NCLEX RN COMPLETE TEST BANK WITH MORE THAN 850 QUESTIONS COMPLETE WITH ALL THE CORRECT, Exams of Nursing

Download NCLEX RN COMPLETE TEST BANK WITH MORE THAN 850 QUESTIONS COMPLETE WITH ALL THE CORRECT and more Exams Nursing in PDF only on Docsity! NCLEX RN COMPLETE TEST BANK WITH MORE THAN 850 QUESTIONS COMPLETE WITH ALL THE CORRECT ANSWERS QUESTION 1 Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy? A. Positive inotropes B. Vasodilators C. Diuretics D. Antidysrhythmics Answer: A Explanation: (A) Positive inotropic agents should not be administered owing to their action of increasing myocardial contractility. Increased ventricular contractility would increase outflow tract obstruction in the client with hypertrophic cardiomyopathy. (B) Vasodilators are not typically prescribed but are not contraindicated. (C) Diuretics are used with caution to avoid causing hypovolemi A. (D) Antidysrhythmics are typically needed to treat both atrial and ventricular dysrhythmias. QUESTION 2 Signs and symptoms of an allergy attack include which of the following? A. Wheezing on inspiration B. Increased respiratory rate C. Circumoral cyanosis D. Prolonged expiration Answer: D Explanation: (A) Wheezing occurs during expiration when air movement is impaired because of constricted edematous bronchial lumin A. (B) Respirations are difficult, but the rate is frequently normal. (C) The circumoral area is usually pale. Cyanosis is not an early sign of hypoxi A. (D) Expiration is prolonged because the alveoli are greatly distended and air trapping occurs. QUESTION 3 A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination? A. Auditory B. Gustatory C. Olfactory D. Visceral Answer: B Explanation: (A) Auditory hallucinations involve sensory perceptions of hearing. (B) Gustatory hallucinations involve sensory perceptions of taste. (C) Olfactory hallucinations involve sensory perceptions of smell. (D) Visceral hallucinations involve sensory perceptions of sensation. NCLEX RN COMPLETE TEST BANK WITH MORE THAN 850 QUESTIONS COMPLETE WITH ALL THE CORRECT ANSWERS QUESTION 4 Which of the following findings would be abnormal in a postpartal woman? A. Chills shortly after delivery B. Pulse rate of 60 bpm in morning on first postdelivery day C. Urinary output of 3000 mL on the second day after delivery D. An oral temperature of 101F (38.3C) on the third day after delivery Answer: D Explanation: (A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. (B) The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. (C) Urinary output increases during the early postpartal period (12–24 hours) owing to diuresis. The kidneys must eliminate an estimated 2000–3000 mL of extracellular fluid associated with a normal pregnancy. (D) A temperature of 100.4F (38C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4F needs further investigation to identify any infectious process. QUESTION 5 A six- month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the parents, the nurse states that: A. Sustained temperature elevation over 103F is generally related to febrile seizures B. Febrile seizures do not usually recur C. There is little risk of neurological deficit and mental retardation as sequelae to febrile seizures D. Febrile seizures are associated with diseases of the central nervous system Answer: C Explanation: (A) The temperature elevation related to febrile seizures generally exceeds 101F, and seizures occur during the temperature rise rather than after a prolonged elevation. (B) Febrile seizures may recur and are more likely to do so when the first seizure occurs in the 1st year of life. (C) There is little risk of neurological deficit, mental retardation, or altered behavior secondary to febrile seizures. (D) Febrile seizures are associated with disease of the central nervous system. QUESTION 6 A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Whic h of the following nutritional interventions would be most therapeutic for him at this time? A. Small, frequent feedings of foods that can be carried B. Tube feedings with nutritional supplements C. Allowing him to eat when and what he wants D. Giving him a quiet place where he can sit down to eat meals Answer: A Explanation: (A) The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with NCLEX RN COMPLETE TEST BANK WITH MORE THAN 850 QUESTIONS COMPLETE WITH ALL THE CORRECT ANSWERS Answer: A Explanation: (A) The recommended range is 70–120 mg/dL to reduce the risk of perinatal mortality. (B, C, D) These levels are not recommended. The higher the blood glucose, the worse the prognosis for the fetus. Hypoglycemia can also have detrimental effects on the fetus. QUESTION 13 When evaluating a client with symptoms of shock, it is important for the nurse to differentiate between neurogenic and hypovolemic shock. The symptoms of neurogenic shock differ from hypovolemic shock in that: A. In neurogenic shock, the skin is warm and dry B. In hypovolemic shock, there is a bradycardia C. In hypovolemic shock, capillary refill is less than 2 seconds D. In neurogenic shock, there is delayed capillary refill Answer: A Explanation: (A) Neurogenic shock is caused by injury to the cervical region, which leads to loss of sympathetic control. This loss leads to vasodilation of the vascular beds, bradycardia resulting from the lack of sympathetic balance to parasympathetic stimuli from the vagus nerve, and the loss of the ability to sweat below the level of injury. In neurogenic shock, the client is hypotensive but bradycardiac with warm, dry skin. (B) In hypovolemic shock, the client ishypotensive and tachycardiac with cool skin. (C) In hypovolemic shock, the capillary refill would be>5 seconds. (D) In neurogenic shock, there is no capillary delay, the vascular beds are dilated, and peripheral flow is good. QUESTION 14 A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay-colored stools. His admitting diagnosis is ―rule out hepatitis.‖ Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposure to hepatitis. Which of the following represents a high-risk group for contracting this disease? A. Heterosexual males B. Oncology nurses C. American Indians D. Jehovah‘s Witnesses Answer: B Explanation: (A) Homosexual males, not heterosexual males, are at high risk for contracting hepatitis. (B) Oncology nurses are employed in high-risk areas and perform invasive procedures that expose them to potential sources of infection. (C) The literature does not support the idea that any ethnic groups are at higher risk. (D) There is no evidence that any religious groups are at higher risk. QUESTION 15 A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, ―My doctor is in love with me and wants to marry me.‖ This client is using which of the following defense mechanisms? NCLEX RN COMPLETE TEST BANK WITH MORE THAN 850 QUESTIONS COMPLETE WITH ALL THE CORRECT ANSWERS A. Displacement B. Projection C. Reaction formation D. Suppression Answer: B Explanation: (A) Displacement involves transferring feelings to a more acceptable object. (B) Projection involves attributing one‘s thoughts or feelings to another person. (C) Reaction formation involves transforming an unacceptable impulse into the opposite behavior. (D) Suppression involves the intentional exclusion of unpleasant thoughts or experiences. QUESTION 16 When teaching a sex education class, the nurse identifies the most common STDs in the United States as: A. Chlamydia B. Herpes genitalis C. Syphilis D. Gonorrhea Answer: A Explanation: (A) Chlamydia trachomatis infection is the most common STD in the United States. The Centers for Disease Control and Prevention recommend screening of all high-risk women, such as adolescents and women with multiple sex partners. (B) Herpes simplex genitalia is estimated to be found in 5–20 million people in the United States and is rising in occurrence yearly. (C) Syphilis is a chronic infection caused by Treponema pallidum. Over the last several years the number of people infected has begun to increase. (D) Gonorrhea is a bacterial infection caused by the organism Neisseria gonorrhoeae. Although gonorrhea is common, chlamydia is still the most common STD. QUESTION 17 The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should: A. Increase his nasal O2 to 6 L/min B. Place him in a lateral Sims‘ position C. Encourage pursed- lip breathing D. Have him breathe into a paper bag Answer: C Explanation: (A) Giving too high a concentration of O2 to a client with em-physema may remove his stimulus to breathe. (B) The client should sit forward with his hands on his knees or an overbed table and with shoulders elevated. (C) Pursed-lip breathing helps the client to blow off CO2 and to keep air passages open. (D) Covering the face of a client extremely short of breath may cause anxiety and further increase dyspnea. NCLEX RN COMPLETE TEST BANK WITH MORE THAN 850 QUESTIONS COMPLETE WITH ALL THE CORRECT ANSWERS QUESTION 18 In a client with chest trauma, the nurse needs to evaluate mediastinal position. This can best be done by: A. Auscultating bilateral breath sounds B. Palpating for presence of crepitus C. Palpating for trachial deviation D. Auscultating heart sounds Answer: C Explanation: (A) No change in the breath sounds occurs as a direct result of the mediastinal shift. (B) Crepitus can occur owing to the primary disorder, not to the mediastinal shift. (C) Mediastinal shift occurs primarily with tens ion pneumothorax, but it can occur with very large hemothorax or pneumothorax. Mediastinal shift causes trachial deviation and deviation of the heart‘s point of maximum impulse. (D) No change in the heart sounds occurs as a result of the mediastinal shift. QUESTION 19 Clinical manifestations seen in left-sided rather than in right-sided heart failure are: A. Elevated central venous pressure and peripheral edema B. Dyspnea and jaundice C. Hypotension and hepatomegaly D. Decreased peripheral perfusion and rales Answer: D Explanation: (A, B, C) Clinical manifestations of right-sided heart failure are weakness, peripheral edema, jugular venous distention, hepatomegaly, jaundice, and elevated central venous pressure. (D) Clinical manifestations of left- sided heart failure are left ventricular dysfunction, decreased cardiac output, hypotension, and the backward failure as a result of increased left atrium and pulmonary artery pressures, pulmonary edema, and rales. QUESTION 20 In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware that there is typically: A. Decreased pulmonary blood flow and cyanosis B. Increased pressure in the pulmonary veins and pulmonary edema C. Systemic venous engorgement D. Increased left ventricular systolic pressures and hypertrophy Answer: D Explanation: (A) These signs are seen in pulmonic stenosis or in response to pulmonary congestion and edema and mitral stenosis. (B) These signs are seen primarily in mitral stenosis or as a late sign in aortic stenosis after left ventricular failure. (C) These signs are seen primarily in right-sided heart valve dysfunction. (D) Left ventricular hypertrophy occurs to increase muscle mass and overcome the stenosis; left ventricular pressures increase as left ventricular volume increases owing to insufficient emptying. NCLEX RN COMPLETE TEST BANK WITH MORE THAN 850 QUESTIONS COMPLETE WITH ALL THE CORRECT ANSWERS extend the depth of burn are A. (B) The use of large amounts of water to flush the area is recommended for chemical burns. (C) Calcium chloride is not recommended therapy and would likely worsen the problem. (D) Lanolin is of no benefit in the initial treatment of a chemical injury and may actually extend a thermal injury. QUESTION 27 Dietary planning is an essential part of the diabetic client‘s regimen. The American Diabetes Association recommends which of the following caloric guidelines for daily meal planning? A. 50% complex carbohydrate, 20%–25% protein, 20%–25% fat B. 45% complex carbohydrate, 25%–30% protein, 30%–35% fat C. 70% complex carbohydrate, 20%–30% protein, 10%–20% fat D. 60% complex carbohydrate, 12%–15% protein, 20%–25% fat Answer: D Explanation: (A) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney as it is metabolized. (B) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney. (C) The percentage of carbohydrates is too high; the percent range of protein is too high, and of fat, too low. (D) This combination provides enough carbohydrates to maintain blood glucose levels, enough protein to maintain body repair, and enough fat to ensure palatability. QUESTION 28 The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment: A. Decreases hypertrophic scar formation B. Assists with ambulation C. Covers burn scars and decreases the psychological impact during recovery D. Increases venous return and cardiac output by normalizing fluid status Answer: A Explanation: (A) Tubular support, such as that received with a Jobst garment, applies tension of 10–20 mm Hg. This amount of uniform pressure is necessary to prevent or reduce hypertrophic scarring. Clients typically wear a pressure garment for 6–12 months during the recovery phase of their care. (B) Pressure garments have no ambulatory assistive properties. (C) Pressure garments can worsen the psychological impact of burn injury, especially if worn on the face. (D) Pressure garments do not normalize fluid status. QUESTION 29 The nurse would expect to include which of the following when planning the management of the client with Lyme disease? A. Complete bed rest for 6–8 weeks B. Tetracycline treatment C. IV amphotericin B D. High-protein diet with limited fluids NCLEX RN COMPLETE TEST BANK WITH MORE THAN 850 QUESTIONS COMPLETE WITH ALL THE CORRECT ANSWERS Answer: B Explanation: (A) The client is not placed on complete bed rest for 6 weeks. (B) Tetracycline is the treatment of choice for children with Lyme disease who are over the age of 9. (C) IV amphotericin B is the treatment for histoplasmosis. (D) The client is not restricted to a high-protein diet with limited fluids. QUESTION 30 The physician recommends immediate hospital admission for a client with PIH. She says to the nurse, ―It‘s not so easy for me to just go right to the hospital like that.