NCLEX RN & NCLEX PN Test Bank (Q and A) with Review Information Different Versions, Exams of Nursing

Download NCLEX RN & NCLEX PN Test Bank (Q and A) with Review Information Different Versions and more Exams Nursing in PDF only on Docsity! NCLEX RN & NCLEX PN Test Bank Question and Answers with Review Information Different Versions Question 1 A c. What document should be in guiding the care of this client? A) Client Self Determination Act B) Physician's treatment orders C) Advance Directives. D) Clinical Pathway protocols Review Information: The correct answer is: C) Advance Directives. This document specifies the client's wishes Question 2 You are the of a health care team that consists of one licensed practical/vocational nurse, one nursing assistant , a nursing student and yourself. To whom is it appropriate to assign complete care for A) Yourself B) The nursing student C) The licensed vocational nurse D) The nursing assistant Review Information: The correct answer is:A) Yourself. While the nurse may delegate a bed bath for a stable client, this care should be performed by an RN for a new admission. Only tasks that do not require independent judgment should be delegated. 3Question 3 A mother brings her the clinic, complaining that the child seems to be The nurse expects to find which of the following on t he initial history and physical assessment? A) Increased temperature and lethargy B) Rash and restlessness C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor Review Information: The correct answer is:B) Rash and restlessness. Question 4 As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? A) "The child has been listless and has lost weight." B) "Her urine is dark yellow and small in amounts." C) "Clothes are becoming tighter across her abdomen." D+) "We notice muscle weakness and some unsteadiness." Review Information: The correct answer is:C) "Clothes are becoming tighter across her abdomen.". One of the most common signs of neuroblastoma is increasing abdominal girth. The parents'' report that clothing is tight is significant, and should be followed by additional assessments. Question 5 A 16 year-old presents to the emergency department. The triage nurse finds that this teenager is legally married and signed the consent form for treatment. What would be the appropriate INITIAL action by the nurse? A) Refuse to see the client until a parent or legal guardian can be contacted B) Withhold treatment until telephone consent can be obtained from the spouse C) Refer the client to a community pediatric hospital emergency room D) Assess and treat in the same manner as any adult client Review Information: The correct answer is:D) Assess and treat in the same manner as any adult client. Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this client, who is married, has the legal capacity of an adult. Question 6 A newly admitted elderly client is severely dehydrated. When planning care for this client, which one of the following is an appropriate task for an Unlicensed Assistive Personnel (UAP)? A) Obtain a history of fluid loss The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant's a bility to perform the job and not discriminate on the basis of a disability. Employers also must make "reasonable accommodations. Question 12 The mother of a school-aged child in a long leg cast asks the nurse how to relieve itching inside the cast. Which of the following is appropriate for the nurse to suggest as a remedy? A) Scratching the outside of the cast vigorously, applying pressure over the area B) Blowing a hair dryer or heat lamp on the cast over the area that is itching C) Using a long, smooth piece of wood to gently scratch the affected area D) Applying an ice pack over the area of the cast that is affected Review Information: The correct answer is:D) Applying an ice pack over the area of the cast that is affected. Applying ice is a safe method of relieving the itching. Question 13 Which of the following BEST describes the application of time management strategies in the role of the nurse manager? A) Scheduling staff efficiently to cover client needs B) Assuming a fair share of the client care as a role model C) Setting daily goals to prioritize work D) Delegating tasks to reduce work load Review Information: The correct answer is:C) Setting daily goals to prioritize work. Time management strategies must include setting priorities and meeting goals. Question 14 The clinic nurse assesses a toddler with a tentative diagnosis of neuroblastoma. Symptoms the nurse observes that suggest this problem include A) Lymphedema and nerve palsy B) Hearing loss and ataxia C) Headaches and vomiting D) Abdominal mass and weakness Review Information: The correct answer is:D) Abdominal mass and weakness. Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline, weakness, pallor, anorexia, weight loss and irritability. Question 15 A fifteen year-old client has been placed in a Milwaukee Brace. Which one of the following statements from the client indicates the need for additional teaching? A) "I will only have to wear this for six months." B) "I should inspect my skin daily." C) "The brace will be worn day and night." D) "I can take it off when I shower." Review Information: The correct answer is:A) "I will only have to wear this for six months.". The brace must be worn long-term, usually for 1-2 years. Question 16 The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that A) Quality of care will improve B) Staff turnover should decrease C) Flexible scheduling will occur D) Team morale will improve Review Information: The correct answer is:D) Team morale will improve. Nurses are more satisfied with autonomy and control. The nurse manager becomes the facilitator of scheduling rather than the decision-maker of the schedule. Question 17 A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? A) Diffuse expiratory wheezing B) Loose, productive cough C) No relief from inhalant D) Fever and chills Review Information: The correct answer is:A) Diffuse expiratory wheezing. In asthma, the airways are narrowed - creating difficulty getting air in and a wheezing sound. Question 18 The nurse manager hears a physician loudly criticizing one of the staff nurses in the hearing of others. The employee does not respond to the physician's complaints. The nurse manager's FIRST action should be A) Walk up to the physician and quietly ask that this unacceptable behavior stop B) Allow the staff nurse to handle this situation without interference C) Notify the Nursing Director and Medical Staff Chief of a breech of professional conduct D) Request an immediate private meeting with the physician and staff nurse Review Information: The correct answer is:D) Request an immediate private meeting with the physician and staff nurse. Assertive communication respects the needs of all parties to express themselves, but not at the expense of others. The nurse manager needs first to protect clients and other staff from this display and come to the assistance of the nurse employee. Question 19 A client voluntarily admits herself to the hospital due to suicidal ideation. The client has been on the unit for two days and is now demanding to be released. The MOST appropriate action is for the nurse to A) Tell the client that she cannot be released because she is still suicidal B) Inform the client that she can be released only if she signs a no suicide contract C) Discuss with the client the decision to leave and prepare for her discharge D) Instruct her regarding her right to sign out upon receipt of the physician's discharge order Review Information: The correct answer is:C) Discuss with the client the decision to leave and prepare for her discharge. Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing the decision allows opportunity for other interventions. Question 20 A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition? A) Dyspnea B) Heart murmur C) Macular rash When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis). Question 26 As the nurse interviews the parents of a child with asthma, it is a PRIORITY to ask about A) Household pets B) New furniture C) Lead based paint D) Plants such as cactus Review Information: The correct answer is:A) Household pets. Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting and household dust. Question 27 An 80 year-old client was admitted with a diagnosis of possible cerebral vascular accident. Blood pressure has ranged from 180/110 to 160/100. Over the past several hours, the nurse noted increasing lethargy. Which of the following assessments should the nurse report IMMEDIATELY to the physician? A) Slurred speech B) Incontinence C) Muscle weakness D) Rapid pulse Review Information: The correct answer is:A) Slurred speech. Changes in speech patterns and level of conscious can be indicators of continued intercranial bleeding. Treatment options may change based on further diagnostic tests. Question 28 A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would INITIALLY assess for A) Allergies B) Hyperactivity C) Regression D) Pinworms Review Information: The correct answer is:D) Pinworms. Signs of pinworm infection include intense perianal itching, poor sleep patterns, general irritability, restlessness, bed-wetting, distractibility and short attention span. Question 29 A 72 year-old client with osteomyelitis requires a six week course of intravenous antibiotics. In planning for home care, the MOST important action by the nurse is A) Investigating the client's insurance coverage for home IV antibiotic therapy B) Determining if there are adequate hand washing facilities in the home C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver D) Selecting the appropriate venous access device Review Information: The correct answer is:C) Assessing the client''s ability to participate in self care and/or the reliability of a caregiver. The cognitive ability of the client as well as the availability and reliability of a caregiver must be assessed to determine if home care is a feasible option. Question 30 The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. The BEST response by the nurse is A) "Folic