NCLEX-RN EXAM QUESTIONS WITH ANSWERS TESTED AND VERIFIED ANSWERS WITH ,SATISFACTION GUARAN, Exams of Nursing

Download NCLEX-RN EXAM QUESTIONS WITH ANSWERS TESTED AND VERIFIED ANSWERS WITH ,SATISFACTION GUARAN and more Exams Nursing in PDF only on Docsity! NCLEX-RN EXAM QUESTIONS WITH ANSWERS TESTED AND VERIFIED ANSWERS WITH ,SATISFACTION GUARANTEED DOWNLOAD FOR A+ RESULTS QUESTION 1 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 Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: (A)March 27 is a miscalculation. (B) February 1 is a miscalculation. (C) February 27 is the correct answer. To calculate the estimated date of confinement using Nagele's rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result. (D) January 3 is a miscalculation. QUESTION 2 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 68 lb weight gain D. Abdominal enlargement Correct Answer: A Section: (none) Explanation Explanation/Reference: 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 1820 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 24 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 3 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) Correct Answer: D Section: (none) Explanation Explanation/Reference: 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 an 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 4 A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical 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. C. One small scoop (90 g) vanilla ice cream and 1 tbsp chocolate syrupD. One package vitamin-fortified gelatin drink Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: (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 9 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 Correct Answer: D Section: (none) Explanation Explanation/Reference: 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 (1224 hours) owing to diuresis. The kidneys must eliminate an estimated 20003000 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 10 What is the most effective method to identify early breast cancer lumps? A. Mammograms every 3 years B. Yearly checkups performed by physician C. Ultrasounds every 3 years D. Monthly breast self-examination Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: (A) Mammograms are less effective than breast self-examination for the diagnosis of abnormalities in younger women, who have denser breast tissue. They are more effective forwomen older than 40. (B) Up to 15% of early-stage breast cancers are detected by physical examination; however, 95% are detected by women doing breast self-examination. (C) Ultrasound is used primarily to determine the location of cysts and to distinguish cysts from solid masses. (D) Monthly breast self-examination has been shown to be the most effective method for early detection of breast cancer. Approximately 95% of lumps are detected by women themselves. QUESTION 11 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 Correct Answer: C Section: (none) Explanation Explanation/Reference: 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. QUESTION 12 The nurse should know that according to current thinking, the most important prognostic factor for a client with breast cancer is: A. Tumor size B. Axillary node status C. Client's previous history of disease D. Client's level of estrogen-progesterone receptor assays Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: (A) Although tumor size is a factor in classification of cancer growth, it is not an indicator of lymph node spread. (B) Axillary node status is the most important indicator for predicting how far the cancer has spread. If the lymph nodes are positive for cancer cells, the prognosis is poorer. (C) The client's previous history of cancer puts her at an increased risk for breast cancer recurrence, especially if the cancer occurred in the other breast. It does not predict prognosis, however. (D) The estrogen-progesterone assay test is used to identify present tumors being fedfrom an estrogen site within the body. Some breast cancers grow rapidly as long as there is an estrogen supply such as from the ovaries. The estrogen-progesterone assay test does not indicate the prognosis. QUESTION 13 A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes him as being "on the move," sleeping 34 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, the nurse would expect him to exhibit which of the following? A. Short, polite responses to interview questions B. Introspection related to his present situation C. Exaggerated self-importance D. Feelings of helplessness and hopelessness Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: (A) During the manic phase of bipolar disorder, clients have short attention spans and may be abusive toward authority figures. (B) Introspection requires focusing and concentration; clients with mania experience flight of ideas, which prevents concentration. (C) Grandiosity and an inflated sense of self-worth are characteristic of this disorder. (D) Feelings of helplessness and hopelessness are symptoms of the depressive stage of bipolar disorder. QUESTION 14 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." Correct Answer: C Section: (none) Explanation Explanation/Reference: 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 19 A long-term goal for the nurse in planning care for a depressed, suicidal client would be to: A. Provide him with a safe and structured environment. B. Assist him to develop more effective coping mechanisms. C. Have him sign a "no-suicide" contract. D. Isolate him from stressful situations that may precipitate a depressive episode. Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: (A) This statement represents a short-term goal. (B) Long-term therapy should be directed toward assisting the client to cope effectively with stress. (C) Suicide contracts represent short- term interventions. (D) This statement represents an unrealistic goal. Stressful situations cannot be avoided in reality. QUESTION 20 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 B. Exacerbation of depressive symptoms C. Violence toward others D. Psychotic behavior Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: (A) When the severely depressed client suddenly begins to feel better, it often indicates that the client has made the decision to kill himself or herself and has developed a plan to do so. (B) Improvement in behavior is not indicative of an exacerbation of depressive symptoms. (C) Thedepressed client has a tendency for self-violence, not violence toward others. (D) Depressive behavior is not always accompanied by psychotic behavior. QUESTION 21 Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes: A. Maintaining seizure precautions B. Restricting fluid intake C. Increasing sensory stimuli D. Applying ankle and wrist restraints Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: (A) These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. (B) Fluid intake should be increased