the nurse when he can return to work. The nurse should tell the client that:
A. He can return to work when he has three negative sputum cultures.
B. He can return to work as soon as he feels well enough.
C. He can return to work after a week of being on the medication.
D. He should think about applying for disability because he will no longer be able to work.

885. The physician has ordered lab work for a client with suspected disseminated intravascular coagulation (DIC). Which lab finding would provide a definitive diagnosis of DIC?
A. Elevated erythrocyte sedimentation rate
B. Prolonged clotting time
C. Presence of fibrin split compound
D. Elevated white cell count

886. The nurse is caring for a client with rheumatoid arthritis. The nurse knows that the client’s early morning symptoms will be most improved by:
A. Taking a warm shower upon awakening
B. Applying ice packs to the joints
C. Taking two aspirin before going to bed
D. Going for an early morning walk

887. A client with schizophrenia has been taking Clozaril (clozapine) for the past six months. This morning the client’s temperature was elevated to 102°F. The nurse should give priority to:
A. Placing a note in the chart for the doctor
B. Rechecking the temperature in four hours
C. Notifying the physician immediately
D. Asking the client if he has been feeling sick

888. Which one of the following clients is most likely to develop acute respiratory distress syndrome?
A. A 20-year-old with fractures of the tibia
B. A 36-year-old who is HIV positive
C. A 40-year-old with duodenal ulcers
D. A 32-year-old with barbiturate overdose

889. The complete blood count of a client admitted with anemia reveals that the red blood cells are hypochromic and microcytic. The nurse recognizes that the client has:
A. Aplastic anemia
B. Iron-deficiency anemia
C. Pernicious anemia
D. Hemolytic anemia

890. While performing a neurological assessment on a client with a closed head injury, the nurse notes a positive Babinski reflex. The nurse should:
A. Recognize that the client’s condition is improving.
B. Reposition the client and check reflexes again.
C. Do nothing because the finding is an expected one.
D. Notify the physician of the finding.

891. The doctor has ordered neurological checks every 30 minutes for a client injured in a biking accident. Which finding indicates that the client’s condition is satisfactory?
A. A score of 13 on the Glascow coma scale
B. The presence of doll’s eye movement
C. The absence of deep tendon reflexes
D. Decerebrate posturing

892. The nurse is developing a plan for bowel and bladder retraining for a client with paraplegia. The primary goal of a bowel and bladder retraining program is:
A. Optimal restoration of the client’s elimination pattern
B. Restoration of the client’s neurosensory function
C. Prevention of complications from impaired elimination
D. Promotion of a positive body image

893. When checking patellar reflexes, the nurse is unable to elicit a knee-jerk response. To facilitate checking the patellar reflex, the nurse should tell the client to:
A. Pull against her interlocked fingers
B. Shrug her shoulders and hold for a count of five
C. Close her eyes tightly and resist opening
D. Cross her legs at the ankles

894. The nurse is performing a physical assessment on a newly admitted client. The last step in the physical assessment is:
A. Inspection
B. Auscultation
C. Percussion
D. Palpation

895. A client with schizophrenia spends much of his time pacing the floor, rocking back and forth, and moving from one foot to another. The client’s behaviors are an example of:
A. Dystonia
B. Tardive dyskinesia
C. Akathisia
D. Oculogyric crisis

896. The nurse is assessing a recently admitted newborn. Which finding should be reported to the physician?
A. The umbilical cord contains three vessels.
B. The newborn has a temperature of 98°F.
C. The feet and hands are bluish in color.
D. A large, soft swelling crosses the suture line.

897. Which statement is true regarding the infant’s susceptibility to pertussis?
A. If the mother had pertussis, the infant will have passive immunity.
B. Most infants and children are highly susceptible from birth.
C. The newborn will be immune to pertussis for the first few months of life.
D. Infants under one year of age seldom get pertussis.

898. A client in labor has been given epidural anesthesia with Marcaine (bupivacaine). To reverse the hypotension associated with epidural anesthesia, the nurse should have which medication available?
A. Narcan (naloxone)
B. Dobutrex (dobutamine)
C. Romazicon (flumazenil)
D. Adrenalin (epinephrine)

899. The physician has prescribed Gantrisin (sulfasoxazole) 1gm in divided doses for a client with a urinary tract infection. The nurse should administer the medication:
A. With meals or a snack
B. 30 minutes before meals
C. 30 minutes after meals
D. At bedtime

900. A client with a history of depression is treated with Parnate (tranylcypromine), an MAO inhibitor. Ingestion of foods containing tyramine while taking an MAO inhibitor can result in:
A. Extreme elevations in blood pressure
B. Rapidly rising temperature
C. Abnormal movement and muscle spasms
D. Damage to the eighth cranial nerve