Critical Thinking Exam

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EXAM CODE CT1

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1. The nurse is caring for clients in the outpatient clinic.

Which of the following messages should the nurse return FIRST?
a) A mother reports that the umbilical cord of her five-day-old

infant is dry and hard to the touch.
b) A mother reports that the "soft spot" on the head of her
four-day-old infant feels slightly elevated when the baby
sleeps.
c) A mother reports that the circumcision of her 3-day-old
infant is covered with yellowish exudate.
d) A father reports that he bumped the crib of his two-day-old
infant and she violently extended her extremities and
returned to them their previous position.
2 . The parents of a child with hemophilia want to know the cause

of the disease. Which of the following would be the BEST response
by the nurse?
a) "The father transmits the gene to his son."

b) "Both the mother and the father carry a recessive trait."
c) "The mother transmits the gene to her son."
d) "There is a 50% chance that the mother will pass the trait
to each of her daughters."
3 . A six-month-old is brought to the clinic for a well-baby

check-up. During the exam, the nurse should expect to assess
which of the following?
a) A pincer grasp.
b) Sitting with support.
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c) Tripling of the birth weight.

d) Presence of the posterior fontanelle.
4. A 48-year-old man with an endotracheal tube needs suctioning.

Which of the following statements is an accurate description of
how the nurse should perform the procedure?
a) Insert the suction catheter four inches into the tube. Apply
suction for 30 seconds, using a twirling motion as the
catheter is withdrawn.
b) Hyperoxygenate the client and then insert the suction
catheter into the tube. Suction while you remove the
catheter using a back and forth motion.
c) Explain the procedure to the patient. Insert the catheter
gently applying suction, and withdraw using a twisting
motion.
d) Insert the suction catheter until resistance is met, then
withdraw it slightly. Apply suction intermittently as the
catheter is withdrawn.
5. A 47-year-old woman comes to the outpatient psychiatric clinic

for treatment of a fear of heights. The nurse knows that phobias
involve
a) projection and displacement.

b) sublimation and internalization.
c) rationalization and intellectualization.
d) reaction formation and symbolization.
6. The prenatal client at eight-weeks gestation has a positive

VDRL. In preparing the teaching plan, which of the following

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would be MOST appropriate for the nurse to include?
a) The importance of not taking any medications so as not to

damage the fetus.
b) Instructing the client on the importance of taking the
penicillin for the prescribed time.
c) Instructing the client to refrain from sexual activity.
d) Maintaining the confidentiality of sexual partners or
contacts.
7. An elderly client who has been recently immobilized is ordered

to begin passive range-of-motion (ROM) exercises.
What should
the nurse understand about ROM before initiating this order?
a) Passive range-of-motion exercises increase muscle strength.

b) A full range of motion must be completed for the elderly
client.
c) Exercises should be completed to the point of discomfort.
d) A sufficient range of motion assists the elderly to carry
out activities of daily living (ADLs).
8. A 65-year-old man is scheduled for a colon resection this

morning. Last night he had polyethylene glycolelectrolyte
solution (GoLytely) and a soapsuds enema. This morning he passes
a medium amount of soft brown stool. The nurse should know that
this
a) indicates that the bowel preparation is incomplete.

b) is evidence that the patient ate something after midnight.
c) is an expected finding before this type of surgery.


d) is the last stool that was left in the colon.
9. The nurse cares for a newborn infant with fetal alcohol

syndrome. The nurse would expect to see which of the following
physical characteristics?
a) An infant that is large for gestational age (LGA) with

craniofacial abnormalities and hydrocephalus.
b) An infant with a small head circumference, low birth weight,
and undeveloped cheekbones.
c) An infant small head circumference, low birth weight, and
excessive rooting and sucking behaviors.
d) An infant with a normal head circumference, low birth
weight, and respiratory distress syndrome.
10. The physician orders hydromorphone hydrochloride (Dilaudid)

15 mg IM for a 56-year-old woman. Side effects of this medication
the nurse should observe the patient for include
a) photosensitivity and constipation.

b) hypotension and respiratory depression.
c) tardive dyskinesia and diplopia.
d) dry mouth and tinnitus.
11. The out-patient clinic nurse is caring for a 66-year-old

woman with insulin-dependent diabetes mellitus (IDDM). Because
the client is unwilling to perform blood glucose monitoring, she
tests her urine for sugar and acetone. The nurse knows that blood
glucose monitoring is preferred over urine testing for glucose
because
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a) the renal threshold for glucose is elevated in the elderly.

b) blood glucose monitoring is easier and less costly for
clients to perform.
c) urine testing for glucose provides false-positive readings.
d) determination of the color on a reagent strip varies from
person to person.
12. At 32-weeks gestation, a client has an order for an

ultrasound. The client indicates an understanding of this
procedure if she makes which of the following statements to the
nurse?
a) "The results will inform us of the gestational age."

b) "This test will evaluate the baby's lungs."
c) "The test will show us if there is any problem in the spinal
cord."
d) "Early problems with the baby's blood can be identified with
this test."
13. A child has pediculosis capitis (head lice) and is being

treated with 1% gamma benzene hexachloride (Kwell) shampoo. The
nurse should explain to the child's parents that
a) treatment should be continued every other day for 1 week.

b) clothing and personal belongings require normal cleansing
with soap and water.
c) application of the shampoo is repeated in 7 to 10 days.
d) one treatment with Kwell kills both lice and nits.


