NCLEX-PN Test-Bank (200 Questions with Answers and Explanation) latest 2024/2025, Exams of Nursing

Download NCLEX-PN Test-Bank (200 Questions with Answers and Explanation) latest 2024/2025 and more Exams Nursing in PDF only on Docsity! NCLEX-PN TEST- BANK (200 QUESTIONS WITH ANSWERS AND EXPLANATION) 1. The nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. The nurse should be particularly alert for: A. Nasal congestion B. Abdominal tenderness C. Muscle tetany D. Oliguria Answer A: Removal of the pituitary gland is usually done by a transsphenoidal approach, through the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are not correct because they are not directly associated with the pituitary gland. 2. A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following? A. Hypernatremia B. Hypokalemia C. Myelosuppression D. Leukocytosis Answer B: Hypokalemia is evident from the lab values listed. The other laboratory findings are within normal limits, making answers A, C, and D incorrect. 3. A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse? A. Taking the vital signs B. Obtaining the permit C. Explaining the procedure D. Checking the lab work 9. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug? A. Uric acid of 5mg/dL B. Hematocrit of 33% C. WBC 2,000 per cubic millimeter D. Platelets 150,000 per cubic millimeter Answer C: Tegretol can suppress the bone marrow and decrease the white blood cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and D are within normal limits, and answer B is a lower limit of normal; therefore, answers A, B, and D are incorrect. 10. A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? A. “Tell me about his pain.” B. “What does his vomit look like?” C. “Describe his usual diet.” D. “Have you noticed changes in his abdominal size?” Answer C: The least-helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process and, thus, are incorrect. 11. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided? A. Bran B. Fresh peaches C. Cucumber salad D. Yeast rolls Answer C: The client with diverticulitis should avoid foods with seeds. The foods in answers A, B, and D are allowed; in fact, bran cereal and fruit will help prevent constipation. 12. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? A. Teaching how to irrigate the illeostomy B. Stopping electrolyte loss in the incisional area C. Encouraging a high-fiber diet D. Facilitating perineal wound drainage Answer D: The client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not ordered at this time. 13. The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet? A. Roasted chicken B. Noodles C. Cooked broccoli D. Custard Answer C: The client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as those listed in answers A, B, and D are allowed. 14. The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is: A. The baby is dehydrated due to polyuria. D. The baby can lose up to 10% of weight due to meconium stool, loss of B. The baby is hypoglycemic due to lack of glucose. C. The baby is allergic to the formula the mother is giving him. extracellular fluid, and initiation of breast-feeding. Answer D: After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding cause the infant to lose body mass. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula; thus, answers A, B, and C are incorrect. 15. The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis? A. Foul breath B. Dysphagia C. Diarrhea D. Chronic hiccups Answer C: Diarrhea is not common in clients with mouth and throat cancer. All the findings in answers A, B, and D are expected findings. 16. A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included in the plan? A. Closed chest drainage B. A tracheostomy C. A mediastinal tube D. Percussion vibration and drainage Answer A: The client with a lung resection will have chest tubes and a drainage- collection device. He probably will not have a tracheostomy or mediastinal tube, and he will not have an order for percussion, vibration, or drainage. Therefore, answers B, C, and D are incorrect. D. “You will not be able to drink fluids for 24 hours before the study.” Answer B: Portions of the exam are painful, especially when the sample is being withdrawn, so this should be included in the session with the client. Answer A is incorrect because the client will be positioned prone, not in a sitting position, for the exam. Anesthesia is not commonly given before this test, making answer C incorrect. Answer D is incorrect because the client can eat and drink following the test. 22. The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis? A. A weight loss of 10 pounds in 2 weeks B. Complaints of numbness and tingling in the extremities C. A red, beefy tongue D. A hemoglobin level of 12.0gm/dL Answer C: A red, beefy tongue is characteristic of the client with pernicious anemia. Answer A, a weight loss of 10 pounds in 2 weeks, is abnormal but is not seen in pernicious anemia. Numbness and tingling, in answer B, can be associated with anemia but are not particular to pernicious anemia. This is more likely associated with peripheral vascular diseases involving vasculature. In answer D, the hemoglobin is low normal. 23. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: A. Trendelenburg position B. Ice to the entire extremity C. Buck’s traction D. An abduction pillow Answer C: The client with a fractured femur will be placed in Buck’s traction to realign the leg and to decrease spasms and pain. The Trendelenburg position is the wrong position for this client, so answer A is incorrect. Ice might be ordered after repair, but not for the entire extremity, so answer B is incorrect. An abduction pillow is ordered after a total hip replacement, not for a fractured femur; therefore, answer D is incorrect. 24. A client with cancer is to undergo an intravenous pyelogram. The nurse should: A. Force fluids 24 hours before the procedure B. Ask the client to void immediately before the study C. Hold medication that affects the central nervous system for 12 hours pre- and post-test D. Cover the client’s reproductive organs with an x-ray shield Answer B: The client having an intravenous pyelogram will have orders for laxatives or enemas, so asking the client to void before the test is in order. A full bladder or bowel can obscure the visualization of the kidney ureters and urethra. In answers A, C, and D, there is no need to force fluids before the procedure, to withhold medications, or to cover the reproductive organs. 25. The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor: A. That cannot be assessed B. That is in situ C. With increasing lymph node involvement D. With distant metastasis Answer B: Cancer in situ means that the cancer is still localized to the primary site. Cancer is graded in terms of tumor, grade, node involvement, and mestatasis. Answer A is incorrect because it is an untrue statement. Answer C is incorrect because T indicates tumor, not node involvement. Answer D is incorrect because a tumor that is in situ is not metastasized. 26. A client is 2 days post-operative colon resection. After a coughing episode, the client’s wound eviscerates. Which nursing action is most appropriate? A. Reinsert the protruding organ and cover with 4×4s B. Cover the wound with a sterile 4×4 and ABD dressing C. Cover the wound with a sterile saline-soaked dressing D. Apply an abdominal binder and manual pressure to the wound Answer C: If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked dressing. Reinserting the content should not be the action and will require that the client return to surgery; thus, answer A is incorrect. Answers B and D are incorrect because they are not appropriate to this case. 27. The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery? A. Hearing aid B. Contact lenses C. Wedding ring D. Artificial eye Answer B: It is most important to remove the contact lenses because leaving them in can lead to corneal drying, particularly with contact lenses that are not extended-wear lenses. Leaving in the hearing aid or artificial eye will not harm the client. Leaving the wedding ring on is also allowed; usually, the ring is covered with tape. Therefore, answers A, C, and D are incorrect. 28. The nurse on the 3–11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action? A. Call the surgeon and ask him or her to see the client to clarify the information B. Explain the procedure and complications to the client Answer A: If the nurse is exposed to the client with a cough, the best item to wear is a mask. If the answer had included a mask, gloves, and a gown, all would be appropriate, but in this case, only one item is listed; therefore, answers B and C are incorrect. Shoe covers are not necessary, so answer D is incorrect. 