‖ After acknowledging her feelings, which of these approaches by the nurse would probably be best? A. Stress to the client that her husband would want her to do what is best for her health. B. Explore with the client her perceptions of why she is unable to go to the hospital. C. Repeat the physician‘s reasons for advising immediate hospitalization. D. Explain to the client that she is ultimately responsible for her own welfare and that of her baby. Answer: B Explanation: (A) This answer does not hold the client accountable for her own health. (B) The nurse should explore potential reasons for the client‘s anxiety: are there small children at home, is the husband out of town? The nurse should aid the client in seeking support or interventions to decrease the anxiety of hospitalization. (C) Repeating the physician‘s reason for recommending hospitalization may not aid the client in dealing with her reasons for anxiety. (D) The concern for self and welfare of baby may be secondary to a woman who is in a crisis situation. The nurse should explore the client‘s potential reasons for anxiety. For example, is there another child in the home who is ill, or is there a husband who is overseas and not able to return on short notice? QUESTION 31 The child with iron poisoning is given IV deforoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticari A. The initial nursing intervention would be to: A. Discontinue the IV B. Stop the medication, and begin a normal saline infusion C. Take all vital signs, and report to the physician D. Assess urinary output, and if it is 30 mL an hour, maintain current treatment Answer: B Explanation: (A) The IV line should not be discontinued because other IV medications will be needed. (B) Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction and could go into shock if the medication is not stopped. The line should be kept opened for other medication. (C) Taking vital signs and reporting to the physician is not an adequate intervention because the IV medication continues to flow. (D) Assessing urinary output and, if it is 30 mL an hour, maintaining current treatment is an inappropriate intervention owing to the child‘s obvious allergic reaction. NCLEX RN COMPLETE TEST BANK WITH MORE THAN 850 QUESTIONS COMPLETE WITH ALL THE CORRECT ANSWERS QUESTION 32 Provide the 1- minute Apgar score for an infant born with the following findings: Heart rate: Above 100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry Color: Body pink, blue extremities A. 7 B. 10 C. 8 D. 9 Answer: A Explanation: (A) Seven out of a possible perfect score of 10 is correct. Two points are given for heart rate above 100; 1 point is given for slow, irregular respiratory effort; 1 point is given for some flex- ion of extremities in assessing muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed for color when the body is pink with blue extremities (acrocyanosis). (B) For a perfect Apgar score of 10, the infant would have a heart rate over 100 but would also have a good cry, active motion, and be completely pink. (C) For an Apgar score of 8 the respiratory rate, muscle tone, or color would need to fall into the 2-point rather than the 1-point category. (D) For this infant to receive an Apgar score of 9, four of the areas evaluated would need ratings of 2 points and one area, a rating of 1 point. QUESTION 33 A client has been diagnosed as being preeclamptic. The physician orders magnesium sulfate. Magnesium sulfate (MgSO4) is used in the management of preeclampsia for: A. Prevention of seizures B. Prevention of uterine contractions C. Sedation D. Fetal lung protection Answer: A Explanation: (A) MgSO4 is classified as an anticonvulsant drug. In preeclampsia management, MgSO4 is used for prevention of seizures. (B) MgSO4 has been used to inhibit hyperactive labor, but results are questionable. (C) Negative side effects such as respiratory depression should not be confused with generalized sedation. (D) MgSO4 does not affect lung maturity. The infant should be assessed for neuromuscular and respiratory depression. QUESTION 34 In the client with a diagnosis of coronary artery disease, the nurse would anticipate the complication of bradycardia with occlusion of which coronary artery? A. Right coronary artery B. Left main coronary artery C. Circumflex coronary artery D. Left anterior descending coronary artery NCL EX QUESTION 43 The predominant purpose of the first Apgar scoring of a newborn is A. ―It concerns me that you feel so badly when you have so many positive things in your life.‖ B. ―It will take a few weeks for you to feel better, so you need to be patient.‖ C. ―You are telling me that you are feeling hopeless at this point?‖ D. ―Let‘s play cards with some of the other clients to get your mind off your problems for now.‖ Answer: C Explanation: (A) This response does not acknowledge the client‘s feelings and may increase his feelings of guilt. (B) This response denotes false reassurance. (C) This response acknowledges the client‘s feelings and invites a response. (D) This response changes the subject and does not allow the client to talk about his feelings. QUESTION 41 The usual treatment for diabetes insipidus is with IM or SC injection of vasopressin tannate in oil. Nursing care related to the client receiving IM vasopressin tannate would include: A. Weigh once a week and report to the physician any weight gain of10 lb. B. Limit fluid intake to 500 mL/day. C. Store the medication in a refrigerator and allow to stand at room temperature for 30 minutes prior to administration. D. Hold the vial under warm water for 10–15 minutes and shake vigorously before drawing medication into the syringe. Answer: D Explanation: (A) Weight should be obtained daily. (B) Fluid is not restricted but is given according to urine output. (C) The medication does not have to be stored in a refrigerator. (D) Holding the vial under warm water for 10–15 minutes or rolling between your hands and shaking vigorously before drawing medication into the syringe activates the medication in the oil solution. QUESTION 42 Proper positioning for the child who is in Bryant‘s traction is: A. Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed B. Both legs extended, and the hips are not flexed C. The affected leg extended with slight hip flexion D. Both hips and knees maintained at a 90-degree flexion angle, and the back flat on the bed Answer: A Explanation: (A) The child‘s weight supplies the countertraction for Bryant‘s traction; the buttocks are slightly elevated off the bed, and the hips are flexed at a 90-degree angle. Both legs are suspended by skin traction. (B) The child in Buck‘s extension traction maintains the legs extended and parallel to the bed. (C) The child in Russell traction maintains hip flexion of the affected leg at the prescribed angle with the leg extended. (D) The child in ―90– 90‖ traction maintains both hips and knees at a 90-degree flexion angle and the back is flat on the bed. NCL EX QUESTION 46 A client returns for her 6- month prenatal checkup and has gained 10 lb in 2 months. The results of her A. Determine gross abnormal motor function B. Obtain a baseline for comparison with the infant‘s future adaptation to the environment C. Evaluate the infant‘s vital functions D. Determine the extent of congenital malformations Answer: C Explanation: (A) Apgar scores are not related to the infant‘s care, but to the infant‘s physical condition. (B) Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation. (C) The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. (D) Congenital malformations are not one of the areas assessed with Apgar scores. QUESTION 44 Hematotympanum and otorrhea are associated with which of the following head injuries? A. Basilar skull fracture B. Subdural hematoma C. Epidural hematoma D. Frontal lobe fracture Answer: A Explanation: (A) Basilar skull fractures are fractures of the base of the skull. Blood behind the eardrum or blood or cerebrospinal fluid (CSF) leaking from the ear are indicative of a dural laceration. Basilar skull fractures are the only type with these symptoms. (B, C, D) These do not typically cause dural lacerations and CSF leakage. QUESTION 45 Which of the following risk factors associated with breast cancer would a nurse consider most significant in a client‘s history? A. Menarche after age 13 B. Nulliparity C. Maternal family history of breast cancer D. Early menopause Answer: C Explanation: (A) Women who begin menarche late (after 13 years old) have a lower risk of developing breast cancer than women who have begun earlier. Average age for menarche is 12.5 years. (B) Women who have never been pregnant have an increased risk for breast cancer, but a positive family history poses an even greater risk. (C) A positive family history puts a woman at an increased risk of developing breast cancer. It is recommended that mammography screening begin 5 years before the age at which an immediate female relative was diagnosed with breast cancer. (D) Early menopause decreases the risk of developing breast cancer. NCL EX decreased peripheral perfusion and bradycardi A. (B) Dobutamine‘s side effects include increased heart rate and blood pressure, ventricular ectopy, examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control? A. She is compliant with her diet as previously taught. B. She needs further instruction and reinforcement. C. She needs to increase her caloric intake. D. She needs to be placed on a restrictive diet immediately. Answer: B Explanation: (A) She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is approximately 12 lb. (B) Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement of proper dietary habits for pregnancy. A 2200-calorie diet is recommended for most pregnant women with a weight gain of 27–30 lb over the 9-month period. With rapid and excessive weightgain, PIH should also be suspected. (C) She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits. Ten pounds in 2 months is excessive weight gain during pregnancy, and health teaching is warranted. (D) Restrictive dieting is not recommended during pregnancy. QUESTION 47 The priority nursing goal when working with an autistic child is: A. To establish trust with the child B. To maintain communication with the family C. To promote involvement in school activities D. To maintain nutritional requirements Answer: A Explanation: (A) The priority nursing goal when working with an autistic child is establishing a trusting relationship. (B) Maintaining a relationship with the family is important but having the trust of the child is a priority. (C) To promote involvement in school activities is inappropriate for a child who is autistic. (D) Maintaining nutritional requirements is not the primary problem of the autistic child. QUESTION 48 The nurse would need to monitor the serum glucose levels of a client receiving which of the following medications, owing to its effects on glycogenolysis and insulin release? A. Norepinephrine (Levophed) B. Dobutamine (Dobutrex) C. Propranolol (Inderal) D. Epinephrine (Adrenalin) Answer: D Explanation: (A) Norepinephrine‘s side effects are primarily related to safe, effective care environment and include NCL EX D. Decreased tidal volume and Answer: Explanation: (A) Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemi A. (B) An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. (C) Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five ―P‘s‖: pain, pallor, pulselessness, pa resthesia, and paralysis. (D) Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia. QUESTION 55 A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report: A. Dizziness and tachypnea B. Circumoral pallor and lightheadedness C. Headache and facial flushing D. Pallor and itching of the face and neck Answer: C Explanation: (A) Tachypnea is not a symptom. (B) Circumoral pallor is not a symptom. (C) Autonomic dysreflexia is an uninhibited and exaggerated reflex of the autonomic nervous system to stimulation, which results in vasoconstriction and elevated blood pressure. (D) Pallor and itching are not symptoms. QUESTION 56 A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect of the drug therapy, which of the following foods should be included in his diet? A. Celery B. Potatoes C. Tomatoes D. Liver Answer: B Explanation: (A) Celery is high in sodium. (B) Potatoes are high in potassium. (C) Tomatoes are high in sodium. (D) Liver is high in iron. QUESTION 57 Which of the following signs and symptoms indicates a tension pneumothorax as compared to an open pneumothorax? A. Ventilation-perfusion (V./Q.) mismatch B. Hypoxemia and respiratory acidosis C. Mediastinal tissue and organ shifting NCL EX Explanation: (A, B, D) These occur in both tension pneumothorax and open pneumothorax. (C) The tension pneumothorax acts like a one- way valve so that the pneumothorax increases with each breath. Eventually, it occupies enough space to shift mediastinal tissue toward the unaffected side away from the midline. Tracheal deviation, movement of point of maximum impulse, and decreased cardiac output will occur. The other three options will occur in both types of pneumothorax. QUESTION 58 A 38-year-old pregnant woman visits her nurse practitioner for her regular prenatal checkup. She is 30 weeks‘ gestation. The nurse should be alert to which condition related to her age? A. Iron-deficiency anemia B. Sexually transmitted disease (STD) C. Intrauterine growth retardation D. Pregnancy-induced hypertension (PIH) Answer: D Explanation: (A) Iron-deficiency anemia can occur throughout pregnancy and is not age related. (B) STDs can occur prior to or during pregnancy and are not age related. (C) Intrauterine growth retardation is a n abnormal process where fetal development and maturation are delayed. It is not age related. (D) Physical risks for the pregnant client older than 35 include increased risk for PIH, cesarean delivery, fetal and neonatal mortality, and trisomy. QUESTION 59 A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expect which of the following to be present in relation to his blood sugar level? A. A normal blood sugar level B. A decreased blood sugar level C. An increased blood sugar level D. Fluctuating levels with a predawn increase Answer: C Explanation: (A) Blood sugar levels increase when the body responds to stress and illness. (B) Blood sugar levels increase when the body responds to stress and illness. (C) Hyperglycemia occurs because glucose is produced as the body responds to the stress and illness of cellulitis. (D) Blood sugar levels remain elevated as long as the body responds to stress and illness. QUESTION 60 A laboratory technique specific for diagnosing Lyme disease is: A. Polymerase chain reaction B. Heterophil antibody test C. Decreased serum calcium level D. Increased serum potassium level Answer: A NCL EX B. Exacerbation of depressive Explanation: (A) Polymerase chain reaction is the laboratory technique specific for Lyme disease. (B) Heterophil antibody test is used to diagnose mononucleosis. (C) Lyme disease does not decrease the serum calcium level. (D) Lyme disease does not increase the serum potassium level. QUESTION 61 The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to: A. Digoxin (Lanoxin) B. Lidocaine (Xylocaine) C. Quinidine gluconate or sulfate (Quinaglute, Quinidex) D. Nitroglycerin IV (Tridil) Answer: B Explanation: (A) Side effects of digoxin include headache, hypotension, AV block, blurred vision, and yellow-green halos. (B) Side effects of lidocaine include heart block, headache, dizziness, confusion, tremor, lethargy, and convulsions. (C) Side effects of quinidine include heart block, hepatotoxicity, thrombocytopenia, and respiratory depression. (D) Side effects of nitroglycerin include postural hypotension, headache, dizziness, and flushing. QUESTION 62 A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of ―not feeling well.‖ At 4:30 PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to: A. Give him 3 tbsp of sugar dissolved in 4 oz of grape juice to drink B. Ask him to dissolve three pieces of hard candy in his mouth C. Have him drink 4 oz of orange juice D. Monitor him closely until dinner arrives Answer: C Explanation: (A) The combination of sugar and juice will increase the blood sugar beyond the normal range. (B) Concentrated sweets are not absorbed as fast as juice; consequently, they elevate the blood sugar beyond the normal limit. (C) Four ounces of orange juice will act immediately to raise the blood sugar to a normal level and sustain it for 30 minutes until supper is served. (D) There is an increased potential for the client‘s blood sugar to decrease even further, resulting in diabetic coma. QUESTION 63 After 3 weeks of treatment, a severely depressed client suddenly begins to feel better and starts interacting appropriately with other clients and staff. The nurse knows that this client has an increased risk for: A. Suicide NCL EX D. Auditory nerve damage resulting in permanent hearing loss Answer: A Explanation: (A) Waterhouse-Friderichsen syndrome is peripheral circulatory collapse, which may result in extensive and diffuse intravascular coagulation and thrombocytopenia resulting in death. (B) Syndrome of inappropriate antidiuretic hormone is a complication of meningitis, but it is not Waterhouse- Friderichsen syndrome. (C) Cerebral edema resulting in hydrocephalus is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (D) Auditory nerve damage resulting in permanent hearing loss is a complication of meningitis, but it is not Waterhouse- Friderichsen syndrome. QUESTION 70 Priapism may be a sign of: A. Altered neurological function B. Imminent death C. Urinary incontinence D. Reproductive dysfunction Answer: A Explanation: (A) Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. (B) Priapism is not associated with death. (C) Urinary retention, rather than incontinence, may occur. (D) Reproductive dysfunction may be a secondary problem. QUESTION 71 When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take? A. Continue monitoring because this is a normal occurrence. B. Turn client on right side. C. Decrease IV fluids. D. Report to physician or midwife. Answer: D Explanation: (A) This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery. (B) To increase O2 perfusion to the unborn infant, the mother should be placed on her left side. (C) IV fluids should be increased, not decreased. (D) Immediate action is warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client. QUESTION 72 The most commonly known vectors of Lyme disease are: A. Mites B. Fleas NCL EX C. Ticks D. Mosquitoes Answer: C Explanation: (A) Mites are not the common vector of Lyme disease. (B) Fleas are not the common vector of Lyme disease. (C) Ticks are the common vector of Lyme disease. (D) Mosquitoes are not the common vector of Lyme disease. QUESTION 73 A child is admitted to the emergency room with her mother. Her mother states that she has been exposed to chickenpox. During the assessment, the nurse would note a characteristic rash: A. That is covered with vesicular scabs all in the macular stage B. That appears profusely on the trunk and sparsely on the extremities C. That first appears on the neck and spreads downward D. That appears especially on the cheeks, which gives a ―slapped-cheek‖ appearance Answer: B Explanation: (A) A rash with vesicular scabs in all stages (macule, papule, vesicle, and crusts). (B) A rash that appears profusely on the trunk and sparsely on the extremities. (C) A rash that first appears on the neck and spreads downward is characteristic of rubeola and rubella. (D) A rash, especially on the cheeks, that gives a ―slapped-cheek‖ appearance is characteristic of roseola. QUESTION 74 A client is 6 weeks pregnant. During her first prenatal visit, she asks, ―How much alcohol is safe to drink during pregnancy?