14. The nurse is supervising an LPN/LVN administering an enema to

a patient.
During the administration, it is MOST important for
the LPN/LVN to take which of the following actions?
a) Place the solution 20 inches above the anus.

b) Adjust the temperature of the solution.
c) Insert the tube six inches.
d) Position the patient left side-lying (Sim's) with knee
flexed.
15. An 18-month-old is admitted to the unit with a diagnosis of

laryngotracheobronchitis (LTB). During the initial assessment,
the nurse should expect to find which of the following early
symptoms?
a) Kussmaul respirations and bradycardia.

b) Elevated temperature and slow respiratory rate.
c) Expiratory wheezing and substernal retractions.
d) Inspiratory stridor and restlessness.
16. A client has been receiving chlorpromazine hydrochloride

(Thorazine). When the nurse checks on the patient, the patient is
restless, unable to sit still, and complains of insomnia and fine
tremors of her hands. The nurse knows that these symptoms are
a) a side effect of the medication that she will tolerate

better as time passes.
b) the reason she is receiving this medication.
c) extrapyramidal side effects resulting from this medication.
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d) an indication that the dosage of the medication needs to be

increased.
17. The nurse is caring for a client with
a tracheostomy.
An
appropriate nursing diagnosis for this client is
a) impaired verbal communication related to absence of speaking

ability.
b) ineffective airway clearance related to increased
tracheobronchial secretions.
c) risk for impaired skin integrity related to tracheostomy
incision.
d) alteration in comfort: pain related to tracheostomy.
18. Which of the following types of foods should the nurse

encourage in the diet of a client with hypoparathyroidism?
a) High in phosphorus.
b) High in calcium.
c) Low in sodium.
d) Low in potassium.
19. A 20-year-old woman arrives at the hospital in active labor.

The admitting nurse attaches an internal fetal monitor. The nurse
knows the MOST important reason for the fetal monitor is
a) to evaluate the progress of the client's labor.

b) to assess the strength and duration of the client's
contractions.


c) to monitor the oxygen status of the fetus during labor.

d) to decide if an oxytocin drip is necessary.
20. A mentally retarded client is to be discharged home on

warfarin sodium (Coumadin), 5 mg each day. To maintain client
safety, which of the following would be an appropriate FIRST
nursing action?
a) Instruct a significant other about the medication regimen.

b) Evaluate client comprehension of the medication
administration.
c) Prepackage the medication to encourage correct
administration.
d) Encourage a return demonstration of medication selfadministration.
21. A client, gravida 2 para 1, is admitted with hypertension and

complains that her wedding band is tight. The nurse should expect
to assess which of the following with early pre-eclampsia?
a) Blurred vision and proteinuria.

b) Epigastric pain and headache.
c) Facial swelling and proteinuria.
d) Polyuria and hypertonic reflexes.
22. The nurse is caring for clients in a drug rehabilitation

facility.
Which of the following complications of IV drug abuse
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is the nurse MOST likely to observe?
a) Jaundice.
b) Rash.
c) Bruising.
d) Cellulitis.
23. The client is admitted with cerebrovascular accident (CVA)

and has facial paralysis. Nursing care should be planned to
prevent which of the following complications?
a) Inability to talk.
b) Inability to swallow caused by loss of the gag reflex.
c) Inability to open the affected eye.
d) Corneal abrasion.
24. A client is ordered to take aspirin gr. X, PO. The drug label
reads: "Aspirin 325 mg per tablet." Which of the following
actions should the nurse take?
a) Request that the pharmacy send a correctly labeled

medication.


b) Notify the doctor regarding the dosage.

c) Give one tablet.
d) Give two tablets.
25. The nurse recognizes which of the following as early signs of

lithium toxicity?
a) Restlessness, shuffling gait, involuntary muscle movements.