34. The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention? A. Suggest that the client take warm showers B.I.D. B. Add baby oil to the client’s bath water C. Apply powder to the client’s skin D. Suggest a hot-water rinse after bathing Answer B: Oils can be applied to help with the dry skin and to decrease itching, so adding baby oil to bath water is soothing to the skin. Answer A is incorrect because bathing twice a day is too frequent and can cause more dryness. Answer C is incorrect because powder is also drying. Rinsing with hot water, as stated in answer D, dries out the skin as well. 35. A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate? A. Blood pressure every 15 minutes B. Insertion of a Levine tube C. Cardiac monitoring D. Dressing changes two times per day Answer B: The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a Levine tube should be anticipated. Answers A and C are incorrect because blood pressures are not required every 15 minutes, and cardiac monitoring might be needed, but this is individualized to the client. Answer D is incorrect because there are no dressings to change on this client. 36. The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because: A. The client is at risk for evisceration. B. The client will require frequent dressing changes. C. The straps provide support for drains that are inserted in the incision. D. No sutures or clips are used to secure the incision. Answer B: Montgomery straps are used to secure dressings that require frequent dressing changes because the client with a cholecystectomy usually has a large amount of drainage on the dressing. Montgomery straps are also used for clients who are allergic to several types of tape. This client is not at higher risk of evisceration than other clients, so answer A is incorrect. Montgomery straps are not used to secure the drains, so answer C is incorrect. Sutures or clips are used to secure the wound of the client who has had gallbladder surgery, so answer D is incorrect. 37. The physician has ordered that the client’s medication be administered intrathecally. The nurse is aware that medications will be administered by which method? A. Intravenously B. Rectally C. Intramuscularly D. Into the cerebrospinal fluid Answer D: Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client with metastases, the client with chronic pain, or the client with cerebrospinal infections. Answers A, B, and C are incorrect because intravenous, rectal, and intramuscular injections are entirely different procedures. 38. Which client can best be assigned to the newly licensed practical nurse? A. The client receiving chemotherapy B. The client post–coronary bypass C. The client with a TURP D. The client with diverticulitis Answer D: The best client to assign to the newly licensed nurse is the most stable client; in this case, it is the client with diverticulitis. The client receiving chemotherapy and the client with a coronary bypass both need nurses experienced in these areas, so answers A and B are incorrect. Answer D is incorrect because the client with a transurethral prostatectomy might bleed, so this client should be assigned to a nurse who knows how much bleeding is within normal limits. 39. The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse? A. Notify the police department as a robbery B. Report this behavior to the charge nurse C. Monitor the situation and note whether any items are missing D. Ignore the situation until items are reported missing Answer B: The best action at this time is to report the incident to the charge nurse. Further action might be needed, but it should be determined by the charge nurse. Answers A, C, and D are incorrect because notifying the police is overreacting at this time, and monitoring or ignoring the situation is an inadequate response. 40. The nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should: A. Change the nursing assistant’s assignment B. Explore the interaction with the nursing assistant C. Discuss the matter with the client’s family D. Initiate a group session with the nursing assistant dietary restrictions before a mammogram. Answer C is incorrect because the mammogram does not replace the need for self-breast exams. Answer D is incorrect because a mammogram does not require higher doses of radiation than an x-ray. 46. Which of the following roommates would be best for the client newly admitted with gastric resection? A. A client with Crohn’s disease B. A client with pneumonia C. A client with gastritis D. A client with phlebitis Answer D: The most suitable roommate for the client with gastric resection is the client with phlebitis because phlebitis is an inflammation of the blood vessel and is not infectious. Crohn’s disease clients, in answer A, have frequent stools that might spread infections to the surgical client. The client in answer B with pneumonia is coughing and will disturb the gastric client. The client with gastritis, in answer C, is vomiting and has diarrhea, which also will disturb the gastric client. 47. The licensed practical nurse is working with a registered nurse and a patient care assistant. Which of the following clients should be cared for by the registered nurse? A. A client 2 days post-appendectomy B. A client 1 week post-thyroidectomy C. A client 3 days post-splenectomy D. A client 2 days post-thoracotomy Answer D: The most critical client should be assigned to the registered nurse; in this case, that is the client 2 days post-thoracotomy. The clients in answers A and B are ready for discharge, and the client in answer C who had a splenectomy 3 days ago is stable enough to be assigned to an LPN. 48. The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching? A. The graduate places the client in a supine position to read the manometer. B. The graduate turns the stop-cock to the off position from the IV fluid to the client. the CVP reading. D. The graduate notes the level at the top of the meniscus. Answer C: The client should breathe normally during a central venous pressure monitor reading. Answer A indicates understanding because the client should be placed supine if he can tolerate being in that position. Answers B and D indicate understanding because the stop-cock should be turned off to the IV fluid, and the reading should be done at the top of the meniscus. 49. Which of the following roommates would be most suitable for the client with myasthenia gravis? A. A client with hypothyroidism B. A client with Crohn’s disease C. A client with pylonephritis D. A client with bronchitis Answer A: The most suitable roommate for the client with myasthenia gravis is the client with hypothyroidism because he is quiet. The client with Crohn’s disease in answer B will be up to the bathroom frequently; the client with pylonephritis in answer C has a kidney infection and will be up to urinate frequently. The client in answer D with bronchitis will be coughing and will disturb any roommate. 50. The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care? A. A 10-year-old with lacerations of the face C. The graduate instructs the client to perform the Valsalva maneuver during B. A 15-year-old with sternal bruises C. A 34-year-old with a fractured femur D. A 50-year-old with dislocation of the elbow Answer B: The teenager with sternal bruising might be experiencing airway and oxygenation problems and, thus, should be seen first. In answer A, the 10-year-old with lacerations might look bad but is not in distress. The client in answer C with a fractured femur should be immobilized but can be seen after the client with sternal bruising. The client in answer D with the dislocated elbow can be seen later as well. 51. The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should: A. Document the finding B. Send a specimen to the lab C. Strain the urine D. Obtain a complete blood count Answer B: If the dialysate returns cloudy, infection might be present and must be evaluated. Documenting the finding, as stated in answer A, is not enough; straining the urine, in answer C, is incorrect; and dialysate, in answer D, is not urine at all. However, the physician might order a white blood cell count. 52. The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is: A. To lower the blood glucose level B. To lower the uric acid level C. To lower the ammonia level D. To lower the creatinine level Answer C: Lactulose is administered to the client with cirrhosis to lower ammonia levels. Answers A, B, and D are incorrect because this does not have an effect on the other lab values. 