acid should be taken before and after conception." B) "Multivitamin supplements are recommended during pregnancy." C) "A well balanced diet promotes normal fetal development." D) "Increased dietary iron improves the health of mother and fetus." Review Information: The correct answer is:A) "Folic acid should be taken before and after conception.". The American Academy of Pediatrics recommends that all childbearing women increase folic acid from dietary sources and/or supplements. There is evidence that increased amounts of folic acid prevents neural tube defects. Question 31 The nurse is caring for a newborn with a neural tube defect. The BEST covering for the lesion is A) Telfa dressing with antibiotic ointment B) Moist sterile nonadherent dressing C) Dry sterile dressing D) Sterile occlusive pressure dressing Review Information: The correct answer is:B) Moist sterile nonadherent dressing. Before surgical closure the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist. Question 32 A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation , which of the following is most important to prevent lead poisoning? A) Use ready-to-feed commercial infant formula B) Boil the tap water for 10 minutes prior to preparing the formula C) Let tap water run for 2 minutes before adding to concentrate D) Buy bottled water labeled "lead free" to mix the formula Review Information: The correct answer is:C) Let tap water run for 2 minutes before adding to concentrate. Use of lead-contaminated water to prepare formula is a major source of poisoning in infants. Drinking water may be contaminated by lead from old lead pipes or lead solder used insealing water pipes. Letting tap water run for several minutes will diminish the lead contamination. Question 33 A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The MOST appropriate intervention for thi s client is A) Position client in upright position while eating B) Place client on a clear liquid diet C) Tilt head back to facilitate swallowing reflex D) Offer finger foods such as crackers or pretzels Review Information: The correct answer is:A) Position client in upright position while eating. An upright position facilitates proper chewing and swallowing. Question 34 The exhibited findings of the infant indicate a severe reaction to the immunizations. Immediate attention is needed & an ambulance with trained staff needs to transport because of the risk of grand mal seizures from potential encephalopathy which is a critical reaction. The mother would need to be instructed after this acute reaction to inform the provider of this reaction to the first dose of DTaP. Based on the need and risk involved to the infant, the health care provider may decide that further DTaP immunizations are contraindicated for life. The clinic nurse would need to document in the notes for this infant: the instructions given, findings reported by the mother and specific follow-up needs for the next clinic visit in relation to teaching and evaluation of the outcome of this event. Question 40 The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? A) Donating blood B) Using public bathrooms C) Unprotected sex D) Touching a person with AIDS Review Information: The correct answer is:C) Unprotected sex. Because HIV is spread through exposure to bodily fluids, unprotected intercourse and shared drug paraphernalia remain the highest risk for infection. Question 41 A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has short palpebral fissures, thinned upper lip, and hypoplastic philtrum of the upper lip. The mother states that the child seems to have problems in learning to count and recognizing basic colors. Based on this data, the nurse suspects that the child is MOST likely showing the effects of A) Congenital abnormalities B) Chronic toxoplasmosis C) Fetal alcohol syndrome D) Lead poisoning Review Information: The correct answer is:C) Fetal alcohol syndrome. Major features of fetal alcohol syndrome consist of facial and associated physical features, such as short palpebral fissure, hypoplastic philtrum, thinned upper lip, short, upturned nose. Behavioral problems, cognitive impairment and psychosocial deficits are also associated with this syndrome. Question 42 The nurse is performing the admission assessment of a client with an acute episode of asthma. Which of the following assessments would the nurse anticipate finding? A) Prolonged inspiration B) Expiratory wheezes C) Expectorating large amounts of purulent mucous D) Lethargy Review Information: The correct answer is:B) Expiratory wheezes. Asthma is characterized by expiratory wheezes caused by obstruction of the airways. Wheezes are a high pitched musical sounds produced by air moving through narrowed airways. Clients often associate wheezes with the feeling of tightness in the chest. Question 43 The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which of the following dinner menus would be BEST? A) Fish sticks, french fries, banana, cookies, milk B) Ground beef patty, lima beans, wheat roll, raisins, milk C) Chicken nuggets, macaroni, peas, cantaloupe, milk D) Peanut butter and jelly sandwich, apple slices, milk Review Information: The correct answer is:B) Ground beef patty, lima beans, wheat roll, raisins, milk. Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, dried fruits such as raisins. This dinner is the best choice, high in iron and is appropriate for a toddler. Question 44 A ten year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The BEST approach for the nurse to use is to A) Limit milk and milk products B) Encourage bed activities and games C) Plan nursing care around lengthy rest periods D) Promote a diet rich in iron Review Information: The correct answer is:C) Plan nursing care around lengthy rest periods. The initial priority for this client is rest due to the inability of red blood cells to carry oxygen. Question 45 The nurse planning care for a 12 year-old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include which one of the following as a PRIORITY? A) Limit fluids B) Client controlled analgesia C) Cold compresses to elbow D) Passive range of motion exercise Review Information: The correct answer is:B) Client controlled analgesia. Management of a crisis is directed towards supportive and symptomatic treatment. The priority of care is pain relief. In a 12 year-old child, client controlled analgesia promotes maximum comfort. Question 46 As the nurse provides discharge teaching to the parents of a 15 month-old child with Kawasaki Disease who has received immunoglobulin therapy, which one of the following instructions would be MOST appropriate? A) High doses of aspirin will be continued for some time B) Complete recovery is expected within several days C) Active range of motion exercises should be done frequently D) The measles, mumps and rubella vaccine should be delayed Review Information: The correct answer is:D) The measles, mumps and rubella vaccine should be delayed. Discharge instructions for a child with Kawasaki Disease should include immunoglobulin therapy may interfere with the body''s ability to form appropriate amounts of antibodies and live immunizations should be delayed. Question 47 The nurse is giving instructions to the parents of a child with Cystic Fibrosis. The nurse would emphasize that pancreatic enzymes should be taken A) Once each day B) Three times daily after meals C) With each meal or snack D) Each time carbohydrates are eaten Review Information: The correct answer is:C) With each meal or snack. Pancreatic enzymes should be taken with each meal and every snack to allow for digestion of all foods that are eaten. Question 54 The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. The nurse's BEST recommendation for the client is A) Nebulized treatments for home care B) Adding a spacer device to the MDI canister C) Asking a family member to assist the client with the MDI D) Request a visiting nurse to follow the client at home Review Information: The correct answer is:B) Adding a spacer device to the MDI canister. The majority of pulmonary medications for COPD are delivered by inhalation.This is often preferred over oral administration b ecause a lower drug dose is needed and systemic side effects are reduced. In addition, the onset of action of bronchodilator medication given via inhalation is faster. Question 55 Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? A) Scratching the head more than usual B) Flakes evident on a student's shoulders C) Oval pattern occipital hair loss D) Whitish oval specks sticking to the hair Review Information: The correct answer is:D) Whitish oval specks sticking to the hair. Diagnosis of pediculosis capitis is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment includes shampoo application, such as lindane for children over 2 years of age, and meticulous combing and removal of all nits. Question 56 When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the BEST action the nurse would suggest to the parents is A) Administer syrup of ipecac B) Offer small amounts of water C) Have the child drink milk D) Give ginger ale or cola Review Information: The correct answer is:B) Offer small amounts of water. Small amounts of water will dilute the corrosive substance prior to gastric lavage. Question 57 A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client's history indicate a potential hazard for this test? A) Reflex incontinence B) Allergic to shellfish C) Claustrophobia D) Hypertension Review Information: The correct answer is:B) Allergic to shellfish. It is important to know if the client has an allergy to iodine or shellfish. If the client does, they may have an allergic reaction to the IVP contrast dye injected during the procedure. Question 58 A high school nurse is advising a class of unwed pregnant students that the MOST important action they can perform to deliver a healthy child is A) Maintaining good nutrition B) Staying in school C) Keeping in contact with the child's father D) Getting adequate sleep Review Information: The correct answer is:A) Maintaining good nutrition. Nurses can serve a pivotal role in providing