to prevent dehydration. (C) Environmental stimuli should be decreased to prevent precipitation of seizures. (D) Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion. QUESTION 22 A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion? A. Somatic B. Grandiose C. Persecutory D. Nihilistic Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: (A) These delusions are related to the belief that an individual has an incurable illness. (B) These delusions are related to feelings of self- importance and uniqueness. (C) These delusions are related to feelings of being conspired against. (D) These delusions are related to denial of self- existence. QUESTION 23 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 Correct Answer: B Section: (none) Explanation Explanation/Reference: 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. QUESTION 24 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? A. Displacement B. Projection C. Reaction formation D. Suppression Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: QUESTION 29 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 Correct Answer: A Section: (none) Explanation Explanation/Reference: 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 30 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 68 weeks B. Tetracycline treatment C. IV amphotericin B D. High-protein diet with limited fluids Correct Answer: B Section: (none) Explanation Explanation/Reference: 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 31 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 pressureB. Serum potassium level C. Urine output D. Pulse rate Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: (A) Blood pressure can remain normotensive even in a state of hypovolemia. (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 32 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 Correct Answer: A Section: (none) Explanation Explanation/Reference: 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 "9090" traction maintains both hips and knees at a 90-degree flexion angle and the back is flat on the bed. QUESTION 33 A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include: A. Bleeding, bruising, and hemorrhageB. Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase C. Pain, pallor, pulselessness, paresthesia, and paralysis D. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: (A) Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. (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, paresthesia, 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 34 When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is: A. Stephens-Johnson syndrome B. Folate deficiency C. Leukopenic aplastic anemia D. Granulocytosis and nephrosis Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: (A) Stephens-Johnson syndrome is a toxic effect of phenytoin. (B) Folate deficiency is a side effect of phenytoin, but not a toxic effect. (C) Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol). (D) Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione). QUESTION 35 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. Soy-based, lactose-free formulaD. Regular formulas mixed with electrolyte solutions Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: (A) Diluted fruit juices are not recommended for rehydration because they tend to aggravate the diarrhea. (B) Diluted soft drinks have a high- carbohydrate content, which aggravates the diarrhea. (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 40 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 Correct Answer: A Section: (none) Explanation Explanation/Reference: 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 41 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) Correct Answer: D Section: (none) Explanation Explanation/Reference: 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. QUESTION 42 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 Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: (A) Sinus bradycardia and atrioventricular (AV) heart block are usually a result of right coronary artery occlusion. The right coronary artery perfuses the sinoatrial and AV nodes in mostindividuals. (B) Occlusion of the left main coronary artery causes bundle branch blocks and premature ventricular contractions. (C) Occlusion of the circumflex artery does not cause bradycardia. (D) Sinus tachycardia occurs primarily with left anterior descending coronary artery occlusion because this form of occlusion impairs left ventricular function. QUESTION 43 When a client questions the nurse as to the purpose of exercise electrocardiography (ECG) in the diagnosis of cardiovascular disorders, the nurse's response should be based on the fact that: A. The test provides a baseline for further tests B. The procedure simulates usual daily activity and myocardial performance C. The client can be monitored while cardiac conditioning and heart toning are doneD. Ischemia can be diagnosed because exercise increasesO2 consumption and demand Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: (A) The purpose of the study is not to provide a baseline for further tests. (B) The test causes an increase in O2 demand beyond that required to perform usual daily activities. (C) Monitoring does occur, but the test is not for the purpose of cardiac toning and conditioning. (D) Exercise ECG, or stress testing, is designed to elevate the peripheral and myocardial needs for O2 to evaluate the ability of the myocardium and coronary arteries to meet the additional demands. QUESTION 44 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) Correct Answer: B Section: (none) Explanation Explanation/Reference: 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 45 Which of the following ECG changes would be seen as a positive myocardial stress test response? A. Hyperacute T wave B. Prolongation of the PR interval C. ST-segment depression Section: (none) Explanation Explanation/Reference: 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 50 A client with a C-34 fracture has just arrived in the emergency room. The primary nursing intervention is: A. Stabilization of the cervical spine B. Airway assessment and stabilization C. Confirmation of spinal cord injury D. Normalization of intravascular volume Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: (A) If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also protects the cervical spine. (B) Primary intervention is protection of the airway and adequate ventilation. (C, D) All other interventions are secondary to adequate ventilation. QUESTION 51 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 Correct Answer: C Section: (none) Explanation Explanation/Reference: 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 tension 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 52 Priapism may be a sign of: A. Altered neurological function B. Imminent death C. Urinary incontinence D. Reproductive dysfunction Correct Answer: A Section: (none) Explanation Explanation/Reference: 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 53 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 Correct Answer: A Section: (none) Explanation Explanation/Reference: 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 54 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 Correct Answer: D Section: (none) Explanation Explanation/Reference: 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 edema. (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 55 A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to: A. Pass a nasogastric tube through the left nostril B. Place a 4 X 4 gauze in the nares to impede the flow C. Gently suction the nasal drainage to protect the airway D. Perform a halo test and glucose level on the drainage Correct Answer: D Section: (none) Explanation (A) Absorption would be increased, not decreased. (B) IM injections should not be used until the client is hemodynamically stable and has adequate tissue perfusion. Medications will remain in the subcutaneous tissue with the fluid that is present in the interstitial spaces in the acute phase of the thermal injury. The client will have a poor response to the medication administered, and a "dumping" of the medication can occur when the medication and fluid are shifted back into the intravascular spaces in the next phase of healing. (C) IV administration of the medication would hasten respiratory compromise, if present. (D) The desire to avoid causing the client additional pain is not a primary reason for this route of administration. QUESTION 60 The medication that best penetrates eschar is: A. Mafenide acetate (Sulfamylon) B. Silver sulfadiazine (Silvadene) C. Neomycin sulfate (Neosporin) D. Povidone-iodine (Betadine) Correct Answer: A Section: (none) Explanation Explanation/Reference: 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 61 When the nurse is evaluating lab data for a client 1824 hours after a major thermal burn, the expected physiological changes would include which of the following? A. Elevated serum sodium B. Elevated serum calcium C. Elevated serum protein D. Elevated hematocrit Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: (A) Sodium enters the edema fluid in the burned area, lowering the sodium content of the vascular fluid. Hyponatremia may continue for days to several weeks because of sodium loss to edema, sodium shifting into the cells, and later, diuresis. (B) Hypocalcemia occurs because of calcium loss to edema fluid at the burned site (third space fluid). (C) Protein loss occurs at the burn site owing to increased capillary permeability. Serum protein levels remain low until healing occurs. (D) Hematocrit level is elevated owing to hemoconcentration from hypovolemia. Anemia is present in the postburn stage owing to blood loss and hemolysis, but it cannot be assessed until the client is adequately hydrated. QUESTION 62 The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts? A. Neosporin sulfate B. Mafenide acetate C. Silver sulfadiazine D. Povidone-iodine Correct Answer: B Section: (none) Explanation Explanation/Reference: 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 63 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 Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: (A) Tubular support, such as that received with a Jobst garment, applies tension of 1020 mm Hg. This amount of uniform pressure is necessary to prevent or reduce hypertrophic scarring. Clients typically wear a pressure garment for 612 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 64 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 Correct Answer: B Section: (none) Explanation Explanation/Reference: 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 65 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 Correct Answer: A Section: (none) Explanation Explanation/Reference: 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 emphysema. (D) Increased 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 C. High carbohydrate and high calorie D. Low carbohydrate and high calorie Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: (A) Protein increases the workload of the liver. Increased carbohydrates provide needed calories and promote palatability. (B) Dietary intake should be adequate to ensure wound healing. (C) Increased carbohydrates provide needed calories. (D) A highcalorie diet is best obtained from carbohydrates because of their palatability. Fats increase the workload of the liver. QUESTION 71 Which of the following nursing orders should be included in the plan of care for a client with hepatitis C? A. The nurse should use universal precautions when obtaining blood samples. B. Total bed rest should be maintained until the client is asymptomatic. C. The client should be instructed to maintain a low semi-Fowler position when eating meals. D. The nurse should administer an alcohol backrub at bedtime. Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: (A) The source of infection with hepatitis C is contaminated blood products. (B) Modified bed rest should be maintained while the client is symptomatic. Routine activities can be slowly resumed once the client is asymptomatic. (C) Nausea and vomiting occur frequently with hepatitis C. A high Fowler position may decrease the tendency to vomit. (D) The buildup of bilirubin in the client's skin may cause pruritus. Alcohol is a drying agent. QUESTION 72 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 Correct Answer: C Section: (none) Explanation Explanation/Reference: 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 73 A male client receives 10 U of regular human insulin SC at 9:00 AM. The nurse would expect peak action from this injection to occur at: A. 9:30 AM B. 10:30 AM C. 12 noon D. 4:00 PM Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: (A) This is too early for peak action to occur. (B) This is too early for peak action to occur. (C) Regular insulin peak action occurs 24 hours after administration. (D) This is too late for peak action to occur. QUESTION 74 The physician has ordered that a daily exercise program be instituted by a client with type I diabetes following his discharge from the hospital. Discharge instructions about exercise should include which of the following? A. Exercise should be performed 30 minutes before meals.B. A nack may be needed before and/or during exercise. C. Hyperglycemia may occur 24 hours after exercise. D. The blood glucose level should be 100 mg or below before exercise is begun. Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: (A) Exercise should not be performed before meals because the blood sugar is usually lower just prior to eating; therefore, there is an increased risk for hypoglycemia. (B) Exercise lowers blood sugar levels; therefore, a snack may be needed to maintain the appropriate glucose level. (C) Exercise lowers blood sugar levels. (D) Exercise lowers blood sugar levels. If the blood glucose level is 100 mg or below at the start of exercise, the potential for hypoglycemia is greater. QUESTION 75 A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, "Oh dear, I feel like I have to urinate again!" Which of the following is the most appropriate initial nursing response? A. Assure her that this is most likely the result of bladder spasms. B. Check the collection bag and tubing to verify that the catheter is draining properly. C. Instruct her to do Kegel exercises to diminish the urge to void. D. Ask her if she has felt this way before. Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: (A) Although this may be an appropriate response, the initial response would be to assure the patency of the catheter. (B) The most frequent reason for an urge to void with an indwelling catheter is blocked tubing. This response would be the best initial response. (C) Kegel exercises while a retention catheter is in place would not help to prevent a voiding urge and could irritate the urethral sphincter. (D) Though the nurse would want to ascertain whether the client has felt the same urge to void before, the initial response should be to assure the patency of the catheter. QUESTION 76 Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include: B. Eye pain and itching C. Feeling of eye pressure and headache D. Eye discharge and hemoptysis Correct Answer: B Section: (none) Explanation Explanation/Reference: 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 81 With a geriatric client, the nurse should also assess whether he has been obtaining a yearly vaccination against influenza. Why is this assessment important? A. Influenza is growing in our society. B. Older clients generally are sicker than others when stricken with flu. C. Older clients have less effective immune systems. D. Older clients have more exposure to the causative agents. Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: (A) Although influenza is common, the elderly are more at risk because of decreased effectiveness of their immune system, not because the incidence is increasing. (B) Older clients have the same degree of illness when stricken as other populations. (C) As people age, their immune system becomes less effective, increasing their risk for influenza. (D) Older clients have no more exposure to the causative agents than do school-age children, for example. QUESTION 82 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 breadD. Cauliflower and lettuce salad Correct Answer: A Section: (none) Explanation Explanation/Reference: 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 83 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 Correct Answer: C Section: (none) Explanation Explanation/Reference: 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 84 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." Correct Answer: C Section: (none) Explanation Explanation/Reference: 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 85 A 54-year-old client is admitted to the hospital with a possible gastric ulcer. He is a heavy smoker. When discussing his smoking habits with him, the nurse should advise him to: A. Smoke low-tar, filtered cigarettes B. Smoke cigars instead C. Smoke only right after meals D. Chew gum instead Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: (A, B, D) Cigarettes, cigars, and chewing gum would stimulate gastric acid secretion. (C) Smoking on a full stomach minimizes effect of nicotine on gastric acid. QUESTION 86 Iron dextran (Imferon) is a parenteral iron preparation. The nurse should know that it: 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 (A) Fluids up to 25003000 mL/day are needed to prevent kidney stones. (B) The client should be instructed to take oral preparations with meals or snacks to lessen gastric irritation. (C) Sulfasalazine causes skin rash and diarrhea. (D) Blood pressure and pulse are not altered by sulfasalazine. QUESTION 91 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 Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: (A) Methylprednisolone sodium succinate is used for its anti-inflammatory effects. (B) Loperamide would be used to control diarrhea. (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 92 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 Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: (A) There is no NPO restriction prior to a liver biopsy. (B) The client would need to hold his breath for 510 seconds. (C) There is no pretest laxative given. (D) Following the test, the client is watched for hemorrhage and shock. QUESTION 93 After a liver biopsy, the best position for the client is: A. High Fowler B. Prone C. Supine D. Right lateral Correct Answer: D Section: (none) Explanation Explanation/Reference: 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 94 A complication for which the nurse should be alert following a liver biopsy is: A. Hepatic coma B. Jaundice C. Ascites D. Shock Correct Answer: D Section: (none) Explanation Explanation/Reference: 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 95 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. Correct Answer: A Section: (none) Explanation Explanation/Reference: 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 96 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." Correct Answer: B Section: (none) Explanation Explanation/Reference: 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 97 A couple is planning the conception of their first child. The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is most likely to ovulate if she states that ovulation should occur on day: A. 14+2 days (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 2033 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 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 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 Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: (A) This answer is an incorrect application of gravida and para. 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 para. 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 para. 