58. The first exercise that should be performed by the client who had a mastectomy is: A. Walking the hand up the wall B. Sweeping the floor C. Combing her hair D. Squeezing a ball Answer D: The first exercise that should be done by the client with a mastectomy is squeezing the ball. Answers A, B, and C are incorrect as the first step; they are implemented later. 59. The client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test? A. Atropine sulfate B. Furosemide C. Prostigmin D. Promethazine Answer A: Atropine sulfate is the antidote for Tensilon and is given to treat cholenergic crises. Furosemide (answer B) is a diuretic, Prostigmin (answer C) is the treatment for myasthenia gravis, and Promethazine (answer D) is an antiemetic, antianxiety medication. Thus, answers B, C, and D are incorrect. 60. The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam? A. “You will need to lay flat during the exam.” B. “You need to empty your bladder before the procedure.” C. “You will be asleep during the procedure.” D. “The doctor will inject a medication to treat your illness during the procedure.” Answer B: The client scheduled for a pericentesis should be told to empty the bladder, to prevent the risk of puncturing the bladder when the needle is inserted. A pericentesis is done to remove fluid from the peritoneal cavity. The client will be positioned sitting up or leaning over a table, making answer A incorrect. The client is usually awake during the procedure, and medications are not commonly inserted into the peritoneal cavity during this procedure; thus, answers C and D are incorrect (although this could depend on the circumstances). 61. To ensure safety while administering a nitroglycerine patch, the nurse should: A. Wear gloves B. Shave the area where the patch will be applied C. Wash the area thoroughly with soap and rinse with hot water D. Apply the patch to the buttocks Answer A: To protect herself, the nurse should wear gloves when applying a nitroglycerine patch or cream. Answer B is incorrect because shaving the shin might abrade the area. Answer C is incorrect because washing with hot water will vasodilate and increase absorption. The patches should be applied to areas above the waist, making answer D incorrect. 62. A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct? A. Use a magnet to remove the object. B. Rinse the eye thoroughly with saline. C. Cover both eyes with paper cups. D. Patch the affected eye only. Answer C: Covering both eyes prevents consensual movement of the affected eye. The nurse should not attempt to remove the object from the eye because this might cause trauma, as stated in answer A. Rinsing the eye, as stated in answer B, might be ordered by the doctor, but this is not the first step for the nurse. Answer D is not correct because often when one eye moves, the other also does. 63. The physician has ordered sodium warfarin (Coumadin) for the client with thrombophlebitis. The order should be entered to administer the medication at: A. 0900 B. 1200 C. 1700 D. 2100 Answer C: Sodium warfarin is administered in the late afternoon, at approximately 1700 hours. This allows for accurate bleeding times to be drawn in the morning. Therefore, answers A, B, and D are incorrect. 64. The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion? A. The security guard B. The registered nurse C. The licensed practical nurse D. The nursing assistant Answer B: The registered nurse is the only one of these who can legally put the client in seclusion. The only other healthcare worker who is allowed to initiate seclusion is the doctor; therefore, answers A, C, and D are incorrect. 65. The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal pH 7.36, CO2 45, O2 84, HCO3 28. The nurse would assess the client to be in: A. Uncompensated acidosis B. Compensated alkalosis B. Hypoactive deep tendon reflexes become more active with rest. C. Stretch reflexes are increased with rest. D. Fine motor movements are improved. Answer A: Frequent rest periods help to relax tense muscles and preserve energy. Answers B, C, and D are incorrect because they are untrue statements. 71. The nurse is making assignments for the day. Which client should be assigned to the nursing assistant? A. A client with Alzheimer’s disease B. A client with pneumonia C. A client with appendicitis D. A client with thrombophebitis Answer A: The client with Alzheimer’s disease is the most stable of these clients and can be assigned to the nursing assistant, who can perform duties such as feeding and assisting the client with activities of daily living. The clients in answers B, C, and D are less stable and should be attended by a registered nurse. 72. A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by: A. Offering hard candy B. Administering analgesic medications C. Splinting swollen joints D. Providing saliva substitute Answer D: Xerostomia is dry mouth, and offering the client a saliva substitute will help the most. Eating hard candy in answer A can further irritate the mucosa and cut the tongue and lips. Administering an analgesic might not be necessary; thus, answer B is incorrect. Splinting swollen joints, in answer C, is not associated with xerostomia. 73. A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first? A. A client with brain attack (stroke) with tube feedings B. A client with congestive heart failure complaining of nighttime dyspnea C. A client with a thoracotomy 6 months ago D. A client with Parkinson’s disease Answer B: The client with congestive heart failure who is complaining of nighttime dyspnea should be seen first because airway is number one in nursing care. In answers A, C, and D, the clients are more stable. 74. A client with glomerulonephritis is placed on a low-sodium diet. Which of the following snacks is suitable for the client with sodium restriction? A. Peanut butter cookies B. Grilled cheese sandwich C. Cottage cheese and fruit D. Fresh peach Answer D: The fresh peach is the lowest in sodium of these choices. Answers A, B, and C have much higher amounts of sodium. 75. Due to a high census, it has been necessary for a number of clients to be transferred to other units within the hospital. Which client should be transferred to the postpartum unit? A. A 66-year-old female with a gastroenteritis B. A 40-year-old female with a hysterectomy C. A 27-year-old male with severe depression D. A 28-year-old male with ulcerative colitis Answer B: The best client to transport to the postpartum unit is the 40-year- old female with a hysterectomy. The nurses on the postpartum unit will be aware of normal amounts of bleeding and will be equipped to care for this client. The clients in answers A and D will be best cared for on a medical- surgical unit. The client with depression in answer C should be transported to the psychiatric unit. 76. During the change of shift, the oncoming nurse notes a discrepancy in the number of Percocet (Oxycodone) listed and the number present in the narcotic drawer. The nurse’s first action should be to: A. Notify the hospital pharmacist B. Notify the nursing supervisor C. Notify the Board of Nursing D. Notify the director of nursing Answer B: The first action the nurse should take is to report the finding to the nurse supervisor and follow the chain of command. If it is found that the pharmacy is in error, it should be notified, as stated in answer A. Answers C and D, notifying the director of nursing and the Board of Nursing, might be necessary if theft is found, but not as a first step; thus, these are incorrect answers. 77. The nurse is assigning staff for the day. Which assignment should be given to the nursing assistant? A. Taking the vital signs of the 5-month-old with bronchiolitis B. Taking the vital signs of the 10-year-old with a 2-day post-appendectomy C. Administering medication to the 2-year-old with periorbital cellulites D. Adjusting the traction of the 1-year-old with a fractured tibia Answer B: The client with the appendectomy is the most stable of these clients and can be assigned to a nursing assistant. The client with bronchiolitis has an alteration in the airway, the client with periorbital cellulitis has an infection, and the client with a fracture might be an abused child. Therefore, answers A, C, and D are incorrect. 83. The nurse has just received a change-of-shift report. Which client should the nurse assess first? A. A client 2 hours post-lobectomy with 150ccs drainage B. A client 2 days post-gastrectomy with scant drainage C. A client with pneumonia with an oral temperature of 102°F D. A client with a fractured hip in Buck’s traction Answer A: The first client to be seen is the one who recently returned from surgery. The other clients in answers B, C, and D are more stable and can be seen later. 