b) Ataxia, confusion, seizures.
c) Fine tremors, nausea, vomiting, diarrhea.
d) Elevated white blood cell count, orthostatic hypotension.
26. The nurse suggests that the client not eat or drink anything
just before going to bed. The appropriateness of this comment is
based on which of these understandings about a sliding hiatal
hernia?
a) The client is less likely to awaken during the night with

heartburn if the stomach is empty.
b) Early-morning vomiting will be less of a problem if the
stomach is empty.
c) Drinking or eating before lying down causes decreased
respirations due to increased pressure on the lungs.
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d) The client may develop fluid overload if fluids are taken

just before going to bed.
27. A new mother is taking her infant home. The client asks the
nurse when she should start giving her child solid foods. The
nurse's response should be based on which of the following
statements?
a) Rice cereal is usually the first solid food and is started

around four to five months.
b) Strained fruits are well tolerated as the first solid food,
and infants like them.
c) Introduction of solid foods is not important at this time.
d) Solid foods are usually not started until the infant is
around six months old.
29. The nurse understands that the primary reason elderly adults
have problems with constipation is that they
a) eat a small volume of food with decreased bulk.

b) have less activity and decreased muscle tone.
c) have neurological changes in the gastrointestinal tract.
d) have decreased sensation in the gastrointestinal tract.


30. The nurse is discussing growth and development with the

parents of a four-year-old child. The nurse should identify which
of the following as the type of play characteristic of this age
group?
a) Solitary play.
b) Parallel play.
c) Associative play.
d) Aggressive play.
31. Which of the following should be charted by the nurse to

reflect a client's emotional adjustment to being hospitalized in
the intensive care unit?
a) "The client is unable to complete activities of daily living

without assistance."
b) "The client appears to be depressed and anxious regarding
his/her surgery."
c) "The client constantly calls for nurses, pleads for them to
stay at the bedside, and cries uncontrollably."
d) "The family is unable to visit more often than once a week
because they live far away."
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32. Which nursing observation would suggest that a client has

developed an Addisonian crisis?
a) Muscular weakness and fatigue.

b) Restlessness and rapid, weak pulse.
c) Dark pigmentation of the skin.
d) Gastrointestinal disturbances and anorexia.
33. A client had a thoracotomy 3 hours ago. For the past 2 hours
there has been 100 cc per hour of bloody chest drainage. Which of
the following actions should the nurse take FIRST?
a) Increase the IV fluid rate.
b) Administer oxygen at 5 L/min per oxygen mask.
c) Elevate the head of the bed.
d) Advise the physician of the amount of drainage.
34. A postoperative cataract client is cautioned about not making
sudden movements or bending over.
The nurse understands that the
rationale for this recommendation is to prevent which of the

following?
a) Impairment of cerebral blood flow and headaches.

b) Increased intracranial pressure.
c) Pressure on the ocular suture line.


d) Displacement of the lens implant.
35. Which information should the nurse recognize as being the

MOST pertinent to the diagnosis of cholecystitis?
a) Flatulence.
b) Nausea and vomiting.
c) Right upper abdominal pain.
d) Dyspepsia.
36. Which of the following might alert the nurse to consider an

alcohol problem in a client hospitalized for a physical illness?
a) Depression, difficulty falling asleep, decreased

concentration.
b) Elevated liver enzymes, cirrhosis, decreased platelets.
c) Tremors, elevated temperature, complaints of nocturnal leg
cramps, complaints of pain symptoms.
d) Flulike symptoms, diarrhea, night sweats, elevated
temperature, decreased deep tendon reflexes.
37. A 7-year-old girl is seen in the clinic with a diagnosis of

pituitary dwarfism. Which of the following clinical
manifestations is the nurse MOST likely to observe?
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a) Abnormal body proportions.

b) Early sexual maturation.
c) Delicate features.
d) Coarse, dry skin.
38. The physician orders mannitol (Osmitrol) for a client with a

closed head injury. Which of the following should the nurse
recognize as the desired response to this medication?
a) The blood pressure increases to 150/90.

b) Urinary output increases to 175 cc/hour.
c) There is a decrease in the level of activity.
d) There is absence of fine tremors of the fingers.
39. The nurse knows that according to Erikson's stages of

psychosocial development, which of the following best represents
a 50-year-old client?
a) Integrity versus despair and disgust.

b) Generativity versus stagnation.
c) Intimacy versus isolation.


d) Identity versus role diffusion.
40. A 54-year-old client developed a postoperative infection and

has been receiving ceftriaxone sodium (Rocephin) IV every day.
It is MOST important for the nurse to monitor which of the
following?
a) The surface of the tongue.

b) Hemoglobin and hematocrit.
c) Skin surfaces in skin folds.
d) Changes in urine characteristics.
41. The nurse should caution the client with hypothyroidism to

avoid
a) warm environmental temperatures.

b) narcotic sedatives.
c) increased physical exercise.
d) a diet high in fiber.
42. The nurse performs the Rinne tests on a 6-year-old girl.