nutritional education and case management interventions. Weight gain during pregnancy is one of the strongest predictors of infant birth weight. Specifically, teens need to increase their intake of protein, vitamins, and minerals including iron. Pregnant teens who gain between 26 and 35 pounds have the lowest incidence of low-birth-weight babies. Question 59 The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which of the following should be included in the teaching materials? A) Solid foods are introduced one at a time beginning with cereal B) Finely ground meat should be started early to provide iron C) Egg white is added early to increase protein intake D) Solid foods should be mixed with formula in a bottle Review Information: The correct answer is:A) Solid foods are introduced one at a time beginning with cereal. Solid foods should be added one at a time between 4-6 months. If the infant is able to tolerate the food, another may be added in a week. Iron fortified cereal is the recommended first food. Question 60 The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion? A) Storing the packed red cells in the medicine refrigerator while starting IV B) Slow the rate of infusion if the client develops fever or chills C) Limit the infusion time of each of the unit to a maximum of four hours D) Assess vital signs every 15 minutes throughout the entire infusion Review Information: The correct answer is:C) Limit the infusion time of each of the unit to a maximum of four hours. Infuse the specified amount of blood within 4 hours. If the infusion will exceed this time, the blood should be divided into appropriately sized quantities. Question 61 A client with a documented pulmonary embolism has the following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 - 22. Based on thisdata, what is the FIRST nursing action? A) Review other lab data B) Notify the physician C) Administer oxygen D) Calm the client Review Information: The correct answer is:C) Administer oxygen. The client has a low PCO2 due to increased respiratory rate from the hypoxemia and signs of respiratory alkalosis. Immediate intervention is indicated. Question 62 A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which of the following as the MOST important data? A) Recent travel to Central America Question 68 Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment? A) An increase in appetite B) A decrease in fluid retention C) A decrease in lethargy D) A reduction in jaundice Review Information: The correct answer is:C) A decrease in lethargy. Lactulose produces and acid environment in the bowel and trapsammonia in the gut; the laxative effect then aids in removing the ammonia from the body. This decreases the effects of hepatic encephalopathy, including lethargy and confusion. Question 69 The mother of a 3 month-old infant tells the nurse that she wants to change from formula towhole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? A) Solid foods should be introduced at 3-4 months B) Whole milk is difficult for a young infant to digest C) Fluoridated tap water should be used to dilute milk D) Supplemental apple juice can be used between feedings Review Information: The correct answer is:B) Whole milk is difficult for a young infant to digest. Cow''s milk is not given to infants younger than 1 year because the tough, hard curd is difficult to digest. Also it contains little iron and creates a high renal solute load. Question 70 The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombusformation in the post-operative period? A) Estrogen replacement therapy B) 10% less than ideal body weight C) Hypersensitivity to heparin D) History of hepatitis Review Information: The correct answer is:A) Estrogen replacement therapy. Estrogen increases the hypercoagualability of the blood and increased the risk for development of thrombophlebitis. Question 71 The nurse is planning discharge for a 90 year-old client with musculo-skeletal weakness. Which of the following interventions would be MOST effective in preventing falls? A) Place nightlights in bedroom B) Wear eyeglasses at all times C) Install grab bars in the bathroom D) Teach muscle strengthening exercises Review Information: The correct answer is:A) Place nightlights in bedroom. Because more falls occur in the bedroom than any other location, begin there. However, work in partnership with the client and family so they are willing to move furniture, lamp cords, and storage areas; add lighting; remove throw rugs; and decrease ot her environmental hazards. Question 72 While obtaining the history of a two week-old infant during the well-baby exam, the nurse finds that the neonatal screening for phenylketonuria (PKU) was done when the infant was less than 24 hours-old. It is a PRIORITY for the nurse to A) Schedule the infant for a repeat test in two weeks B) Obtain a repeat blood test at this point C) Contact the hospital of birth for the results D) Document that the test results are pending Review Information: The correct answer is:B) Obtain a repeat blood test at this point. Testing for PKU is most reliable when protein has been ingested. A repeat blood specimen must be obtained by the third week of life if the initial specimen was taken from an infant less than 24 hours-old. Question 73 Two hours after the normal spontaneous vaginal delivery of a woman who is gravida 4 para 4, the nurse notes that the fundus is boggy and displaced slightly above and to the left of the umbilicus. The appropriate INITIAL nursing action is to A) Assess lochia for color and amount B) Monitor pulse and blood pressure C) Call the physician immediately D) Ask the woman to empty her bladder Review Information: The correct answer is:D) Ask the woman to empty her bladder. A full bladder can displace the uterus and prevent contraction. After the woman empties the bladder, the fundus should be assessed again. Question 74 An 8 year-old client is admitted to the hospital for surgery. The child's parent reports several allergies. Which of the following should all health care personnel be aware of? A) Shellfish B) Molds C) Balloons D) Perfumed soap Review Information: The correct answer is:C) Balloons. Allergy to balloons indicates a latex allergy. All personnel in contact with the child will need to be aware of this condition and use non-latex gloves. Question 75 The nurse is caring for a client who is post-op following a thoracotomy. The client has two chest tubes in place,connected to one chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the MOST appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Continue to monitor the client to see if the bubbling increases D) Instruct the client to try to avoid coughing Review Information: The correct answer is:C) Continue to monitor the client to see if the bubbling increases. Bubbling associated with coughing after lung surgery is to be expected as small amounts of air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only nursing action required. Question 76 B) 1 in 4 risk for each child to have the disease C) 1 in 2 chance of avoiding the trait and disease D) 1 in 2 chance that each child will have the disease Review Information: The correct answer is:B) 1 in 4 risk for each child to have the disease. Cystic Fibrosis is an autosomal recessive transmission pattern. In this situation, both parents must be carriers of the trait for the disease since neither one of them has the disease. Therefore, for each pregnancy, there is a 25% chance of the child having t he disease, 50% chance of carrying the trait and a 25% chance of having neither the trait or the disease. Question 83 A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is meas ured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do FIRST? A) Notify the physician B) Administer the prn dose of Albuterol C) Apply oxygen at 2 liters per nasal cannula D) Repeat the peak flow reading in 30 minutes Review Information: The correct answer is: B) Administer the prn dose of Albuterol. Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-to-severe persistent asthma to determine the severity of the exacerbation and to guide the treatment. A peak flow reading of less than 50% of the client''s baseline reading is a medical alert condition and a short-acting beta-agonist must be taken immediately. Question 84 What nursing observation signifies that a client has attained the stage of concrete operations (Piaget)? A) Explores his environment using sight and movement B) Can think in mental images or word pictures C) Makes the moral judgment that "stealing is wrong" D) Reasons that homework is time-consuming but necessary Review Information: The correct answer is:C) Makes the moral judgment that "stealing is wrong". The stage of concrete operations is depicted by logical thinking and moral judgments. Question 85 The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab reports should the nurse review FIRST? A) Protime (PT) and partial thromboplastin time (PTT) B) Red blood cell and white blood cell counts C) Blood urea nitrogen and creatinine clearance D) Liver enzymes (AST and ALT) Review Information: The correct answer is:D) Liver enzymes (AST and ALT). Because acetaminophen is toxic to the liver and causes hepatic cellular necrosis, liver enzymes are released into the blood s tream and serum levels of those enzymes rise. Other lab values are reviewed as well. Question 86 The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include A) Formula or breast milk B) Broth and tea C) Rice cereal and apple juice D) Gelatin and ginger ale Review Information: The correct answer is:A) Formula or breast milk. The usual diet for a young infant should be followed. Question 87 The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk because this medication A) Retards pepsin production B) Stimulates hydrochloric acid production C) Slows stomach emptying time D） Decreases production of hydrochloric acid Review Information: The correct answer is:B) Stimulates hydrochloric acid production. Decadron increases the production of hydrochloric acid, which may cause gastrointestinal ulcers. Question 88 