84. Several clients are admitted to the emergency room following a three-car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster? A. The schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm C. A child whose pupils are fixed and dilated and his parents, and the client with a frontal head injury D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain Answer B: Out of all of these clients, it is best to hold the pregnant client and the client with a broken arm and facial lacerations in the same room. The clients in answer A need to be placed in separate rooms because these clients are disruptive or have infections. In the case of answer C, the child is terminal and should be in a private room with his parents. 85. The home health nurse is planning for the day’s visits. Which client should be seen first? A. The 78-year-old who had a gastrectomy 3 weeks ago with a PEG tube D. The 30-year-old with an exacerbation of multiple sclerosis being treated B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line with cortisone via a centrally placed venous catheter Answer D: The priority client is the one with multiple sclerosis who is being treated with cortisone via the central line. This client is at highest risk for complications. MRSA, in answer C, is methicillin-resistant staphylococcus aureas. Vancomycin is the drug of choice and can be administered later, but its use must be scheduled at specific times of the day to maintain a therapeutic level. Answers A and B are incorrect because these clients are more stable. 86. The nurse is found to be guilty of charting blood glucose results without actually performing the procedure. After talking to the nurse, the charge nurse should: A. Call the Board of Nursing B. File a formal reprimand C. Terminate the nurse D. Charge the nurse with a tort Answer B: The action after discussing the problem with the nurse is to document the incident and file a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but this is not the first step. A tort is a wrongful act committed against a client or his belongings. Answers A, C, and D are incorrect. 87. Which information should be reported to the state Board of Nursing? A. The facility fails to provide literature in both Spanish and English. B. The narcotic count has been incorrect on the unit for the past 3 days. C. The client fails to receive an itemized account of his bills and services received during his hospital stay D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath. Answer B: The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to assist the client with hepatitis should be reported to the charge nurse. If the behavior continues, termination may result. Answer D is incorrect because failure to feed and bathe the client should be reported to the superior, not the Board of Nursing. 88. Which nurse should be assigned to care for the postpartal client with preeclampsia? A. The nurse with 2 weeks of experience on postpartum B. The nurse with 3 years of experience in labor and delivery C. The nurse with 10 years of experience in surgery D. The nurse with 1 year of experience in the neonatal intensive care unit Answer B: The nurse in answer B has the most experience with possible complications involved with preeclampsia. The nurse in answer A is a new nurse to this unit and should not be assigned to this client; the nurses in answers C and D have no experience with the postpartal client and also should not be assigned to this client. 89. The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority? A. Continue to monitor the vital signs B. Contact the physician C. Ask the client how he feels D. Ask the LPN to continue the post-op care Answer B: The vital signs are abnormal and should be reported to the doctor immediately. Answer A, continuing to monitor the vital signs, can result in deterioration of the client’s condition. Answer C, asking the client how he feels, 94. The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin? A. Cyanocobalamine B. Protamine sulfate C. Streptokinase D. Sodium warfarin Answer B: The antidote for heparin is protamine sulfate. Cyanocobalamine is B12, Streptokinase is a thrombolytic, and sodium warfarin is an anticoagulant. Therefore, answers A, C, and D are incorrect. 95. The client is admitted with a BP of 210/120. Her doctor orders furosemide (Lasix) 40mg IV stat. How should the nurse administer the prescribed furosemide to this client? A. By giving it over 1–2 minutes B. By hanging it IV piggyback C. With normal saline only D. By administering it through a venous access device Answer A: Lasix should be given approximately 1mL per minute to prevent hypotension. Answers B, C, and D are incorrect because it is not necessary to be given in an IV piggyback, with saline, or through a venous access device (VAD). 96. The physician prescribes captopril (Capoten) 25mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten? A. Tinnitus B. Persistent cough C. Muscle weakness D. Diarrhea Answer B: A persistent cough might be related to an adverse reaction to Captoten. Answers A and D are incorrect because tinnitus and diarrhea are not associated with the medication. Muscle weakness might occur when beginning the treatment but is not an adverse effect; thus, answer C is incorrect. 97. The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes: A. Rotating application sites B. Limiting applications to the chest C. Rubbing it into the skin D. Covering it with a gauze dressing Answer A: Sites for the application of nitroglycerin should be rotated, to prevent skin irritation. It can be applied to the back and upper arms, not to the lower extremities, making answer B incorrect. Answer C is contraindicated to the question, and answer D is incorrect because the medication should be covered with a prepared dressing made of a thin paper substance, not gauze. 98. Lidocaine is a medication frequently ordered for the client experiencing: A. Atrial tachycardia B. Ventricular tachycardia C. Heart block D. Ventricular brachycardia Answer B: Lidocaine is used to treat ventricular tachycardia. This medication slowly exerts an antiarrhythmic effect by increasing the electric stimulation threshold of the ventricles without depressing the force of ventricular contractions. It is not used for atrial arrhythmias; thus, answer A is incorrect. Answers C and D are incorrect because it slows the heart rate, so it is not used for heart block or brachycardia. 99. The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for: A. Peaked P wave B. Elevated ST segment C. Inverted T wave D. Prolonged QT interval Answer D: Quinidine can cause widened Q-T intervals and heart block. Other signs of myocardial toxicity are notched P waves and widened QRS complexes. The most common side effects are diarrhea, nausea, and vomiting. The client might experience tinnitus, vertigo, headache, visual disturbances, and confusion. Answers A, B, and C are not related to the use of quinidine. 100. The physician has prescribed tranylcypromine sulfate (Parnate) 10mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause: A. Hypertension B. Hyperthermia C. Melanoma D. Urinary retention Answer A: If the client eats foods high in tyramine, he might experience malignant hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sherry, beer, pickled herring, liver, canned figs, raisins, bananas, avocados, chocolate, soy sauce, fava beans, and yeast. These episodes are treated with Regitine, an alpha- adrenergic blocking agent. Answers B, C, and D are not related to the question. 101. The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient’s mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy? A. “She is very irritable lately.” B. “She sleeps quite a bit of the time.” warming the solution will not help. Answer C is incorrect, and answer D requires a doctor’s order. 107. The client is diagnosed with multiple myoloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client? A. “Walk about a mile a day to prevent calcium loss.” B. “Increase the fiber in your diet.” C. “Report nausea to the doctor immediately.” D. “Drink at least eight large glasses of water a day.” Answer D: Cytoxan can cause hemorrhagic cystitis, so the client should drink at least eight glasses of water a day. Answers A and B are not necessary and, so, are incorrect. Nausea often occurs with chemotherapy, so answer C is incorrect. 