1. A nurse is assessing the extent of pitting edema in a client with congestive heart failure. The nurse gently presses a finger on the client's ankle and notes a barely perceptible pit. The nurse interprets this finding as which measurement of pitting edema?
a. 1+
b. 2+
c. 3+
d. 4+
2. The nurse notes documentation that a client's peripheral pulses are +3. The nurse determines that the pulses are
a. Full and brisk
b. Absent
c. Normal or average
d. Palpable, but diminished
3. A nurse is reviewing a client’s record and notes that the results of the client’s vision test using a Snellen chart is 20/50. The nurse interprets this to mean that the client
a. Has normal vision
b. Has minimal visual
c. Can read at a distance of 20 feet what a client with normal vision can read at 50 feet
d. Can read at a distance of 50 feet what a client with normal vision can read at 20 feet
4. A prenatal client tells the nurse that she is really worried about knowing how to care for her first-born child. The nurse formulates which nursing diagnosis for this client?
a. Ineffective Coping
b. Dysfunctional Grieving
c. Situational Low Self-esteem
d. Deficient Knowledge
5. The nurse notes documentation that a client has the presence of cherry angiomas located on the abdomen. On assessment of the client, the nurse would expect to note which characteristic of this skin lesion?
a. Ruby red papules
b. Thickened skin areas
c. Pinpoint-sized red or purple spots
d. Areas of redness warm to touch
6. A nurse is assessing the risk factors for acquiring pneumonia during hospitalization for a group of clients. The nurse determines that which of the following clients is at lowest risk?
a. An older client with diabetes mellitus
b. A client with human immunodeficiency virus (HIV)
c. A client with a spinal cord injury who is immobile
d. A postoperative client who is ambulating
7. A nurse working in a prenatal clinic is reviewing the records of clients scheduled for prenatal visits. The nurse interprets that the client at greatest risk for abruptio placenta is the one who
a. Is 26 years old and is a primipara
b. Rides an exercise bike for 30 minutes 3 times weekly
c. Has maternal hypertension
d. Takes folic acid supplements daily
8. The nurse teaches a client with gastroesophageal reflux disease (GERD) about the measures to prevent reflux while sleeping. The nurse determines that the client needs additional instructions if the client states
a. "I shouldn't eat anything at bedtime."
b. "I should take an antacid at bedtime."
c. "I should sleep flat on my right side."
d. "Losing weight will decrease some of the stomach pressure."
9. A nurse provides instructions to a client about the measures to treat gout. The nurse determines that the client needs additional instructions if the client states that
a. The intake of red meats needs to be limited.
b. Weight loss can help prevent an attack.
c. Medication can help keep the uric acid level down.
d. Fluid intake needs to be limited.
10. A nurse provides instructions to a client who is being discharged 24 hours after undergoing a percutaneous renal biopsy. Which statement by the client indicates a need to reinforce the instructions?
a. "I need to avoid any strenuous lifting for about two weeks."
b. "I shouldn't work out at the gym for about two weeks."
c. "I will call the physician if my urine becomes bloody."
d. "A fever is normal after this procedure."
11. A clinic nurse has provided instructions to the mother of a child with a urinary tract infection. Which statement by the mother indicates a need for further instructions?
a. "I should wipe my child from front to back after urination or a bowel movement."
b. "I should increase my child's fluid intake."
c. "I should encourage my child to hold the urine and to urinate at least four times a day."
d. "I should avoid the use of bubble baths with my child."
12. A nurse provides dietary instructions to a client with hypertension. The nurse determines that the client understands the instructions if the client states that it is acceptable to eat which of the following food items?
a. Hot dogs
b. Turkey
c. Salad with blue cheese dressing
d. Corned beef hash
13. The nurse is providing dietary instructions to a client with ascites who will be discharged to home from the hospital. The nurse determines that the client understands the instructions if the client states that it is acceptable to eat which food item?
a. Canned green beans
b. Fresh plums
c. Cooked ham
d. Bologna
14. A nurse has provided instructions to a client with chronic obstructive pulmonary disease about the procedure for performing pursed lip breathing. The nurse observes the client perform the procedure and determines that he or she is performing it correctly if the client
a. Takes a deep breath and exhales quickly
b. Monitors inspiration time and ensures that expiration time is less than inspiration time
c. Lies on the side in a supine position to perform the procedure
d. Sits in an upright position, takes a deep breath, and exhales slowly
15. A nurse has completed discharge teaching with the family of a client who requires dressing changes at home. Which method of evaluation would the nurse use to best determine the family’s competence in performing the dressing changes?
a. Asking a family member to perform the dressing change and observing the procedure
b. Asking a family member to identify the supplies needed to perform the dressing change
c. Asking a family member to list the steps of the procedure for performing the dressing change
d. Asking a family member to verbalize the procedure for performing the dressing change
16. A nurse is teaching a client diagnosed with iron deficiency anemia about the foods that are high in iron. The nurse tells the client to consume which high-iron food?
a. Refined white bread
b. Egg whites
c. Mushrooms
d. Spinach
17. A clinic nurse provides instructions to a woman in the second trimester of pregnancy regarding measures to relieve backache. Which statement by the client indicates an understanding of these measures?
a. "I will sleep on a soft mattress."
b. "I will avoid doing those pelvic tilt exercises."
c. "I will avoid getting tired, and I should work at maintaining a good posture."
d. "I will wear shoes with a heel of at least 2 inches."
18. A prenatal client reports heartburn, and the nurse provides instructions to the client regarding measures to alleviate the discomfort. Which statement by the client indicates a need for further instructions?
a. "I need to eat small, frequent meals."
b. "I need to avoid fatty or spicy foods."
c. "I need to lie down after eating."
d. "I need to drink approximately 2000 mL fluid per day."
19. During the administration of a blood transfusion to a client, the nurse notes the presence of crackles in the client’s lung bases. On further assessment, the nurse notes that the client has distended neck veins and an increase in central venous pressure. The nurse suspects that the client is experiencing what complication of the blood transfusion?
a. Transfusion reaction
b. Allergic reaction
c. Sepsis
d. Circulatory overload
20. A client with type 1 diabetes mellitus has a blood glucose level of 554 mg/dL. The nurse calls the physician to report the level and monitors the client closely for which acid-base imbalance?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
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