The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to A) Assess for abdominal distention B) Maintain infant in an upright position C) Begin formula feedings when infant is alert D) Pump the shunt to assess for proper function Review Information: The correct answer is:A) Assess for abdominal distention. The child is observed for abdominal distention because cerebrospinal fluid may cause peritonitis or a postoperative ileus as a complication of distal catheter placement. Question 89 The mother of a two year-old hospitalized child asksthe nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The BEST response of the nurse would be to A) Request the mother to remain with the child at all times B) Explain that this behavior will stop with in a few days C) Help the mother understand this is a normal response to hospitalization D) Suggest that the mother "sneak out" of the child's room when he sleep Review Information: The correct answer is:C) Help the mother understand this is a normal response to hospitalization. The protest phase of separation anxiety is a normal response for a child this age. Question 90 When caring for a client receiving warfarin sodium (Coumadin), the nurse would monitor the results of the client's A) Bleeding time B) Coagulation time C) Prothrombin time D) Partial thromboplastin time Review Information: The correct answer is:C) Prothrombin time. Coumadin is ordered daily, based on the client''s prothrombin time (PT). This test evaluates the adequacy of the extrinsicsystem and common pathway in the clotting cascade; Coumadin affects the Vitamin K dependent clotting factors. Review Information: The correct answer is:C) Record the findings as "normal". Newborn infants of both sexes may have engorged breasts and may secrete milk during the first few days and weeks following birth. Question 97 A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive PRIORITY? A) Maintaining proper body alignment B) Frequent neurovascular assessments of the affected leg C) Inspection of pin sites for evidence of drainage or inflammation D) Applying an over-bed trapeze to assist the client with movement in bed Review Information: The correct answer is:B) Frequent neurovascular assessments of the affected leg. The most important activity for the nurse is to assess neurovascular status. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular problem and early intervention may prevent permanent limb damage. Question 98 The nurse is teaching a client newly diagnosed with asthma how to use the metered-dose inhaler (MDI). The client asks when they will know the canister is empty. The BEST response is A) Drop the canister in water to observe floating B) Estimate how many doses are usually in the canister C) Count the number of doses as the inhaler is used D) Shake the canister to detect any fluid movement Review Information: The correct answer is:A) Drop the canister in water to observe floating. Dropping the canister into a bowl of water assesses the amount of medications remaining in a metereddose inhaler. The client should obtain a refill when the inhaler rises to the surface and begins to tip over. Question 99 While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is MOST important f or the nurse to teach them to A) Maintain good oral hygiene and dental care B) Omit medication if the child is seizure free C) Administer acetaminophen to promote sleep D) Serve a diet that is high in iron Review Information: The correct answer is:A) Maintain good oral hygiene and dental care. Swollen and tender gums occur often with use of phenytoin. Oral hygiene and regular visits to the dentist should be emphasized. Question 100 A two year-old child has just been diagnosed with Cystic Fibrosis. The child's father asks the nurse "What are the chances that another child of ours will have Cystic Fibrosis?" Which of the following is the BEST response? A) "The probability of recurrence is unknown." B) "Cystic Fibrosis is more common in Asians." C) "Each of your children have a 25% chance of having Cystic Fibrosis." D) "The incidence of Cystic Fibrosis is approximately 1: 14,000 live births." Review Information: The correct answer is:C) "Each of your children have a 25% chance of having Cystic Fibrosis.". Cystic Fibrosis is an autosomal recessive disease. There is a 25% chance of each pregnancy of these parents resulting in a child with Cystic Fibrosis. Question 101 A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate A) Non stress test B) Abdominal ultrasound C) Pelvic exam D) X-ray of abdomen Review Information: The correct answer is:B) Abdominal ultrasound. The standard for diagnosis of placenta previa, which is suggested in the client''s history, is abdominal ultrasound. Question 102 The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate? A) Increased serum glucose B) Decreased albumin C) Decreased potassium D) Increased sodium retention Review Information: The correct answer is:C) Decreased potassium. In bulimia, loss of electrolytes can occur in addition to signs and symptoms of starvation and dehydration. Question 103 An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze FIRST? A) Potassium levels B) Blood pH C) Magnesium levels D) Blood urea nitrogen Review Information: The correct answer is:A) Potassium levels. The most common cause of digitalis toxicity is a low potassium level. Clients must be taught that it is important to have adequate potassium intake while taking diuretics. Question 104 A mother telephones the clinic and tells the nurse she is concerned because her breastfed 1 month-old has soft, yellow stoolsafter each feeding. The nurse's BEST response would be based on the knowledge that A) This type of stool is normal for breast fed infants B) The stool should have turned to light brown by now C) Formula supplements will add bulk to the stools D) Water should be offered several times each day Review Information: The correct answer is:A) This type of stool is normal for breast fed infants. D) DorsogluteaI Review Information: The correct answer is:C) Vastus lateralis. Vastus lateralis, a large and well developed muscle, is the preferred site, since it is removed from major nerves and blood vessels. Question 111 A client experienced the loss of a seven month fetus. The nurse planning for discharge should emphasize A) Discussing feelings with support persons B) Focusing on the other healthy children C) Seeking causes for the fetal death D) Planning another pregnancy very soon Review Information: The correct answer is:A) Discussing feelings with support persons. In communicating therapeutically, the nurse helps the couple begin the grief process by suggesting they seek family, friends and support groups to listen to their feelings. Question 112 The parents of a 4 year-old hospitalized child tell the nurse they will leave for a time and return at 6 PM. When the child asks when the parents will come again, the nurse can BEST respond by saying A) "They will be back right after supper." B) "In about 2 hours, you will see them." C) "After you play awhile, they will be here." D) "When the clock hands are on 6 and 12." Review Information: The correct answer is:A) "They will be back right after supper." Time is not completely understood by a 4 year-old. The child interprets time with his own frame of reference. Thus it is best to explain time in relationship to an event. Question 113 The nurse is providing instructions for a client with asthma. Which of the following should the client monitor on a daily basis? A) Respiratory rate B) Peak air flow volumes C) Pulse oximetry D) Skin color Review Information: The correct answer is:B) Peak air flow volumes. The peak airflow volume decreases about 24 hours before clinical manifestations. Question 114 Therapeutic nurse-client interaction occurs when the nurse A) Assists the client to clarify the meaning of what the client is communicating B) Interprets the client's covert communication C) Praises the client for appropriate behavior D) Advises the client on ways to resolve problems Review Information: The correct answer is:A) Assists the client to clarify the meaning of what the client is communicating. Clarification is a facilitating/therapeutic communication strategy. Approval, changing the focus/subject, and advising are non- therapeutic/barriers to communication. Question 115 A 14 month-old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see in the child? A) Hypothermia B) Edema C) Dyspnea D) Epistaxis Review Information: The correct answer is:D) Epistaxis. A large dose of aspirin inhibits prothrombin formation and lowers platelet levels. With an overdose, clotting time is prolonged. Question 116 The nurse is caring for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to groin cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees F. The FIRST assessment the nurse should perform is A) Orientation to time, place and person B) Pulse oximetry C) Circulation to casted extremity D) Blood pressure Review Information: The correct answer is:B) Pulse oximetry. Restlessness, confusion, irritability and disorientation may be the first signs of fat embolism syndrome followed by a very high temperature. The nurse needs to confirm hypoxia first. Question 117 Which nursing intervention will be MOST effective in helping a withdrawn client to develop relationship skills? A) Offer the client frequent opportunities to interact with you B) Remind the client frequently to interact with other clients C) Assist the client to analyze the meaning of her behavior D) Identify for her other clients who have similar problems Review Information: The correct answer is:A) Offer the client frequent opportunities to interact with you. The withdrawn client is uncomfortable in social interaction. The nurse client relationship is a corrective relationship in which the client learns both tolerance and skills for relationships. Question 118 The nurse is assessing a client with a stage 2 skin ulcer. Which of the following treatments is most effective to promote healing? A) Covering the wound with a dry dressing B) Using hydrogen peroxide soaks C) Leaving the area open to dry D) Applying a transparent film cover