108. The client is taking rifampin 600mg po daily to treat his tuberculosis. Which action by the nurse indicates understanding of the medication? A. Telling the client that the medication will need to be taken with juice B. Telling the client that the medication will change the color of the urine C. Telling the client to take the medication before going to bed at night D. Telling the client to take the medication if night sweats occur Answer B: Rifampin can change the color of the urine and body fluid. Teaching the client about these changes is best because he might think this is a complication. Answer A is not necessary, answer C is not true, and answer D is not true because this medication should be taken regularly during the course of the treatment. 109. The client is taking prednisone 7.5mg po each morning to treat his systemic lupus errythymatosis. Which statement best explains the reason for taking the prednisone in the morning? A. There is less chance of forgetting the medication if taken in the morning. B. There will be less fluid retention if taken in the morning. C. Prednisone is absorbed best with the breakfast meal. corticosteroid. Answer D: Taking corticosteroids in the morning mimics the body’s natural release of cortisol. Answers A is not necessarily true, and answers B and C are not true. 110. A 20-year-old female has a prescription for tetracycline. While teaching the client how to take her medicine, the nurse learns that the client is also taking Ortho-Novum oral contraceptive pills. Which instructions should be included in the teaching plan? A. The oral contraceptives will decrease the effectiveness of the tetracycline. B. Nausea often results from taking oral contraceptives and antibiotics. C. Toxicity can result when taking these two medications together. D. Antibiotics can decrease the effectiveness of oral contraceptives, so the client should use an alternate method of birth control. Answer D: Taking antibiotics and oral contraceptives together decreases the effectiveness of the oral contraceptives. Answers A, B, and C are not necessarily true. 111. A 60-year-old diabetic is taking glyburide (Diabeta) 1.25mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching? A. “I will keep candy with me just in case my blood sugar drops.” B. “I need to stay out of the sun as much as possible.” C. “I often skip dinner because I don’t feel hungry.” D. “I always wear my medical identification.” Answer C: The client should be taught to eat his meals even if he is not hungry, to prevent a hypoglycemic reaction. Answers A, B, and D are incorrect because they indicate an understanding of the nurse’s teaching. D. Morning administration mimics the body’s natural secretion of 112. The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to exert an effect: A. In 5–10 minutes B. In 10–20 minutes C. In 30–60 minutes D. In 60–120 minutes Answer C: The time of onset for regular insulin is 30–60 minutes; therefore, answers A, B, and D are incorrect. 113. The client is admitted from the emergency room with multiple injuries sustained from an auto accident. His doctor prescribes a histamine blocker. The reason for this order is: A. To treat general discomfort B. To correct electrolyte imbalances C. To prevent stress ulcers D. To treat nausea Answer C: Histamine blockers are frequently ordered for clients who are hospitalized for prolonged periods and who are in a stressful situation. They are not used to treat discomfort, correct electrolytes, or treat nausea; therefore, answers A, B, and D are incorrect. 114. The client with a recent liver transplant asks the nurse how long he will have to take cyclosporine (Sandimmune). Which response is correct? A. 1 year B. 5 years C. 10 years D. The rest of his life Answer C: Viokase is a pancreatic enzyme that is used to facilitate digestion. It should be given with meals and snacks, and it works well in foods such as applesauce. Answers A, B, and D are incorrect times to administer this medication. 120. Isoniazid (INH) has been prescribed for a family member exposed to tuberculosis. The nurse is aware that the length of time that the medication will be taken is: A. 6 months B. 3 months C. 18 months D. 24 months Answer A: The expected time for contact to tuberculosis is 1 year. Therefore, answers B, C, and D are incorrect. 121. The client is admitted to the postpartum unit with an order to continue the infusion of Pitocin. Which finding indicates that the Pitocin is having the desired effect? A. The fundus is deviated to the left. B. The fundus is firm and in the midline. C. The fundus is boggy. D. The fundus is two finger breadths below the umbilicus. Answer B: Pitocin is used to cause the uterus to contract and decrease bleeding. A uterus deviated to the left, as stated in answer A, indicates a full bladder. It is not desirable to have a boggy uterus, making answer C incorrect. This lack of muscle tone will increase bleeding. Answer D is incorrect because the position of the uterus is not related to the use of Pitocin. 122. The nurse is teaching a group of new graduates about the safety needs of the client receiving chemotherapy. Before administering chemotherapy, the nurse should: A. Administer a bolus of IV fluid B. Administer pain medication C. Administer an antiemetic D. Allow the patient a chance to eat Answer C: Before chemotherapy, an antiemetic should be given because most chemotherapy agents cause nausea. It is not necessary to give a bolus of IV fluids, medicate for pain, or allow the client to eat; therefore, answers A, B, and D are incorrect. 123. Before administering Methytrexate orally to the client with cancer, the nurse should check the: A. IV site B. Electrolytes C. Blood gases D. Vital signs Answer D: The vital signs should be taken before any chemotherapy agent. If it is an IV infusion of chemotherapy, the nurse should check the IV site as well. Answers B and C are incorrect because it is not necessary to check the electrolytes or blood gases. 124. Vitamin K (aquamephyton) is administered to a newborn shortly after birth for which of the following reasons? A. To prevent dehydration B. To treat infection C. To replace electrolytes D. To facilitate clotting Answer D: Vitamin K is given after delivery because the newborn’s intestinal tract is sterile and lacks vitamin K needed for clotting. Answer A is incorrect because vitamin K is not directly given to prevent dehydration, but will facilitate clotting. Answers B and C are incorrect because vitamin K does not prevent infection or replace electrolytes. 125. The client with an ileostomy is being discharged. Which teaching should be included in the plan of care? A. Use Karaya powder to seal the bag. B. Irrigate the ileostomy daily. C. Stomahesive is the best skin protector. D. Neosporin ointment can be used to protect the skin. Answer C: The best protector for the client with an ileostomy to use is tomahesive. Answer A is not correct because the bag will not seal if the client uses Karaya powder. Answer B is incorrect because there is no need to irrigate an ileostomy. Neosporin, answer D, is not used to protect the skin because it is an antibiotic. 126. The client has an order for FeSo4 liquid. Which method of administration would be best? A. Administer the medication with milk B. Administer the medication with a meal C. Administer the medication with orange juice D. Administer the medication undiluted Answer C: FeSO4 or iron should be given with ascorbic acid (vitamin C). This helps with the absorption. It should not be given with meals or milk because this decreases the absorption; thus, answers A and B are incorrect. Giving it undiluted, as stated in answer D, is not good because it tastes bad. 127. The client arrives in the emergency room with a hyphema. Which action by the nurse would be best? A. Elevate the head of the bed and apply ice to the eye B. Place the client in a supine position and apply heat to the knee Answers B, C, and D are all indicated for caring for the client. The arm should be elevated to decrease edema. It is best to position the client on the unaffected side and perform a dextrostix on the unaffected side. 133. The charge nurse is making assignments for the day. After accepting the assignment to a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which action should the charge nurse take? A. Change the nurse’s assignment to another client B. Explain to the nurse that there is no risk to the client C. Ask the nurse if the chickenpox have scabbed D. Ask the nurse if she has ever had the chickenpox Answer D: The nurse who has had the chickenpox has immunity to the illness. Answer A is incorrect because more information is needed to determine whether a change in assignment is necessary. Answer B is incorrect because there could be a risk to the immune-suppressed client. Answer C is incorrect because the client who is immune-suppressed could still be at risk from the nurse’s exposure to the chickenpox, even if scabs are present. 