‖ The nurse‘s response is: A. Up to 1 oz daily B. Up to 2 oz daily C. Up to 4 oz weekly D. No alcohol Answer: D Explanation: (A, B, C) No amount of alcohol has been determined safe for pregnant women. Alcohol should be avoided owing to the risk of fetal alcohol syndrome. (D) The recommended safe dosage of alcohol consumption during pregnancy is none. QUESTION 75 Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema? A. Distant breath sounds B. Increased heart sounds C. Decreased anteroposterior chest diameter D. Collapsed neck veins NCL EX Answer: A Explanation: (A) Distant breath sounds are found in clients with emphysema owing to increased anteroposterior chest diameter, overdistention, and air trapping. (B) Deceased heart sounds arepresent because of the increased anteroposterior chest diameter. (C) A barrel-shaped chest is characteristic of emphysem A. (D) Increased distention of neck veins is found owing to right-sided heart failure, which may be present in advanced emphysema. QUESTION 76 Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)? A. Increased core body temperature B. Decreased serum osmolality C. Administration of hypo-osmolar fluids D. Decreased PaCO2 Answer: D Explanation: (A) An increase in core body temperature increases metabolism and results in an increase in ICP. (B) Decreased serum osmolality indicates a fluid overload and may result in an increase in ICP. (C) Hypo-osmolar fluids are generally voided in the neurologically compromised. Using IV fluids such as D5W results in the dextrose being metabolized, releasing free water that is absorbed by the brain cells, leading to cerebral edem A. (D) Hypercapnia and hypoventilation, which cause retention of CO2 and lead to respiratory acidosis, both increase ICP. CO2 is the most potent vasodilator known. QUESTION 77 When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child: A. Fruit juices B. Diluted carbonated drinks C. Soy-based, lactose- free formula D. Regular formulas mixed with electrolyte solutions Answer: C Explanation: (A) Diluted fruit juices are not recommended for rehydration because they tend to aggravate the diarrhe A. (B) Diluted soft drinks have a high-carbohydrate content, which aggravates the diarrhe A. (C) Soy-based, lactose-free formula reduces stool output and duration of diarrhea in most infants. (D) Regular formulas contain lactose, which can increase diarrhea. QUESTION 78 The nurse is aware that nutrition is an important aspect of care for a client with hepatitis. Which of the following diets would be most therapeutic? A. High protein and low carbohydrate B. Low calorie and low protein NCL EX B. Mafenide acetate C. Silver sulfadiazine D. Povidone- iodine Answer: B Explanation: (A) The side effects of neomycin sulfate include rash, urticaria, nephrotoxicity, and ototoxicity. (B) The side effects of mafenide acetate include bone marrow suppression, hemolytic anemia, eosinophilia, and metabolic acidosis. The hyperventilation is a compensatory response to the metabolic acidosis. (C) The side effects of silver sulfadiazine include rash, itching, leukopenia, and decreased renal function. (D) The primary side effect of povidone- iodine is decreased renal function. QUESTION 85 The nurse practitioner determines that a client is approximately 9 weeks‘ gestation. During the visit, the practitioner informs the client about symptoms of physical changes that she will experience during her first trimester, such as: A. Nausea and vomiting B. Quickening C. A 6–8 lb weight gain D. Abdominal enlargement Answer: A Explanation: (A) Nausea and vomiting are experienced by almost half of all pregnant women during the first 3 months of pregnancy as a result of elevated human chorionic gonadotropin levels and changed carbohydrate metabolism. (B) Quickening is the mother‘s perception of fetal movement and generally does not occur until 18–20 weeks after the last menstrual period in primigravidas, but it may occur as early as 16 weeks in multigravidas. (C) During the first trimester there should be only a modest weight gain of 2–4 lb. It is not uncommon for women to lose weight during the first trimester owing to nausea and/or vomiting. (D) Physical changes are not apparent until the second trimester, when the uterus rises out of the pelvis. QUESTION 86 Which of the following medications requires close observation for bronchospasm in the client with chronic obstructive pulmonary disease or asthma? A. Verapamil (Isoptin) B. Amrinone (Inocor) C. Epinephrine (Adrenalin) D. Propranolol (Inderal) Answer: D Explanation: (A) Verapamil has the respiratory side effect of nasal or chest congestion, dyspnea, shortness of breath (SOB), and wheezing. (B) Amrinone has the effect of increased contractility and dilation of the vascular smooth muscle. It has no noted respiratory side effects. (C) Epinephrine has the effect of bronchodilation through stimulation. (D) Propranolol, esmolol, and labetalol are all - blocking agents, which can increase airway resistance and cause bronchospasms. NCL EX QUESTION 87 Which of the following procedures is necessary to establish a definitive diagnosis of breast cancer? A. Diaphanography B. Mammography C. Thermography D. Breast tissue biopsy Answer: D Explanation: (A) Diaphanography, also known as transillumination, is a painless, noninvasive imaging technique that involves shining a light source through the breast tissue to visualize the interior. It must be used in conjunction with a mammogram and physical examination. (B) Mammography is a useful tool for screening but is not considered a means of diagnosing breast cancers. (C) Thermography is a pictorial representation of heat patterns on the surface of the breast. Breast cancers appear as a ―hot spot‖ owing to their higher metabolic rate. (D) Biopsy either by needle aspiration or by surgical incision is the primary diagnostic technique for confirming the presence of cancer cells. QUESTION 88 Pregnant women with diabetes often have problems related to the effectiveness of insulin in controlling their glucose levels during their second half of pregnancy. The nurse teaches the client that this is due to: A. Decreased glomerular filtration and increased tubular absorption B. Decreased estrogen levels C. Decreased progesterone levels D. Increased human placental lactogen levels Answer: D Explanation: (A) There is a rise in glomerular filtration rate in the kidneys in conjunction with decreased tubular glucose reabsorption, resulting in glycosuri A. (B) Insulin is inhibited by increased levels of estrogen. (C) Insulin is inhibited by increased levels of progesterone. (D) Human placental lactogen levels increase later in pregnancy. This hormonal antagonist reduces insulin‘s effectiveness, stimulates lipolysis, and increases the circulation of free fatty acids. QUESTION 89 A pregnant woman at 36 weeks‘ gestation is followed for PIH and develops proteinuri A. To increase protein in her diet, which of the following foods will provide the greatest amount of protein when added to her intake of 100 mL of milk? A. Fifty milliliters light cream and 2 tbsp corn syrup B. Thirty grams powdered skim milk and 1 egg C. One small scoop (90 g) vanilla ice cream and 1 tbsp chocolate syrup D. One package vitamin- fortified gelatin drink Answer: B Explanation: NCL EX (A) This choice would provide more unwanted fat and sugar than protein. (B) Skim milk would add protein. Eggs are good sources of protein while low in fat and calories. (C) The benefit of protein from ice cream would be outweighed by the fat content. Chocolate syrup has caffeine, which is contraindicated or limited in pregnancy. (D) Although most animal proteins are higher in protein than plant proteins, gelatin is not. It loses protein during the processing for food consumption. QUESTION 90 A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child? A. Blood pressure B. Serum potassium level C. Urine output D. Pulse rate Answer: C Explanation: (A) Blood pressure can remain normotensive even in a state of hypovolemi A. (B) Serum potassium is not reliable for determining adequacy of fluid resuscitation. (C) Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. (D) Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation. QUESTION 91 The medication that best penetrates eschar is: A. Mafenide acetate (Sulfamylon) B. Silver sulfadiazine (Silvadene) C. Neomycin sulfate (Neosporin) D. Povidone- iodine (Betadine) Answer: A Explanation: (A) Mafenide acetate is bacteriostatic against gram-positive and gram- negative organisms and is the agent that best penetrates eschar. (B) Silver sulfadiazine poorly penetrates eschar. (C) Neomycin sulfate does not penetrate eschar. (D) Povidoneiodine does not penetrate eschar. QUESTION 92 A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nägele‘s rule is: A. March 27 B. February 1 C. February 27 D. January 3 NCL EX and dislocate tissue. (D) Testing the fluid from the nares would determine the presence of CSF. Elevation of the head, notification of the medical staff, and prophylactic antibiotics are appropriate therapy. QUESTION 99 To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following? A. Positive inotropic therapy B. Negative chronotropic therapy C. Increase in balance of myocardial O2 supply and demand D. Afterload reduction therapy Answer: A Explanation: (A) Inotropic therapy will increase contractility, which will increase myocardial O2 demand. (B) Decreased heart rate to the point of bradycardia will increase coronary artery filling time. This should be used cautiously because tachycardia may be a compensatory mechanism to increase cardiac output. (C) The goal in the care of the MI client with angina is to maintain a balance between myocardial O2 supply and demand. (D) Decrease in systemic vascular resistance by drug therapy, such as IV nitroglycerin or nitroprusside, or intra-aortic balloon pump therapy, would decrease myocardial work and O2 demand. QUESTION 100 The most important reason to closely assess circumferential burns at least every hour is that they may result in: A. Hypovolemia B. Renal damage C. Ventricular arrhythmias D. Loss of peripheral pulses Answer: D Explanation: (A) Hypovolemia could be a result of fluid loss from thermal injury, but not as a result of the circumferential injury. (B) Renal damage is typically seen because of prolonged hypovolemia or myoglobinuri A. (C) Electrical injuries and electrolyte changes typically cause arrhythmias in the burn client. (D) Full- thickness circumferential burns are nonelastic and result in an internal tourniquet effect that co mpromises distal blood flow when the area involved is an extremity.Circumferential full-thickness torso burns compromise respiratory motion and, when extreme, cardiac return. QUESTION 101 A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record: A. 3-2-0-0-2 B. 2-2-0-2-2 C. 3-1-1-0-2 NCL EX D. 2-1-1-0-2 Answer: C Explanation: (A) This answer is an incorrect application of the GTPAL method. One prior pregnancy was a preterm birth at 36 weeks (T =1, P= 1; not T = 2). (B) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G = 3, not 2), one prior pregnancy was preterm (T= 1, P= 1; not T= 2), and she has had no prior abortions (A =0). (C) This answer is the correct application of GTPAL method. The client is currently pregnant for the third time (G =3), her first pregnancy ended at term (>37 weeks) (T = 1), her second pregnancy ended preterm 20–33 weeks) (P = 1), she has no history of abortion (A=0), and she has two living children (L = 2). ( D) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G =3, not 2). QUESTION 102 A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD). She is started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline level is drawn. Which of the following values represents a therapeutic level? A. 14 µ g/mL B. 25 µ g/mL C. 4 µ g/mL D. 30 µ g/mL Answer: A Explanation: (A) The therapeutic blood level range of theophylline is 10–20 mg/mL. Therapeutic drug monitoring determines effective drug dosages and prevents toxicity. (B, D) This value is a toxic level of the drug. (C) This value is a nontherapeutic level of the drug. QUESTION 103 A nasogastric (NG) tube inserted preoperatively is attached to low, intermittent suctions. A client with an NG tube exhibits these symptoms: He is restless; serum electrolytes are Na 138, K 4.0, blood pH 7.53. This client is most likely experiencing: A. Hyperkalemia B. Hyponatremia C. Metabolic acidosis D. Metabolic alkalosis Answer: D Explanation: (A) Sodium level is within normal limits. (B) Sodium level is within normal limits. (C) pH level is consistent with alkalosis. (D) With an NG tube attached to low, intermittent suction, acids are removed and a client will develop metabolic alkalosis. QUESTION 104 A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best NCL EX auscultated just: A. Below the umbilicus toward left side of mother‘s abdomen B. Below the umbilicus toward right side of mother‘s abdomen C. At the umbilicus D. Above the umbilicus to the left side of mother‘s abdomen Answer: A Explanation: (A) LOA identifies a fetus whose back is on its mother‘s left side, whose head is the presenting part, and whose back is toward its mother‘s anterior. It is easiest to auscultate fetal heart tones (FHTs) through the fetus‘s back. (B) The identified fetus‘s back is on its mother‘s left side, not right side. It is easiest to auscultate FHTs through the fetus‘s back. (C) In an LOA position, the fetus‘s head is presenting with the back to the left anterior side of the mother. The umbilicus is too high of a landmark for auscultating the fetus‘s heart rate through its back. (D) This is the correct auscultation point for a fetus in the left sacroanterior position, where the sacrum is presenting, not LOA. QUESTION 105 A mother came to the pediatric clinic with her 17- month-old child. The mother would like to begin toilet training. What should the nurse teach her about implementing toilet training? A. Take two or three favorite toys with the child. B. Have a child-sized toilet seat or training potty on hand. C. Explain to the child she is going to ―void‖ and ―defecate.