Which of the following is an accurate statement of how this test
should be performed?
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a) The stem of a vibrating tuning fork is held against the

auditory canal until the child indicates that she can no
longer hear the sound. Then the tuning fork is moved away
from the canal.
b) The stem of a vibrating tuning fork is held against the
mastoid bone until the child indicates that she can no
longer hear the sound. Then the tuning fork is moved in
front of the auditory canal.
c) The stem of a vibrating tuning fork is held in the middle of
the forehead and the girl's hearing is assessed in both
ears.
d) The stem of a vibrating tuning fork is positioned two inches
behind the girl's head, and the length of time she hears the
sound is documented.
43. The nurse would explain to the diabetic client that the
decreased vision he has experienced is due to which of the
following?
a) Bleeding into the inner ocular chamber of the eye.

b) Gradual separation of the retina from the base of the eye.
c) An increase in the size of the vessels in the back of the
eye.
d) Gradual destruction and degeneration of the retina.


44. A woman is being evaluated for infertility. The doctor gives

the client clomiphene citrate (Clomid) 50 mg daily for five days.
The client says to the nurse, "What is the purpose of this
medicine?" The nurse should instruct her that the action of
medication is to
a) induce ovulation by changing hormonal effects on the ovary.

b) change the uterine lining to be more conducive to
implantation.
c) alter the vaginal pH to increase sperm motility.
d) produce multiple pregnancy for those who desire twins.
45. A client had a kidney transplant yesterday. The client's son

has come to visit.
The nurse should instruct the son to do which
of the following?
a) No special isolation techniques are necessary.

b) Wear a double mask and gloves.
c) Perform good hand washing.
d) Wear a gown and a mask.
46. The physician orders naproxen sodium (Naprosyn) for a 77year-old man. The nurse should assess the patient for
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a) stomatitis and photosensitivity.

b) brachycardia and dry mouth.
c) fluid retention and dizziness.
d) gynecomastia and impotence.
47. The nurse is caring for a postoperative client whose diabetes

has been controlled with oral antihyperglycemic agents in the
past.
The client asks why the physician ordered subcutaneous
insulin injections after surgery. The nurse's response should be

based on which of the following statements?
a) Tissue injury after surgery decreases blood sugar.

b) Anesthesia acts to increase glycogen stores.
c) Being NPO inhibits normal blood sugar control.
d) Surgery often leads to insulin dependency.
48. Which of the following would be MOST important for the

rehabilitation nurse to assess during a new client's admission?
a) The client's expectations of family members.

b) The client's understanding of available supportive services.


c) The client's personal goals for rehabilitation.

d) The client's past experiences in the hospital.
49. The nurse knows that Cortisol is responsible for
a) preparing the body for "flight or fight."

b) regulating the calcium metabolism.
c) converting proteins and fat into glucose.
d) enhancing musculoskeletal activity.
50. A middle-aged man is admitted to an inpatient psychiatric

unit. Over the last several months he has become convinced that
his brother is trying to steal his property. He is diagnosed with
paranoid disorder. The nurse knows that this client is
demonstrating which of the following?
a) Delusions of persecution.
b) Command hallucinations.
c) Delusions of reference.
d) Persecution hallucinations.
51. The nurse is administering oral verapamil (Isoptin) to a

client. Before administering the verapamil the nurse should check
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the client's
a) electrolytes.
b) urine output.
c) weight.
d) heart rate.
52. The nurse knows which of the following mood-altering drugs is

most often associated with an increased risk for HIV infection
related to intravenous drug use?
a) Benzodiazepines.
b) Marijuana.
c) Barbiturates.
d) Narcotics.
53. The nurse is teaching a parenting class to a group of

expectant mothers.
The nurse should advise that the
breastfeeding mother should increase her daily caloric intake by

how many calories?
a) 200.


b) 300.
c) 400.
d) 500.
54. The physician writes an order for a STAT dose of Demerol 50

mg IM for pain. Three hours later the client again complains of
pain, and the nurse administers a second injection of Demerol.
Which of the following describes the nurse's liability?
a) The nurse administered the medication appropriately; there

is no liability.
b) The nurse violated the narcotic law in not having an order
to administer the Demerol a second time.
c) The client was not injured; if injury did not occur, then
the nurse is not liable.
d) The nurse should have waited at least four hours; then there
would be no liability.
55. The nurse is caring for a patient with a pneumothorax

resulting from an auto accident three days ago. He has a chest
tube connected to a three-chamber water-seal drainage system
(Pleur-evac) with 20 cm suction. How would the nurse know if the
lung had re-expanded?
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EXAM CODE CT1

a) There is no drainage in the collection chamber for three

hours.
b) The fluid in the water-seal chamber does not fluctuate with
respirations.
c) There is continuous bubbling in the water-seal chamber.
d) There is gentle bubbling in the suction-control chamber.
56. The nurse on a psychiatric unit of the hospital refuses to

agree to a 32-year-old patient's request to organize a party on
the unit with his friends. The patient becomes angry and uses
abusive language with the nurse. Which of the following
statements indicates that the nurse has an understanding of the
patient's behavior?
a) Allowing the patient to use abusive language will undermine

the authority of the nurse.
b) Responding in kind to a patient who uses abusive language
will perpetuate the behavior.
c) Abusive language is one of the behaviors that is a symptom
of the patient''s illness.
d) The nurse should model acceptable behavior and language for
all patients.
57. The nurse is caring for a three-month-old infant that is

scheduled for a barium swallow in the morning.