Review Information: The correct answer is:D) Applying a transparent film cover. For this type of ulcer, the most effective treatment is a transparent cover. Question 119 A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my husband will never come near me." The nurse's BEST response would be A) "You are underestimating your husband's ability to love you." B) "Are you concerned that your husband will reject you?" C) "Are you wondering about the effect on your sexual relations?" B) Impact phase C) Crisis phase D) Resolution phase Review Information: The correct answer is:B) Impact phase. The impact of crisis is indicative of high levels of stress, sense of helplessness, confusion, disorganization, and the inabi lity to apply problem solving behavior. Question 126 A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's BEST initial intervention is to A) Discuss with the mother sharing parenting responsibilities B) Help the mother to express her feelings and concerns C) Arrange for the parents to attend infant care classes D) Talk with the father and help him accept the wife's decision Review Information: The correct answer is:B) Help the mother to express her feelings and concerns. Non-judgmental support for expressed feelings may lead to resolution of competitive feelings in a new family. Cultural influences may also be revealed. Question 127 Which of the following statements made by a female client indicate to the nurse that she may have a thought disorder? A) "I'm so angry about this. Wait until my husband hears about this." B) "I'm a little confused. What time is it?" C) "I can't find my 'mesmer' shoes. Have you seen them?" D) "I'm fine. It's my daughter who has the problem." Review Information: The correct answer is:C) "I can''t find my ''mesmer'' shoes. Have you seen them?". A Neologism is a new word self invented by a person and not readily understood by another that is often associated with a thought disorder. Question 128 The nurse is aware that which of the following psychosocial needs are BEST described in the adolescent when hospitalized? A) Independence, confidence, narcissism B) Group sports, competition, being right C) Privacy, autonomy, peer interactions D) School performance, reading, journal writing Review Information: The correct answer is:C) Privacy, autonomy, peer interactions. Adolescents display the need for privacy, autonomy and peer interaction concurrent with an evolving sense of identity. Question 129 The nurse is observing a client with an obsessive-compulsive disorder in an in-patient setting. Which of the following behaviors is consistent with this diagnosis? A) Repeatedly checking that the door is locked B) Verbalized suspicions about thefts C) Preference for consistent care givers D) Repetitive, involuntary movements Review Information: The correct answer is:A) Repeatedly checking that the door is locked. Behaviors that are repeated are symptomatic of obsessive-compulsive disorders. These behaviors often interfere with normal function and employment. Question 130 A young adult seeks treatment in an out-patient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the MOST therapeutic approach by the nurse? A) Listen quietly without comment B) Ask for further information on the spies C) Confront the client on a delusion D) Contact the government agency Review Information: The correct answer is:A) Listen quietly without comment. The client''s comments demonstrate grandiose ideas. The most therapeutic response is to listen but avoid incorporation into the delusion. Question 131 The client's self-esteem is MOST damaged by the nurse's A) Anger B) Indifference C) Disapproval D) Fear Review Information: The correct answer is:B) Indifference. Positive connectedness/caring objectivity characterizes therapeutic relationships and is incongruent with indifference. Question 132 An 8 year-old client is admitted to the child mental health unit for evaluation. Following his mother's departure, the client cries and refuses his dinner. The BEST approach by the nurse is to A) Offer to play with him B) Remind him that he is expected to eat his meals C) Tell him that he will be denied privileges for uncooperative behavior D) Tell him that his mother will be upset with him if he does not cooperate Review Information: The correct answer is:A) Offer to play with him. Play is both distracting and an avenue for a child's communication. Play facilitates mastery of feelings. Question 133 A client is admitted to a psychiatric unit with delusions. The nurse can expect which of the following signs and symptoms? A) Flight of ideas and hyperactivity B) Suspiciousness and resistance to therapy C) Anorexia and hopelessness D) Panic and multiple physical complaints Review Information: The correct answer is:B) Suspiciousness and resistance to therapy. Clinical features of delusional disorder include extreme suspiciousness, jealousy, distrust, belief that others intend to harm. B) Knowledge deficit related to misunderstanding of disease state C) Defensive coping related to chronic illness D) Altered health maintenance related to occupation Review Information: The correct answer is: A) Noncompliance related to medication side effects. The client kept his appointment, and stated he knew the pills were important. He is unable to comply with the regimen due to side effects, not a lack of knowledge about his disease. Question 140 A spouse is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that A) Such fantasies can gratify unconscious wishes or prepare for anticipated future events B) Detaching or dissociating in this way postpones painful feelings C) This conversion or transferring of a mental conflict to a physical symptom can lead to marital conflict D) Isolating her feelings in this way reduces conflict Review Information: The correct answer is: A) Such fantasies can gratify unconscious wishes or prepare for anticipated future events. Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratifying unconscious wishes. Question 141 An important goal in the development of a therapeutic in-patient milieu is A) Providing a businesslike atmosphere where clients can work on individual goals B) Providing a group forum in which clients decide on unit rules, regulations, and policies C) Providing a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions D) Discouraging expressions of anger because they can be disruptive to other clients Review Information: The correct answer is: C) Providing a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions. A therapeutic milieu is purposeful and planned to provide safety and a testing ground for new patterns of behavior. Question 142 The nurse's PRIMARY intervention for a client who is experiencing a panic attack is to A) Develop a trusting relationship B) Assist the client to describe his experience in detail C) Maintain safety for the client D) Teach the client to control his or her own behavior Review Information: The correct answer is: C) Maintain safety for the client. Clients who display signs of severe anxiety need to be supervised closely until the anxiety is decreased because they may har m themselves or others. Question 143 A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove her dentures prior to leaving the unit for the operating room. The MOST appropriate intervention by the nurse is A) Explain to the client that the dentures must come out as they may get lost or broken in the operating room B) Ask the client if she is having second thoughts about the procedure C) Notify the surgeon of the client's refusal D) Ask the client if she would prefer removing the dentures in the operating room receiving area Review Information: The correct answer is: D) Ask the client if she would prefer removing the dentures in the operating room receiving area. Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client''s sense of self-esteem and self-concept. Question 144 Which of the following interventions BEST demonstrates the nurse's sensitivity to a 16 year-old's appropriate need for autonomy? A) Alertness for feelings regarding body image B) Allows young siblings to visit C) Provides opportunity to discuss concerns without presence of parents D) Explores his feelings of resentment to identify causes Review Information: The correct answer is: C) Provides opportunity to discuss concerns without presence of parents. This intervention provides the teen with the opportunity to have control and encourages decision making. Question 145 A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance and cardiac dysrhythmias. Additional assessment findings that the nurse would expect to observe are A) Brittle hair, lanugo, amenorrhea B) Diarrhea, nausea, vomiting, dental erosion C) Hyperthermia, tachycardia, increased metabolic rate D) Excessive anxiety about symptoms Review Information: The correct answer is: A) Brittle hair, lanugo, amenorrhea. Physical findings associated with anorexia are brittle hair, lanugo, and dehydration, lowered metabolic rate and vital signs. Question 146 A depressed client in an assisted living facility tells the nurse that "life isn't worth living anymore." What is the BEST response to this statement? A) "Come on, it is not that bad." B) "Have you thought about hurting yourself?" The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a researc h study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of A) Anonymity B) Beneficence C) Justice D) Autonomy Review Information: The correct answer is: D) Autonomy. Individuals must be free to make independent decisions about participation in research without coercion from others. Question 2 The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse do FIRST? A) Explain that the procedure will help him to get well B) Show a cartoon character with a blood pressure cuff C) Explain that the blood pressure checks the heart pump D) Permit handling the equipment before putting the cuff in place Review Information: The correct answer is: D) Permit handling the equipment before putting the cuff in place. The best way to gain the toddler's cooperation is to encourage handling the equipment. Detailed explanations are