‖ D. Show disapproval if she does not void or defecate. Answer: B Explanation: (A) Giving her toys will distract her and interfere with toilet training because of inappropriate reinforcement. (B) A child-sized toilet seat or training potty gives a child a feeling of security. (C) She should use words that are age appropriate for the child. (D) Children should be praised for cooperative behavior and/or successful evacuation. QUESTION 106 Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to 25% of her body? A. Urine output B. Edema C. Hypertension D. Bulging fontanelle Answer: A Explanation: (A) Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid resuscitation is adequate. IV fluids are adjusted based on the urinary output of the child during fluid resuscitation. (B) Edema is an indication of increased capillary permeability following a burn injury. (C) Hypertension is an indicator of fluid volume excess. (D) Fontanelles close by 18 months of age. NCL EX on this drug.‖ Answer: A Explanation: (A) This response will help to prevent the occurrence of postural hypotension, a common side effect of this drug and a common reason for falls. (B) Although walking is an excellent exercise, it is not specific to the reduction of risks associated with diuretic therapy. (C) Clients on diuretic therapy are generally taught to ensure that their fluid intake is at least 2000–3000 mL daily, unless contraindicated. (D) Aspirin is a safe drug to take along with furosemide. QUESTION 113 A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurse‘s first intervention should be to: A. Check FHT B. Notify the attending physician C. Turn off the IV oxytocin D. Prepare for the delivery because the client is probably in transition Answer: C Explanation: (A) FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. (B) The physician should be notified, but this is not the first intervention the nurse should do. (C) The standard of care for an induction according to the Association of Women‘s Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. (D) Contractions lasting 60–90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor. QUESTION 114 A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should: A. Explain that he will be kept NPO for 24 hours before the exam B. Practice with him so he will be able to hold his breath for 1 minute C. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver D. Explain that his vital signs will be checked frequently after the test Answer: D Explanation: (A) There is no NPO restriction prior to a liver biopsy. (B) The client would need to hold his breath for 5–10 seconds. (C) There is no pretest laxative given. (D) Following the test, the client is watched for hemorrhage and shock. QUESTION 115 After a liver biopsy, the best position for the client is: NCL EX A. High Fowler B. Prone C. Supine D. Right lateral Answer: D Explanation: (A) This position does not help to prevent bleeding. (B) This position does not help to prevent bleeding. (C) This position does not help to prevent bleeding. (D) The right lateral position would allow pressure on the liver to prevent bleeding. QUESTION 116 In assisting preconceptual clients, the nurse should teach that the corpus luteum secretes progesterone, which thickens the endometrial lining in which of the phases of the menstrual cycle? A. Menstrual phase B. Proliferative phase C. Secretory phase D. Ischemic phase Answer: C Explanation: (A) Menses occurs during the menstrual phase, during which levels of both estrogen and progesterone are decreased. (B) The ovarian hormone responsible for the proliferative phase, during which the uterine endometrium enlarges, is estrogen. (C) The ovarian hormone responsible for the secretory phase is progesterone, which is secreted by the corpus luteum and causes marked swelling in the uterine endometrium. (D) The corpus luteum begins to degenerate in the ischemic phase, causing a fall in both estrogen and progesterone. QUESTION 117 A 4-year-old child is being discharged from the hospital after being treated for severe croup. Which one of the following instructions should the nurse give to the child‘s mother for the home treatment of croup? A. Take him in the bathroom, turn on the hot water, and close the door. B. Give him a dose of antihistamine. C. Give large amounts of clear liquids if drooling occurs. D. Place him near a cool mist vaporizer and encourage crying. Answer: A Explanation: (A) Initial home treatment of croup includes placing the child in an environment of high humidity to liquefy and mobilize secretions. (B) Antihistamines should be avoided because they can cause thickening of secretions. (C) Drooling is a characteristic sign of airway obstruction and the child should be taken directly to the emergency room. (D) Crying increases respiratory distress and hypoxia in the child with croup. The nurse should promote methods that will calm the child. QUESTION 118 A male client is started on IV anticoagulant therapy with heparin. Which of the following laboratory studies will be ordered to monitor the therapeutic effects of heparin? NCL EX A. Partial thromboplastin time B. Hemoglobin C. Red blood cell (RBC) count D. Prothrombin time Answer: A Explanation: (A) Partial thromboplastin time is used to monitor the effects of heparin, and dosage is adjusted depending on test results. It is a screening test used to detect deficiencies in all plasma clotting factors except factors VII and XIII and platelets. (B) Hemoglobin is the main component of RBCs. Its main function is to carry O2from the lungs to the body tissues and to transport CO2back to the lungs. (C) RBC count is the determination of the number of RBCs found in each cubic millimeter of whole blood. (D) PT is used to monitor the effects of oral anticoagulants, e.g., coumarintype anticoagulants. QUESTION 119 A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention? A. Increased pulse rate B. Increased expectorate of secretions C. Decreased inspiratory difficulty D. Increased respiratory rate Answer: C Explanation: (A) A side effect of epinephrine is fatal ventricular fibrillation owing to its effects on cardiac stimulation. (B) Medications used to treat asthma are designed to decrease bronchospasm, not to increase expectorate of secretions. (C) Epinephrine decreased inspiratory difficulty by stimulating -, 1, and 2-receptors causing sympathomimetic stimulation (e.g., bronchodilation). (D) The person with asthma fights to inspire sufficient air thus increasing respiratory rate. QUESTION 120 Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include: A. Cleanse area around the meatus twice a day B. Empty the catheter drainage bag at least daily C. Change the catheter tubing and bag every 48 hours D. Maintain fluid intake of 1200–1500 mL every day Answer: A Explanation: (A) Catheter site care is to be done at least twice daily to prevent pathogen growth at the catheter insertion site. (B) Catheter drainage bags are usually emptied every 8 hours to prevent urine stasis and pathogen growth. (C) Tubing and collection bags are not changed this often, because research studies have not demonstrated the efficacy of this practice. NCL EX B. Restrain the child so he will not injure himself. C. Go to the nurses station and call the physician. D. Move furniture out of the way and place a blanket under his head. Answer: D Explanation: (A) The nurse should not put anything in the child‘s mouth during a seizure; this action could obstruct the airway. (B) Restraining the child‘s movements could cause constrictive injury. (C) Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. (D) The nurse should provide safety for the child by moving objects and protecting the head. QUESTION 127 A mother frantically calls the emergency room (ER) asking what to do about her 3- year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to: A. Give the child 15 mL of syrup of ipecac. B. Give the child 10 mL of syrup of ipecac with a sip of water. C. Give the child 1 cup of water to induce vomiting. D. Bring the child to the ER immediately. Answer: D Explanation: (A) Before giving any emetic, the substance ingested must be known. (B) At least 8 oz of water should be administered along with ipecac syrup to increase volume in the stomach and facilitate vomiting. (C) Water alone will not induce vomiting. An emetic is necessary to facilitate vomiting. (D) Vomiting should never be induced in an unconscious client because of the risk of aspiration. QUESTION 128 A mother continues to breast-feed her 3- month-old infant. She tells the nurse that over the past 3 days she has not been producing enough milk to satisfy the infant. The nurse advises the mother to do which of the following? A. ―Start the child on solid food.‖ B. ―Nurse the child more frequently during this growth spurt.‖ C. ―Provide supplements for the child between breastfeeding so you will have enough milk.‖ D. ―Wait 4 hours between feedings so that your breasts will fill up.‖ Answer: B Explanation: (A) Solid foods introduced before 4–6 months of age are not compatible with the abilities of the GI tract and the nutritional needs of the infant. (B) Production of milk is supply and demand. A common growth spurt occurs at 3 months of age, and more frequent nursing will increase the milk supply to satisfy the infant. (C) Supplementation will decrease the infa nt‘s appetite and in turn decrease the milk supply. When the infant nurses less often or with less vigor, the amount of milk produced decreases. (D) Rigid feeding schedules lead to a decreased milk supply, whereas frequent nursing signals the mother‘s body to produce a correspondingly increased amount of milk. NCL EX QUESTION 129 A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching? A. ―If he develops diarrhea lasting for more than 2–3 days, I will contact the doctor or nurse.‖ B. ―I should anticipate that he will gain about 1 lb/day now that he is on continuous feedings.‖ C. ―It is important to keep the head of his bed elevated or sit him in the chair during feedings.‖ D. ―I should use prepared or open formula within 24 hours and store unused portions in the refrigerator.‖ Answer: B Explanation: (A) Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. (B) A consistent weight gain of more than 0.22 kg/day (12 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. (C) Elevating the client‘s head prevents reflux and thus formula from entering the airway. (D) Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis. QUESTION 130 Which nursing implication is appropriate for a client undergoing a paracentesis? A. Have the client void before the procedure. B. Keep the client NPO. C. Observe the client for hypertension following the procedure. D. Place the client on the right side following the procedure. Answer: A Explanation: (A) A full bladder would impede withdrawal of ascitic fluid. (B) Keeping the client NPO is not necessary. (C) The client may exhibit signs and symptoms of shock and hypertension. (D) No position change is needed after the procedure. QUESTION 131 One of the medications that is prescribed for a male client is furosemide (Lasix) 80 mg bid. To reduce his risk of falls, the nurse would teach him to take this medication: A. On arising and no later than 6 PM B. At evenly spaced intervals, such as 8 AM and 8 PM C. With at least one glass of water per pill D. With breakfast and at bedtime Answer: A Explanation: (A) This option provides adequate spacing of the medication and will limit the client‘s need to get up to go to the bathroom during the night hours, when he is especially at high risk for falls. (B) This option would result in the need to get up during the night to urinate and would thus increase the risk of falls. This option also does not take into consideration the client‘s usual daily routine. (C) Taking this medication with at least one glass of NCL EX water would not have an impact on the risk of falls. (D) This option would result in the need to get up during the night to urinate and would thus increase the risk of falls. QUESTION 132 The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include: A. Ordering a full liquid diet for her B. Ordering five small meals for her C. Ordering a mechanical soft diet for her D. Ordering a puréed diet for her Answer: C Explanation: (A) Full liquids would be difficult to swallow if the muscle control of the swallowing act is affected; this is a probable reason for her difficulties, given her medical diagnosis of multiple sclerosis. (B) Five small meals would do little if anything to decrease her swallowing difficulties, other than assure that she tires less easily. (C) A mechanical soft diet should be easier to chew and swallow, because foods would be more evenly consistent. (D) A pureed diet would cause her to regress more than might be needed; the mechanical soft diet should be tried first. QUESTION 133 In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that which of the following alterations is abnormal during pregnancy? A. Striae gravidarum B. Chloasma C. Dysuria D. Colostrum Answer: C Explanation: (A) Striae gravidarum are the normal stretch marks that frequently occur on the breasts, abdomen, and thighs as pregnancy progresses. (B) Chloasma is the ―mask of pregnancy‖ that normally occurs in many pregnant women. (C) Dysuria is an abnormal danger sign during pregnancy and may indicate a urinary tract infection. (D) Colostrum is a yellow breast secretion that is normally present during the last trimester of pregnancy. QUESTION 134 Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client‘s depression alert the nurse to prioritize problems and care by addressing which of the following problems first: A. Nutritional status B. Impaired thinking C. Possible harm to self D. Rest and activity impairment NCL EX D. 140/90 to 148/98 Answer: C Explanation: (A) These blood pressure changes reflect only an 8 mm Hg systolic and a 5 mm Hg diastolic increase, which is insufficient for blood pressure changes indicating PIH. (B) These blood pressure changes reflect a decrease in systolic pressure of 8 mm Hg and diastolic pressure of 2 mm Hg; these values are not indicative of blood pressure increases reflecting PIH. (C) The definition of PIH is an increase in systolic blood pressure of 30 mm Hg and/or diastolic blood pressure of 15 mm Hg. These blood pressures reflect a change of 26 mm Hg systolically and 18mm Hg diastolically. (D) These blood pressures reflect a change of only 8 mm Hg systolically and 8 mm Hg diastolically, which is insufficient for blood pressure changes indicating PIH. QUESTION 140 An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction? A. Boardlike, rigid abdomen B. Loss of the urge to defecate C. Liquid stool D. Abdominal pain Answer: C Explanation: (A) A boardlike, rigid abdomen would point to a perforated bowel, not a fecal impaction. (B) When a client is fecally impacted, a common symptom is the urge to defecate but the inability to do so. (C) When an impaction is present, only liquid stool will be able to pass around the impacted site. (D) Abdominal pain without distention is not a sign of a fecal impaction. QUESTION 141 A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of: A. Afterbirth pains B. Constipation C. Cystitis D. A hematoma of the vagina or vulva Answer: D Explanation: (A) Afterbirth pains are a common complaint in the postpartum client, but they are located in the uterus. (B) Constipation may cause rectal pressure but is not usually associated with ―severe pain.‖ (C) Cystitis may cause pain, but the location is different. (D) Hematomas are frequently associated with severe pain and pressure. Further assessments are indicated for this client. QUESTION 142 Iron dextran (Imferon) is a parenteral iron preparation. The nurse should know that it: NCL EX A. Is also called intrinsic factor B. Must be given in the abdomen C. Requires use of the Z-track method D. Should be given SC Answer: C Explanation: (A) Intrinsic factor is needed to absorb vitamin B12.(B) Iron dextran is given parenterally, but Z-track in a large muscle. (C) A Ztrack method of injection is required to prevent staining and irritation of the tissue. (D) An SC injection is not deep enough and may cause subcutaneous fat abscess formation. QUESTION 143 The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include: A. Blurred vision and dizziness B. Eye pain and itching C. Feeling of eye pressure and headache D. Eye discharge and hemoptysis Answer: B Explanation: (A) Although blurred vision may occur, dizziness would not be associated with an infection or hemorrhage. (B) Eye pain is a symptom of hemorrhage within the eye, and itching is associated with infection. (C) Nausea and headache would not be usual symptoms of eye hemorrhage or infection. (D) Some eye discharge might be anticipated if an infection is present; hemoptysis would not. QUESTION 144 The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 1–2 minutes; strong, large amount of ―bloody show.