Prior to the

procedure, the MOST appropriate nursing action would be to
a) offer the infant only clear liquids.

b) make the infant NPO for three hours.
c) feed the infant regular formula.
d) maintain the infant NPO for six hours.
58. The client has been receiving a blood transfusion for

approximately 30 minutes. Which of these assessments, if made by
the nurse, would indicate an allergic reaction?
a) Hypotension.
b) Chills.
c) Respiratory wheezing.
d) Lower back discomfort.
59. The physician inserts a temporary pacemaker in a 45-year-old

man following a myocardial infarction. The nurse knows that the
primary purpose of the pacemaker is to
a) increase the force of myocardial contraction.

b) increase the cardiac output.
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c) prevent premature ventricular contractions (PVCs).

d) prevent systemic overload.
60. Which of the following instructions should be given by the

nurse to an adult client in preparation for a plasma cholesterol
screening?
a) Eat a vegetarian diet for one week before the test.

b) Limit alcohol intake to two glasses of wine the day before
the test.
c) Abstain from dairy products for 48 hours before the test.
d) Only sips of water should be taken for 12 hours before the
test.
61. A toddler with lead poisoning is admitted to the pediatric

unit. There is an order to encourage fluids. Which of the
following fluids would be the best for the nurse to offer to the
child?
a) Milk.
b) Water.
c) Orange juice.


d) Fruit punch.
62. In the process of a normal adjustment to a terminal illness,

the nurse knows that the client's initial denial and isolation
will give way to the second stage, which is characterized by
a) acceptance.
b) bargaining.
c) anger.
d) depression.
63. The nurse prepares a 67-year-old man for an intravenous

pyelogram (IVP). The client asks the nurse to explain the reason
why the procedure is performed. The nurse's response should be
based on the knowledge that the primary purpose of an IVP is to
a) observe the renal pelvis directly.

b) assess glomerulofiltration rate.
c) examine the urinary tract by x-ray.
d) inject medication into the urinary system.
64. The mother of a child with chickenpox asks the physician's

office nurse why her child will not come down with chickenpox
again if exposed to the virus at school at a later date. The
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nurse's response should be based on the information that
a) natural passive immunity occurs because the child receives

antibodies from outside the body.
b) artificial active immunity occurs because the child receives
specific antigens against the chickenpox virus.
c) natural active immunity occurs because the child's body
actively makes antibodies against the chickenpox virus.
d) artificial passive immunity occurs because of the
inflammatory process of chickenpox.
65. Several days after the delivery of a stillborn, the parents

say, "We wish we could talk with other couples who have gone
through this trauma." Which of the following nursing responses
would be BEST?
a) "SIDS will provide you with this opportunity."

b) "SHARE will provide you with this opportunity."
c) "RESOLVE will provide you with this opportunity."
d) "CANDLELIGHTERS will provide you with this opportunity."
66. Which of the following is the BEST way for a nurse to assess
the fluid balance of a 70-year-old man?


a) Assess the client's blood pressure.

b) Check the client's tissue turgor.
c) Ask the client if he is thirsty.
d) Maintain an accurate intake and output.
67. In planning diet teaching for a child in the early stages of

nephrotic syndrome, the nurse should discuss with the parents
which of the following dietary changes?
a) Adequate protein intake, low sodium.

b) Low-protein, low-potassium intake.
c) Low-potassium, low-calorie intake.
d) Limited-protein, high-carbohydrate intake.
68. In preparing a teaching plan regarding colostomy irrigations,

the nurse should include which of the following?
a) The colostomy needs to be irrigated at the same time every

day.
b) Irrigate the colostomy after meals to increase peristalsis.
c) Insert the catheter about ten inches into the stoma.
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d) The solution should be very warm to increase dilation and

flow.
69. The nurse knows which of the following would have the
greatest impact on an elderly client's ability to complete
activities of daily living (ADLs)?
a) Perseveration.
b) Aphasia.
c) Mnemonic disturbance.
d) Apraxia.
70. Prior to sending a client for a cardiac catheterization, it

would be MOST important for the nurse to report which of the
following?
a) The client has an allergy to shellfish.