not helpful. Question 3 The nurse must know that the MOST accurate oxygen delivery system available is A) The venturi mask B) Nasal cannula C) Partial non-rebreather mask D) Simple face mask Review Information: The correct answer is: A) The venturi mask. The most accurate way to deliver oxygen to the client is through a venturi system such as the Venti Mask. The Venti Mask is a high flow device that entrains room air into a reservoir device on the mask and mixes the room air with 100% oxygen. The size of the opening to the reservoir determines the concentration of oxygen. The client's respiratory rate and respiratory pattern do not affect the concentration of oxygen delivered. The maximum amount of oxygen that can be delivered by this system is 55%. Question 4 The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an IMMEDIATE response from the nurse? A) Decreased breath sounds in right lower lobe B) Aspiration of a residual of 100cc of formula C) Decrease in bowel sounds D) Urine output of 250 cc in past eight hours Review Information: The correct answer is: A) Decreased breath sounds in right lower lobe. The most common problem associated with enteral feedings is atelectasis. Maintain client at 30 degrees during feedings and monitor for signs of aspiration. Check for tube placement prior to each feeding or every four to eight hours if continuous feeding. Question 5 A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). The nurse would anticipate the physician ordering A) Oral Coumadin therapy B) Heparin 5000 units subcutaneously b.i.d. C) Heparin infusion to maintain the PTT at 1.5-2.5 times the control value D) Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value Review Information: The correct answer is: D) Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value. Several studies have been conducted in pregnant women where oral anticoagulation agents are contraindicated. Warfarin (Coumadin) is known to cross the placenta and is therefore reported to be teratogenic. Question 6 Which of the following BEST describes the goal of total quality management or continuous quality improvement in a health care setting? A) Observing reactive service and product problem solving B) Improving processes in a proactive, preventive mode C) Conducting chart audits to find common errors D) Creating a flow chart to organize daily tasks Review Information: The correct answer is: B) Improving processes in a proactive, preventive mode. Total Quality Management and Continuous Quality Improvement have a major goal of identifying ways to do the right thing at the right time in the right way by proactive problemsolving. Question 7 A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which of the following interview strategies is the BEST? A) Vary the interview style for each candidate to learn different techniques B) Use simple questions requiring "yes" and "no" answers to gain definitive information C) Develop an interview guide for consistency in interviewing each candidate D) Ask personal information of each applicant to assure meeting of job demands Review Information: The correct answer is: C) Develop an interview guide for consistency in interviewing each candidate. An interview guide used for each candidate enables the nurse manager to be more objective in the decision making. Question 8 The nurse is caring for a client who has altered cerebral tissue perfusion related to a subarachnoid hemorrhage. To reduce the risk of rebleeding, the nurse should plan to A) Restrict visitors to immediate family A five year-old has been rushed to the emergency room several hours after acetaminophen poisoning. Which of the following laboratory results should receive PRIORITY attention by the nurse? A) Sedimentation rate B) Profile 2 C) Bilirubin D) Neutrophils Review Information: The correct answer is: C) Bilirubin. Bilirubin, along with liver enzymes ALT and AST, may rise in the second stage (1-3 days) after a significant overdose, indicating cellular necrosis and liver dysfunction. A prolonged prothrombin may also occur. Question 14 An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When the nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The PRIORITY nursing action is based on the understanding that A) Live vaccines are withheld in children with renal chronic illness B) The MMR vaccine should be given now, prior to the transplant C) An inactivated form of the vaccine can be given at any time D) The risk of vaccine side effects precludes giving the vaccine Review Information: The correct answer is: B) The MMR vaccine should be given now, prior to the transplant. MMR is a live virus vaccine, and should be given at this time. Post-transplant, immunosuppressive drugs will be given and the administration of the live vaccine at that time would be contraindicated becaus e of the compromised immune system. Question 15 The nurse working with clients from many different cultures recognizes that it is a PRIORITY to A) Speak another language B) Learn about all the cultures C) Refer to experts from those countries D) Recognize personal attitudes and biases Review Information: The correct answer is: D) Recognize personal attitudes and biases. The nurse must discover personal attitudes, prejudices and biases. Sensitivity to these will affect interactions with clients and families across cultures. Question 16 When teaching a client about the use of sublingual nitroglycerin, the nurse should emphasize that the MOST common side effect is A) Headache B) Dry mouth C) Depression D) Anorexia Review Information: The correct answer is: A) Headache. The most common side effect is headache, related to the generalized vasodilatation. Question 17 The nurse is planning care for an 8 year-old child. Which of the following should be included in the plan of care? A) Encourage child to engage in activities in the playroom B) Promote independence in activities of daily living C) Talk with the child and allow him to express his opinions D) Provide frequent reassurance and cuddling Review Information: The correct answer is: A) Encourage child to engage in activities in the playroom. According to Erikson, the school age child is in the stage of industry versus inferiority. To help them achieve industry, the nurse should encourage them to carry out tasks and activities in their room or in the playroom. Question 18 The nurse is preparing to administer a tube feeding to a post-operative client. To accurately assess for a gastostomy tube placement, the PRIORITY is to A) Auscultate the abdomen while instilling 10 cc of air into the tube B) Place the end of the tube in water to check for air bubbles C) Retract the tube several inches to check for resistance D) Measure the length of tubing from nose to epigastrium Review Information: The correct answer is: A) Auscultate the abdomen while instilling 10 cc of air into the tube. If a swoosh of air is heard over the abdominal cavity while instilling air into the gastric tube, this indicates that it is accurately placed in the stomach. The feeding can begin after assessing the client for bowel sounds. Question 19 You are caring for a client with Parkinson's disease who has developed hallucinations. Which of the following medications tha t the client is receiving may have been a contributing factor? A) L-Dopa B) Cogentin C) Baclofen D) Benadryl Review Information: The correct answer is: A) L-Dopa. While it is unclear whether some 1/3 of clients with Parkinson's disease have a dementia, the nurse should ask about hallucinations because the Parkinson's disease medications will cause hallucinations when they are at too high a dose. This should be asked at each client visit in home care or clinic visits. Question 20 A nurse admits a client transferred from the emergency room. The client, diagnosed with a myocardial infarction, is complaining of substernal chest pain, diaphoresis and nausea. The FIRST action by the nurse should be A) Order an EKG B) Administer pain medication as ordered C) Start an IV The cocaine abusing mother puts her newborn and other children at risk for neglect and abuse. Continuing to use drugs has the potential to impact parenting behaviors. Social service referrals are indicated. Question 26 As a part of a 9 pound newborn's assessment, the nurse performs a dextro-stick at one hour. The blood glucose level is 45 mg/dl. What FIRST action by the nurse is appropriate? A) Give oral glucose B) Notify the pediatrician C) Repeat the test in 2 hours D) Check other laboratory findings Review Information: The correct answer is: C) Repeat the test in 2 hours. This blood sugar is within the normal range for a full term newborn. Because of the birth weight, repeated blood sugars will be drawn. Question 27 A client with atrial fibrillation is receiving digoxin (Lanoxin). It is MOST important for the nurse to A) Monitor blood pressure every 4 hours B) Measure apical pulse prior to administration C) Maintain accurate intake and output records D) Record an EKG strip after administration Review Information: The correct answer is: B) Measure apical pulse prior to administration. Digitoxin decreases conduction velocity through the AV node and prolongs the refractory period. If the apical heart rate is l ess than 60 beats/minute, withhold the drug. The apical pulse should be taken with a stethoscope so that there will be no mistake about what the heart rate actually is. Question 28 A client is brought to the emergency room following a motor vehicle accident. When assessing the client one -half hour after admission, the nurse notes several physical changes. Which of the following changes would require the nurse's IMMEDIATE attention? A) Increased restlessness B) Tachycardia C) Tracheal deviation D) Tachypnea Review Information: The correct answer is: C) Tracheal deviation. The deviated trachea is a sign that a mediastinal shift has occurred. This is a medical emergency. Question 29 A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which of the following client statements from the assessment data is likely to explain his noncompliance? A) "I have problems with diarrhea." B) "I have difficulty falling