134. The client with brain cancer refuses to care for herself. Which action by the nurse would be best? A. Alternate nurses caring for the client so that the staff will not get tired of caring for this client B. Talk to the client and explain the need for self-care C. Explore the reason for the lack of motivation seen in the client D. Talk to the doctor about the client’s lack of motivation Answer C: The nurse should explore the cause for the lack of motivation. The client might be anemic and lack energy, might be in pain, or might be depressed. Alternating staff, as stated in answer A, will prevent a bond from being formed with the nurse. Answer B is not enough, and answer D is not necessary. 135. The nurse is caring for the client who has been in a coma for 2 months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife? A. Contact organ retrieval to come talk to the wife B. Tell her that because her husband signed a donor card, the hospital has the right to take the organs upon the death of her husband C. Drop the subject until a later time D. Refrain from talking about the subject until after the death of her husband Answer A: Contacting organ retrieval to talk to the family member is the best choice because a trained specialist has the knowledge to assist the wife with making the decision to donate or not to donate the client’s organs. The hospital will certainly honor the wishes of family members even if the patient has signed a donor card. Answer B is incorrect; answer C might be done, but there might not be time; and answer D is not good nursing etiquette and, therefore, is incorrect. 136. The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is: A. Inspection, auscultation, palpation B. Auscultation, palpation, inspection C. Palpation, inspection, auscultation D. Inspection, palpation, auscultation Answer A: The nurse should inspect first, then auscultate, and finally palpate. If the nurse palpates first, the assessment might be unreliable. Therefore, answers B, C, and D are incorrect. 137. The nurse is assisting in the assessment of the patient admitted with abdominal pain. Why should the nurse ask about medications that the client is taking? A. Interactions between medications can be identified. B. Various medications taken by mouth can affect the alimentary tract. D. “Peptic ulcers are associated with H. pylori, although there are other ulcers C. This will provide an opportunity to educate the patient regarding the medications used. D. The types of medications might be attributable to an abdominal pathology not already identified. Answer B: Many medications can irritate the stomach and contribute to abdominal pain. For answer A, the primary reason for asking about medications is not to identify interactions between medication. Although this might provide an opportunity for teaching, this is not the best time to teach. Therefore, answers C and D are incorrect. 138. The nurse is asked by the nurse aide, “Are peptic ulcers really caused by stress?” The nurse would be correct in replying with which of the following: A. “Peptic ulcers result from overeating fatty foods.” B. “Peptic ulcers are always caused from exposure to continual stress.” C. “Peptic ulcers are like all other ulcers, which all result from stress.” that are associated with stress.” Answer D: H. pylori bacteria and stress are directly related to peptic ulcers. Answers A and B are incorrect because peptic ulcers are not caused by overeating or always caused by continued stress. Answer C is incorrect because peptic ulcers are related to but not directly caused by stress. 139. The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority? A. Anxiety B. Pain C. Knowledge deficit D. Altered thought process Answer C: The new diabetic has a knowledge deficit. Answers A, B, and D are not supported within the stem and so are incorrect. A. “This medication should be taken only until you begin to feel better.” B. “This medication should be taken on an empty stomach to increase absorption.” C. “While taking this medication, you do not have to be concerned about being in the sun.” alcohol should be avoided.” Answer D: Alcohol will cause extreme nausea if consumed with Flagyl. Answer A is incorrect because the full course of treatment should be taken. The medication should be taken with a full 8oz. of water, with meals, and the client should avoid direct sunlight because he will most likely be photosensitive; therefore, answers A, B, and C are incorrect. 146. In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnoses as a priority? A. Anxiety B. Impaired skin integrity C. Fluid volume deficit D. Nutrition altered, less than body requirements Answer C: Fluid volume deficit can lead to metabolic acidosis and electrolyte loss. The other nursing diagnoses in answers A, B, and D might be applicable but are of lesser priority. 147. The nurse is teaching about irritable bowel syndrome (IBS). Which of the following would be most important? A. Reinforcing the need for a balanced diet B. Encouraging the client to drink 16 ounces of fluid with each meal C. Telling the client to eat a diet low in fiber D. “While taking this medication, alcoholic beverages and products containing D. Instructing the client to limit his intake of fruits and vegetables Answer A: The nurse should reinforce the need for a diet balanced in all nutrients and fiber. Foods that often cause diarrhea and bloating associated with irritable bowel syndrome include fried foods, caffeinated beverages, alcohol, and spicy foods. Therefore, answers B, C, and D are incorrect. 148. The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse should instruct the patient to avoid which of the following for breakfast? A. Cream of wheat B. Banana C. Puffed rice D. Cornflakes Answer A: Clients with celiac disease should refrain from eating foods containing gluten. Foods with gluten include wheat barley, oats, and rye. The other foods are allowed. 149. The nurse is caring for a patient with suspected diverticulitis. The nurse would be most prudent in questioning which of the following diagnostic tests ordered? A. Colonoscopy B. Barium enema C. Complete blood count D. Computed tomography (CT) scan Answer B: A barium enema is contraindicated in the client with diverticulitis because it can cause bowel perforation. Answers A, C, and D are appropriate diagnostic studies for the client with diverticulitis. 150. When the nurse is gathering information for the assessment, the patient states, “My stomach hurts about 2 hours after I eat.” Based upon this information, the nurse knows the patient likely has a: A. Gastric ulcer B. Duodenal ulcer C. Peptic ulcer D. Curling’s ulcer Answer B: Individuals with ulcers within the duodenum typically complain of pain occurring 2–3 hours after a meal, as well as at night. The pain is usually relieved by eating. The pain associated with gastric ulcers, answer A, occurs 30 minutes after eating. Answer C is too vague and does not distinguish the type of ulcer. Answer D is associated with stress. 151. The registered nurse is conducting an in-service for colleagues about peptic ulcers. The nurse would be correct in identifying which of the following as a causative factor? A. N. gonorrhea B. H. influenza C. H. pylori D. E. coli Answer C: H. pylori bacteria has been linked to peptic ulcers. Answers A, B, and D are not typically cultured within the stomach, duodenum, or esophagus, and are not related to the development of peptic ulcers. 152. The nurse is caring for the patient’s post-surgical removal of a 6mm oral cancerous lesion. The priority nursing measure would be to: A. Maintain a patent airway B. Perform meticulous oral care every 2 hours B. Breaking suction by placing a finger between the baby’s mouth and the A. Feeding the baby during the first 48 hours after delivery breast when she terminates the feeding C. Applying warm, moist soaks to the breast several times per day D. Wearing a support bra Answer B: To decrease the potential for soreness of the nipples, the client should be taught to break the suction before removing the baby from the breast. Answer A is incorrect because feeding the baby during the first 48 hours after delivery will provide colostrum but will not help the soreness of the nipples. Answers C and D are incorrect because applying warm, moist soaks and wearing a support bra will help with engorgement but will not help the nipples. 