b) The client has diminished palpable peripheral pulses.
c) The client has cool lower extremities bilaterally.
d) The client is anxious about
the pending procedure.
71. If a client has ataxia, the MOST important nursing action

would be to


a) supervise ambulation.
b) measure the intake and output accurately.
c) consult the speech therapist.
d) elevate the foot of the bed.
72. A 14-year-old girl is brought to the hospital for treatment

of second- and third-degree burns sustained in a house fire. An
intravenous infusion is started in the patient's left forearm.
The nurse knows that the primary purpose of the IV is to
a) provide a route for pain medications.

b) maintain fluid balance.
c) prevent gastrointestinal upset.
d) obtain blood specimens for analysis.
73. An 80-year-old client is admitted with a possible fractured

right hip. During the initial nursing assessment, which of the
following observations of the right leg would validate or support
this diagnosis?
a) The leg appears to be shortened and is abducted and

externally rotated.
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EXAM CODE CT1

b) Plantar flexion is observed with sciatic pain radiating down

the leg.
c) From the hip, the leg appears to be longer and is externally
rotated.
d) There is evidence of paresis with decreased sensation and
limited mobility.
74. The nurse has collected the following data: anger directed by
client toward staff in the form of frequent sarcastic or crude
comments, increased wringing of hands, and purposeless pacing,
particularly after the client has used the telephone. Based on
this data, the nurse should make which nursing diagnosis?
a) Impaired social interaction related to conversion reaction.

b) Risk for potential activity intolerance as evidenced by
purposeless pacing.
c) Powerlessness in hospital situation.
d) Ineffective individual coping related to recent anger and
anxiety.
75. The nursing team consists of a RN who has been practicing for
six months, a LPN/LVN who has been practicing for 15 years, and a
nursing assistant who has been caring for clients for three
years.
The RN should care for which of the following clients?


a) A client 1 day postop after an internal fixation of a

fractured left femur.
b) A client receiving diltiazem (Cardizem) and phenytoin
(Dilantin).
c) A client who is to receive 2 units of packed cells prior to
an upper endoscopy procedure.
d) A client admitted yesterday with exhaustion and a diagnosis
of acute bipolar disorder.
76. The nurse is caring for a patient following a right

adrenalectomy.
During the immediate postoperative period, it is
MOST important for the nurse to observe for which of the

following?
a) Fluid and electrolyte imbalance.
b) Temperature fluctuation.
c) Respiratory atelectasis.
d) Blood pressure alteration.
77. A client on continuous mechanical ventilation desires to go

home. In order to determine the client's ability for home care,
the nurse should
a) assess the ability of others in the home to be trained to
provide appropriate care for the client.
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b) confer with the client's physician and discuss the

feasibility of the client's request.
c) assess the number of people in the home and the adequacy of
space to care for the client.
d) examine the client's reasons for wanting to go home, and
discuss the implications of home care.
78. Prior to helping a client out of bed on the first day after
an anterior cervical fusion, the nurse should
a) remove the client's cervical collar.
b) raise the head of the bed.
c) position the client supine at the edge of the bed.
d) ask the client to fold both arms across his chest.
79. The daughter of an 80-year-old woman with Alzheimer's disease

provides care for her mother in her home. The nurse knows that
which of the following observations would most likely represent
caregiver burnout?
a) The daughter fails to get her mother into a wheelchair
daily.
b) The home environment is extremely cluttered at each visit.
c) The daughter is always in a housecoat at the times of the
visits.
d) The daughter's husband is seen assisting with his mother-inlaw's care.
80. The nurse assesses the daily lab reports for a patient with a
long history of cirrhosis with acute hepatic encephalopathy.


Which of the following findings would indicate to the nurse that

the patient is improving?
a) The patient's fasting blood sugar decreased from 100 to 90
mg/dL.
b) The patient's prothrombin time (PT) increased from 20 to 25
seconds.
c) The patient's ammonia level decreased from 160 to 120
micrograms/dL.
d) The patient's AST (SGOT) increased from 24 to 30 units.
81. When using palpation techniques during the physical

assessment of an adult female with abdominal pain, which of the
following actions should the nurse take FIRST?
a) Instruct the client to take a deep breath and hold it.
b) Inform the client to breathe slowly.
c) Use bimanual palpation technique.
d) Apply light palpation in the area.
82. Which of the following interventions should be the priority

during the nursing care of a two-month-old infant after surgery?
a) Minimize stimuli for the infant.
b) Restrain all of the infant's extremities.
c) Encourage the parents to stroke the infant.
d) Demonstrate to the parents how they can assist with their
infant's care.
83. On the morning after surgery to repair a fractured hip, the

nurse finds a 66-year-old woman struggling to get out of bed.
The client tells the nurse, "I have to clean the kitchen now."