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 para. Client is currently pregnant for third time (G = 3, not 2). QUESTION 102 A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate (MgSO4) therapy, the nurse knows it is safe to repeat the dosage if: A. Deep tendon reflexes are absent B. Urine output is 20 mL/hr C. MgSO4serum levels are>15 mg/dL D. Respirations are>16 breaths/min Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: (A) MgSO4is a central nervous system depressant. Loss of reflexes is often the first sign of developing toxicity. (B) Urinary output at <25 mL/hr or 100 mL in 4 hours may result in the accumulation of toxic levels of magnesium. (C) The therapeutic serum range for MgSO4is 68 mg/dL. Higher levels indicate toxicity. (D) Respirations of>16 breaths/min indicate that toxic levels of magnesium have not been reached. Medication administration would be safe. QUESTION 103 Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH? A. 136/88 to 144/93 B. 132/78 to 124/76 C. 114/70 to 140/88 D. 140/90 to 148/98 Correct Answer: C Section: (none) Explanation Explanation/Reference: 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 104 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 Correct Answer: C Section: (none) Explanation Explanation/Reference: 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 105 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 Correct Answer: D Section: (none) Explanation Explanation/Reference: 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 trauma. (D) By inserting a finger into the infant's mouth beside the nipple, the lactating mother can break the suction and the nipple can be removed without trauma. QUESTION 106 A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to: A. Notify the physician B. Place the client on a pad count A. NonreactiveB. R cti C. Positive D. Negative Correct Answer: B Section: (none) Explanation Explanation/Reference: 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 111 The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 12 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. Correct Answer: C Section: (none) Explanation Explanation/Reference: 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 112 A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station 12 means that the: A. Presenting part is 2 cm above the level of the ischial spinesB. Biparietal diameter is at the level of the ischial spines C. Presenting part is 2 cm below the level of the ischial spines D. Biparietal diameter is 5 cm above the ischial spines Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: (A) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is above the ischial spines, the station is negative. (B) When the biparietal diameter is at the level of the ischial spines, the presenting part is generally at a +4 or +5 station. (C) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is below the ischial spines, the station is positive. Thus, 2 cm below the ischial spines is the station +2. (D) When the biparietal diameter is above the ischial spines by 5 cm, the presenting part is usually engaged or at station 0. QUESTION 113 A pregnant client is at the clinic for a third trimester prenatal visit. During this examination, it has been 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 Correct Answer: B Section: (none) Explanation Explanation/Reference: 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 114 Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, "Begin oxytocin induction at 1 mU/min." The nurse should: A. Begin the oxytocin induction as ordered B. Increase the dosage by 2 mU/min increments at15-minute intervals C. Maintain the dosage when duration of contractions is 4060 seconds and frequency is at 21/2 4 minute intervals D. Question the order Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: (A) Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. (B) This answer is the correct protocol for oxytocin administration, but the medication should not be used until CPD is ruled out. (C) This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used until 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 115 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 1620 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." Correct Answer: B Section: (none) Explanation Explanation/Reference: 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 Lamazeprepared laboring woman is taught to breathe with her chest, not abdominal, muscles. (D) 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 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? A. Partial thromboplastin time B. Hemoglobin C. Red blood cell (RBC) count D. Prothrombin time Correct Answer: A Section: (none) Explanation Explanation/Reference: 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 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." Correct Answer: C Section: (none) Explanation Explanation/Reference: 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 120 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 Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: (A) The therapeutic blood level range of theophylline is 1020 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 121 A client is being discharged with albuterol (Proventil) and beclomethasone dipropionate (Vanceril) to be administered via inhalation three times a day and at bedtime. Client teaching regarding the sequential order in which the drugs should be administered includes: A. Glucocorticoid followed by the bronchodilator B. Bronchodilator followed by the glucocorticoid C. Alternate successive administrations D. According to the client's preference Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: (A) The client would not receive therapeutic effects of the glucocorticoid when it is inhaled through constricted airways. (B) Bronchodilating the airways first allows for the glucocorticoid to be inhaled through open airways and increases the penetration of the steroid for maximum effectiveness of the drug. (C) Inac- Inaccurate use of the inhalers will lead to decreased effectiveness of the treatment. (D) Client teaching regarding the use and effects of inhalers will promote client understanding and compliance. QUESTION 122 To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to: A. Rinse the plastic holder that aerosolizes the drug with hydrogen peroxide every other day B. Rinse the mouth and gargle with warm water after each use of the inhaler C. Take antacids immediately before inhalation to neutralize mucous membranes and prevent infection D. Rinse the mouth before each use to eliminate colonization of bacteria Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: (A) It is sufficient to rinse the plastic holders with warm water at least once per day. (B) It is important to rinse the mouth after each use to minimize the risk of fungal infections by reducing the droplets of the glucocorticoid left in the oral cavity. (C) Antacids act by neutralizing or reducing gastric acid, thus decreasing the pH of the stomach. "Neutralizing" the oral mucosa prior to inhalation of a steroid inhaler does not minimize the risk of fungal infections. (D) Rinsing prior to the use of the glucocorticoid will not eliminate the droplets left on the oral mucous membranes following the use of the inhaler. QUESTION 123 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 Correct Answer: C Section: (none) Explanation Explanation/Reference: 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 to the retention of sodium ions and fluid and is one of the three cardinal symptoms of PIH. QUESTION 128 MgSO4 is ordered IV following the established protocol for a client with severe PIH. The anticipated effects of this therapy are anticonvulsant and: A. Vasoconstrictive B. Vasodilative C. Hypertensive D. Antiemetic Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: (A) An anticonvulsant effect is the goal of drug therapy for PIH. However, we would not want to increase the vasoconstriction that is already present. This would make the symptoms more severe. (B) An anticon-vulsant effect and vasodilation are the desired outcomes when administering this drug. (C) An anticonvulsant effect is the goal of drug therapy for PIH; however, hypertensive drugs would increase the blood pressure even more. (D) An anticonvulsant effect is the goal of drug therapy for PIH. MgSO4is not classified as an antiemetic. Antiemetics are not indicated for PIH treatment. QUESTION 129 A nurse should carefully monitor a client for the following side effect of MgSO4: A. Visual blurring B. Tachypnea C. Epigastric pain D. Respiratory depression Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: (A, C) The nurse should provide good distractors because these symptoms indicate that PIH has become more severe and may precede the convulsive or eclamptic phase. (B) This is the oppositeside effect of this medication. (D) This is a common side effect of this medication and needs to be monitored and recorded frequently. QUESTION 130 MgSO4 blood levels are monitored and the nurse would be prepared to administer the following antidote for MgSO4 side effects or toxicity: A. Magnesium oxide B. Calcium hydroxide C. Calcium gluconate D. Naloxone (Narcan) Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: (A, B) These drugs are not antidotes for MgSO4. (C) This drug is the standard antidote and should always be readily available when MgSO4is being administered. (D) This drug is an antidote for narcotics, not MgSO4. QUESTION 131 A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding: A. The client is restless. B. The elevated blood pressure causes photophobia. C. Noise or bright lights may precipitate a convulsion. D. External stimuli are annoying to the client with PIH. Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: (A) The client may be anxious and hyperresponsive to stimuli but not necessarily restless. (B) This is not a physiological response to an elevated blood pressure in PIH. (C) The nurse must know the nursing measures that decrease the potential for convulsions. A quiet, darkened room decreases stimuli and promotes rest. (D) External stimuli might induce a convulsion but are not annoying to the client with PIH. QUESTION 132 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 Correct Answer: C Section: (none) Explanation Explanation/Reference: 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 133 In addition to changing the mother's position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina: A. Immediately pour sterile saline on the cord, and repeat this every 15 minutes to prevent drying. B. Cover the cord with a wet sponge. C. Apply a cord clamp to the exposed cord, and cover with a sterile towel. D. Keep the cord warm and moist by continuous applications of warm, sterile saline compresses. Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: (A) Saline should be warmed; waiting 15 minutes may not keep the cord moist. (B) This choice does not specify what the sponge was "wet" with. (C) This measure would stop circulation to the fetus. (D) The cord should be kept warm and moist to maintain fetal circulation. This measure is an accepted nursing action. QUESTION 134 Which of the following signs might indicate a complication during the labor process with vertex presentation? QUESTION 138 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 Correct Answer: D Section: (none) Explanation Explanation/Reference: 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 139 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." Correct Answer: B Section: (none) Explanation Explanation/Reference: 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 37 days. QUESTION 140 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. C. Avoid applying pressure after injection. D. Change needles after injection. Correct Answer: B Section: (none) Explanation Explanation/Reference: 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 37 days. QUESTION 141 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 Correct Answer: B Section: (none) Explanation Explanation/Reference: 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 142 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 QuestionnaireB. Goodenough Draw-a-Person Screening Test C. Denver Development Screening Test D. Caldwell Home Inventory Correct Answer: C Section: (none) Explanation Explanation/Reference: 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. QUESTION 143 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. Correct Answer: B Section: (none) Explanation Explanation/Reference: 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 144 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? QUESTION 148 A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate? A. Put in a nasogastric tube and lavage the child's stomach. B. Monitor muscular status. C. Teach mother poison prevention techniques. D. Place child on respiratory assistance. Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: (A) The immediate treatment for drug overdose is removal of the drug from the stomach by either forced emesis or gastric lavage. The child's unconscious state prohibits forced emesis. (B) Toxic amounts of salicylates directly affect the respiratory system, which could lead to respiratory failure. (C) The mother's anxiety is probably so high that preventive guidance will be ineffective. (D) Respiratory assistance is not needed if the child's respiratory function is unaltered. QUESTION 149 A parent told the public health nurse that her 6-year-old son has been taking tetracycline for a chronic skin condition. The parent asked if this could cause any problems for the child. What should the nurse explain to the parent? A. Giving tetracycline to a child younger than 8 years may cause permanent staining of his teeth. B. If you give tetracycline with milk, it may be absorbed readily. C. The medication should be given to adults, not children. D. Secondary infections of chronic skin disorders do not respond to antibiotics. Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: (A) Tetracycline should be avoided during tooth development because it interferes with enamel formation and dental pigmentation. (B) Milk interferes with the absorption of tetracyclines. (C) Children older than 9 years or past the tooth development stage may be given tetracycline. (D) Secondary infections of chronic skin disorders may respond to antibiotics such as penicillin or tetracyclines. QUESTION 150 A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation? A. Responsive to touch, wants to be held B. Uncomforted by touch, refuses bottle C. Maintains eye-to-eye contact D. Finicky eater, easily pacified, cuddly Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: (A) Normal infant attachment behaviors include responding to touch and wanting to be held. (B) Maternal deprivation behaviors include poor feeding, stiffening and refusal to eat, and inconsistencies in responsiveness. (C) Attachment behavior includes maintaining eye contact. (D) Maternal deprivation behaviors include displeasure with touch and physical contact. QUESTION 151 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." Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: (A) Solid foods introduced before 46 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 infant'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. QUESTION 152 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." 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." Correct Answer: D Section: (none) Explanation Explanation/Reference: 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 153 The nurse is preparing a 6-year-old child for an IV insertion. Which one of the following statements by the nurse is appropriate when preparing a child for a potentially painful procedure? A. "Some say this feels like a pinch or a bug bite. You tell me what it feels like." B. "This is going to hurt a lot; close your eyes and hold my hand." C. "This is a terrible procedure, so don't look." D. "This will hurt only a little; try to be a big boy." Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: (A) Educating the child about the pain may lessen anxiety. The child should be prepared for a potentially painful procedure but avoid suggesting pain. The nurse QUESTION 158 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. Correct Answer: A Section: (none) Explanation Explanation/Reference: 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 159 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 Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: (A) Clinical manifestations of acute tracheitis include a 23 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 dysphagia. (D) Clinical manifestations of acute laryngotracheobronchitis (LTB) include slow onset with a history of URI, low-grade fever, stridor, brassy cough, and irritability. QUESTION 160 The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be: A. "Blowing air under the cast using a hair dryer on cool setting often relieves itching." B. "Slide a ruler under the cast and scratch the area." C. "Guide a towel under and through the cast and moveit back and forth to relieve the itch." D. "Gently thump on cast to dislodge dried skin that causes the itching." Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: (A) Cool air will often relieve pruritus without damaging the cast or irritating the skin. (B) The nurse should never force anything under the cast, because the cast may become damaged and skin breakdown may occur. (C) Forcing an object under the cast could lead to cast damage and skin breakdown. The object may become lodged under the cast necessitating cast removal. (D) This technique does not dislodge skin cells. It could damage the cast and cause skin breakdown. QUESTION 161 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." Correct Answer: C Section: (none) Explanation Explanation/Reference: 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 162 A 26-year-old client is in a treatment center for aprazolam (Xanax) abuse and continues to manifest moderate levels of anxiety 3 weeks into the rehabilitation program, often requesting medication for "his nerves." Included in the client's plan of care is to identify alternate methods of coping with stress and anxiety other than use of medication. After intervening with assistance in stress reduction techniques, identifying feelings and past coping, the nurse evaluates the outcome as being met if: A. Client promises that he will not abuse aprazolam after discharge 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 Correct Answer: B Section: (none) Explanation Explanation/Reference: 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 163 A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by: A. Placing her in seclusion until the behavior is under control B. Walking up to the client and touching her on the arm to get her attention C. Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet area D. Confronting the client, letting her know the consequences for getting angry and disrupting the unit Correct Answer: C Section: (none) 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 Correct Answer: D Section: (none) Explanation Explanation/Reference: 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 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 168 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 Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: (A) Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. (B) Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. (C) Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. (D) Rest and activity impairment may take time and further assessment to determine client's sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present. Topic 3, Questions Set C QUESTION 169 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 Correct Answer: A Section: (none) Explanation Explanation/Reference: 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 170 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 Correct Answer: B Section: (none) Explanation Explanation/Reference: 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 171 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 Correct Answer: D Section: (none) Explanation Explanation/Reference: 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 172 A client experiencing delusions states, "I came here because there were people surrounding my house that wanted to take me away and use my body for science." The best response by the nurse would be: A. "Describe the people surrounding your house that want to take you away." B. "I need more information on why you think others want to use your body for science." C. "There were no people surrounding your house, your relatives brought you here, and no one really wants your body for science." D. "I know that must be frightening for you; let the staff know when you are having thoughts that trouble you." Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: Explanation Explanation/Reference: Explanation: (A) Approaching a client's aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). (B) Approaching a client in a challenging manner is threatening and inappropriate. A nonchallenging and calm approach reflects staff in control and may increase client's internal control. (C) It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. (D) Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention. QUESTION 177 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. Correct Answer: B Section: (none) Explanation Explanation/Reference: 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 178 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: A. March 17 B. June 3 C. August 30 D. January 10 Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: (A) Using Nägele's rule, count back 3 calendar months from the first day of the last menstrual period. The answer is March 10. Then add 7 days and 1 year, which would be March 17 of the following year. (B, C, D) This date is incorrect. QUESTION 179 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 is to: A. Reinforce an incompetent cervix B. Repair the amniotic sac C. Evaluate cephalopelvic disproportion D. Dilate the cervix Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: (A) The treatment most commonly uses the Shirodkar-Barter procedure (McDonald procedure) or cerclage to enforce the weakened cervix by encircling it with a suture at the level of the internal os. (B) There is no known procedure that is used to repair the amniotic sac. (C) Cephalopelvic disproportion is evaluated later in pregnancy. It is not related to this procedure. (D) No procedure is done to dilate the cervix at 16 weeks' gestation unless the pregnancy is to be terminated. QUESTION 180 A pregnant client continues to visit the clinic regularly during her pregnancy. During one of her visits while lying supine on the examining table, she tells the RN that she is becoming light- headed. The RN notices that the client has pallor in her face and is perspiring profusely. The first intervention the RN should initiate is to: A. Place the examining table in the Trendelenburg position B. Assess the client to see if she is having vaginal bleeding C. Obtain the client's vital signs immediately D. Help the client to a sitting position Correct Answer: D Section: (none) Explanation Explanation/Reference: 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 cava. (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 181 At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, "What is the greatest risk to my baby if it is born prematurely?" The RN's answer should be: A. Hyperglycemia B. Hypoglycemia C. Lack of development of the intestines D. Lack of development of the lungs Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: (A) Any infant would be at risk for hyperglycemia because the infant's liver is missing the islets of Langerhans, which secrete insulin to break down glucose for cellular use. Prematurity is not an added risk for hyperglycemia. (B) Both premature and mature infants can be at risk for hypoglycemia if their mother had gestational diabetes during pregnancy or entered the pregnancy with diabetes mellitus. These infants are exposed to high levels of maternal glucose while in utero, which causes the islets of Langerhans in the infant's liver to produce insulin. After birth when the umbilical cord is severed, the generous amount of maternal blood glucose is eliminated; however, there is continued islet cell hyperactivity in the infant's liver, which can lead to excessive insulin levels and depleted blood glucose. (C) Mature infants are born with an immature GI system. The nervous control of the stomach is incomplete at birth, salivary glands are immature at birth, and the intestinal tract is sterile. This is not the greatest risk to the premature infant. (D) Infants born before 37 weeks' gestation are at greatest risk for an insufficient amount of surfactant in the alveoli system of the lungs. Surfactant helps to prevent lung collapse and ensures stability of the respiratory system so that the infant Explanation/Reference: Explanation: (A) Cold is not a symptom of hyperventilation. This could be due to the temperature of the room. (B) Backache is not a symptom of hyperventilation. This is probably due to the gravid uterus and its effect on the back muscles, or it may be due to the client's position in bed. (C) Dizziness is the first symptom of hyperventilation. It occurs because the body is eliminating too much CO2. (D) Nausea is not a symptom of hyperventilation. It could be a symptom of pain. QUESTION 186 After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis? A. One centimeter below the ischial spines B. One centimeter above the ischial spines C. Has not entered the pelvic inlet yet D. Located in the pelvic outlet Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: (A) The ischial spines are located on both sides of the midpelvis. These spines mark the diameter of the narrowest part of the pelvis that the fetus will encounter. They are not sharp protrusions that will harm the fetus. Station refers to the relationship between the ischial spines in the pelvis and the fetus. The ischial spines are designated at 0 station. If the presenting part of the fetus is located above the ischial spines, a negative number is assigned, noting the number of centimeters above the ischial spines. Therefore, 1 centimeter below the ischial spines is designated as +1 station. (B) See explanation in A. One centimeter above the ischial spines is designated as +1 station. (C) The pelvic inlet is the first part of the pelvis that the fetus enters in routine delivery. The midpelvis is the second part of the pelvis to be entered by the fetus. The ischial spines are located on both sides of the midpelvis. (D) The pelvic outlet is the last part of the pelvis that the fetus will enter. When the fetus reaches this part of the pelvis, birth is near. QUESTION 187 A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client's fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process: http://www.gratisexam.com/ A. Decreases the overall time of the labor process B. Prolongs the client's first stage of labor C. Decreases the time of the client's first stage of labor D. Prolongs the client's third stage of labor Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: (A) Posterior position causes a larger diameter of the fetal head to enter the pelvis than an anterior position. Pressure on the sacral nerves is increased, and it takes the fetus a longer time to enter the pelvic inlet. (B) This position will prolong the first stage of labor. When the larger diameter of the fetal head enters the pelvis first, it will have a more difficult time accommodating to the pelvis; therefore, it will take a longer time for the fetus to move through the pelvis. (C) It will increase the time of labor because the larger diameter of the fetal head will have a more difficult time accommodating to the pelvic inlet and thus will move through the pelvis slower. (D) In the third stage of labor the placenta is delivered; therefore, the infant has been delivered. QUESTION 188 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 Correct Answer: B Section: (none) Explanation Explanation/Reference: 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 189 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. Correct Answer: A Section: (none) Explanation Explanation/Reference: 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 4560 seconds occurring every 2 minutes and a uterine tonus of 6070 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 190 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.