158. The nurse asked the client if he has an advance directive. The reason for asking the client this question is: A. She is curious about his plans regarding funeral arrangements. B. Much confusion can occur with the client’s family if he does not have an advanced directive. C. An advanced directive allows the medical personnel to make all decisions for the client. D. An advanced directive allows active euthanasia. Answer B: An advanced directive allows the client to make known his wishes regarding care if he becomes unable to act on his own. Much confusion regarding life-saving measures can occur if the client does not have an advanced directive. Answers A, C, and D are incorrect because the nurse doesn’t need to know about funeral plans and cannot make decisions for the client, and active euthanasia is illegal in most states in the United States. 159. The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client: A. “You may be electrocuted if you use water with this unit.” B. “Please report skin irritation to the doctor.” C. “The unit may be used anywhere on the body without fear of adverse reactions.” D. “A cream should be applied to the skin before applying the unit.” Answer B: Skin irritation can occur if the TENS unit is used for prolonged periods of time. To prevent skin irritations, the client should change the location of the electrodes often. Electrocution is not a risk because it uses a battery pack; thus, answer A is incorrect. Answer C is incorrect because the unit should not be used on sensitive areas of the body. Answer D is incorrect because no creams are to be used with the device. 160. The doctor has ordered a patient-controlled analgesia (PCA) pump for the client with chronic pain. The client asks the nurse if he can become overdosed with pain medication using this machine. The nurse demonstrates understanding of the PCA if she states: A. “The machine will administer only the amount that you need to control your pain without your taking any action.” B. “The machine has a locking device that prevents overdosing to occur.” C. “The machine will administer one large dose every 4 hours to relieve your pain.” D. “The machine is set to deliver medication only if you need it.” Answer B: The client is concerned about overdosing himself. The machine will deliver a set amount as ordered and allow the client to self-administer a small amount of medication. PCA pumps usually are set to lock out the amount of medication that the client can give himself at 5- to 15-minute intervals. Answer A does not address the client’s concerns, answer C is incorrect, and answer D does not address the client’s concerns. 161. The 84-year-old male has returned from the recovery room following a total hip repair. He complains of pain and is medicated by morphine sulfate and promethazine. Which medication should be kept available for the client being treated with opoid analgesics? A. Nalozone (Narcan) B. Ketorolac (Toradol) C. Acetylsalicylic acid (aspirin) D. Atropine sulfate (Atropine) Answer A: Narcan is the antidote for the opoid analgesics. Toradol (answer B) is a nonopoid analgesic; aspirin (answer C) is an analgesic, anticoagulant, and antipyretic; and atropine (answer D) is an anticholengergic. 162. The nurse is taking the vital signs of the client admitted with cancer of the pancreas. The nurse is aware that the fifth vital sign is: A. Anorexia B. Pain C. Insomnia D. Fatigue Answer B: The fifth vital sign is pain. Nurses should assess and record pain just as they would temperature, respirations, pulse, and blood pressure. Answers A, C, and D are included in the charting but are not considered to be the fifth vital sign and are, therefore, incorrect. 163. The client with AIDS tells the nurse that he has been using acupuncture to help with his pain. The nurse should question the client regarding this treatment because acupuncture: Answer C: The treatment for ventricular tachycardia is lidocaine. A precordial thump is sometimes successful in slowing the rate, but this should be done only if a defibrillator is available. In answer A, atropine sulfate will speed the rate further; in answer B, checking the potassium is indicated but is not the priority; and in answer D, defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation. Also, defibrillation should begin at 200 joules and be increased to 360 joules. 169. A client is being monitored using a central venous pressure monitor. If the pressure is 2cm of water, the nurse should: A. Call the doctor immediately B. Slow the intravenous infusion C. Listen to the lungs for rales D. Administer a diuretic Answer A: The normal central venous pressure is 5–10cm of water. A reading of 2cm is low and should be reported. Answers B, C, and D indicate that the nurse believes that the reading is too high and is incorrect. 170. The nurse is evaluating the client’s pulmonary artery pressure. The nurse is aware that this test will evaluate: A. Pressure in the left ventricle B. The systolic, diastolic, and mean pressure of the pulmonary artery C. The pressure in the pulmonary veins D. The pressure in the right ventricle Answer B: The pulmonary artery pressure will measure the pressure during systole, diastole, and the mean pressure in the pulmonary artery. It will not measure the pressure in the left ventricle, the pressure in the pulmonary veins, or the pressure in the right ventricle. Therefore, answers A, C, and D are incorrect. 171. The physician has ordered atropine sulfate 0.4mg IM before surgery. The medication is supplied in 0.8mg per milliliter. The nurse should administer how many milliliters of the medication? A. 0.25mL B. 0.5mL C. 1mL D. 1.25mL Answer B: If the doctor orders 0.4mgm IM and the drug is available in 0.8/1mL, the nurse should make the calculation: ?mL = 1mL / 0.8mgm; × 0.4mg / 1 = 0.5m:. Answers A, C, and D are incorrect. 172. If the nurse is unable to illicit the deep tendon reflexes of the patella, the nurse should ask the client to: A. Pull against the palms B. Grimace the facial muscles C. Cross the legs at the ankles D. Perform Valsalva maneuver Answer A: If the nurse cannot elicit the patella reflex (knee jerk), the client should be asked to pull against the palms. This helps the client to relax the legs and makes it easier to get an objective reading. Answers B, C, and D will not help with the test. 173. A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which of the following should be reported to the doctor? A. An elevated white blood cell count B. An abdominal bruit C. A negative Babinski reflex D. Pupils that are equal and reactive to light Answer A: The elevated white blood cell count should be reported because this indicates infection. A bruit will be heard if the client has an aneurysm, and a negative Babinski is normal in the adult, as are pupils that are equal and reactive to light and accommodation; thus, answers B, C, and D are incorrect. 174. A 4-year-old male is admitted to the unit with nephotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should: A. Apply ice to the scrotum B. Elevate the scrotum on a small pillow C. Apply heat to the abdominal area D. Administer a diuretic Answer B: The child with nephotic syndrome will exhibit extreme edema. Elevating the scrotum on a small pillow will help with the edema. Applying ice is contraindicated; heat will increase the edema. Administering a diuretic might be ordered, but it will not directly help the scrotal edema. Therefore, answers A, C, and D are incorrect. 175. The nurse is taking the blood pressure of an obese client. If the blood pressure cuff is too small, the results will be: A. A false elevation B. A false low reading C. A blood pressure reading that is correct D. A subnormal finding Answer A: If the blood pressure cuff is too small, the result will be a blood pressure that is a false elevation. Answers B, C, and D are incorrect. If the blood pressure cuff is too large, a false low will result. Answers C and D have basically the same meaning. 176. The client is admitted with thrombophlebitis and an order for heparin. The medication should be administered using: A. Dietary patterns B. Mobility C. Fluid intake D. Sexual function Answer D: When assisting the client with bowel and bladder training, the least helpful factor is the sexual function. Dietary history, mobility, and fluid intake are important factors; these must be taken into consideration because they relate to constipation, urinary function, and the ability to use the urinal or bedpan. Therefore, answers A, B, and C are incorrect. 