35
EXAM CODE CT1

Which of the following actions, if taken by the nurse, is MOST

appropriate?
a) Obtain blood gas studies.
b) Instruct the client to remain in bed.
c) Take the client's blood pressure.
d) Ask the family to remain with the client.
84. The nursing team includes three RNs, one LPN/LVN, and one
nursing assistant.
The nurse should consider the assignments
appropriate if the nursing assistant is assigned to which of the

following clients?
a) A client with an appendectomy.
b) A client with infectious meningitis.
c) An immunosuppressed client.
d) A client who had a radical mastectomy.
85. The nurse reading an EKG rhythm strip determines that there
are 8 QRS complexes in 30 large squares for a 6-second strip. The
nurse calculates the heart rate to be which of the following?
a) 60.
b) 70.
c) 80.
d) 120.
86. After abdominal surgery, a client complains of gas pains in

her abdomen.
It is MOST important for the nurse to take which of
the following actions?



a) Offer the client fresh fruits and vegetables.

b) Ambulate the client frequently.
c) Teach the client how to splint the abdomen during activity.
d) Position the client on her right side.
87. A client has recently been placed on warfarin (Coumadin) for

transient ischemic attacks (TIAs).
The nurse would be MOST
concerned if the patient made which of the following statements?

a) "I eat cantaloupe and bananas every day."
b) "I can eat potato chips and dill pickles."
c) "I eat strawberries and oranges every day."
d) "I have to eat more green salads and pork."
88. A 34-year-old man is seen in the physician's office for

follow-up after treatment for renal calculi. The nurse discusses
methods to prevent a reoccurrence of the problem. Which of the
following instructions by the nurse is MOST beneficial?
a) "Drink at least 3,000 ml of fluid a day."
b) "Reduce the amount of dairy products and eggs in your diet."
c) "Increase the amount of whole grains and vegetables you
eat."
d) "Avoid foods that contain tyramine, such as wine and
cheese."
89. The nurse is observing the psychiatric staff interact with a

client exhibiting manipulative behavior.
The nurse should
intervene in which of the following situations?

a) The staff discusses with the client the consequences of the
manipulative behavior.

37
EXAM CODE CT1

b) The staff collaborates to establish limits on the

c) The staff clarifies the consequences of the client's
d) The staff decreases demands placed on the client that
triggers the manipulative behavior.
90. A 32-year-old male with acute lymphocytic leukemia is

admitted with shortness of breath, anemia, and tachycardia. The
MOST appropriately stated nursing diagnosis would be
a) Altered protection, immunosuppression: leukemia.
b) Impaired gas exchange related to decreased RBCs.
c) Risk for infection related to altered immune system.
d) Risk of injury related to decreased platelets.
91. An order has been received to obtain a stool specimen and

test for occult blood. The nurse would be MOST concerned if the
client made which of the following statements?
a) "I take Feosol every day."
b) "My physician prescribed Vicodin."
c) "I've been taking Lomotil."
d) "I sometimes take Motrin."
92. A 60-year-old woman receives thiethylperazine maleate

(Torecan) 10 mg IM after surgery for repair of a hernia. The
ordered activity is up ad lib. One half-hour after administration
of the medication, the patient has to void. The nurse should
a) accompany the patient to the bathroom.


b) place the patient on the bedpan.

c) obtain a bedside commode for the patient to use.
d) obtain an order to catheterize the patient.
93. The nurse is caring for a client recovering from lower bowel
surgery.
The nurse determines that teaching has been successful
if the client selects which of the following menus?

a) Milk, green beans, whole-wheat bread.
b) Creamed chicken soup, broccoli, pudding.
c) Baked chicken, buttered rice, plain gelatin.
d) Cabbage salad, fried chicken, applesauce.
94. The nurse is caring for a teenaged boy in Buck's traction.

It is MOST important for the nurse to take which of the following
actions?
a) Check the pin sites for bleeding or infection.
b) Apply topical or antibiotic ointment as ordered.
c) Assess that the elastic bandages are not too loose or too
tight.
d) Remove the bandages daily to lubricate the skin.
95. A 41-year-old woman was brought to the emergency room by two

police officers after she had been standing barefoot in the rain
for more than two hours. The police officers report that the
woman had to be restrained after she resisted and became
agitated. The intake nurse's FIRST action should be to
a) complete a physical examination.
b) maintain a safe environment.
c) ascertain the client's mental status.