‖ The most appropriate nursing goal for this client would be: A. Maintain client‘s privacy. B. Assist with assessment procedures. C. Provide strategies to maintain client control. D. Enlist additional caregiver support to ensure client‘s safety. Answer: C Explanation: (A) Privacy may help the laboring client feel safer, but measures that enhance coping take priority. (B) The frequency of assessments do increase in transition, but helping the client to maintain control and cope with this phase of labor takes on importance. (C) This laboring client is in transition, the most difficult part of the first stage of labor because of decreased frequency, increased duration and intensity, and decreased resting phase of the uterine contraction. The client‘s ability to cope is most threatened during this phase of labor, and nursing actions aredirected toward helping the client to maintain control. (D) Safety is a concern throughout labor, but helping the client to cope takes on importance in transition. QUESTION 145 A complication for which the nurse should be alert following a liver biopsy is: NCL EX A. Hepatic coma B. Jaundice C. Ascites D. Shock Answer: D Explanation: (A) Hepatic coma may occur in liver disease due to the increased NH3levels, not due to liver biopsy. (B) Jaundice may occur due to increased bilirubin levels, not due to liver biopsy. (C) Ascites would occur due to portal hypertension, not due to liver biopsy. (D) Hemorrhage and shock are the most likely complications after liver biopsy because of already existing bleeding tendencies in the vascular makeup of the liver. QUESTION 146 A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, ―I just couldn‘t take it anymore.‖ The nurse‘s best response to this disclosure would be: A. ―You shouldn‘t do things like that, just tell someone you feel bad.‖ B. ―Tell me more about what you couldn‘t take anymore.‖ C. ―I‘m sure you probably didn‘t mean to kill yourself.‖ D. ―How long have you been in the hospital.‖ Answer: B Explanation: (A) Disapproving gives the impression that the nurse has a right to pass judgment on the client‘s thoughts, actions, or ideas. (B) Giving a broad opening gives the client encouragement to continue with verbalization. (C) Failing to acknowledge the client‘s feelings conveys a lack of understanding and empathy. (D) Changing the subject takes the conversation away from the client and is indicative of the nurse‘s anxiety or insensitivity. QUESTION 147 After a 10-year-old child with insulin-dependent diabetes mellitus receives her dinner tray, she tells the nurse that she hates broccoli and wants some corn on the cob. The nurse‘s appropriate response is: A. ―No vegetable exchanges are allowed.‖ B. ―Corn and other starchy vegetables are considered to be bread exchanges.‖ C. ―Yes, you may exchange any vegetable for any other vegetable.‖ D. ―Yes, but only one-half ear is allowed.‖ Answer: B Explanation: (A) Sites for injection need to be rotated, including abdominal sites, to enhance insulin absorption. (B) The pinch technique is the most effective method for obtaining skin tightness to allow easy entrance of the needle to subcutaneous tissues. (C) Massaging the site of injectionfacilitates absorption of the insulin. (D) Changing the needle will break the sterility of the system. It has become acceptable practice to reuse disposable needles and syringes for 3–7 days. NCL EX sedation or drowsiness. Conversely, its side effects may be exhibited by central nervous system stimulation. (D) Cimetidine decreases theophylline clearance from the system and increases theophylline levels in the blood, thus increasing the risk of toxicity. QUESTION 154 A 56-year-old client is admitted to the psychiatric unit in a state of total despair. She feels hope less and worthless, has a flat affect and very sad appearance, and is unable to feel pleasure from anything. Her husband has been assisting her at home with the housework and cooking; however, she has not been eating much, lies around or sits in a chair most of the day, and is becoming confused and thinks her family does not want her around anymore. In assessing the client, the nurse determines that her behavior is consistent with: A. Transient depression B. Mild depression C. Moderate depression D. Severe depression Answer: D Explanation: (A) Transient depression manifests as sadness or the ―blues‖ as seen with everyday disappointments and is not necessarily dysfunctional. (B) Mild depression manifests as symptoms seen with grief response, such as denial, sadness, withdrawal, somatic symptoms, and frequent or continuous thoughts of the loss. (C) Moderate depression manifests as feelings of sadness, negativism; low self-esteem; rumination about life‘s failures; decreased interest in grooming and eating; and possibly sleep disturbances. These symptoms are consistent with dysthymi A. (D) Severe depression manifests as feelings of total despair, hopelessness, emptiness, inability to feel pleasure; possibly extreme psychomotor retardation; inattention to hygiene; delusional thinking; confusion; self- blame; and suicidal thoughts. These symptoms are consistent with major depression. QUESTION 155 A client is pregnant with her second child. Her last menstrual period began on January 15. Her expected date of delivery would be: A. October 8 B. October 15 C. October 22 D. October 29 Answer: C Explanation: (A) Incorrect application of Nägele‘s rule: correctly subtracted 3 months but subtracted 7 days rather than added. (B) Incorrect application of Nägele‘s rule: correctly subtracted 3 months but did not add 7 days. (C) Correct application of Nägele‘s rule: correctly subtracted 3 months and added 7 days. (D) Incorrect application of Nägele‘s rule: correctly subtracted 3 months but added 14 days instead of 7 days. QUESTION 156 Which of the following changes in blood pressure readings should be of greatest concern to the nurse when assessing a prenatal client? NCL EX A. 130/88 to 144/92 B. 136/90 to 148/100 C. 150/96 to 160/104 D. 118/70 to 130/88 Answer: D Explanation: (A, B, C) The individual‘s systolic and diastolic changes are more significant than the relatively high initial blood pressure readings. (D) The systolic pressure went up 12 mm Hg and the diastolic pressure 18 mm Hg. This is a more significant rise than the increases in A–C choices, and client should receive more frequent evaluations and care. QUESTION 157 The nurse would assess the client‘s correct understanding of the fertility awareness methods that enhance conception, if the client stated that: A. ―My sexual partner and I should have intercourse when my cervical mucosa is thick and cloudy.‖ B. ―At ovulation, my basal body temperature should rise about 0.5F.‖ C. ―I should douche immediately after intercourse.‖ D. ―My sexual partner and I should have sexual intercourse on day 14 of my cycle regardless of the length of the cycle.‖ Answer: B Explanation: (A) At ovulation, the cervical mucus is increased, stretchable, and watery clear. (B) Under the influence of progesterone, the basal body temperature increases slightly after ovulation. (C) To enhance fertility, measures should be taken that promote retention of sperm rather than removal. (D) Ovulation, the optimal time for conception, occurs 14+2 days before the next menses; therefore, the date of ovulation is directly related to the length of the menstrual cycle. QUESTION 158 In evaluating the laboratory results of a client with severe pressure ulcers, the nurse finds that her albumin level is low. A decrease in serum albumin would contribute to the formation of pressure ulcers because: A. The proteins needed for tissue repair are diminished. B. The iron stores needed for tissue repair are inadequate. C. A decreased serum albumin level indicates kidney disease. D. A decreased serum albumin causes fluid movement into the blood vessels, causing dehydration. Answer: A Explanation: (A) Serum albumin levels indicate the adequacy of protein stores available for tissue repair. (B) Serum albumin does not measure iron stores. (C) Serum albumin levels do not measure kidney function. (D) A decreased serum albumin level would cause fluid movement out of blood vessels, not into them. NCL EX QUESTION 159 A client is being discharged on warfarin (Coumadin), an oral anticoagulant. The nurse instructs him about using this drug. Which following response by the client indicates the need for further teaching? A. ―I should shave with my electric razor while on Coumadin.‖ B. ―I will inform my dentist that I am on anticoagulant therapy before receiving dental work.‖ C. ―I will continue with my usual dosage of aspirin for my arthritis when I return home.‖ D. ―I will wear an ID bracelet stating that I am on anticoagulants.‖ Answer: C Explanation: (A) Using an electric razor prevents the risk of cuts while shaving. (B) Any physician or dentist should be informed of anticoagulant therapy because of the risk of bleeding due to a prolonged PT. (C) The client should be instructed to consult with his physician. Aspirin is avoided because it potentiates the affects of oral anticoagulants by interfering with platelet aggregation. (D) Identification bracelets are necessary to direct treatment, especially in an emergency situation. QUESTION 160 When a client with pancreatitis is discharged, the nurse needs to teach him how to prevent another occurrence of acute pancreatitis. Which of the following statements would indicate he has an understanding of his disease? A. ―I will not eat any raw or uncooked vegetables.‖ B. ―I will limit my alcohol to one cocktail per day.‖ C. ―I will look into attending Alcoholics Anonymous meetings.‖ D. ―I will report any changes in bowel movements to my doctor.‖ Answer: C Explanation: (A) Raw or uncooked vegetables are all right to eat postdischarge. (B) This client must avoid any alcohol intake. (C) The client displays awareness of the need to avoid alcohol. (D) This action would be pertinent only if fatty stools associated with chronic hepatitis were the problem. QUESTION 161 A client decided early in her pregnancy to breast- feed her first baby. She gave birth to a normal, full- term girl and is now progressing toward the establishment of successful lactation. To remove the baby from her breast, she should be instructed to: A. Gently pull the infant away B. Withdraw the breast from the infant‘s mouth C. Compress the areolar tissue until the infant drops the nipple from her mouth D. Insert a clean finger into the baby‘s mouth beside the nipple Answer: D Explanation: (A) In pulling the infant away from the breast without breaking suction, nipple trauma is likely to occur. (B) In pulling the breast away from the infant without breaking suction, nipple trauma is likely to occur. (C) Compressing the maternal tissue does not break the suction of the infant on the breast and can cause nipple traum NCL EX determined that her fetus is in a vertex presentation with the occiput located in her right anterior quadrant. On her chart this would be noted as: A. Right occipitoposterior B. Right occipitoanterior C. Right sacroanterior D. LOA Answer: B Explanation: (A) The fetus in the right occipitoposterior position would be presenting with the occiput in the maternal right posterior quadrant. (B) Fetal position is defined by the location of the fetal presenting part in the four quadrants of the maternal pelvis. The right occipitoanterior is a fetus presenting with the occiput in mother‘s right anterior quadrant. (C) The fetus in right sacroanterior position would be presenting a sacrum, not an occiput. (D) The fetus in left occipitoanterior position would be presenting with the occiput in the mother‘s left anterior quadrant. QUESTION 168 Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels? A. Broiled fish with rice B. Bran flakes with fresh peaches C. Lasagna with garlic bread D. Cauliflower and lettuce salad Answer: A Explanation: (A) Broiled fish and rice are both excellent sources of protein. (B) Fresh fruits are not a good source of protein. (C) Foods in the bread group are not high in protein. (D) Most vegetables are not high in protein; peas and beans are the major vegetables higher in protein. QUESTION 169 A 42-year-old client with bipolar disorder has been hospitalized on the inpatient psychiatric unit. She is dancing around, talking incessantly, and singing. Much of the time the client is anorexic and eats very little from her tray before she is up and about again. The nurse‘s intervention would be to: A. Confront the client with the fact that she will have to eat more from her tray to sustain her B. Try to get the client to focus on her eating by offering a detailed discussion on the importance of nutrition C. Let her have snacks and drinks anytime that she wants them because she will not eat at regular meal times D. Not expect the client to sit down for complete meals; monitor intake, offering snacks and juice frequently Answer: D Explanation: A. The manic client‘s mood may easily change from euphoric to irritable. The nurse should avoid confrontation and let the client know what she can do, rather than what she cannot. B. Although helpful to refocus or redirect the manic client to discuss only one topic at a time, distractibility is NCL EX very high and it‘s best to avoid long discussions. (C) Manic clients have a tendency to manipulate persons in their environment. Staff should monitor intake, including at mealtime and snacks, and be consistent in their approach to meeting nutritional needs. (D) Manic clients may not sit and eat complete meals, but they can carry foods and liquids from regular meals with them. Staff can monitor and give high-caloric and high-energy snacks and liquids. QUESTION 170 A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20- minute examination, the nurse notes three fetal movements accompanied by accelerations of the fetal heart rate, each 15 bpm, lasting 15 seconds. The nurse interprets this test to be: A. Nonreactive B. Reactive C. Positive D. Negative Answer: B Explanation: (A) In a nonreactive NST, the criteria for reactivity are not met. (B) A reactive NST shows at least two accelerations of FHR with fetal movements, each 15 bpm, lasting 15 seconds or more, over 20 minutes. (C, D) This term is used to interpret a contraction stress test (CST), or oxytocin challenge test, not an NST. QUESTION 171 A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months. The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, ―I don‘t know what to do, I‘m afraid to go home.‖ The best response by the nurse to the client would be: A. ―I wouldn‘t want to go home either; call a friend who could help you.‖ B. ―Did you do something that could have made him so angry?‖ C. ―Let‘s talk about people and resources available to you so that you don‘t have to go home.‖ D. ―I‘ll call the police and they will take care of him, and you can go home and get some rest.‖ Answer: C Explanation: (A) A person in crisis needs support, assistance, and direction from a caregiver rather than just an instruction. (B) A battered person may feel guilt and think that they cause the abuser‘s behavior; however, the abuser has the problem and goes through phases of violence. (C) The nurse should provide support and guidance to the client in crisis by offering alternatives and assist in referrals. (D) Focusing on help from law enforcement may be a very temporary solution, because the victim may be fearful of pressing charges. This answer does not address the crisis of going home. QUESTION 172 A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as ―a cramp in my leg.