asleep." C) "I have diminished sexual function." D) "I often feel jittery." Review Information: The correct answer is: C) "I have diminished sexual function." Inderal beta-blocks cells prohibiting the release of epinephrine into the cells; this may result in hypotension which results in decreased libido and impotence. Question 30 The nurse is instructing a client with moderate persistent asthma on the proper method for using MDI's (multi-dose inhalers). Which medication should be administered FIRST? A) Steroid B) Anticholinergic C) Mast cell stabilizer D) Beta agonist Review Information: The correct answer is: D) Beta agonist. The beta-agonist is taken first to open the airway. Dettenrneier, .A. (1992). Pulmonary Nursing Care. St. Louis: Mosby. Lewis, S., Collier, I., & Heitkemper, M.M. (1996). Medical-Surgical Nursing. (4th ed.). St. Louis: Mosby. Question 31 A nurse assessing the newborn of a diabetic mother understands that hypoglycemia is related to A) Disruption of fetal glucose supply B) Pancreatic insufficiency C) Maternal insulin dependency D) Reduced glycogen reserves Review Information: The correct answer is: A) Disruption of fetal glucose supply. After delivery, the high glucose levels which crossed the placenta to the fetus are suddenly stopped. The newborn continues to secrete insulin in anticipation of glucose. When oral feedings begin, the newborn will adjust insulin production within a day or two. Lowdermilk, D., Perry, S., Bobak, I. (1997). Maternal and Women's Health Care. (6th ed.). St. Louis, Mosby. Wong, D. (1999). Whaley and Wong's Nursing Care of Infants and Children. (5th ed.). Review Information: The correct answer is: B) Blood glucose levels every twelve hours. The drug Decadron increases glycogenesis. This may lead to hyperglycemia. Therefore the blood sugar level and acetone production must be monitored. Nettina, Sandra (2000). The Lippincott Manual of Nursing Practice. Philadelphia-New York: Lippincott. Skidmore-Roth, Linda. (2001). Mosby's Nursing Drug Reference 2002. St. Louis: Mosby-Year Book, Inc. Question 35 When managing a client's pain, which of the following statements BEST describes the ethical considerations of the nurse? A) The client's self-report is the most important consideration B) Cultural sensitivity is fundamental to pain management C) Clients have the right to have their pain relieved D) Nurses should not prejudge a client's pain using their own values Review Information: The correct answer is: A) The client's self-report is the most important consideration. Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is. Luckmann, Joan. (1997). Saunders Manual of Nursing Care. Philadelphia: W.B. Saunders Company. Springhouse. (1997). Diseases. (2nd ed.). Springhouse, PA: Springhouse Corporation. Question 36 The nurse is performing an assessment of the motor function in a client with a head injury. The BEST technique is A) A firm touch to the trapezius muscle or arm B) Pinching any body part C) Sternal rub D) Gentle pressure on eye orbit Review Information: The correct answer is: D) Gentle pressure on eye orbit. This is an acceptable stimuli. Urden, L., Davie, J. & Thelan, L. (1997). Essentials of Critical Care. (2nd ed.). St. Louis: Mosby-Yearbook. Barker, E. (1994). Neuro-Science Nursing. St. Louis: Mosby. Question 37 A 3 year-old child has tympanostomy tubes in place. The child's mother asks the nurse if he can swim in the family pool. The BEST response from the nurse is A) "Your child should not swim at all while the tubes are in place." B) "Your child may swim in your own pool but not in a lake or ocean." C) "Your child may swim if he wears ear plugs." D) "Your child may swim anywhere." Review Information: The correct answer is: C) "Your child may swim if he wears ear plugs.". Water should not enter the ears. Children should use ear plugs when bathing or swimming and should not put their head under the water. Ashwill, J. W. & Droske, S. C. (1997). Nursing Care of Children: Principles and Practice. Philadelphia: W. B. Saunders. Ball, J. & Bindler, R. (2000). Pediatric Nursing: Caring for Children. Norwalk: Appleton & Lange. Question 38 The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects? A) Neurotoxicity B) Hepatomegaly C) Nephrotoxicity The nurse is performing an assessment on a client with pneumococcal pneumonia. Which of the following assessments would the nurse anticipate finding? A) Bronchial breath sounds in outer lung fields B) Decreased tactile fremitus C) Hacking, nonproductive cough D) Hyperresonance of areas of consolidation Review Information: The correct answer is: A) Bronchial breath sounds in outer lung fields. Pneumonia causes a marked increase in interstitial and alveolar fluid. Consolidated lung tissue transmits bronchial breath sounds to outer lung fields. Black, J. & Matassarin-Jacobs, E. (1997). Medical-Surgical Nursing, Clinical Management for Continuity of Care. (5th ed.). Philadelphia: Saunders. Lewis, S., Collier, I., & Heitkemper, M. (1996). Medical-Surgical Nursing; Assessment and Management of Clinical Problems. (4th ed.). St. Louis: Mosby. Question 2 In providing care to a 14 year-old adolescent with scoliosis, which of the following will be MOST difficult for this client? A) Compliance with treatment regimens B) Looking different from their peers C) Lacking independence in activities D) Reliance on family for their social support Review Information: The correct answer is: B) Looking different from their peers. Conformity to peer influences peaks at around age 14. Since many persons view any disability as deviant, the client will need help in learning how to deal with reactions of others. Treatment of scoliosis is long-term and involves bracing and/or surgery. Wong, D. (1999). Whaley & Wong''s Nursing Care of Infants and Children.. St. Louis: Mosby. Ashwill, J. W. & Droske, S. C. (1997). Nursing Care of Children: Principles and Practice. Philadelphia: W. B. Saunders. Question 3 When counseling parents of a child who has recently been diagnosed with hemophilia, the nurse must know that in the offspring of a normal father and a carrier mother A) It is likely that all sons are affected B) There is a 50% probability that sons will have the disease C) Every daughter is likely to be a carrier D) There is a 25% chance a daughter will be a carrier Review Information: The correct answer is: D) There is a 25% chance a daughter will be a carrier. Hemophilia A is a sex-linked recessive traitseen almost exclusively in males. With a normal father and carrier mother, affected individuals are male. There is a 25% chance of having an affected male, 25% chance of having a carrier female, 25% chance of having a normal female and 25% chance of having a normal male. Ball, J. & Bindler, R. (2000). Pediatric Nursing: Caring for Children. Norwalk: Appleton & Lange. Wong, D. (1999). Whaley & Wong''s Nursing Care of Infants and Children.. St. Louis: Mosby. Question 4 A three year-old child is treated in the emergency room after ingesting an ounce of a liquid narcotic. What FIRST action should the nurse take? A) Provide humidified oxygen B) Suction mouth and nose C) Assess airway and circulation D) Start intravenous fluids Review Information: The correct answer is: C) Assess airway and circulation. The first step in treatment of a toxic exposure or ingestion is to assess the airway, breathing and circulation; then stabilize the client. Other nursing actions will follow. Wong, D. (1999). Whaley & Wong''s Nursing Care of Infants and Children.. St. Louis: Mosby. Ashwill, J. W. & Droske, S. C. (1997). Nursing Care of Children: Principles and Practice. Philadelphia: W. B. Saunders. National Institutes of Health. Springhouse. (1998). Nursing 98 Drug Handbook Question 8 The nurse measures the head and chest circumferences of a 20 month-old infant. After comparing the measurements, the nurse finds that they are approximately the same. The appropriate action for the nurse to take would be to A) Notify the physician B) Palpate the anterior fontanel C) Feel the posterior fontanel D) Record these normal findings Review Information: The correct answer is: D) Record these normal findings. The rate of increase in head circumference slows by the end of infancy, and the head circumference is usually equal to chest circumference at 1 to 2 years of age. Wong, D. (1999). Whaley & Wong''s Nursing Care of Infants and Children.. St. Louis: Mosby. Ashwill, J. W. & Droske, S. C. (1997). Nursing Care of Children: Principles and Practice. Philadelphia: W. B. Saunders. Question 9 A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse informs the child and family that the MOST important reason for this diet is to A) Promote healing and strengthen the immune system B) Provide a well balanced nutritional intake C) Stimulate increased peristalsis absorption D) Spare protein catabolism to meet metabolic needs Review Information: The correct answer is: D) Spare protein catabolism to meet metabolic needs. Because of the burn injury, the child has increased metabolism and catabolism. By providing a high carbohydrate diet, the breakdown of protein for energy is avoided. Proteins are then used to restore tissue. Betz, C., Hunsberger, M. & Wright, S. (1994). Family-Centered Nursing Care of Children. (2nd ed.). Philadelphia: Saunders. Wong, D. (1999). Whaley & Wong''s Nursing Care of Infants and Children.. St. Louis: Mosby. Question 10 The nurse prepares to give a one year-old child an intramuscular injection. The BEST site for this injection would be in the A) Deltoid muscle B) Ventrogluteal muscle C) Dorsogluteal muscle D) Vastus lateralis muscle Review Information: The correct answer is: D) Vastus lateralis muscle. The preferred site for an injection for an infant is the vastus lateralis muscle which lies along the lateral aspect of the thigh. This site is able to tolerate larger volumes, and it is not located near any nerves or blood vessels. Ashwill, J. W. & Droske, S. C. (1997). Nursing Care of Children: Principles and Practice. Philadelphia: W. B. Saunders. Ball, J. & Bindler, R. (2000). Pediatric Nursing: Caring for Children. Norwalk: Appleton & Lange. Question 11 A client is