Part 3 (1-30)

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1. Which intervention is an example of primary prevention?

A. Administering digoxin (Lanoxicaps) to a patient with heart failure
B. Administering a measles, mumps, and rubella immunization to an infant
C. Obtaining a Papanicolaou smear to screen for cervical cancer
D. Using occupational therapy to help a patient cope with arthritis

2. The nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse use first?

A. Auscultation
B. Inspection
C. Percussion
D. Palpation

3. Which statement regarding heart sounds is correct?

A. S1 and S2 sound equally loud over the entire cardiac area.
B. S1 and S2 sound fainter at the apex
C. S1 and S2 sound fainter at the base
D. S1 is loudest at the apex, and S2 is loudest at the base

4. The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the nursing process?

A. Assessment
B. Nursing diagnosis
C. Planning
D. Evaluation

5. A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.D. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming:

A. Fresh, green vegetables
B. Bananas and oranges
C. Lean red meat
D. Creamed corn

6. The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol?

A. Lethal arrhythmias
B. Malignant hypertension
C. Status epilepticus
D. Bone marrow suppression

7. A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time?

A. Impaired gas exchanges related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusionrelated to venous congestion

8. When positioned properly, the tip of a central venous catheter should lie in the:

A. Superior vena cava
B. Basilica vein
C. Jugular vein
D. Subclavian vein

9. Nurse Nikki is revising a client’s care plan. During which step of the nursing process does such revision take place?

A. Assessment
B. Planning
C. Implementation
D. Evaluation

10. A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, “How long will it take for my scars to disappear?” which statement would be the nurse’s best response?

A. “The contraction phase of wound healing can take 2 to 3 years.”
B. “Wound healing is very individual but within 4 months the scar should fade.”
C. “With your history and the type of location of the injury, it’s hard to say.”
D. “If you don’t develop an infection, the wound should heal any time between 1 and 3 years from now.”

11. One aspect of implementation related to drug therapy is:

A. Developing a content outline
B. Documenting drugs given
C. Establishing outcome criteria
D. Setting realistic client goals

12. A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important?

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