‖ An appropriate nursing action is to: NCL EX A. Assess for pain with plantiflexion B. Assess for edema and heat of the right leg C. Instruct him to rub the cramp out of his leg D. Elevate right lower extremity with pillows propped under the knee Answer: B Explanation: (A) Calf pain with dorsiflexion of the foot (Homans‘ sign) can be a sign of a deep venous thrombosis; however, it is not diagnostic of the condition. (B) Swelling and warmth along the affected vein are commonly observed clinical manifestations of a deep venous thrombosis as a result of inflammation of the vessel wall. (C) Rubbing or massaging of the affected leg is contraindicated because of the risk of the clot breaking loose and becoming an embolus. (D) A pillow behind the knee can be constricting and further impair blood flow. QUESTION 173 A 26-year-old client is admitted to the labor, delivery, recovery, postpartum unit. The nurse completes her assessment and determines the client is in the first stage of labor. The nurse should instruct her: A. To hold her breath during contractions B. To be flat on her back C. Not to push with her contractions D. To push before becoming fully dilated Answer: C Explanation: (A) This nursing action may cause hyperventilation. (B) This nursing action could cause inferior vena cava syndrome. (C) The client is allowed to push only after complete dilation during the second stage of labor. The nurse needs to know the stages of labor. (D) If the client pushes before dilation, it could cause cervical edema and/or edema to the fetal scalp; both of these could contribute to increased risk of complications. QUESTION 174 A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse? A. ―Keep breathing with your abdominal muscles as long as you can.‖ B. ―Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breathe about 16–20 times a minute with shallow chest breaths.‖ C. ―Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles.‖ D. ―If a woman in labor listens to her body and takes rapid, deep breaths, she will be able to deal with her contractions quite well.‖ Answer: B Explanation: (A) Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. (B) In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. (C) It is important to assume a comfortable position in labor, but the NCL EX B. Client demonstrates use of exercise or physical activity to handle nervous energy following conflicts of everyday life C. Client is able to verbalize effects of substance abuse on the body D. Client has remained substance free during hospitalization and is discharged Answer: B Explanation: (A) This client response does not address stress reduction techniques. Verbal response focuses only on the problem. (B) Exercise or physical activity is a common strategy or coping technique used to reduce stress and anxiety. (C) Verbalizing effects of substance abuse on the body may help with insight and break through denial, but it is not a strategy to reduce anxiety. (D)Remaining substance- free does indicate motivation to change lifestyle of substance abuse or dependence, and it is not a stress reduction strategy in itself. QUESTION 181 In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see? A. Clay-colored stools B. Steatorrhea stools C. Dark brown stools D. Blood-tinged stools Answer: B Explanation: (A) Clay-colored stools indicate dysfunction of the liver or biliary tract. (B) In the early stages of cystic fibrosis, fat absorption is primarily affected resulting in fat, foul, frothy, bulky stools. (C) Dark brown stools indicate normal passage through the colon. (D) Blood-tinged stools indicate dysfunction of the gastrointestinal (GI) tract. QUESTION 182 A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful? A. Pork chop, baked acorn squash, brussel sprouts B. Chicken breast, rice, and green beans C. Roast beef, baked potato, and diced carrots D. Tuna casserole, noodles, and spinach Answer: A Explanation: (A) Both acorn squash and brussels sprouts are potassium- rich foods. (B) None of these foods is considered potassium rich. (C) Only the baked potato is a potassium-rich food. (D) Spinach is the only potassium- rich food in this option. QUESTION 183 The nurse is teaching a 10-year-old insulin-dependent diabetic how to administer insulin. Which one of the following steps must be taught for insulin administration? A. Never use abdominal site for a rotation site. B. Pinch the skin up to form a subcutaneous pocket. NCL EX C. Avoid applying pressure after injection. D. Change needles after injection. Answer: B Explanation: (A) Sites for injection need to be rotated, including abdominal sites, to enhance insulin absorption. (B) The pinch technique is the most effective method for obtaining skin tightness to allow easy entrance of the needle to subcutaneous tissues. (C) Massaging the site of injection facilitates absorption of the insulin. (D) Changing the needle will break the sterility of the system. It has become acceptable practice to reuse disposable needles and syringes for 3–7 days. QUESTION 184 A client is experiencing muscle weakness and lethargy. His serum K+is 3.2. What other symptoms might he exhibit? A. Tetany B. Dysrhythmias C. Numbness of extremities D. Headache Answer: B Explanation: (A) Tetany is seen with low calcium. (B) Low potassium causes dysrhythmias because potassium is responsible for cardiac muscle activity. (C) Numbness of extremities is seen with high potassium. (D) Headache is not associated with potassium excess or deficiency. QUESTION 185 Other drugs may be ordered to manage a client‘s ulcerative colitis. Which of the following medications, if ordered, would the nurse question? A. Methylprednisolone sodium succinate (Solu-Medrol) B. Loperamide (Imodium) C. Psyllium D. 6-Mercaptopurine Answer: D Explanation: (A) Methylprednisolone sodium succinate is used for its anti- inflammatory effects. (B) Loperamide would be used to control diarrhe A. (C) Psyllium may improve consistency of stools by providing bulk. (D) An immunosuppressant such as 6- mercaptopurine is used for chronic unrelenting Crohn‘s disease. QUESTION 186 An 8-week-old infant has been diagnosed with gastroesophageal reflux. The nurse is teaching the infant‘s mother to care for the infant at home. Which one of the following statements by the nurse is appropriate regarding the infant‘s home care? A. ―Lay the infant flat on her left side after feeding.‖ NCL EX B. ―Feed the infant every 4 hours with half-strength formula.‖ C. ―Antacids need to be given an hour before feeding.‖ D. ―Play activities should be carried out before instead of after feedings.‖ Answer: D Explanation: (A) Elevating the child‘s head to a 30-degree angle is the recommended position for gastroesophageal reflux. The supine position predisposes the child to aspiration. (B) Small, frequent feedings with thickened formula are recommended to minimize vomiting. (C) Antacids should be given at the same time as the feeding to improve their buffering action. (D) The infant should be kept still after feedings to reduce the risk of vomiting and aspiration. Vigorous activities should be carried out before feedings. QUESTION 187 A mother is unsure about the type of toys for her 17- month-old child. Based on knowledge of growth and development, what toy would the nurse suggest? A. A pull toy to encourage locomotion B. A mobile to improve hand-eye coordination C. A large toy with movable parts to improve pincer grasp D. Various large colored blocks to teach visual discrimination Answer: A Explanation: (A) Increased locomotive skills make push-pull toys appropriate for the energetic toddler. (B) Infants progress from reflex activity through simple repetitive behaviors to imitative behavior. Hand-eye coordination forms the foundation of other movements. (C) At age 8 months, infants begin to have pincer grasp. Toys that help infants develop the pincer grasp are recommended for this age group. (D) Various large colored blocks are suggested toys for infants 6–12 months of age to help visual stimulation. QUESTION 188 A group of nursing students at a local preschool day care center are going to screen each child‘s fine and gross motor, language, and social skills. The students will use which one of the most widely used screening tests? A. Revised Prescreening Developmental Questionnaire B. Goodenough Draw-a-Person Screening Test C. Denver Development Screening Test D. Caldwell Home Inventory Answer: C Explanation: (A) The Revised Prescreening Developmental Questionnaire is more age appropriate and offers simplified parent scoring and easier comparison. It is used by parents instead of professionals. (B) The Goodenough Draw- a-Person test is used to assess intellectual development. (C) The Denver Developmental Screening Test is one of the most widely used screening tests. It offers a concise, easy-to-administer, systematic approach to assessing the preschool child. It is widely used because of its reliability and validity. (D) The Caldwell Home Inventory is used to assess the home environment in areas of social, emotional, and cognitive supports. NCL EX CPD is ruled out. (D) This answer is the appropriate nursing action because the scenario presents adysfunctional labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD. QUESTION 195 A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the gravida and para system to record the client‘s obstetrical history, the nurse should record: A. Gravida 3 para 1 B. Gravida 3 para 2 C. Gravida 2 para 1 D. Gravida 2 para 2 Answer: B Explanation: (A) This answer is an incorrect application of gravida and par A. The client has had two prior deliveries of more than 20 weeks‘ gestation; therefore, para equals 2, not 1. (B) This answer is the correct application of gravida and par A. The client is currently pregnant for the third time (G = 3), regardless of the length of the pregnancy, and has had two prior pregnancies with birth after the 20th week (P = 2), whether infant was alive or dead. (C) This answer is an incorrect application of gravida and par A. The client is currently pregnant for the third time (G = 3, not 2); prior pregnancies lasted longer than 20 weeks (therefore, P = 2, not 1). (D) This is an incorrect application of gravida and par A. Client is currently pregnant for third time (G = 3, not 2). QUESTION 196 Which of the following would indicate the need for further teaching for the client with COPD? The client verbalizes the need to: A. Eat high-calorie, high-protein foods B. Take vitamin supplementation C. Eliminate intake of milk and milk products D. Eat small, frequent meals Answer: C Explanation: (A) Protein is vital for the maintenance of muscle to aid in breathing. A high-calorie diet using higher fat than carbohydrate content is given because clients are unable to breathe off the excess CO2that is an end product of carbohydrate metabolism. (B) Inadequate nutritional status, in particular, deficiencies in vitamins A and C, decreases resistance to infection. (C) Milk does not make mucus thicker. It may coat the back of the throat and make it feel thicker. Rinsing the mouth with water after drinking milk will prevent this problem. (D) Small, frequent meals minimize a fullness sensation and reduce pressure on the diaphragm. The work of breathing and SOB are also reduced. QUESTION 197 The nurse provides a male client with diet teaching so that he can help prevent constipation in the future. Which NCL EX food choices indicate that this teaching has been understood? A. Omelette and hash browns B. Pancakes and syrup C. Bagel with cream cheese D. Cooked oatmeal and grapefruit half Answer: D Explanation: (A) Eggs and hash browns do not provide much fiber and bulk, so they do not effectively prevent constipation. (B) Pancakes and syrup also have little fiber and bulk, so they do not effectively prevent constipation. (C) Bagel and cream cheese do not provide intestinal bulk. (D) A combination of oatmeal and fresh fruit will provide fiber and intestinal bulk. QUESTION 198 In cleansing the perineal area around the site of catheter insertion, the nurse would: A. Wipe the catheter toward the urinary meatus B. Wipe the catheter away from the urinary meatus C. Apply a small amount of talcum powder after drying the perineal area D. Gently insert the catheter another 12 inch after cleansing to prevent irritation from the balloon Answer: B Explanation: (A) Wiping toward the urinary meatus would transport microorganisms from the external tubing to the urethra, thereby increasing the risk of bladder infection. (B) Wiping away from the urinary meatus would remove microorganisms from the point of insertion of the catheter, thereby decreasing the risk of bladder infection. (C) Talcum powder should not be applied following catheter care, because powders contribute to moisture retention and infection likelihood. (D) The catheter should never be inserted further into the urethra, because this would serve no useful purpose and would increase the risk of infection. QUESTION 199 A 7-year-old child is brought to the ER at midnight by his mother after symptoms appeared abruptly. The nurse‘s initial assessment reveals a temperature of 104.5F (40.3C), difficulty swallowing, drooling, absence of a spontaneous cough, and agitation. These symptoms are indicative of which one of the following? A. Acute tracheitis B. Acute spasmodic croup C. Acute epiglottis D. Acute laryngotracheobronchitis Answer: C Explanation: (A) Clinical manifestations of acute tracheitis include a 2–3 day history of URI, croupy cough, stridor, purulent secretions, high fever. (B) Clinical manifestations of spasmodic croup include a history of URI, croupy cough, stridor, dyspnea, low-grade fever, and a slow progression. The age group most affected is 3 months to 3 years. (C) Three clinical observations have been found to be predictive of epiglottitis: the presence of drooling, absence of spontaneous cough, and agitation.Epiglottitis has a rapid onset that is accompanied by high fever and NCL EX dysphagi A. (D) Clinical manifestations of acute laryngotracheobronchitis (LTB) include slow onset with a history of URI, low-grade fever, stridor, brassy cough, and irritability. QUESTION 200 A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will: A. Drink at least 8 oz of cranberry juice daily B. Maintain a fluid intake of at least 2000 mL daily C. Wash her hands before and after voiding D. Limit her fluid intake after 6 PM so that there is not a great deal of urine in her bladder while she sleeps Answer: D Explanation: (A) Cranberry juice helps to maintain urine acidity, thereby retarding bacterial growth. (B) A generous fluid intake will help to irrigate the bladder and to prevent bacterial growth within the bladder. (C) Hand washing is an effective means of preventing pathogen transmission. (D) Restricting fluid intake would contribute to urinary stasis, which in turn would contribute to bacterial growth. QUESTION 201 A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to: A. Control the delivery by guiding expulsion of fetus B. Leave the room to call the physician C. Push against the perineum to stop delivery D. Cross client‘s legs tightly Answer: A Explanation: (A) Controlling the rapid delivery will reduce the risk of fetal injury and perineal lacerations. (B) The nurse should always remain with a client experiencing a precipitous delivery. (C) Pushing against the perineum may cause fetal distress. (D) Crossing of legs may cause fetal distress and does not stop the delivery process. QUESTION 202 A client is diagnosed with organic brain disorder. The nursing care should include: A. Organized, safe environment B. Long, extended family visits C. Detailed explanations of procedures D. Challenging educational programs Answer: A Explanation: (A) A priority nursing goal is attending to the client‘s safety and well-being. Reorient frequently, remove dangerous objects, and maintain consistent environment. (B) Short, NCL EX Explanation: (A) This position would cause the gravid uterus to bear the increased pressure of the vena cava, which could lead to maternal hypotension, in turn causing the client to continue to have pallor and to feel light- headed. (B) This would not be the first intervention the RN should initiate. TheRN should understand the supine position and its effect on the gravid uterus and vena cav A. (C) The RN‘s first intervention should be one that helps to alleviate the client‘s symptoms. Obtaining her vital signs will not alleviate her symptoms. (D) This would move the gravid uterus off of the client‘s vena cava, which would alleviate the maternal hypotension that is the cause of her symptoms. QUESTION 209 A mother who is breast- feeding her newborn asks the RN, ―How can I express milk from my breasts manually?