39
EXAM CODE CT1

d) orient the client to place and time.
96. A nursing team consists of an RN, an LPN/LVN, and a nursing

assistant.
The nurse should assign which of the following
patients to the LPN/LVN?

a) A 72-year-old patient with diabetes who requires a dressing
change for a stasis ulcer.
b) A 55-year-old patient with terminal cancer being transferred
to hospice home care.
c) A 42-year-old patient with cancer of the bone complaining of
pain.
d) A 23-year-old patient with a fracture of the right leg who
asks to use the urinal.
97. A primipara is admitted in early labor, and her membranes

rupture. Which of the following assessments by the nurse is MOST
important?
a) Determine the pH of the amniotic fluid.
b) Evaluate the mother's blood pressure.
c) Check the monitor for decelerations.
d) Assess for a prolapsed cord.
98. A client had a mitral valve replacement three days ago. It is

MOST important for the nurse to take which of the following
actions?
a) Maintain the client in the supine position to prevent
tension on the mediastinal suture line.


b) Encourage deep breathing, but discourage coughing because of

increased central venous pressure.
c) Decrease fluids to prevent fluid retention and development
of congestive heart failure.
d) Encourage early activity to promote ventilation and improve
quality of circulation.
99. A client is given an aminophylline (Somophyllin) capsule four

hours too early. This incident is discovered 30 minutes after
administration of the medication. The nurse should
a) document the event on an incident report form and notify the
physician.
b) change the time for the next medication administration.
c) assess for bradycardia and lethargy and notify the
physician.
d) skip the next dose of the medication.
100. A pregnant client at 16 weeks gestation has a blood sample

for rubella antibody screening drawn. The test results reveal a
low titer. When discussing the results with the client, the nurse
should
a) arrange for her to have an MMR immunization immediately.
b) explain to her that the results are expected and nothing
needs to be done.
c) explore options with her about whether or not she should
terminate the pregnancy.
d) encourage her to receive the rubella immunization
immediately after delivery.

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1

EXAM CODE CT1

1. The nurse is caring for clients in the outpatient clinic.

a) A mother reports that the umbilical cord of her five-day-old

2 . The parents of a child with hemophilia want to know the cause

a) "The father transmits the gene to his son."

3 . A six-month-old is brought to the clinic for a well-baby

NCLEX/CGFNS/CRN CRITICAL THINKING Materials 1

www.onlinenursereviewalternative.com NCLEX/CGFNS/CRN CRITICAL THINKING Materials

c) Tripling of the birth weight.

4. A 48-year-old man with an endotracheal tube needs suctioning.

5. A 47-year-old woman comes to the outpatient psychiatric clinic

a) projection and displacement.

6. The prenatal client at eight-weeks gestation has a positive

would be MOST appropriate for the nurse to include?

a) The importance of not taking any medications so as not to

7. An elderly client who has been recently immobilized is ordered

the nurse understand about ROM before initiating this order?

a) Passive range-of-motion exercises increase muscle strength.

8. A 65-year-old man is scheduled for a colon resection this

a) indicates that the bowel preparation is incomplete.

NCLEX/CGFNS/CRN CRITICAL THINKING Materials 3

www.onlinenursereviewalternative.com NCLEX/CGFNS/CRN CRITICAL THINKING Materials

d) is the last stool that was left in the colon.

9. The nurse cares for a newborn infant with fetal alcohol

a) An infant that is large for gestational age (LGA) with

10. The physician orders hydromorphone hydrochloride (Dilaudid)

a) photosensitivity and constipation.

11. The out-patient clinic nurse is caring for a 66-year-old

a) the renal threshold for glucose is elevated in the elderly.

12. At 32-weeks gestation, a client has an order for an

a) "The results will inform us of the gestational age."

13. A child has pediculosis capitis (head lice) and is being

a) treatment should be continued every other day for 1 week.

NCLEX/CGFNS/CRN CRITICAL THINKING Materials 5

www.onlinenursereviewalternative.com NCLEX/CGFNS/CRN CRITICAL THINKING Materials

14. The nurse is supervising an LPN/LVN administering an enema to

During the administration, it is MOST important for

the LPN/LVN to take which of the following actions?

a) Place the solution 20 inches above the anus.

15. An 18-month-old is admitted to the unit with a diagnosis of

a) Kussmaul respirations and bradycardia.

16. A client has been receiving chlorpromazine hydrochloride

a) a side effect of the medication that she will tolerate

d) an indication that the dosage of the medication needs to be

17. The nurse is caring for a client with

appropriate nursing diagnosis for this client is

a) impaired verbal communication related to absence of speaking

18. Which of the following types of foods should the nurse

19. A 20-year-old woman arrives at the hospital in active labor.

a) to evaluate the progress of the client's labor.

NCLEX/CGFNS/CRN CRITICAL THINKING Materials 7

www.onlinenursereviewalternative.com NCLEX/CGFNS/CRN CRITICAL THINKING Materials

c) to monitor the oxygen status of the fetus during labor.

20. A mentally retarded client is to be discharged home on

a) Instruct a significant other about the medication regimen.

21. A client, gravida 2 para 1, is admitted with hypertension and

a) Blurred vision and proteinuria.

22. The nurse is caring for clients in a drug rehabilitation

Which of the following complications of IV drug abuse

is the nurse MOST likely to observe?

23. The client is admitted with cerebrovascular accident (CVA)

a) Request that the pharmacy send a correctly labeled

NCLEX/CGFNS/CRN CRITICAL THINKING Materials 9