unconscious following a tonic-clonic seizure. What should the nurse do FIRST? A) Check the pulse B) Administer Valium C) Place the client in a side-lying position D) Place a tongue blade in the mouth Review Information: The correct answer is: C) Place the client in a side-lying position. Place the client in a side-lying position to maintain an open airway, drain secretions, and prevent aspiration if vomiting occurs. JAMA. (1992). Textbook of ACLS. (4th ed.). JAMA. Black, J. & Matassarin-Jacobs, E. (1997). Nursing Care of Children: Principles and Practice. Philadelphia: W. B. Saunders. Ball, J. & Bindler, R. (2000). Pediatric Nursing: Caring for Children. Norwalk: Appleton & Lange. Question 15 The nurse is caring for a newborn who has just been diagnosed with hypospadias. After discussing the defect with the parents, the nurse should expect that A) Circumcision can be performed at any time B) Initial repair is delayed until ages 6-8 C) Post-operative appearance will be normal D) Surgery will be performed in stages Review Information: The correct answer is: D) Surgery will be performed in stages. Hypospadias, a condition in which the urethral opening is located on the ventral surface or below the penis, is corrected in stages as soon as the infant can tolerate surgery. Wong, D. (1999). Whaley & Wong''s Nursing Care of Infants and Children.. St. Louis: Mosby. Ball, J. & Bindler, R. (2000). Pediatric Nursing: Caring for Children. Norwalk: Appleton & Lange. Question 16 One reason that domestic violence remains extensively undetected is A) Few battered victims seek medical care B) As few as one in twenty battered victims are accurately identified C) Expenses due to police and court costs D) Very little knowledge is currently known about batterers and battering relationships Review Information: The correct answer is: B) As few as one in twenty battered victims are accurately identified. Signs of abuse may not be clearly manifested and a series a minor complaints such as headache, abdominal pain, insomnia, back pain, and dizziness may be covert indications of abuse undetected. Complaints may be vague. Fontaine, K. & Fletcher, J. (1998). Essentials of Mental Health Nursing. Menlo Park, CA: Addison- Wesley. Varcarolis, E. (1998). Foundations of Psychiatric Mental Health Nursing. Philadelphia: W.B. Saunders. Question 17 The nurse is caring for a client with COPD who suddenly complains of sharp pains in the right side of his chest, is cyanotic and has a tracheal deviation toward the right side. The nurse recognizes that these symptoms are probably due to A) Atelectasis B) Respiratory acidosis C) Tension pneumothorax D) Bronchospasm Review Information: The correct answer is: C) Tension pneumothorax. Tracheal deviation is away from the affected side in tension pneumothorax. This situation also produces air hunger, agitation, hypotension, and cyanosis. Nettina, Sandra (2000). The Lippincott Manual of Nursing Practice. Philadelphia-New York: Lippincott. Luckmann, Joan. (1997). Saunders Manual of Nursing Care. Philadelphia: W.B.Saunders Company. Question 18 An anxious parent of a 4 year-old consults the nurse for guidance in how to answer the child's question, "Where do babies come from?" What is the BEST response to the parent? A) "When a child asks a question, give a simple answer." B) "Children ask many questions, but are not looking for answers." C) "This question indicates interest in sex beyond this age." D) "Full and detailed answers should be given to all questions." Review Information: The correct answer is: A) "When a child asks a question, give a simple answer.". During discussions related to sexuality, honesty is very important. However, honesty does not mean imparting every fact of li fe associated with the question. When children ask one question, they are looking for one answer. When they are ready , they will ask about the other pieces. Wong, D. (1999). Review Information: The correct answer is: C) Reddened tissue. As the wound granulates, redness indicates healing. Beuscher, T. (1997). Wound Care. In Martin, K., Larson, B., Gorski, L. & Hayko, D. Mosby''s Home Health Client Teaching Guides: Rx for Teaching, IV F 2, 1-6. St. Louis: Mosby. Troia, C. & Black, J. (1997). Preventing Pressure Ulcers. In Martin, K., Larson, B., Gorski, L., & Hayko, D. Mosby''s Home Health Client Teaching Guides: Rx for Teaching, IV F 1, 1-6. St. Louis: Mosby. Question 22 Clients taking which of the following drugs are at risk for depression? A) Steroids B) Diuretics C) Folic acid D) Aspirin Review Information: The correct answer is: A) Steroids. Adverse medication effects can cause a syndrome that may or may not remit when the medication is discontinued. Examples include: phenothiazines, steroids, and reserpine. Shives, L. (1998). Basic Concepts of Psychiatric-Mental Health Nursing. New York: J.B. Lippincott Co. Varcarolis, E. (1998). Foundations of Psychiatric Mental Health Nursing. Philadelphia: W.B. Saunders. Question 23 The nurse is assessing a 4 year-old for possible developmental dysplasia of the right hip. Which of the following would the nurse expect to find? A) Pelvic tip downward B) Right leg lengthening C) Ortolani sign D) Characteristic limp Review Information: The correct answer is: D) Characteristic limp. Developmental dysplasia produces a characteristic limp in children who are walking. Wong, D. (1999). Whaley & Wong''s Nursing Care of Infants and Children.. St. Louis: Mosby. Ashwill, J. W. & Droske, S. C. (1997). Nursing Care of Children: Principles and Practice. Philadelphia: W. B. Saunders. Question 24 A client was admitted to the psychiatric unit after refusing to get out of bed. In the hospital the client talks to unseen people and voids on the floor. The nurse could BEST handle the problem of voiding on the floor by A) Requiring the client to mop the floor B) Restricting the client's fluids throughout the day C) Withholding privileges each time the voiding occurs D) Toileting the client more frequently with supervision Review Information: The correct answer is: D) Toileting the client more frequently with supervision. With altered thought processes the most appropriate nursing approach to alter the behavior is by attending to the physical need. Gorman, L., Sulton D. & Rainer, M. (1996). Davis's Manual of Psychosocial Nursing for General client Care. Philadelphia: F.A. Davis. Fortinash, K. & Holoday-Worret, P. (1995). Psychiatric Nursing Care Plan. St. Louis: C.V. Mosby. Question 25 At a routine clinic visit, parents express concern that their four year-old is wetting the bed several times a month. What is the nurse's BEST response? A) "This is normal at this time." B) "How long has this been occurring?" C) "Do you offer fluids at night?" D) "Have you tried waking her to urinate?" Review Information: The correct answer is: B) "How long has this been occurring?". Nighttime control should be present by this age, but may not occur until age 5. Involuntary voiding may occur due to infectious, anatomical and/or physiological reasons. A) Participative or democratic B) Ultraliberal or communicative C) Autocratic or authoritarian D) Laissez faire or permissive Review Information: The correct answer is: C) Autocratic or authoritarian. Autocratic leadership style is suggested in this situation. It is appropriate for groups with little education and experience and who need strong direction, while participative or democratic style is usually more successful on nursing units. Huber, D. (2000). Leadership and Nursing Care Management. Philadelphia: Saunders. Douglass, L. (1996). The Effective Nurse Leader and Manager. (5th ed.). St. Louis: Mosby. Question 29 The nurse is assessing a client with delayed wound healing. Which of the following risk factors is MOST important in this situation? A) Glucose level of 120 B) History of myocardial infarction C) Long term steroid usage D) Diet high in carbohydrates Review Information: The correct answer is: C) Long term steroid usage. Steroid dependency tends to delay wound healing. If the client also smokes, the risk is increased. Black, J. & Matassarin-Jacobs, E. (1997). Medical-Surgical Nursing, Clinical Management for Continuity of Care. (5th ed.). Philadelphia: Saunders. Troia, C. & Black, J. (1997). Preventing Pressure Ulcers. In Martin, K., Larson, B., Gorski, L., & Hayko, D. Mosby''s Home Health Client Teaching Guides: Rx for Teaching, IV F 1, 1-6. St. Louis: Mosby. Question 30 The nurse is caring for a client who is experiencing a seizure. Which of the following is a PRIORITY nursing action? A) Protect the client from injury B) Restrain the client during the seizure C) Insert a tongue blade between the teeth D) Suction the mouth during the convulsion Review Information: The correct answer is: A) Protect the client from injury. It is a priority to note, and then record, what movements are seen during a seizure because the diagnosis and subsequent treatment often rests solely on the seizure description. Wong, D. (1999). Whaley & Wong''s Nursing Care of Infants and Children.. St. Louis: Mosby. Ashwill, J. W. & Droske, S. C. (1997). Nursing Care of Children: Principles and Practice. Philadelphia: W. B. Saunders. Question 31 The nurse is caring for a client with HIV infection who has a secondary Herpes Simplex 1 (HSV 1) infection. The nurse knows t hat the most likely cause of the HSV 1 infection is A) Immunosuppression caused by the HIV infection B) Emotional stress caused by the HIV infection C) Reaction to the HIV medications D) Poor oral hygiene often associated with HIV Review Information: The correct answer is: A) Immunosuppression caused by the HIV infection. The decreased immunity leads to frequent secondary infections. Herpes simplex virus 1 is an opportunistic infection. Black, J. & Matassarin-Jacobs, E. (1997). Medical-Surgical Nursing, Clinical Management for Continuity of Care. (5th ed.). Philadelphia: Saunders. Potter, P. & Perry, A. (2000). Fundamentals of Nursing: Concepts, Process and Practice. St. Louis Question 32 Which of the following therapeutic communication skills is MOST likely to encourage a depressed client to vent feelings? A) Direct confrontation