182. The client returns to the recovery room following repair of an intrathoracic aneurysm. Which finding would require further investigation? A. Pedal pulses bounding and regular B. Urinary output 20mL in the past hour C. Blood pressure 108/50 D. Oxygen saturation 97% Answer B: Because the aorta is clamped during surgery, the blood supply to the kidneys is impaired. This can result in renal damage. A urinary output of 20mL is oliguria. In answer A, the pedal pulses that are thready and regular are within normal limits. For answer C, it is desirable for the client’s blood pressure to be slightly low after surgical repair of an aneurysm. The oxygen saturation of 97% in answer D is within normal limits and, therefore, incorrect. 183. The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching? A. “I will have blood drawn every month.” B. “I will assess my skin for a rash.” C. “I take aspirin for a headache.” D. “I will use an electric razor to shave.” Answer C: The client taking an anticoagulant should not take aspirin because it will further thin the blood. He should return to have a Protime drawn for bleeding time, report a rash, and use an electric razor. Therefore, answers A, B, and D are incorrect. 184. A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with: A. Hypothyroidism B. Diabetic ulcers C. Ulcerative colitis D. Pneumonia Answer A: The best roommate for the post-surgical client is the client with hypothyroidism. This client is sleepy and has no infectious process. Answers B, C, and D are incorrect because the client with a diabetic ulcer, ulcerative colitis, or pneumonia can transmit infection to the post-surgical client. 185. The nurse has just received shift report and is preparing to make rounds. Which client should be seen first? A. The client who has a history of a cerebral aneurysm with an oxygen saturation rate of 99% B. The client who is three days post–coronary artery bypass graft with a temperature of 100.2°F C. The client who was admitted 1 hour ago with shortness of breath D. The client who is being prepared for discharge following a femoral popliteal bypass graft Answer C: The client admitted 1 hour ago with shortness of breath should be seen first because this client might require oxygen therapy. The client in answer A with a low-grade temperature can be assessed after the client with shortness of breath. The client in answer B can also be seen later. This client will have some inflammatory process after surgery, so a temperature of 100.2°F is not unusual. The low-grade temperature should be re-evaluated in 1 hour. The client in answer D can be reserved for later. 186. The doctor has ordered antithrombolic stockings to be applied to the legs of the client with peripheral vascular disease. The nurse knows that the proper method of applying the stockings is: A. Before rising in the morning B. With the client in a standing position C. After bathing and applying powder D. Before retiring in the evening Answer A: The best time to apply antithrombolytic stockings is in the morning before rising. If the doctor orders them later in the day, the client should return to bed, wait 30 minutes, and apply the stockings. Answers B, C, and D are incorrect because there is likely to be more peripheral edema if the client is standing or has just taken a bath; before retiring in the evening is wrong because, late in the evening, more peripheral edema will be present. 187. The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The client should be taught to avoid: A. Using a recliner to rest B. Resting in supine position C. Sitting in a straight chair D. Sleeping in right Sim’s position Answer C: The client with a femoral popliteal bypass graft should avoid activities that can occlude the femoral artery graft. Sitting in the straight chair and wearing tight clothes are prohibited for this reason. Resting in a supine position, resting in a recliner, or sleeping in right Sim’s are allowed, as stated in answers A, B, and D. 188. While caring for a client with hypertension, the nurse notes the following vital signs: BP of 140/20, pulse 120, respirations 36, temperature 100.8°F. The nurse’s initial action should be to: A. Call the doctor C. Able to verbalize needs D. Continually asks “Why?” to most topics Answer C: Children at age 2 can reach for objects that they desire and use simple words such as cookie to express what they want. They already understand “yes” and “no,” so answer A is incorrect. Simple language patterns begin to develop after this age, even though children at this age might understand some words; therefore, answer B is not a good choice. Later, at about age 3 or 4, they begin to ask “Why?,” making answer D incorrect. 194. In terms of cognitive development, a 2-year-old would be expected to: A. Think abstractly B. Use magical thinking C. Understand conservation of matter D. See things from the perspective of others Answer B: A 2-year-old is expected only to use magical thinking, such as believing that a toy bear is a real bear. Answers A, C, and D are not expected until the child is much older. Abstract thinking, conservation of matter, and the ability to look at things from the perspective of others are not skills for small children. 195. The nurse is ready to begin an exam on a 9-month-old infant. The child is sitting in his mother’s lap. What should the nurse do first? A. Check the Babinski reflex B. Listen to the heart and lung sounds C. Palpate the abdomen D. Check tympanic membranes Answer B: The first action that the nurse should take when beginning to examine the infant is to listen to the heart and lungs. If the nurse elicits the Babinski reflex, palpates the abdomen, or looks in the child’s ear first, the child will begin to cry and it will be difficult to obtain an objective finding while listening to the heart and lungs. Therefore, answers A, C, and D are incorrect. 196. Which of the following examples represents parallel play? A. Jenny and Tommy share their toys. B. Jimmy plays with his car beside Mary, who is playing with her doll. C. Kevin plays a game of Scrabble with Kathy and Sue. D. Mary plays with a handheld game while sitting in her mother’s lap. Answer B: Parallel play is play that is demonstrated by two children playing side by side but not together. The play in answers A and C is participative play because the children are playing together. The play in answer D is solitary play because the mother is not playing with Mary. 197. Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning? A. A 6-month-old B. A 4-year-old C. A 10-year-old D. A 13-year-old Answer B: The 4-year-old is more prone to accidental poisoning because children at this age are much more mobile and this makes them more likely to ingest poisons than the other children. Answers A, C, and D are incorrect because the 6-month-old is still too small to be extremely mobile, the 10- year-old has begun to understand risk, and the 13-year-old is also aware of the risks of poisoning and is less likely to ingest poisons than the 4-year-old. 198. An important intervention in monitoring the dietary compliance of a client with bulimia is: A. Allowing the client privacy during mealtimes B. Praising her for eating all her meals C. Observing her for 1–2 hours after meals D. Encouraging her to choose foods she likes and to eat in moderation Answer C: To prevent the client from inducing vomiting after eating, the client should be observed for 1–2 hours after meals. Allowing privacy as stated in answer A will only give the client time to vomit. Praising the client for eating all of a meal does not correct the psychological aspects of the disease; thus, answer B is incorrect. Encouraging the client to choose favorite foods might increase stress and the chance of choosing foods that are low in calories and fats. 199. The client is admitted for evaluation of aggressive behavior and diagnosed with antisocial personality disorder. A key part of the care of such a client is: A. Setting realistic limits B. Encouraging the client to express remorse for behavior C. Minimizing interactions with other clients D. Encouraging the client to act out feelings of rage Answer A: Clients with antisocial personality disorder must have limits set on their behavior because they are artful in manipulating others. Answer B is not correct because they do express feelings and remorse. Answers C and D are incorrect because it is unnecessary to minimize interactions with others or encourage them to act out rage more than they already do. 200. A client with a diagnosis of passive-aggressive personality disorder is seen at the local mental health clinic. A common characteristic of persons with passive-aggressive personality disorder is: A. Superior intelligence B. Underlying hostility C. Dependence on others D. Ability to share feelings