‖ The RN tells her that the correct method for manual milk expression includes using the thumb and the index finger to: B. Alternately compress and release each nipple C. Roll the nipple and gently pull the nipple forward D. Slide the thumb and index finger forward from the outer border of the areola toward the end of the nipple E. Compress and release each breast at the outer border of the areola Answer: D Explanation: (A) Manipulation of nipples will cause soreness and traum A. (B) Pulling the nipples will cause discomfort and soreness. (C) Sliding the thumb and index finger forward over the nipple will cause soreness. (D) The best method to express milk from the breast is to position the thumb and index finger at the outer border of the areola and compress. This is the location of the milk sinuses. QUESTION 210 A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in duration. The fetus is at 0 station, cervix is dilated 8 cm and effaced 90%. The physician orders an oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that the RN discontinue the infusion if which one of the following occur? A. The client‘s contractions are <2 minutes apart. B. Duration of the contractions are 60 seconds. C. The uterus relaxes between contractions. D. The client complains that she is tired. Answer: A Explanation: (A) It is very important that there is a resting phase or relaxation period between the contractions. During this period, the uterus, placenta, and umbilical vessels re-establish blood flow. No resting phase between contractions can lead to fetal bradycardia, fetal hypoxia, and acidosis. It can also result in a tetanic contraction, which can cause uterine rupture. (B) The goal of the oxytocin infusion is to help establish a contraction pattern lasting 45–60 seconds occurring every 2 minutes and a uterine tonus of 60–70 mm Hg. (C) This choice is correct. The uterus has time to recover from the contraction. (D) The client‘s tiring is no indication to stop the infusion. She will be tired even without the infusion. QUESTION 211 A 2-month-old infant is receiving IV fluids with a volume control set. The nurse uses this type of tubing NCL EX because it: A. Prevents administration of other drugs B. Prevents entry of air into tubing C. Prevents inadvertent administration of a large amount of fluids D. Prevents phlebitis Answer: C Explanation: (A) A volume control set has a chamber that permits the administration of compatible drugs. (B) Air may enter a volume control set when tubing is not adequately purged. (C) A volume control set allows the nurse to control the amount of fluid administered over a set period. (D) Contamination of volume control set may cause phlebitis. QUESTION 212 A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to: A. Assess the client‘s respirations B. Notify the physician C. Auscultate fetal heart rate D. Transfer to delivery suite Answer: C Explanation: (A) Immediately following membrane rupture, the fetus is at risk for complications, not necessarily the mother. (B) The physician is notified after the nurse completes an assessment of the mother‘s and fetus‘s conditions. (C) Rupture of membranes facilitates fetal descent. A potential complication is cord prolapse, which is assessed by auscultating fetal heart rate. (D) Rupture of membranes does not necessarily indicate readiness to deliver. QUESTION 213 A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician‘s office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as: A. Delusion B. Illusion C. Hallucination D. Conversion Answer: D Explanation: (A) The client‘s blindness is real. Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations. QUESTION 214 A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6, and 7 on the left and developed a left pneumothorax. Assessment findings include: NCL EX A. Crackles and paradoxical chest wall movement B. Decreased breath sounds on the left and chest pain with movement C. Rhonchi and frothy sputum D. Wheezing and dry cough Answer: B Explanation: (A) Crackles are caused by air moving through moisture in the small airways and occur with pulmonary edem A. Paradoxical chest wall movement occurs with flail chest when a segment of the thorax moves outward on inspiration and inward on expiration. (B) Decreased breath sounds occur when a lung is collapsed or partially collapsed. Chest pain with movement occurs with rib fractures. (C) Rhonchi are caused by air moving through large fluid- filled airways. Frothy sputum may occur with pulmonary edem A. (D) Wheezing is caused by fluid in large airways already narrowed by mucus or bronchospasm. Dry cough could indicate a cardiac problem. QUESTION 215 An 11-year-old boy has received a partial- thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action? A. Apply ice packs to both legs. B. Begin débridement by removing all charred clothing from wound. C. Apply Silvadene cream (silver sulfadiazine). D. Immerse both legs in cool water. Answer: D Explanation: (A) Ice creates a dramatic temperature change in the tissue, which can cause further thermal injury. (B) Charred clothing should not be removed from wound first. This creates further tissue damage. Débridement is not the first nursing action. (C) Applying silver sulfadiazine cream first insulates heat in injured tissue and increases potential for infection. (D) Emergency care of a thermal burn is immersing both legs in cool water. Cool water permits gradual temperature change and prevents further thermal damage. QUESTION 216 The physician is preparing to induce labor on a 40-week multigravid A. The nurse should anticipate the administration of: A. Oxytocin (Pitocin) B. Progesterone C. Vasopressin (Pitressin) D. Ergonovine maleate Answer: A Explanation: (A) Oxytocin is a hormone secreted by the neurohypophysis during suckling and parturition that produces NCL EX QUESTION 222 A 4-year-old child has Down syndrome. The community health nurse has coordinated a special preschool program. The nurse‘s primary goal is to: A. Provide respite care for the mother B. Facilitate optimal development C. Provide a demanding and challenging educational program D. Prepare child to enter mainstream education Answer: B Explanation: (A) Respite care for the family may be needed, but it is not the primary goal of a preschool program. (B) Facilitation of optimal growth and development is essential for every child. (C) A demanding and challenging educational program may predispose the child to failure. Children with retardation should begin with simple and challenging educational programs. (D) Mental retardation associated with Down syndrome may not permit mainstream education. A preschoolprogram‘s primary goal is not preparation for mainstream education but continuation of optimal development. QUESTION 223 A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral formul A. The nurse should feed the infant with: A. Gavage tube B. Nipple and bottle C. A straw and cup D. Syringe Answer: D Explanation: (A) A gavage tube may damage suture line. It is the most invasive and should be the last measure. (B) A nipple and bottle require sucking, which may damage sutures. (C) A 3- month-old infant is not able to drink from a straw. (D) A syringe allows for the formula to be placed to the side and back of the mouth. This minimizes the amount of sucking needed. QUESTION 224 Painless vaginal bleeding in the last trimester may be caused by: A. Menstruation B. Abruptio placentae C. Placenta previa D. Polyhydramnios Answer: C Explanation: (A) Menstruation should not occur during pregnancy. (B) Abruptio placentae is marked by painful vaginal bleeding following a premature placental detachment after 20th week of gestation. (C) A low- lying placenta NCL EX separates from the uterine wall as the uterus contracts and cervix dilates. This separation causes painless bleeding in the 7th-8th month. (D) Polyhydramnios is excessive amniotic fluid. QUESTION 225 A 66-year-old female client has smoked 2 packs of cigarettes per day for 20 years. Her arterial blood gases on room air are as follows: pH 7.35; PO2 70 mm Hg; PCO2 55 mm Hg; HCO3 32 mEq/L. These blood gases reflect: A. Compensated metabolic acidosis B. Compensated respiratory acidosis C. Compensated respiratory alkalosis D. Uncompensated respiratory acidosis Answer: B Explanation: (A) In compensated metabolic acidosis, the pH level is normal, the PCO2level is decreased, and the HCO3level is decreased. The client‘s primary alteration is an inability to remove excess acid via the kidneys. The lungs compensate by hyperventilating and decreasing PCO2. (B) In compensated respiratory acidosis, the pH level is normal, the PCO2level is elevated, and the HCO3level is elevated. The client‘s primary alteration is an inability to remove CO2from the lungs, so over time, the kidneys increase reabsorption of HCO3to buffer the CO2. (C) In compensated respiratory alkalosis, the pH level is normal, the PCO2level is decreased, and the HCO3level is decreased. The client‘s primary alteration is hyperventilation, which decreases PCO2. The client compensates by increasing the excretion of HCO3from the body. (D) In uncompensated respiratory acidosis, the pH level is decreased, the PCO2level is increased, and the HCO3level is normal. The client‘s primary alteration is an inability to remove CO2from the lungs. The kidneys have not compensated by increasing HCO3reabsorption. QUESTION 226 The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine contractions. Her physician assesses her cervix as 95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2F at this time. The physician orders that she be prepared for a cesarean delivery. In preparing the client for the cesarean delivery, which one of the following physician‘s orders should the RN question? A. Administer meperidine (Demerol) 100 mg IM 1 hour prior to the delivery. B. Discontinue the oxytocin infusion. C. Insert an indwelling Foley catheter prior to delivery. D. Prepare abdominal area from below the nipples to below the symphysis pubis are A. Answer: A Explanation: (A) Meperidine is a narcotic analgesic medication that crosses the placental barrier and reaches the fetus, causing respiratory depression in the fetus. A narcotic medication should never be included in the preoperative order for a cesarean delivery. (B) Oxytocin infusion would be discontinued if client is being prepared for a cesarean delivery because the medication would not be needed. (C) The bladder is always emptied prior to and during the surgical intervention to prevent the urinary bladder from accidentally being incised while the uterine incision is made. (D) The abdominal area is always prepared to rid the area of hair before the abdominal NCL EX incision is made. Abdominal hair cannot be sterilized and could become a source for postoperative incisional infection. QUESTION 227 A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, ―This is too much trouble. I would rather just have a Foley.‘‘ An appropriate response for the RN teaching him would be: A. ―I know. It is a lot to learn. In the long run, though, you will be able to reduce infections if you do an intermittent catheterization program.‘‘ B. ―It is not too much trouble. This is the best way to manage urination.‘‘ C. ―OK. I‘ll ask your physician if we can replace the Foley.‘‘ D. ―You need to learn this because your doctor ordered it.‘‘ Answer: A Explanation: (A) This response acknowledges the client‘s feelings, gives him factual information, and acknowledges that the final decision is his. (B) This response is judgmental and discourages the client from expressing his feelings about the procedure. (C) Catheterization is a procedure thattakes time to learn, but which, for the spinal cord– injured client, can significantly reduce the incidence of urinary tract infections. A young client with a T-4 injury has the hand function to learn this procedure fairly easily. (D) The final decision about bladder elimination management ultimately rests with the client and not the physician. QUESTION 228 A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of: A. Impaired communication B. Sensory-perceptual alterations C. Altered thought processes D. Impaired social interaction Answer: B Explanation: (A) Impaired communication refers to decreased ability or inability to use or understand language in an interaction. (B) In sensory-perceptual alterations an individual has distorted, impaired, or exaggerated responses to incoming stimuli (i.e., a hallucination, which is a false sensory perception that is not associated with real external stimuli). (C) An altered thought processes problem statement is used when an individual experiences a disruption in cognitive operations and activities (i.e., delusions, loose associations, ideas of reference). (D) In impaired social interaction, the individual participates too little or too much in social interactions. QUESTION 229 A client calls the prenatal clinic to schedule an appointment. She states she has missed three menstrual periods and thinks she might be pregnant. During her first visit to the prenatal clinic, it is confirmed that she is pregnant. The registered nurse (RN) learns that her last menstrual period began on June 10. According to Nägele‘s rule, the estimated date of confinement is: NCL EX (A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations. QUESTION 235 A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks‘ postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is: A. Autonomic dysreflexia B. Bradycardia C. Central cord syndrome D. Spinal shock Answer: A Explanation: (A) Autonomic dysreflexia is the exaggerated sympathetic nervous system response to various stimuli in the anesthetized are A. Sympathetic stimulation results in severe, uncontrolled hypertension, which may result in myocardial infarction or cerebral hemorrhage. (B) Bradycardia occurs as a result of sympathetic blockade in the immediate postinjury period. After spinal shock recedes, cardiovascular stability returns, but the client will be bradycardiac for life. (C) Central cord syndrome is a specific type of spinal cord injury that occurs as a result of either hyperextension injuries or disrupted blood flow to the spinal cord. (D) Spinal shock occurs in the immediate postinjury phase and usually resolves in approximately 72 hours. QUESTION 236 A physician‘s order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer? A. 1 gtt/min B. 5 gtt/min C. 50 gtt/min D. 100 gtt/min Answer: C Explanation: (A) This answer is a miscalculation. (B) This answer is a miscalculation. (C)50 gtt/min. (D) This answer is a miscalculation. QUESTION 237 A client‘s congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices a 2- lb weight gain in a 24-hour period. Increased weight gain may indicate: A. A diet too high in calories and saturated fat B. Decreasing cardiac output C. Decreasing renal function D. Development of diabetes insipidus NCL EX Answer: B Explanation: (A) Increased calories may result in weight gain, but there is no indication in this question that this man‘s diet has changed in a way that would result in increased calories. (B) Decreasing cardiac output stimulates the renin- angiotensin-aldosterone cycle and results in fluid retention, which is reflected by weight gain. (C) Decreasing renal function may result in fluid retention, but this question gives no indication that this man has any renal problems. (D) Profound diuresis occurs with diabetes insipidus, which results in weight loss. QUESTION 238 The nurse is assessing and getting a history from a client treated for depression with a monoamine oxidase (MAO) antidepressant. The most serious side effect associated with this antidepressant and the ingestion of tyramine in aged foods may be: A. Hypertensive crisis B. Severe rash C. Severe hypotension D. Severe diarrhea Answer: A Explanation: (A) The most serious adverse reactions of MAO inhibitors involve blood pressure and ingestion of tyramine- containing foods, which may provoke a hypertensive crisis. (B) MAO inhibitors cause adverse reactions affecting the central nervous system and serious adverse reactions involving blood pressure. (C) MAO inhibits false neurotransmitters (phenylalanines) and may produce hypotensive reactions from gradual accumulation of these neurotransmitters. (D) The most serious adverse reactions of MAO inhibitors involve blood pressure. QUESTION 239 When planning care for the passive-aggressive client, the nurse includes the following goal: A. Allow the client to use humor, because this may be the only way this client can express self. B. Allow the client to express anger by using ―I‖ messages, such as ―I was angry when . . .,‖ etc. C. Allow the client to have time away from therapeutic responsibilities. D. Allow the client to give excuses if he forgets to give staff information. Answer: B Explanation: (A) Ceasing to use humor and sarcasm is a more appropriate goal, because this client uses these behaviors covertly to express aggression instead of being open with anger. (B) Use of ―I‖ messages demonstrates proper use of assertive behavior to express anger instead of passive-aggressive behavior. (C) Client is expected to complete share of work in therapeutic community because he has often obstructed other‘s efforts by failing to do his share. (D) Client has used conveniently forgetting or withholding information as a passive-aggressive behavior, which is not acceptable. QUESTION 240 A newborn is admitted to the newborn nursery with tremors, apnea periods, and poor sucking reflex. The nurse should suspect: NCL EX A. Central nervous system damage B. Hypoglycemia C. Hyperglycemia D. These are normal newborn responses to extrauterine life Answer: B Explanation: (A) Central nervous system damage presents as seizures, decreased arousal, and absence of newborn reflexes. (B) In a diabetic mother, the infant is exposed to high serum glucose. The fetal pancreas produces large amounts of insulin, which causes hypoglycemia after birth. (C) Hypoglycemia is a common newborn problem. Increased insulin production causes hypoglycemia, not hyperglycemi A. (D) These are not normal adaptive behaviors to extrauterine life. QUESTION 241 A schizophrenic client who is experiencing thoughts of having special powers states that ―I am a messenger from another planet and can rule the earth.‖ The nurse assesses this behavior as: A. Ideas of reference B. Delusions of persecution C. Thought broadcasting D. Delusions of grandeur Answer: D Explanation: (A) Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. (B) Clients experiencing delusions of persecution believe that others in the environment are plotting against them. (C) Clients experiencing thought broadcasting perceive that others can hear their thoughts. (D) Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers. QUESTION 242 A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress? A. Cyanosis B. Increased respirations C. Sternal and subcostal retractions D. Decreased respirations Answer: C Explanation: (A) Cyanosis is a late clinical sign of respiratory distress. (B) Rapid respirations are normal in a newborn. (C) The newborn has to exert an extra effort for ventilation, which is accomplished by using the accessory muscles of ventilation. The diaphragm and abdominal muscles are immature and weak in the newborn. (D) Decreased respirations are a late clinical sign. In the newborn, decreased respirations precede respiratory failure. QUESTION 243 After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the NCL EX blood gases reflect: A. Compensated respiratory acidosis B. Normal blood gases C. Uncompensated metabolic acidosis D. Uncompensated respiratory acidosis Answer: D Explanation: (A) In compensated respiratory acidosis, the pH level is normal, the PCO2level is elevated, and the HCO3level is elevated. The client‘s primary alteration is an inability to remove CO2from the lungs, so over time, the kidneys increase reabsorption of HCO3to buffer the CO2. (B) Normal ranges for arterial blood gases for adults and children are as follows: pH 7.35 –7.45, PO280–100 mm Hg, PCO235–45 mm Hg, HCO321–28 mEq/L. (C) In uncompensated metabolic acidosis the pH level is decreased, the PCO2level is normal, and the HCO3level is decreased. The client‘s primary alteration is an inability to remove excess acid via the kidneys. The lungs are unable to clear the increased acid. (D) In uncompensated respiratory acidosis, the pH level is decreased, the PCO2level is increased, and the HCO3level is normal. In a person with long-standing COPD, the HCO3level will rise gradually over time to compensate for the gradually increasing PCO2, and the person‘s pH level will be normal. When a person with COPD becomes acutely ill, the kidneys do not have time to increase the reabsorption of HCO3, so the person‘s pH level will reflect acidosis even though the HCO3is elevated. QUESTION 249 A newborn has been delivered with a meningomyelocele. The nursery nurse should position the newborn: A. Prone B. Supine C. Side lying D. Semi-Fowler Answer: A Explanation: (A) The prone position reduces pressure and tension on the sac. Primary nursing goals are to prevent trauma and infection of the sac. (B) The supine position exerts pressure on the sac. (C) Newborns usually cannot maintain side- lying position. (D) The semi- Fowler position exerts pressure on the sac. QUESTION 250 Assessment of a newborn for Apgar scoring includes observation for: A. Pupil response B. Respiratory rate C. Heart rate D. Babinski‘s reflex Answer: C Explanation: (A) Pupil response should be assessed but is not part of Apgar scoring. (B) Respiratory effort is an essential part of Apgar scoring, not respiratory rate. (C) Heart rate is the most critical component of Apgar scoring. (D) Assessment of Babinski‘s reflex is not a component of Apgar scoring. NCL EX QUESTION 251 A client suspects that she is pregnant. She reports two missed menstrual periods. The first day of her last menstrual period was August 3. Her estimated date of confinement would be: A. November 7 B. November 10 C. May 7 D. May 10 Answer: D Explanation: (A) Wrong calculation (B) Wrong calculation (C) Wrong calculation (D) Nägele‘s rule is: Expected Date of Confinement = Last Menstrual Period - 3 months + 7 days + 1 year QUESTION 252 A client‘s physician has prescribed theophylline (Theo- Dur) to help control the bronchospasm associated with the client‘s COPD. Instructions that should be given to the client include: A. ―Call your physician if you develop palpitations, dizziness, or restlessness.‘‘ B. ―Cigarette smoking may significantly increase the risk for theophylline toxicity.‘‘ C. ―Take this medication on an empty stomach.‘‘ D. ―Do not take your medicine if your pulse is less than 60 beats per minute.‘‘ Answer: A Explanation: (A) Indications of theophylline toxicity include palpitations, dizziness, restlessness, nausea, vomiting, shakiness, and anorexi A. (B) Cigarette smoking significantly lowers theophylline plasma levels. (C) Theophylline should be taken with food to decrease stomach upset. (D) These instructions are appropriate for someone taking digoxin. QUESTION 253 Which type of insulin can be administered by a continuous IV drip? A. Humulin N B. NPH insulin C. Regular insulin D. Lente insulin Answer: C Explanation: (A) Humulin N cannot be administered IV. (B) NPH insulin cannot be administered IV. (C) Regular insulin is the only insulin that can be administered IV. (D) Lente insulin cannot be administered IV. QUESTION 254 The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking- hold phase? NCL EX A. Mother is concerned about her recovery. B. Mother calls infant by name. C. Mother lightly touches infant. D. Mother is concerned about her weight gain. Answer: B Explanation: (A) This observation can be made during the taking- in phase when the mother‘s needs are more important. (B) This observation can be made during the taking- hold phase when the mother is actively involved with herself and the infant. (C, D) This observation can be made during the taking- in phase. QUESTION 255 A 67-year-old client will be undergoing a coronary arteriography in the morning. Client teaching about postprocedure nursing care should include that: A. Bed rest with bathroom privileges will be ordered B. He will be kept NPO for 8–12 hours C. Some oozing of blood at the arterial puncture site is normal D. The leg used for arterial puncture should be kept straight for 8–12 hours Answer: D Explanation: (A) Bed rest will be ordered for 8–12 hours postprocedure. Flexing of the leg at the arterial puncture site will occur if the client gets out of bed, and this is contraindicated after arteriography. (B) The client will be able to eat as soon as he is alert enough to swallow safely and that will depend on what medications areused for sedation during the procedure. (C) Oozing at the arterial puncture site is not normal and should be closely evaluated. (D) The leg where the arterial puncture occurred must be kept straight for 8–12 hours to minimize the risk of bleeding. QUESTION 256 A type I diabetic client delivers a male newborn. The newborn is 45 minutes old. What is the primary nursing goal in the nursery during the first hours for this newborn? A. Bonding B. Maintain normal blood sugar C. Maintain normal nutrition D. Monitor intake and output Answer: B Explanation: (A) Bonding is necessary but would not be the priority with this newborn in the nursery. (B) The infant will be at risk for hypoglycemia because of excess insulin production. (C) Normal nutrition is a goal for all newborns. (D) Monitoring intake and output is necessary but is not the most critical nursing goal. QUESTION 257 An elective saline abortion has been performed on a 3- week primigravid A. Following the procedure, the nurse should be alert for which early side effect? NCL EX D. Bleeding time of 4 Explanation: (A) Ritodrine is a sympathomimetic 2-adrenergic agonist that can cause an elevation of blood glucose and plasma insulin in pregnant women. Hyperglycemia can occur in women with abnormal carbohydrate metabolism because of their inability to release more insulin. (B) Hypokalemia can occur resulting from the action of the _- mimetics. It results from a displacement of the extracellular potassium into the intracellular space. (C) Ritodrine causes vasodilation of vessel walls, which can lead to hypotension. The body compensates by increasing heart rate and pulse pressure. (D) There is a lowering of serum iron resulting from the action of _- mimetics to activate hematopoiesis. QUESTION 263 Following a vaginal delivery, the postpartum nurse should observe for: A. Dystocia, kraurosis B. Chadwick‘s sign C. Fatigue, hemorrhoids D. Hemorrhage and infection Answer: D Explanation: (A) Dystocia is difficult labor. The delivery has occurred. Kraurosis is atrophy and dryness of skin and any mucous membrane (vulva). (B) Chadwick‘s sign is a bluish color of vaginal mucosa suggestive of pregnancy. (C) Fatigue is a common symptom in the postpartal period. Hemorrhoids may occur with pregnancy. (D) Hemorrhage and infection are potential complications of vaginal delivery. Hemorrhage may result from retained placental fragments or soft uterus. Infection may occur from the introduction of organisms into the uterus during the delivery. QUESTION 264 A physician‘s order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant? A. 5 mg B. 0.5 mg C. 0.05 mg D. 20 mg Answer: A Explanation: (A) 1 mg = 0.1 mL, then 0.5 mL X= 55 mg. (B) Thisanswer is a miscalculation. (C) This answer is a miscalculation. (D) This answer is a miscalculation. QUESTION 265 A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician? A. pH 7.39 B. White blood cell (WBC) count 10,000 WBCs/mm3 C. Hematocrit 60% NCL EX D. Provide an indicator of respiratory Answer: C Explanation: (A) Normal pH of arterial blood gases for an infant is 7.35–7.45. (B) Normal white blood cell count in an infant is 6,000–17,500 WBCs/mm3. (C) Normal hematocrit in infant is 28%–42%. A 60% hematocrit may indicate polycythemia, a common complication of cyanotic heart disease. (D) Normal bleeding time is 2–7 minutes. QUESTION 266 Nursing care of the infant prior to surgical closure of a meningomyelocele would include: A. Cover sac with dry sterile dressing B. Cover sac with saline-soaked sterile dressing C. Do not apply dressing; keep sac open to air D. Aspirate any fluid from sac Answer: B Explanation: (A) A dry, sterile dressing would adhere to the sac, causing tissue damage. (B) A saline-soaked sterile dressing protects the sac from contamination by air and prevents drying. (C) A sac open to air causes drying and potential for contamination. (D) This intervention is not an independent nursing action. QUESTION 267 A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the Trendelenburg position: A. Allows the physician to visualize the subclavian vein B. Reduces the possibility of air embolism C. Reduces the possibility of hematoma formation D. Makes the procedure more comfortable for the client Answer: B Explanation: (A) The subclavian vein is not visible during central line insertion regardless of the client‘s position. (B) The Trendelenburg position reduces the possibility of air embolism because it places slight positive pressure on the central veins. It also distends the veins, and distention facilitates insertion. (C) This response is untrue; it has no effect on hematoma formation. (D) This position is not necessarily more comfortable for the client, and many clients, especially those who may be short of breath, may find the position uncomfortable and difficult to maintain. QUESTION 268 A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to: A. Prevent air from entering the pleural space B. Prevent fluid from entering the pleural space C. Provide a means to measure chest drainage NCL EX Answer: A Explanation: (A) A chest tube extends from the pleural space to a collection device. The tube is placed below the surface of the saline so that air cannot enter the pleural space. (B) Fluid may enter the pleural space as a result of injury or disease. A chest tube may drain fluid from the pleural space, but the water seal is not involved in this. (C) Chest drainage should be measured, but the water seal is not involved in this. (D) Fluctuations in the tube in the water- sealed bottle will give an indication of respiratory effort, but that is not the purpose of the water seal. QUESTION 269 A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure? A. Bulging fontanelles B. Seizure C. Headache D. Ataxia Answer: C Explanation: (A) Bulging fontanelles are a symptom of increased intracranial pressure in infants. (B) Seizure is a late sign of increased intracranial pressure. (C) Headache is a very early symptom of increased intracranial pressure in the child. (D) Ataxia is a late sign of increased intracranial pressure. QUESTION 270 A client is in active labor and has been admitted to the labor and delivery unit. The RN has just done a sterile vaginal exam and determines that the client is dilated 5 cm, effaced 85%, and the fetus‘s head is at 0 station. She asks if she could have a lumbar epidural now. The epidural is started, and the anesthetic agent used is bupivacaine (Marcaine). After the client has received her lumbar epidural, it is important for the RN to monitor her for which of the following side effects: A. Hypertension B. Hypotension C. Hypoglycemia D. Hyperglycemia Answer: B Explanation: (A) The medication bupivacaine will cause vasodilation in the vascular system, and this does not result in elevation of the ma-ternal blood pressure. (B) The medication bupivacaine will cause vasodilation in the vascular system, and this will result in lowering the maternal blood pressure. (C) Bupivacaine does not interfere with the functioning of the endocrine system. (D) Bupivacaine does not interfere with the functioning of the endocrine system. QUESTION 271 At 16 weeks‘ gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure