NCLEX_RN V12.35 EXAM QUESTIONS WITH ANSWERS TESTED AND VERIFIED COMPLETE SOLUTIONS, Exams of Nursing

Download NCLEX_RN V12.35 EXAM QUESTIONS WITH ANSWERS TESTED AND VERIFIED COMPLETE SOLUTIONS and more Exams Nursing in PDF only on Docsity! 1 NCLEX_RN V12.35 EXAM QUESTIONS WITH ANSWERS TESTED AND VERIFIED COMPLETE SOLUTIONS NO.1 A depressed client is seen at the mental health center for follow-up after an attempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that the drug must accumulate to an effective level before symptoms are totally relieved. Symptom relief is expected to occur within: A. 10 days B. 2-4 weeks C. 2 months D. 3 months Answer: B Explanation: (A) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. (B) This answer is correct. Because MAO inhibitors are slow to act, it takes 2-4 weeks before improvement of symptoms is noted. (C) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. (D) This answer is incorrect. Therapeutic effects of the medication are noted within 1 month of drug therapy. NO.2 Cystic fibrosis is transmitted as an autosomal recessive trait. This means that: A. Mothers carry the gene and pass it to their sons B. Fathers carry the gene and pass it to their daughters C. Both parents must have the disease for a child to have the disease D. Both parents must be carriers for a child to have the disease Answer: D Explanation: (A) Cystic fibrosis is not an X-linked or sex-linked disease. (B) The only characteristic on the Y chromosome is the trait for hairy ears. (C) Both parents do not need to have the disease but must be carriers. (D) If a trait is recessive, two genes (one from each parent) are necessary to produce an affected child. NO.3 A 24-year-old client presents to the emergency department protesting "I am God." The nurse identifies this as a: A. Delusion B. Illusion C. Hallucination D. Conversion Answer: A 2 Explanation: (A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations. NO.4 In acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe? A. Diazepam (Valium) B. Haloperidol (Haldol) C. Sertraline (Zoloft) D. Alprazolam (Xanax) Answer: B Explanation: (A) Diazepam is an antianxiety medication and is not designed to reduce psychotic symptoms. (B) Haloperidol is an antipsychotic medication and may be used until the lithium takes effect. (C) Sertraline is an antidepressant and is used primarily to reduce symptoms of depression. (D) Alprazolam is an antianxiety medication and is not designed to reduce psychotic symptoms. NO.5 A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints? A. Give fluids if the client requests them. B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed. C. Measure vital signs at least every 4 hours. D. Release restraints every 2 hours for client to exercise. Answer: D Explanation: (A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are applied and after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2 hours. (D) Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation. NO.6 The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child? A. Administer oral griseofulvin on an empty stomach for best results. B. Discontinue drug therapy if food tastes funny. C. May discontinue medication when the child experiences symptomatic relief. D. Observe for headaches, dizziness, and anorexia. C. Locate the position of the placenta and fetus amniocentesisPrior last menstrual period began May 20 Nagele's rule C. February 27 subtract 3 months add 7 days D. Gestational diabetes mellitus she only shows signs of diabetes when she is pregnant 5 A. Evaluate fetal lung maturity B. Evaluate the amount of amniotic fluid D. Ensure that the fetus is mature enough to perform the amniocentesis Answer: C Explanation: (A) Amniocentesis can be performed to assess for lung maturity. Fetal ultrasound can be used for gestational dating, although it does not separately determine lung maturity. (B) Ultrasound can evaluate amniotic fluid volume, which may be used to determine congenital anomalies. (C) Amniocentesis involves removal of amniotic fluid for evaluation. The needle, inserted through the abdomen, is guided by ultrasound to avoid needle injuries, and the test evaluates the position of the placenta and the fetus. (D) Amniocentesis can be performed as early as the 15th-17th week of pregnancy. NO.13 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 , and her estimated date of confinement using is: A. March 27 B. February 1 D. January 3 Answer: C 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, from the date that the last menstrual cycle began and then to the result. (D) January 3 is a miscalculation. NO.14 A client is now pregnant for the second time. Her first child weighed 4536 g at delivery. The client's glucose tolerance test shows elevated blood sugar levels. Because , she is classified as having: A. Insulin-dependent diabetes B. Type II diabetes mellitus C. Type I diabetes mellitus Answer: D Explanation: (A) Insulin-dependent diabetes mellitus, also known as type I diabetes, usually appears before the age of 30 years with an abrupt onset of symptoms requiring insulin for management. It is not related to onset during pregnancy. (B) Non-insulin-dependent diabetes (type II diabetes) usually appears in older adults. It has a slow onset and progression of symptoms. (C) This type of diabetes is the same as insulin-dependent diabetes. (D) Gestational diabetes mellitus has its onset of symptoms during pregnancy and usually disappears after delivery. These symptoms are usually mild and not life external radiation to her scapula for metastasis of 6 threatening, although they are associated with increased fetal morbidity and other fetal complications. NO.15 A 44-year-old female client is receiving D. Encourage her to avoid direct sunlight on the area being treated. breast cancer 4th-day postoperative cholecystectomy A. Vitamin C B. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision 10-year-old client with a pin in the right femur is immobilized in traction behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony nursing implementations most 7 . Teaching related to skin care for the client would include which of the following? A. Teach her to completely clean the skin to remove all ointments and markings after each treatment . B. Teach her to cover broken skin in the treated area with a medicated ointment. C. Encourage her to wear a tight-fitting vest to support her scapula. Answer: D Explanation: (A) The skin in a treatment area should be rinsed with water and patted dry. Markings should be left intact, and the skin should not be scrubbed. (B) Clients should avoid putting any creams or lotions on the treated area. This could interfere with treatment. (C) Radiation therapy clients should wear loose- fitting clothes and avoid tight, irritating fabrics. (D) The area of skin being treated is sensitive to sunlight, and the client should take care to prevent sun damage by avoiding direct sunlight and covering the area when she is in the sun. NO.16 The nurse is assisting a client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing? B. Vitamin B1 C. Vitamin D D. Vitamin A Answer: A Explanation: (A) Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. (B) Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning of nervous tissue. (C) Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. (D) Vitamin A is necessary for the formation and maintenance of skin and mucous membranes. It is also essential for normal growth and development of bones and teeth. NO.17 A . He is exhibiting . Which of the following helping him cope with immobility? would be effective in A. Providing him with books, challenging puzzles, and games as diversionary activities C. Having a volunteer come in to sit with the client and to read him stories D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's position frequently Answer: B D. Wear a patch over one eye diplopia B. Level of consciousness A. Urine output 10 family privacy in their grief. (D) The family's wish to conduct a religious ceremony in the client's room is part of the grief process. The request is based on specific cultural and religious differences dictating social customs. NO.23 A woman diagnosed with multiple sclerosis is disturbed with to: A. Limit activities which require focusing (close vision) B. Take more frequent naps C. Use artificial tears . The nurse will teach her Answer: D Explanation: (A) Limiting activities requiring close vision will not alleviate the discomfort of double vision. (B) Frequent naps may be comforting, but they will not prevent double vision. (C) Artificial tears are necessary in the absence of a corneal reflex, but they have no effect on diplopia. (D) An eye patch over either eye will eliminate the effects of double vision during the time the eye patch is worn. An eye patch is safe for a person with an intact corneal reflex. NO.24 One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is: A. Blood pressure C. Skin turgor D. Fluid intake Answer: B Explanation: (A) Blood pressure can remain normotensive in a state of hypovolemia. (B) Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. (C) Skin turgor is not a reliable indicator for assessing hydration in a burn client. (D) Fluid intake does not indicate adequacy of fluid resuscitation in a burn client. NO.25 Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to 25% of her body? B. Edema C. Hypertension D. Bulging fontanelle C. Headache and facial flushing D. Phenytoin (Dilantin) C. Administer the morning lithium dose as scheduled 11 Answer: A Explanation: (A) Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid resuscitation is adequate. IV fluids are adjusted based on the urinary output of the child during fluid resuscitation. (B) Edema is an indication of increased capillary permeability following a burn injury. (C) Hypertension is an indicator of fluid volume excess. (D) Fontanelles close by 18 months of age. NO.26 A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report: A. Dizziness and tachypnea B. Circumoral pallor and lightheadedness D. Pallor and itching of the face and neck Answer: C Explanation: (A) Tachypnea is not a symptom. (B) Circumoral pallor is not a symptom. (C) Autonomic dysreflexia is an uninhibited and exaggerated reflex of the autonomic nervous system to stimulation, which results in vasoconstriction and elevated blood pressure. (D) Pallor and itching are not symptoms. NO.27 A client states to his nurse that "I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells." Based on this information, which drug might the nurse expect to be discontinued? A. Prednisone B. Timolol maleate (Blocadren) C. Garamycin (Gentamicin) Answer: D Explanation: (A) Prednisone is not linked with hematological side effects. (B) Timolol, a -adrenergic blocker is metabolized by the liver. It has not been linked to blood dyscrasia. (C) Gentamicin is ototoxic and nephrotoxic. (D) Phenytoin usage has been linked to blood dyscrasias such as aplastic anemia. The drug most commonly linked to aplastic anemia is chloramphenicol (Chlormycetin). NO.28 A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should: A. Notify the physician immediately B. Hold the morning lithium dose and continue to observe the client D. Obtain an order for benztropine (Cogentin) Answer: C Explanation: (A) There is no need to phone the physician because the lithium level is within therapeutic range and A. Maintaining an adequate level of hydration D. "You've been feeling sad and alone for some time now?" client's feelings 12 because there are no indications of toxicity present. (B) There is no reason to withhold the lithium because the blood level is within therapeutic range. Also, it is necessary to give the medication as scheduled to maintain adequate blood levels. (C) The lab results indicate that the client's lithium level is within therapeutic range (0.2-1.4 mEq/L), so the medication should be given as ordered. (D) Benztropine is an antiparkinsonism drug frequently given to counteractextrapyramidal symptoms associated with the administration of antipsychotic drugs (not lithium). NO.29 The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward: B. Providing pain relief C. Preventing infection D. O2 therapy Answer: A Explanation: (A) Maintaining the hydration level is the focus for nursing intervention because dehydration enhances the sickling process. Both oral and parenteral fluids are used. (B) The pain is a result of the sickling process. Analgesics or narcotics will be used for symptom relief, but the underlying cause of the pain will be resolved with hydration. (C) Serious bacterial infections may result owing to splenic dysfunction. This is true at all times, not just during the acute period of a crisis. (D) O2 therapy is used for symptomatic relief of the hypoxia resulting from the sickling process. Hydration is the primary intervention to alleviate the dehydration that enhances the sickling process. NO.30 Three weeks following discharge, a male client is readmitted to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse admits him to the unit, he says, "I wish I were dead because I am worthless to everyone; I guess I am just no good." Which response by the nurse is most appropriate at this time? A. "I don't think you are worthless. I'm glad to see you, and we will help you." B. "Don't you think this is a sign of your illness?" C. "I know with your wife and new baby that you do have a lot to live for." Answer: D Explanation: (A) This response does not acknowledge the client's feelings. (B) This is a closed question and does not encourage communication. (C) This response negates the and does not require a response from the client. (D) This acknowledges the client's implied thoughts and feelings and encourages a response. NO.31 A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. B. Provide time for play and becoming acquainted. D. Diminished or absent femoral pulses D. Urine retention or a distended bladder 15 health maintenance. (C) This statement reflects lack of insight into the importance of compliance. (D) This statement reflects no insight into his illness or his responsibility in health maintenance. NO.36 A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful? A. Examine the 4 year old first. C. Have the mother leave the room with one child, and examine the other child privately. D. Examine painful areas first to get them "over with." Answer: B Explanation: (A) The 6 month old should be examined first. If several children will be examined, begin with the most cooperative and less anxious child to provide modeling. (B) Providing time for play and getting acquainted minimizes stress and anxiety associated with assessment of body parts. (C) Children generally cooperate best when their mother remains with them. (D) Painful areas are best examined last and will permit maximum accuracy of assessment. NO.37 Diagnostic assessment findings for an infant with possible coarctation of the aorta would include: A. A third heart sound B. A diastolic murmur C. Pulse pressure difference between the upper extremities Answer: D Explanation: (A) S1 and S2 in an infant with coarctation of the aorta are usually normal. S3 and S4 do not exist with this diagnosis. (B) Either no murmur will be heard or a systolic murmur from an associated cardiac defect will be heard along the left upper sternal border. A diastolic murmur is not associated with coarctation of the aorta. (C) Pulse pressure differences of>20 mm Hg exist between the upper extremities and the lower extremities. It is important to evaluate the upper and lower extremities with the appropriate- sized cuffs. (D) Femoral and pedal pulses will be diminished or absent in infants with coarctation of the aorta. NO.38 During a client's first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus. This may be due to: A. Endometritis B. Fibroid tumor on the uterus C. Displacement due to bowel distention Answer: D A. A family member who is having marital problems and is regularly abusing alcohol C. Complaints of shortness of breath immediate further evaluation Guillain- Barre syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. emotional problems 16 Explanation: (A, B) Endometritis, urine retention, or bladder distention provide good distractors because they may delay involution but do not usually cause the uterus to be lateral. (C) Bowel distention and constipation are common in the postpartum period but do not displace the uterus laterally. (D) Urine retention or bladder distention commonly displaces the uterus to the right and may delay involution. NO.39 An 80-year-old widow is living with her son and daughter- in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin time test. The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following are signs of persons who are at risk for abusing an elderly person? B. A person with adequate communication and coping skills who is employed by the family C. A friend of the family who wants to help but is minimally competent D. A lifelong friend of the client who is often confused Answer: A Explanation: (A) This answer is correct. Two risk factors are identified in this answer. (B) This answer is incorrect. Persons at risk tend to lack communication skills and effective coping patterns. (C) This answer is incorrect. Persons at risk are usually family members or those reluctant to provide care. (D) This answer is incorrect. This individual has a vested interest in providing care. NO.40 A 32-year-old female client is being treated for would indicate a need for A. Complaints of a headache When conducting a nursing assessment, which finding ? B. Loss of superficial and deep tendon reflexes D. Facial paralysis Answer: C Explanation: (A) Headaches are not associated with Guillain-Barre syndrome. (B) Loss of superficial and deep tendon reflexes is expected with this diagnosis. (C) Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complication of this syndrome. (D) Facial paralysis is expected and is not considered abnormal. NO.41 Plans for the care of a client with an ulcer caused by consideration that: A. His priority needs are limited to medical management need to take into C. The disorder is a threat to his physical well-being B. "Large amounts of salt in your diet can cause you to retain fluid, which increases your blood C. "Six to 10 treatments are common. Are you concerned about permanent effects?" 17 B. There is no real psychological basis for his illness D. He is unable to participate in planning his care Answer: C Explanation: (A) There may be a medical emergency that takes top priority; however, the basis of the problem is emotional. (B) The problem is a physical manifestation of an emotional conflict. (C) The bleeding ulcer can be life threatening. (D) For lifestyle change to occur, the client must participate in the planning of his care so that he is committed to changes that will have positive results. NO.42 A 55-year-old man has recently been diagnosed with hypertension. His physician orders a low- sodium diet for him. When he asks, "What does salt have to do with high blood pressure?'' the nurse's initial response would be: A. "The reason is not known why hypertension is associated with a high-salt diet." pressure." C. "Salt affects your blood vessels and causes your blood pressure to be high." D. "Salt is needed to maintain blood pressure, but too much causes hypertension." Answer: B Explanation: (A) This response is untrue. (B) Decreasing salt intake reduces fluid retention and decreases blood pressure. (C) Salt does not have an effect on the blood vessels themselves, but on fluid retention, which accompanies salt intake. (D) This response is untrue. NO.43 A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2- week period. Her husband asks, "Isn't that a lot?" The nurse's best response is: A. "Yes, that does seem like a lot." B. "You'll have to talk to the doctor about that. The physician knows what's best for the client." D. "Don't worry. Some clients have lots more than that." Answer: C Explanation: (A) This response indicates that the nurse is unsure of herself and not knowledgeable about ECT. It also reinforces the husband's fears. (B) This response is "passing the buck" unnecessarily. The information needed to appropriately answer the husband's question is well within the nurse's knowledge base. (C) The most common range for affective disorders is 6-10 treatments. This response confirms and reinforces the physician's plan for treatment. It also opens communicationwith the husband to identify underlying fears and knowledge deficits. (D) This response offers false reassurance and dismisses the husband's underlying concerns about his wife. A. Have the client void before the procedure. A. "I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner." B. Orthopneic 20 late sign of increased intracranial pressure. (C) Headache is a very early symptom of increased intracranial pressure in the child. (D) Ataxia is a late sign of increased intracranial pressure. NO.50 Which nursing implication is appropriate for a client undergoing a paracentesis? B. Keep the client NPO. C. Observe the client for hypertension following the procedure. D. Place the client on the right side following the procedure. Answer: A Explanation: (A) A full bladder would impede withdrawal of ascitic fluid. (B) Keeping the client NPO is not necessary. (C) The client may exhibit signs and symptoms of shock and hypertension. (D) No position change is needed after the procedure. NO.51 A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, "The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart." The nurse's best response is: B. "You'll probably see strange things for a while until the PCP wears off." C. "Try to sleep. When you wake up, the devil will be gone." D. "You're probably feeling guilty because you used illegal drugs tonight." Answer: A Explanation: (A) The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality. (B) Although this statement may be literally correct, it is nontherapeutic because it lacks validation. (C) This response encourages the client to attempt to do something that may be impossible at this time, offers false reassurance, and reinforces delusional content. (D) The nurse is making an incorrect assumption about the client's feelings by offering a nontherapeutic interpretation of the motivation for the client's actions. NO.52 To facilitate maximum air exchange, the nurse should position the client in: A. High Fowler C. Prone D. Flat-supine Answer: B Explanation: (A) The high Fowler position does increase air exchange, but not to the extent of orthopneic position. (B) The orthopneic position is a sitting position that allows maximum lung expansion. (C) The prone position places pressure on diaphragm and does not promote maximum air exchange. (D) The flat- supine position places pressure on diaphragm by abdominal organs and does not promote maximum D. Serum potassium is low. The nurse should administer KCl as ordered. A. Validate that he is not allergic to iodine or shellfish. transurethral resection of the prostate yesterday small amount of blood that is still in his urine 21 air exchange. NO.53 A 48-year-old client is in the surgical intensive care unit after having had three-vessel coronary artery bypass surgery yesterday. She is extubated, awake, alert and talking. She is receiving digitalis for atrial arrhythmias. This morning serum electrolytes were drawn. Which abnormality would require immediate intervention by the nurse after contacting the physician? A. Serum osmolality is elevated indicating hemoconcentration. The nurse should increase IV fluid rate. B. Serum sodium is low. The nurse should change IV fluids to normal saline. C. Blood urea nitrogen is subnormal. The nurse should increase the protein in the client's diet as soon as possible. Answer: D Explanation: (A) An elevated serum osmolality poses no immediate danger and is not corrected rapidly. (B) A low serum sodium alone does not warrant changing IV fluids to normal saline. Other assessment parameters, such as hydration status, must be considered. (C) A low serum blood urea nitrogen is not necessarily indicative of protein deprivation. It may also be the result of overhydration. (D)A low serum potassium potentiates the effects of digitalis, predisposing the client to dangerous arrhythmias. It must be corrected immediately. NO.54 A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure? B. Instruct him to start active range of motion of his left leg immediately following the procedure. C. Inform him that he will not be able to eat or drink anything for 4 hours after the procedure. D. Inform him that vital signs will be taken every hour for 4 hours after the procedure. Answer: A Explanation: (A) Angiography, an invasive radiographic examination, involves the injection of a contrast solution (iodine) through a catheter that has been inserted into an artery. (B) The client is kept on complete bed rest for 6-12 hours after the procedure. The extremity in which the catheter was inserted must be immobilized and kept straight during this time. (C) The contrast dye, iodine, is nephrotoxic. The client must be instructed to drink a large quantity of fluids to assist the kidneys in excreting this contrast media. (D) The major complication of this procedure is hemorrhage. Vital signs are assessed every 15 minutes initially for signs of bleeding. NO.55 A client had a A. Should not be there on the second day . He is concerned about the . The nurse explains that the blood in his urine: B. Will stop when the Foley catheter is removed C. Is normal and he need not be concerned about it A. The client aspirated tube feeding. fullstrength tube feeding tracheostomy The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color A. Giving aspirin and bismuth subsalicylate (Pepto-Bismol) to treat the symptoms Aspirin should never be given to children with influenza because of the possibility of causing Reye's syndrome 22 D. Can be removed by irrigating the bladder Answer: C Explanation: (A) Some hematuria is usual for several days after surgery. (B) The client will continue to have a small amount of hematuria even after the Foley catheter is removed. (C) Some hematuria is usual for several days after surgery. The client should not be concerned about it unless it increases. (D) Irrigating the bladder will not remove the hematuria. Irrigation is done to remove blood clots and facilitate urinary drainage. NO.56 The nurse is caring for a client who has had a for 7 years. The client is started on a at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. following? . This is indicative of which of the B. The nurse has placed the suction catheter in the esophagus. C. This is a normal finding. D. The feeding is infusing into the trachea. Answer: A Explanation: (A) Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding. (B) Because the trachea provides direct access to a client's airway, it would not be possible to place the catheter in the esophagus. (C) Blue-colored sputum is never considered a normal finding and should be reported and documented. (D) The nurse confirmed placement of the feeding tube in the stomach prior to initiating the tube feeding; therefore, it is highly unlikely that the feeding tube would be located in the trachea. NO.57 A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about: B. Giving clear liquids too soon C. Allowing the child to come in contact with other children for 3 days D. The possibility of pneumonia as a complication Answer: A Explanation: (A) . Pepto- Bismol is also classified as a salicylate and should be avoided. (B) Depending A. Protect the child from infection protective isolationneutropenic D. Delusions of grandeur schizophrenic special powers states another planet and can rule the earth D. Eating a low-carbohydrate diet dumping syndrome gastric resection 25 NO.64 A child becomes isolation is to: and is placed on . The purpose of protective B. Provide the child with privacy C. Protect the family from curious visitors D. Isolate the child from other clients and the nursing staff Answer: A Explanation: (A) The child no longer has normal white blood cells and is extremely susceptible to infection. (B) There are more appropriate ways to provide privacy, and there is no need to protect the child from healthy visitors. (C) Visitors and visiting hours may be at the client's and/or family's request without regard to the isolation precaution. (D) The child may have strong positive relationships with other clients or staff. As long as proper precautions are observed, there is no reason to isolate her from them. NO.65 A client who is experiencing thoughts of having that "I am a messenger from A. Ideas of reference B. Delusions of persecution C. Thought broadcasting ." The nurse assesses this behavior as: Answer: D Explanation: (A) Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. (B) Clients experiencing delusions of persecution believe that others in the environment are plotting against them. (C) Clients experiencing thought broadcasting perceive that others can hear their thoughts. (D) Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers. NO.66 Following a , which of the following actions would the nurse reinforce with the client in order to alleviate the distress from ? A. Eating three large meals a day B. Drinking small amounts of liquids with meals C. Taking a long walk after meals Answer: D Explanation: (A) Six small meals are recommended. (B) Liquids after meals increase the time food empties from the stomach. (C) Lying down after meals is recommended to prevent gravity from producing dumping. (D) A low-carbohydrate diet will prevent a hypertonic bolus, which causes dumping. NO.67 A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening? Strabismus C. ST-segment depression ECG changes would be seen as a positive myocardial stress test response? C. Establish an effective, habitual breathing pattern 26 A. Hearing test B. Gait C. D. Papilledema Answer: C Explanation: (A) Hearing should be assessed separately. (B) Gait should be assessed separately. Client usually remains in one place for vision screening. Gait is part of neurological assessment. (C) Strabismus is crossing of eyes or outward deviation, which may cause diplopia or ambylopia. It is easily assessed during vision screening. (D) Papilledema is assessed by an ophthalmoscopic examination, which follows vision screening. It is part of neurological assessment. NO.68 Which of the following A. Hyperacute T wave B. Prolongation of the PR interval D. Pathological Q wave Answer: C Explanation: (A) Hyperacute T waves occur with hyperkalemia. (B) Prolongation of the P R interval occurs with first-degree AV block. (C) Horizontal ST-segment depression of>1 mm during exercise isdefinitely a positive criterion on the exercise ECG test. (D) Patho-logical Q waves occur with MI. NO.69 A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems associated with his disease. However, he needs to be encouraged to participate in daily physical exercise. The ultimate aim of exercise is to: A. Create a sense of well-being and self-worth B. Help him overcome respiratory infections D. Promote normal growth and development Answer: C Explanation: (A) Regular exercise does promote a sense of well-being and selfworth, but this is not the ultimate goal of exercise for this client. (B) Regular chest physiotherapy, not exercise per se, helps to prevent respiratory infections. (C) Physical exercise is an important adjunct to chest physiotherapy. It stimulates mucus secretion, promotes a feeling of well-being, and helps to establish a habitual breathing pattern. (D) Along with adequate nutrition and minimization of pulmonary complications, exercise does help promote normal growth and development. However, exercise is promoted primarily to help establish a habitual breathing pattern. B. Vitamin K cirrhosis of the liver is prolonged bleeding Vitamin K is a fat-soluble vitamin that depends on liver function for absorption. Vitamin K is essential for clotting. C. Aged cheese monoamine oxidase (MAO) inhibitor coronary arteriography D. The leg used for arterial puncture should be kept straight for 8-12 hours 27 NO.70 A common complication of prepared to administer? A. Vitamin C C. Vitamin E D. Vitamin A Answer: B Explanation: (A) Vitamin C does not directly affect clotting. (B) clotting. (D) Vitamin A does not directly affect clotting. . The nurse should be (C) Vitamin E does not directly affect NO.71 The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a . Which of the following is she restricting from the client's diet? A. Cream cheese B. Fresh fruits D. Yeast bread Answer: C Explanation: (A) Cream cheese does not contain tyramine, which might cause a hypertensive crisis. (B) Fresh fruits do not contain tyramine, which might cause a hypertensive crisis. (C) Aged or matured cheese combined with a monoamine oxidase predisposes the client to a hypertensive crisis. (D) Bread products raised with yeast do not contain tyramine. NO.72 A 67-year-old client will be undergoing a teaching about postprocedure nursing care should include that: A. Bed rest with bathroom privileges will be ordered B. He will be kept NPO for 8-12 hours C. Some oozing of blood at the arterial puncture site is normal in the morning. Client Answer: D Explanation: (A) Bed rest will be ordered for 8-12 hours postprocedure. Flexing of the leg at the arterial puncture site will occur if the client gets out of bed, and this is contraindicated after arteriography. (B) The client will be able to eat as soon as he is alert enough to swallow safely and that will depend on what medications areused for sedation during the procedure. (C) Oozing at the arterial puncture site is not normal and should be closely evaluated. (D) The leg where the arterial puncture occurred must be kept straight for 8-12 hours to minimize the risk of bleeding. A. A low birth weight Asthma is characterized by spasm and constriction of the airways resulting in increased resistance to airflow. C. Increased airway C. Continuing to monitor the FHR closely FHR pattern early decelerations 30 site; this would be extremely painful to the infant. (D) Special care and observance should continue until the site is completely covered with clean, pink granulation tissue, which could take 7-10 days. NO.79 The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have: B. A birth defect C. Anemia D. Nicotine withdrawal Answer: A Explanation: (A) Women who smoke during pregnancy are at increased risk for miscarriage, preterm labor, and IUGR in the fetus. (B) Although smoking produces harmful effects on the maternal vascular system and the developing fetus, it has not been directly linked to fetal anomalies. (C) Smoking during pregnancy has not been directly linked to anemia in the fetus. (D) Smoking during pregnancy has not been linked to nicotine withdrawal symptoms in the newborn. NO.80 Respiratory function is altered in a 16-year-old asthmatic. Which of the following is the cause of this alteration? A. Altered surfactant production B. Paradoxical movements of the chest wall D. Continuous changes in respiratory rate and depth Answer: C Explanation: (A) Altered surfactant production is found in sudden infant death syndrome. (B) Paradoxical breathing occurs when a negative intrathoracic pressure is transmitted to the abdomen by a weakened, poorly functioning diaphragm. (C) (D) If the pulmonary tree is obstructed for any reason, inspired air has difficulty overcoming the resistance and getting out. The rate of respiration increases in order to compensate, thus increasing air exchange. NO.81 The respond by: in a laboring client begins to show . The nurse would best A. Notifying the physician B. Changing the client to the left lateral position D. Administering O2 at 8 L/min via face mask Answer: C Explanation: (A) Early decelerations are reassuring and do not warrant notification of the physician. (B) Because early decelerations is a reassuring pattern, it would not be necessary to change the client's position. Early decelerations warrant the continuation of close FHR monitoring to distinguish them from more ominous signs. B. Auscultate the site for a bruit closed-chest drainage system, the purpose of the water seal is to A. Prevent air from entering the pleural space (A) A chest tube extends from the pleural space to a collection device. The tube is placed below the surface of the saline so that air cannot enter the pleural space. A. "I know that I will not ever be able to socially drink alcohol again and will need the support of the AA group." alcoholic rehabilitation center for physiological alcohol dependence 31 (C) (D) O2 is not warranted in this situation, but it is warranted in situations involving variable and/or late decelerations. NO.82 A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must: A. Assess the site for leakage of blood or fluids C. Assess the site for bruising or hematoma D. Inspect the site for color, warmth, and sensation Answer: B Explanation: (A) This is an internal device. Assessment of the site should include assessing for swelling, pain, warmth, and discoloration. This measure does not assess patency. (B) The presence of a bruit indicates good blood flow through the device. (C) The nurse should inspect the site for bruising or hematoma; however, this measure does not assure patency of the device. (D) The nurse should inspect the vascular access site frequently for signs of infection. However, this does not assure patency. NO.83 A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a : B. Prevent fluid from entering the pleural space C. Provide a means to measure chest drainage D. Provide an indicator of respiratory effort Answer: A Explanation: (B) Fluid may enter the pleural space as a result of injury or disease. A chest tube may drain fluid from the pleural space, but the water seal is not involved in this. (C) Chest drainage should be measured, but the water seal is not involved in this. (D) Fluctuations in the tube in the water-sealed bottle will give an indication of respiratory effort, but that is not the purpose of the water seal. NO.84 A 42-year-old male client has been treated at an . The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information: B. "I know that I can only drink one or two drinks at social gatherings in the future, but at least I don't have to continue AA." C. "I really wasn't addicted to alcohol when I came here, I just needed some help dealing with my (A) The client has insight into the severity of his alcohol addiction and has chosen one of the most effective treatment strategies to support him-Alcoholics Anonymous. C. He should avoid alcoholic beverages during his recovery period. Alcohol is detoxified in the live C. 50 gtt/min microdrip tubing set A. Lifting heavy objects varices to rupture? alcohol abuse cirrhosis 32 divorce." D. "It really wasn't my fault that I had to come here. If my wife hadn't left, I wouldn't have needed those drinks." Answer: A Explanation: (B) The client is still using denial and is not dealing with his alcohol addiction. (C) The client is exhibiting denial about his alcohol addiction and projecting blame on his divorce. (D) The client is projecting blame onto his wife for being in the hospital while still denying his alcohol addiction. NO.85 Which of the following should be included in discharge teaching for a client with hepatitis C? A. He should take aspirin as needed for muscle and joint pain. B. He may become a blood donor when his liver enzymes return to normal. D. He should use disposable dishes for eating and drinking. Answer: C Explanation: (A) Aspirin is hepatotoxic, may increase bleeding, and should be avoided. (B) Blood should not be donated by a client who has had hepatitis C because of the possibility of transmission of disease. (C) r. (D) Hepatitis C is not spread through the oral route. NO.86 A physician's order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a . How many drops per minute should the nurse administer? A. 1 gtt/min B. 5 gtt/min D. 100 gtt/min Answer: C Explanation: (A) This answer is a miscalculation. (B) This answer is a miscalculation. (C)50 gtt/min. (D) This answer is a miscalculation. NO.87 A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice. He has a 20- year history of . The client is diagnosed with . His serum ammonia level is high, indicating hepatic encephalopathy. He has esophageal varices. Which of the following may cause the B. Walking briskly C. Ingestion of barbiturates D. Ingestion of antacids Answer: A Explanation: D. Ineffective breathing pattern A. Positive inotropic therapy Inotropic therapy will increase contractility, which will increase myocardial O2 demand. D. Respirations are>16 breaths/min severe preeclampsia. While she receives magnesium sulfate 35 her postoperative care, the nurse is aware that a priority nursing diagnosis for her will be high risk for: A. Knowledge deficit B. Urinary retention C. Impaired physical mobility Answer: D Explanation: (A) The client may have a knowledge deficit, but reducing the risk for knowledge deficit is not a priority nursing diagnosis postoperatively. (B) The client will have a Foley catheter for a day or two after surgery. Urinary retention is usually not a problem once the Foley catheter is removed. (C) A client having a cholecystectomy should not be physically impaired. In fact, the client is encouraged to begin ambulating soon after surgery. (D) Because of the location of the incision, the client having a cholecystectomy is reluctant to breathe deeply and is at risk for developing pneumonia. These clients have to be reminded and encouraged to take deep breaths. NO.94 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? B. Negative chronotropic therapy C. Increase in balance of myocardial O2 supply and demand D. Afterload reduction therapy Answer: A Explanation: (A) (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. NO.95 A gravida 2 para 1 client is hospitalized with (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 Answer: D D. Rapid neuroleptization is the most effective approach to care for the violent or potentially violent haloperidol Haloperidol is a high-potency neuroleptic and first-line choice for rapid neuroleptization, with low potential for sedation. priority nursing diagnosis for this client would be: A. Decreased cardiac output related to excessive bleeding Based on the client's history, presence of bright red vaginal bleeding, and hemoglobin value on admission, the priority nursing diagnosis would be decreased cardiac output related to excessive bleeding. not a minor tranquilizer. (D) diagnosis of placenta previa is made. The 36 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 6-8 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. NO.96 The physician orders 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 1-2 hours if needed. The most likely rationale for this order is: A. The client will settle down more quickly if he thinks the staff is medicating him B. The medication will sedate the client until the physician arrives C. Haloperidol is a minor tranquilizer and will not oversedate the client client Answer: D Explanation: (A) If the client could think logically, he would not be paranoid. In fact, he is probably suspicious of the staff, too. Newly admitted clients frequently experience high levels of anxiety, which can contribute to delusions. (B) The goal of pharmacological intervention is to calm the client and assist with reality-based thinking, not to sedate him. (C) Haloperidol is a neuroleptic and antipsychotic drug, NO.97 A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs. She denies any pain previously or currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range. On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical B. Potential for fluid volume excess related to fluid resuscitation C. Anxiety related to threat to self D. Alteration in parenting related to potential fetal injury Answer: A Explanation: (A) (B) This nursing diagnosis is a potential problem that does not exist at the present time, and therefore is not the priority problem. (C) The client's expressed anxiety is for her child. The fetus will remain physiologically safe if the decreased cardiac output is resolved. (D) Initial spontaneous bleeding with placenta previa is rarely life threatening to the mother or the fetus. Delivery of the A. Offer her oral hygiene before and after meals. Clients with respiratory diseases are generally mouth breathers. Cleaning the oral cavity may improve the client's appetite, increase her feelings of well-being, and remove the taste and odor of sputum. B. "I'm pleased that you get along so well with the staff. You must still know and abide by the rules." This answer is correct. The nurse made a positive statement followed by a simple, clear, concise setting of limits. rules. I always get along well with the nurses." Which nursing response to him would be most 37 fetus will be postponed until fetal maturity is achieved and survival is likely. NO.98 A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her daughter is very concerned about increasing her nutrition. The nurse helps the daughter devise a plan of care for her mother. The plan of care should include which of the following interventions to promote nutrition? B. Encourage her to consume milk products. C. Encourage her to engage in an activity before a meal to stimulate her appetite. D. Restrict her fluid intake to three glasses of water a day. Answer: A Explanation: (A) (B) Milk causes thick sputum; therefore, milk products would not be beneficial for this client. (C) Exercise prior to a meal would require increased O2 consumption and most likely would decrease the client's ability to eat. (D) Clients with respiratory diseases need increased fluid to liquefy secretions. NO.99 In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of the unit. A client with antisocial personality disorder makes the following remark, "Forget all those effective? A. "OK, don't listen to the rules. See where you end up." C. "It is irrelevant whether you get along with the nurses." D. "I'm not the other nurses. You better read the rules yourself." Answer: B Explanation: (A) This answer is incorrect. A nurse should be an appropriate role model. Threats are not appropriate. No limit setting was stated. (B) (C) This answer is incorrect. It appears to have a negative connotation. There was no limit setting. (D) This answer is incorrect. The nurse obviously responded in a negative manner. Learning takes place more readily when one is accepted, not rejected. No limits were set. NO.100 A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and makeup are perfect. She always dresses immaculately. Recently, she expressed disgust over her appearance after she gained 5 lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on her plate, then runs to the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings. What defense mechanism is she using? 40 (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. NO.106 The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should: A. Give her a small soft blanket to hold B. Give her good perineal care after each diaper change C. Leave the door open to her room D. Pick her up when she cries Answer: D Explanation: (A) A soft blanket may be comforting, but it is not directed toward developing a sense of trust. (B) Good perineal care is important, but it is not directed toward developing a sense of trust. (C) An infant with meningitis needs frequent attention, but leaving the door open does not foster trust. (D) Consistently picking her up when she cries will help the child feel trust in her caregivers. NO.107 The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because: A. Immediate treatment of mild PIH includes the administration of a variety of medications B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation C. Self-discipline is required to control caloric intake throughout the pregnancy D. The client may not recognize the early symptoms of PIH Answer: D Explanation: (A) Mild PIH is not treated with medications. (B) Emotional stress is not the cause of blood pressure elevation in PIH. (C) Excessive caloric intake is not the cause of weight gain in PIH. (D) The client most frequently is not aware of the signs and symptoms in mild PIH. NO.108 A client at 9 weeks' gestation comes for an initial prenatal visit. On assessment, the nurse discovers this is her second pregnancy. Her first pregnancy resulted in a spontaneous abortion. She is 28 years old, in good health, and works full-time as an elementary school teacher. This information alerts the nurse to which of the following: A. An increased risk in maternal adaptation to pregnancy B. The need for anticipatory guidance regarding the pregnancy C. The need for teaching regarding family planning D. An increased risk for subsequent abortions Answer: B 41 Explanation: (A, D) There are no data to support this. (B) Anticipatory guidance and health maintenance is a first- line defense in the promotion of healthy mothers and healthy babies. (C) There are no data to support this at this time. This will be a concern later. NO.109 A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest? A. A pull toy to encourage locomotion B. A mobile to improve hand-eye coordination C. A large toy with movable parts to improve pincer grasp D. Various large colored blocks to teach visual discrimination Answer: A Explanation: (A) Increased locomotive skills make push-pull toys appropriate for the energetic toddler. (B) Infants progress from reflex activity through simple repetitive behaviors to imitative behavior. Hand- eye coordination forms the foundation of other movements. (C) At age 8 months, infants begin to have pincer grasp. Toys that help infants develop the pincer grasp are recommended for this age group. (D) Various large colored blocks are suggested toys for infants 6-12 months of age to help visual stimulation. NO.110 During an examination, the nurse notes that an infant has diaper rash on the convex surfaces of his buttocks, inner thighs, and scrotum. Which of the following nursing interventions will be most effective in resolving the condition? A. Coating the inflamed areas with zinc oxide B. Using talcum powder on the inflamed areas to promote drying C. Removing the diaper entirely for extended periods of time D. Cleaning the inflamed area thoroughly with disposable wet "wipes" at each diaper change Answer: C Explanation: (A) Zinc oxide is not usually applied to inflamed areas because it contributes to sweat retention. (B) Talcum powder is of questionable benefit and poses a hazard of accidental inhalation. (C) Removing the diaper and exposing the area to air and light facilitate drying and healing. (D) Infants may be sensitive to one or more agents in the wet "wipes." It is better to simply clean with a wet cloth. NO.111 The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the client? A. "Do you take aspirin on a regular basis?" B. "Do you drink alcohol on a regular basis?" C. "Do you eat red meat?" D. "Have your stools been normal?" Answer: B 42 Explanation: (A) Aspirin does not affect folic acid absorption. (B) Folic acid deficiency is strongly associated with alcohol abuse. (C) Because folic acid is a coenzyme for single carbon transfer purines, calves liver or other purines are the meat sources. (D) Folic acid does not affect stool character. NO.112 A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug dependent? A. The client requests pain medicine every 4 hours. B. He is asleep 30 minutes after receiving the IV morphine. C. He asks for pain medication although his blood pressure and pulse rate are normal. D. He is euphoric for about an hour after each injection. Answer: D Explanation: (A) Frequent requests for pain medication do not necessarily indicate drug dependence after complex surgeries such as colorectal surgery. (B) Sleeping after receiving IV morphine is not an unexpected effect because the pain is relieved. (C) A person may be in pain even with normal vital signs. (D) A subtle sign of drug dependency is the tendency for the person to appear more euphoric than relieved of pain. NO.113 When preparing insulin for IV administration, the nurse identifies which kind of insulin to use? A. NPH B. Human or pork C. Regular D. Long acting Answer: C Explanation: (A, B, D) Intermediate-acting and long-acting preparations contain materials that increase length of absorption time from the subcutaneous tissues but cause the preparation to be cloudy and unsuitable for IV use. Human insulin must be given SC. (C) Only regular insulin can be given IV. NO.114 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. Answer: B 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 45 A. If the infant vomits within 30 minutes of the digoxin administration, repeat the dose B. They need to mix it with formula so the infant swallows it easily C. If the infant vomits two or more consecutive doses or becomes listless or anorexic, notify the physician D. If a dose of digoxin is skipped for more than 6 hours, a new timetable for administration must be developed Answer: C Explanation: (A) Occasionally the child may vomit. They should not repeat the dose because the amount of digoxin that was absorbed is un-known, and serum levels of digoxin that are too high are more dangerous than those that are temporarily too low. (B) To ensure that the entire dose of digoxin is received, never mix it with food or formula. (C) Vomiting, anorexia, and listlessness are all signs of digoxin toxicity and should be reported to the physician immediately. (D) If a dose is forgotten for more than 6 hours, the nurse should advise the parents to skip that dose and to continue the next dose as scheduled. NO.121 A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24 hours postoperatively, the nurse would be concerned if the client: A. Cries easily and says she is having abdominal pain B. Develops a temperature of 102_F C. Has no bowel sounds D. Has a urine output of 200 mL for 4 hours Answer: B Explanation: (A) The client may be more tearful than normal due to the stress of the surgery and its implications for her future life. She would be expected to have pain following surgery. (B) A temperature of 102_F indicates an infectious process. This is not a normal sequence to surgery and indicates a need for further assessment. (C) The client is expected to have no bowel soundsfor 24-48 hours after surgery because of the trauma to the bowel. (D) Normal urine output is 30 mL/hr. This represents an output of 50 mL/hr, which is greater than normal. NO.122 A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split-thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 24-48 hours postburn? A. Pain related to tissue damage from burns B. Potential for infection related to contamination of wounds C. Fluid volume deficit related to increased capillary permeability D. Potential for impaired gas exchange related to edema of respiratory tract Answer: D Explanation: 46 (A, B, C) These answers are all correct; however, maintenance of airway is the top priority. (D) Persons burned about the face and neck during an explosion are also likely to suffer burns of the respiratory tract, which can lead to edema and respiratory arrest. NO.123 A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood gases indicate the presence of: A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis Answer: D Explanation: (A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3.(D) Metabolic acidosis is determined by low pH and HCO3. NO.124 A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the laboring woman during transition are: A. Frustration, vague in communication B. Seriousness, some difficulty following directions C. Calmness, follows directions easily D. Excitement, openness to instructions Answer: A Explanation: (A) During the transition phase, the mother may become frustrated and unclear in her communication owing to severe pain and fear of loss of control. (B) These behaviors are common in the active phase of labor. (C) These behavioral clues are seen in the latent phase of labor. (D) These characteristics are observed in the latent phase of labor. NO.125 A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician's office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as: A. Delusion B. Illusion C. Hallucination D. Conversion Answer: D Explanation: (A) The client's blindness is real. Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations. 47 NO.126 One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, "It's really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers." The nurse's best response would be: A. "That might be a problem. Tell me more about them." B. "Risk factors can often be controlled by self-responsibility." C. "It sounds like you're intellectualizing your drinking problem." D. "Your grandfather and father were both alcoholics?" Answer: B Explanation: (A) Focusing is an effective therapeutic strategy. This response, however, allows the client to "defocus" off the topic of learning how to accept responsibility for his behavior and future growth. (B) The nurse can educate the client about both the "genetic risk" for the development of alcoholism and ways to make long-term healthy lifestyle changes. (C) This response is inappropriately confrontational and condescending to the client. (D) Reflection of content can be an effective verbal therapeutic technique. It is used inappropriately here. NO.127 A female client at 36 weeks' gestation has been treated successfully for premature labor for 4 weeks. She has begun having uterine contractions today and has been admitted to the labor and delivery suite. Her amniocentesis results reveal a lecithin/sphingomyelin (L/S) ratio of 2 and positive phosphatidylglycerol (PG). These lab values indicate: A. Placental maturity B. Suspected chronic asphyxia C. Cord compression D. Fetal lung maturity Answer: D Explanation: (A) Placental maturity is assessed by a biophysical profile. (B) L/S ratio and presence of phosphatidylglycerol are not used to determine fetal asphyxia. A biophysical profile score of6 may indicate this condition. (C) Cord compression is not reflected by the L/S ratio or presence of phosphatidylglycerol. Variable decelerations observed through electronic fetal monitoring could reflect umbilical cord compression. (D) An L/S ratio>2 and the presence of phosphatidylglycerol in amniotic fluid indicate fetal lung maturity. NO.128 Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients? A. Vitamin C and zinc B. Folic acid and niacin C. Vitamin A and biotin D. Thiamine and pyroxidine Answer: D Explanation: (A) Chronic alcoholism can lead to deficiencies of B complex vitamins including thiamine and 50 D. Meperidine (Demerol) Answer: D Explanation: (A) Morphine sulfate is contraindicated in clients with pancreatitis because it may cause spasms of the sphincter of Oddi and increase pancreatic pain. (B) Ketorolac tromethamine is currently not approved by the Food and Drug Administration for IV use. (C) Promethazine is a medication that has no analgesic properties. (D) Meperidine is the drug of choice for clients with pancreatitis. It will not cause spasms at the sphincter of Oddi, which can lead to increased pancreatic pain. NO.135 The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding? A. Palpate these pulses again in 15 minutes. B. Use a Doppler to determine presence and strength of these pulses. C. Document the finding that the pulses are not palpable. D. Call the physician and notify the physician of this finding. Answer: B Explanation: (A) Palpating these pulses again in 15 minutes may only result in the same findings. (B) Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present. (C) Pulses may be present and assessed through use of a Doppler. Absence of palpable pulses does not indicate absence of blood flow unless pulses cannot be located with a Doppler. (D) The nurse would only call the physician after determining that the pulses are absent by both palpation and Doppler. NO.136 A 33-year-old client is diagnosed with bipolar disorder, acute phase. This is her first psychiatric hospitalization, and she is being evaluated for treatment with lithium. Which of the following diagnostic tests are essential prior to the initiation of lithium therapy with this client? A. Hematocrit, hemoglobin, and white blood cell (WBC) count B. Blood urea nitrogen, electrolytes, and creatinine C. Glucose, glucose tolerance test, and random blood sugar D. X-rays, electroencephalogram, and electrocardiogram (ECG) Answer: B Explanation: (A) These are general diagnostic blood studies (usually done on admission), but they are not reliable indicators of lithium therapy clearance. (B) These are the primary diagnostic tests to determine kidney functioning. Because lithium is excreted through the kidneys and because it can be very toxic, adequate renal function must be ascertained before therapy begins. (C) These are diagnostic blood tests used to determine the presence of endocrine (not renal) dysfunction. (D) These are other types of diagnostic procedures used to determine musculoskeletal, neural, and cardiac (rather than renal) functioning. NO.137 A 60-year-old woman exhibits forgetfulness, emotional lability, confusion, and decreased 51 concentration. She has been unable to perform activities of daily living without assistance. After a thorough medical evaluation, a diagnosis of Alzheimer's disease was made. An appropriate nursing intervention to decrease the anxiety of this client would include: A. Allowing the client to perform activities of daily living as much as possible unassisted B. Confronting confabulations C. Reality testing D. Providing a highly stimulating environment Answer: A Explanation: (A) This answer is correct. The more the client is able to control her daily routine, the less anxiety she will experience. (B) This answer is incorrect. Confrontation tends to increase anxiety. (C) This answer is incorrect. Reality testing is an assessment tool. It does not decrease anxiety. (D) This answer is incorrect. A highly stimulating environment increases distractibility and anxiety. NO.138 On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to: A. Take 2 ibuprofen (Motrin) tablets by mouth now because the baby will be returning for feeding in 20 minutes B. Allow the infant to breast-feed at the next feeding time to empty the breasts C. Apply ice packs to the breasts and wear a supportive, well-fitting bra D. Take a warm shower and express milk from both breasts until empty Answer: C Explanation: (A) Judicious use of analgesics is appropriate with breast engorgement; however, mechanical suppression would be the initial recommendation. (B) Breast-feeding every 112-3 hours will reduce and/or prevent breast engorgement. Breast-feeding will promote milk production, which will compound the distention and stasis of the venous circulation of engorgement in a bottlefeeding mother. (C) Ice packs reduce milk flow while the snug, supportive bra provides mechanical suppression and decreases pulling on Cooper's ligament. In addition, breast binders or ace bandages may be used for some women. (D) Warmth promotes milk production and may stimulate the let- down reflex. These measures would contribute to the venous congestion of engorgement. NO.139 While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding? A. Discontinue the central line. B. Begin a peripheral IV. C. Document in the nurse's notes and notify the physician after redressing the site. D. Clean the site well and redress. Answer: C Explanation: C. 3-1-1-0-2 52 (A) The nurse may never discontinue a central line without a physician's order. (B) The nurse may never initiate a peripheral IV without a physician's order except in an emergency situation. (C) The nurse should always document findings and alert the physician to the findings as well. The physician may then initiate a new central line and order the current central line to be discontinued. (D) Besides cleaning and redressing, the nurse should always document the findings. NO.140 A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record: A. 3-2-0-0-2 B. 2-2-0-2-2 D. 2-1-1-0-2 Answer: C Explanation: (A) This answer is an incorrect application of the GTPAL method. One prior pregnancy was a preterm birth at 36 weeks (T =1, P= 1; not T = 2). (B) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G = 3, not 2), one prior pregnancy was preterm (T= 1, P= 1; not T= 2), and she has had no prior abortions (A =0). (C) This answer is the correct application of GTPAL method. The client is currently pregnant for the third time (G =3), her first pregnancy ended at term (>37 weeks) (T = 1), her second pregnancy ended preterm 20-33 weeks) (P = 1), she has no history of abortion (A=0), and she has two living children (L = 2). (D) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G =3, not 2). NO.141 A 60-year-old male client was hospitalized 3 days ago with the diagnosis of acute anterior wall myocardial infarction. Today he has been complaining of increasing weakness and shortness of breath. Crackles in both lung bases are audible on auscultation. He is developing: A. An extension of his myocardial infarction B. Pneumonia C. Pulmonary edema D. Pulmonary emboli Answer: C Explanation: (A) Extensions of his myocardial infarction would be chest pain unrelieved with nitroglycerin, cardiac enzyme elevations, and electrocardiographic changes. (B) Persons with pneumonia may complain of weakness and shortness of breath and have crackles in their lung bases. However, they would also have sputum production and leukocytosis. (C) Persons who have had myocardial infarctions (especially anterior wall) are at risk of developing left ventricular heart failure, which is a major cause of pulmonary edema. Pulmonary edema is manifest by shortness of breath, weakness, and crackles on auscultation of the lung fields. (D) Pulmonary emboli may be accompanied by shortness of breath, 55 pregnancy. Which of the following factors places her at risk for gestational diabetes? A. Age>25 years B. Maternal weight C. Previous birth of an infant weighing>9 lb D. Family history of heart disease Answer: C Explanation: (A) Maternal age older than 30 years is an identified risk factor for diabetes. Age younger than 30 years is insignificant for diabetes unless there is a familial history of diabetes. (B) The client's weight is appropriate for her height. Obesity or pregnancy weight >20% of the ideal weight is a contributing factor to the development of gestational diabetes. (C) The birth of an infant weighing >9 lb (4000 g) is an identified risk factor for gestational diabetes. (D) A familial history of heart disease is insignificant in the development of diabetes. However, a familial history of type II diabetes mellitus is identified as a risk factor in the development of diabetes during pregnancy. NO.148 When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds: A. 20 mL B. 25 mL C. 30 mL D. 50 mL Answer: D Explanation: (A) A residual volume of 20 mL is not excessive. (B) A residual volume of 25 mL is not excessive. (C) A residual volume of 30 mL is not excessive. (D) Tube feedings should be withheld and physician notified for residual volumes of 50-100 mL. NO.149 A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is hospitalized for additional tests and to begin a course of chemotherapy designed to induce a remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow test previously and is apprehensive about having another. Which of the following interventions will be most effective in relieving her anxiety? A. Explain what will take place and what she will see, feel, and hear. B. Remind her that she has had this procedure before and that it is nothing to be afraid of. C. Tell her not to worry about it, that it will be over soon and she can join her friends in the playroom. D. Give her a big hug and tell her that she is a big girl now and that she will do just fine. Answer: A Explanation: (A) 56 Even though the child has had the procedure before, she will probably need additional explanations and emotional support. (B) The fact that the child has had the procedure before and possibly found it painful or uncomfortable may increase, not relieve, her stress. (C) This intervention does nothing to reassure the child and may well prevent her from expressing her feelings. (D) This does not prepare the child for the test and burdens her with the expectation that she act bigger and braver than she is. NO.150 A female client was employed as a client care technician in a hemodialysis unit. She recently began to experience extreme fatigue, being able to sleep for 16-20 hours at a time. She also noted that her urine was tea colored, which she rationalized was a result of the vitamins she began taking to alleviate fatigue. She was diagnosed with hepatitis B. After a brief hospital stay, she is discharged to her parent's home. Her mother asks the nurse if any precautions are necessary to prevent transmission to the client's family. The nurse explains necessary precautions, which include: A. Isolation of the client from the remainder of the family B. Separate bathroom facilities if possible; if not, then cleansing daily of the facilities with a chloride solution C. No necessary precautions because she is beyond the contagious phase D. Laundering clothes separately in cold water with a chloride solution Answer: B Explanation: (A) Isolation is not necessary, even in the acute phase. (B) Separate bathroom facilities are recommended. If unavailable, daily cleansing with a chloride solution is recommended. (C) Precautions continue to be necessary while the client is in the active phase of hepatitis. (D) Clothes are to be laundered separately in hot water with a chloride solution. NO.151 A 29-year-old client delivered her fifth child by the Lamaze method and developed a postpartal hemorrhage in the recovery room. What are the initial symptoms of shock that she may experience? A. Marked elevation in blood pressure, respirations, and pulse B. Decreased systolic pressure, cold skin, and anuria C. Rapid pulse; narrowed pulse pressure; cool, moist skin D. No urinary output, tachycardia, and restlessness Answer: C Explanation: (A) Early shock does not exhibit the symptom of marked elevation in blood pressure. A narrowing of the pulse pressure is indicative of early shock. (B) Anuria is a clinical finding in late shock. (C) All of these clinical findings are congruent with early shock. (D) Absence of urinary output is a clinical finding in the late phase of shock. NO.152 A successful executive left her job and became a housewife after her marriage to a plastic surgeon. She started doing volunteer work for a charity organization. She developed pain in her legs 57 that advanced to the point of paralysis. Her physicians can find no organic basis for the paralysis. The client's behavior can be described as: A. Housework phobia B. Malingering C. Conversion reaction D. Agoraphobia Answer: C Explanation: (A) A typical phobia does not result in physical symptoms (i.e., paralysis). (B) Malingering is pretending to be ill. This person has a true paralysis. (C) A conversion reaction is a physical expression of an emotional conflict. It has no organic basis. (D) Agoraphobia is fear of public places. NO.153 A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to: A. Assess the client's respirations B. Notify the physician C. Auscultate fetal heart rate D. Transfer to delivery suite Answer: C Explanation: (A) Immediately following membrane rupture, the fetus is at risk for complications, not necessarily the mother. (B) The physician is notified after the nurse completes an assessment of the mother's and fetus's conditions. (C) Rupture of membranes facilitates fetal descent. A potential complication is cord prolapse, which is assessed by auscultating fetal heart rate. (D) Rupture of membranes does not necessarily indicate readiness to deliver. NO.154 A client's wife is concerned over his behavior in recent months. He has been diagnosed with Parkinson's disease, and she is telling his nurse that he has been doing "strange things." The nurse reassures the wife that the following behavior is normal with Parkinson's disease: A. "Your husband will experience some periods of muscle flaccidity. Be sure to make him sit down during these periods." B. "Your husband may move his hands in motions that look like he is rolling a pill between his fingers." C. "Twitching of the muscles is to be expected and can occur at any time during the day." D. "Parkinson's disease causes severe pain in the joints. You should give your husband Tylenol at those times." Answer: B Explanation: (A) Clients with Parkinson's disease generally experience stiffness and rigid movement. (B) Pill-rolling movements are a symptom experienced by the Parkinson client. (C) Twitching of the muscles is not an expected symptom of Parkinson's disease. (D) Parkinson's disease does not cause joint pain. Mild muscular pain may be present. 60 A. Role playing the client's eating behaviors B. Restriction to the unit until she has gained 2 lb C. Encouraging her to verbalize her feelings concerning food and food intake D. Provision for a high-calorie, high-protein snack between meals Answer: B Explanation: (A) This answer is incorrect. Role playing is based on learning but is not based on the behavioral modification model. (B) This answer is correct. The behavioral modification model is based on negative and positive reinforcers to change behavior. (C) This answer is incorrect. Verbal catharsis is not an intervention based on behavioral modification. (D) This answer is incorrect. Although an acceptable nursing intervention, it is not based on behavioral modification. NO.161 An alcoholic client who is completing the inpatient segment of a substance abuse program was placed on disulfiram (Antabuse) drug therapy. What should the nurse include in the discharge instructions? A. If disulfiram is taken and alcohol ingested, the client experiences nausea, vomiting and elevated blood pressure. B. Disulfiram is most effective when prescribed as late as possible in a recovery program. C. Disulfiram works on the desensitization principle. D. The effects of disulfiram can be triggered by alcohol 5 days to 2 weeks after the drug is discontinued. Answer: D Explanation: (A) When alcohol is ingested with disulfiram therapy, the client experiences nausea, vomiting, and a potentially serious drop in blood pressure. (B) Disulfiram is most successful when used early in the recovery process while the individual makes major lifestyle changes necessary for long-term recovery. (C) Disulfiram works on the classical conditioning principle. (D) The effects of disulfiram can be felt when alcohol is ingested 1-2 weeks after disulfiram is discontinued. NO.162 The postpartum nurse should include which of the following instructions to breast-feeding mothers? A. Limit feeding times for several days to avoid nipple soreness. B. Wash the nipples with soap and water before and after each feeding. C. Daily caloric intake should be increased by 500 cal. D. Breast milk is totally digestible by the baby because it contains lactose. Answer: C Explanation: (A) Limiting initial feeding times will only delay nipple soreness as well as the establishment of the letdown reflex, thus encouraging engorgement from clogged ducts and ductules. (B) Soap should be avoided because it may be excessively drying, predisposing nipples to cracking. (C) For optimal milk production, an additional 500 kcal over maintenance levels are needed daily. (D) Lipase, not lactose, emulsifies the fat in breast milk, making it almost totally digestible by infants. 61 NO.163 At her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure should be included in her plan of care to help alleviate it? A. Restrict fluid intake. B. Use Alka-Seltzer as necessary. C. Eat small, frequent bland meals. D. Lie down after eating. Answer: C Explanation: (A) At least eight glasses of fluid per day are encouraged to help dilute stomach contents, thereby decreasing irritation. (B) Alka Seltzer contains aspirin, which is irritating to gastric mucosa, and therefore should be avoided. (C) Small, frequent bland meals help to decrease gastric pressure and to prevent reflux. (D) Lying down after meals may cause gastric reflux and prevents optimal gastric emptying. NO.164 A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expect which of the following to be present in relation to his blood sugar level? A. A normal blood sugar level B. A decreased blood sugar level C. An increased blood sugar level D. Fluctuating levels with a predawn increase Answer: C Explanation: (A) Blood sugar levels increase when the body responds to stress and illness. (B) Blood sugar levels increase when the body responds to stress and illness. (C) Hyperglycemia occurs because glucose is produced as the body responds to the stress and illness of cellulitis. (D) Blood sugar levels remain elevated as long as the body responds to stress and illness. NO.165 An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic blood studies is characteristically abnormal in this disorder? A. Partial thromboplastin time B. Platelet count C. Complete blood count D. Bleeding time Answer: A Explanation: (A) Partial thromboplastic time measures activity of thromboplastin, which depends on the intrinsic clotting factors deficient in children who are hemophiliacs. (B) Platelet counts are normal in hemophilia. (C) Hemophilia does not affect the complete blood count. (D) Bleeding times are normal in hemophiliacs. They measure the time interval for the bleeding from small superficial wounds to cease. NO.166 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? 62 A. Neosporin sulfate B. Mafenide acetate C. Silver sulfadiazine D. Povidone-iodine Answer: B Explanation: (A) The side effects of neomycin sulfate include rash, urticaria, nephrotoxicity, and ototoxicity. (B) The side effects of mafenide acetate include bone marrow suppression, hemolytic anemia, eosinophilia, and metabolic acidosis. The hyperventilation is a compensatory response to the metabolic acidosis. (C) The side effects of silver sulfadiazine include rash, itching, leukopenia, and decreased renal function. (D) The primary side effect of povidone- iodine is decreased renal function. NO.167 Nursing care for the parents of a child with a congenital heart defect would include: A. Encouraging the parents not to tell the child about the seriousness of the congenital heart defect, so the child will function as normally as possible B. Acknowledging the fear and concern surrounding their child's health and assisting the parents through the grieving process as they mourn the loss of their fantasized healthy child C. Identifying anger and resentment as destructive emotions that serve no purpose D. Expressing to the parents after the corrective surgery has been completed successfully that all their grief feelings will resolve Answer: B Explanation: (A) It is important to discuss with parents the need to treat the child as they would any other children, but they must be truthful and honest with the child about the heart defect. As the child grows older, explanations can go into greater depth. (B) Parents of children with congenital heart defects go through a grieving process over the loss of their "healthy" child. The nurse needs to recognize these feelings and give the parents a role in the child's care when they are ready. (C) Anger and resentment are normal feelings that must be dealt with appropriately. (D) Parents may go through a second grieving process after the repair of the cardiac defect. During this grieving period, they mourn the loss of the "defective" child who now may be essentially "normal." NO.168 Three hours postoperatively, a 27-year-old client complains of right leg pain after knee reduction. The first action by the nurse will be to: A. Assess vital signs B. Elevate the extremity C. Perform a lower extremity neurovascular check D. Remind the client that he has a client-controlled analgesic pump, and reinstruct him on its use Answer: C Explanation: (A) Vital signs may be altered if there is acute pain or complications related to bleeding or swelling, but they should not be assessed before checking the affected extremity. (B) The extremity will be 65 A. "Individuals who donate blood are at risk of getting the AIDS virus. You should not donate." B. "It's OK for you to donate because the blood bank has a test that is 100% effective." C. "You should not donate since it takes time to develop antibodies to the AIDS virus. If you donate blood before you develop the antibody, you could pass it on in the blood." D. "It is not a good idea for you to donate. If you have AIDS, the information is made public and could destroy your personal life." Answer: C Explanation: (A) The AIDS virus cannot be transmitted to the donor through the blood donation procedure. (B) The test for the AIDS virus is not absolutely foolproof; therefore, it is not wise for a person with known risk factors to donate blood. (C) It takes time for antibodies to the AIDS virus to develop. An infected individual could donate contaminated blood without it testing positive for the virus. (D) For reasons of confidentiality, information about individuals infected with AIDS is not made public. NO.175 A 56-year-old client is admitted to the psychiatric unit in a state of total despair. She feels hopeless and worthless, has a flat affect and very sad appearance, and is unable to feel pleasure from anything. Her husband has been assisting her at home with the housework and cooking; however, she has not been eating much, lies around or sits in a chair most of the day, and is becoming confused and thinks her family does not want her around anymore. In assessing the client, the nurse determines that her behavior is consistent with: A. Transient depression B. Mild depression C. Moderate depression D. Severe depression Answer: D Explanation: (A) Transient depression manifests as sadness or the "blues" as seen with everyday disappointments and is not necessarily dysfunctional. (B) Mild depression manifests as symptoms seen with grief response, such as denial, sadness, withdrawal, somatic symptoms, and frequent or continuous thoughts of the loss. (C) Moderate depression manifests as feelings of sadness, negativism; low self- esteem; rumination about life's failures; decreased interest in grooming and eating; and possibly sleep disturbances. These symptoms are consistent with dysthymia. (D) Severe depression manifests as feelings of total despair, hopelessness, emptiness, inability to feel pleasure; possibly extreme psychomotor retardation; inattention to hygiene; delusional thinking; confusion; self-blame; and suicidal thoughts. These symptoms are consistent with major depression. NO.176 A client had a ruptured abdominal aortic aneurysm that was repaired surgically. Her postoperative recovery progressed without complications, and she is ready for discharge. Client education in preparation for discharge began 7 days ago on her admission to the nursing unit. Evaluation of nursing care related to client education is based on evaluation of expected outcomes. Which statement made by the client would indicate that she is ready for discharge? A. "I will not drive but ride in the front seat of the car with a seat belt on for my first doctor's 66 appointment." B. "When I bathe tomorrow morning, I will be very careful not to get soap on my incision." C. "I am allowed to exercise by walking for short periods." D. "Teach my husband about the diet. He'll be doing all the cooking now." Answer: C Explanation: (A) Postoperatively, clients with major abdominal surgery are instructed to avoid driving, riding in the front seat, and wearing seat belts because any sudden impact may injure a fresh incision. She should ride in back seat without a seat belt. (B) Clients should not sit in the tub and allow the incision to soak in water because this may predispose the client to infection. A short, cool shower would be preferable. Allowing soap to come in contact with the incision would not harm it and is frequently used as postoperative wound care at home on discharge from the hospital. (C) Activity instructions include: avoid sitting for long periods and get exercise by walking. Lifting more than 5 lb of weight is also prohibited. (D) The client must also learn her diet. Her husband cooking is probably a temporary measure unless he did the cooking prior to her hospitalization.A statement such as this may indicate the need for further exploration of feelings regarding her illness, dependence, and self-care expectations. NO.177 In caring at home for a child who just ingested a caustic alkali, the nurse would immediately tell the mother to: A. Give vinegar, lemon juice, or orange juice B. Phone the doctor C. Take the child to the emergency room D. Induce vomiting Answer: A Explanation: (A) The immediate action is to neutralize the action of the chemical before further damage takes place. (B) This action should be done after neutralizing the chemical. (C) This action should be done after neutralizing the chemical. (D) Never induce vomiting with a strong alkali or acid. Additional damage will be done when the child vomits the chemical. NO.178 A 1000-mL dose of lactated Ringer's solution is to be infused in 8 hours. The drop factor for the tubing is 10 gtt/mL. How many drops per minute should the nurse administer? A. 125 gtt/min B. 48 gtt/min C. 20 gtt/min D. 21 gtt/min Answer: D Explanation: (A) This answer is a miscalculation. (B) This answer is a miscalculation. (C) This answer has not been rounded off to an even number. (D) 20.8, or 21 gtt/min. NO.179 Home-care instructions for the child following a cardiac catheterization should include: 67 A. Notify the physician if a slight bruise develops around the insertion site. B. Use sponge bathing until stitches are removed. C. Give aspirin if the child complains of pain at the insertion site. D. Keep a clean, dry dressing on the insertion site for 2 days. Answer: B Explanation: (A) A small bruise may develop around the insertion site and is not a reason for alarm. (B) It is best to keep the child out of the bathtub until the sutures are removed. (C) Acetaminophen, not aspirin, is the drug of choice if there is pain at the insertion site. (D) The insertion site should be kept clean and dry and open to air. NO.180 A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5'4" and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to: A. Obtain an accurate weight B. Search the client's purse for pills C. Assess vital signs D. Assign her to a room with someone her own age Answer: C Explanation: (A) On admission, vital signs are the highest priority. Weight is not a vital sign. (B) Belongings are routinely searched on admission to a psychiatric unit, but this search is not a high priority. (C) Vital signs are a high priority when working with selfdestructive clients. (D) Room assignment is of low priority. NO.181 A couple is experiencing difficulties conceiving a baby. The nurse explains basal body temperature (BBT) by instructing the female client to take her temperature: A. Orally in the morning and at bedtime B. Only one time during the day as long as it is always at the same time of day C. Rectally at bedtime D. As soon as she awakens, prior to any activity Answer: D Explanation: (A) Monitoring temperature twice a day predicts the biphasic pattern of ovulation. (B) Prediction of ovulation relies on consistency in taking temperature. (C) Nightly rectal temperatures are more accurate in predicting ovulation. (D) Activity changes the accuracy of basal body temperature and ability to detect the luteinizing hormone surge. NO.182 Four days after admission for cirrhosis of the liver, the nurse observes the following when 70 C. Ordering a mechanical soft diet for her D. Ordering a pureed diet for her Answer: C Explanation: (A) Full liquids would be difficult to swallow if the muscle control of the swallowing act is affected; this is a probable reason for her difficulties, given her medical diagnosis of multiple sclerosis. (B) Five small meals would do little if anything to decrease her swallowing difficulties, other than assure that she tires less easily. (C) A mechanical soft diet should be easier to chew and swallow, because foods would be more evenly consistent. (D) A pureed diet would cause her to regress more than might be needed; the mechanical soft diet should be tried first. NO.188 A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed: A. Gastritis B. Evisceration C. Peritonitis D. Pulmonary embolism Answer: C Explanation: (A) Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. (B) Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. (C) Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity. This causes infection and irritation. (D) Assessment findings of pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing often accompanied by blood-tinged sputum. NO.189 Hypoxia is the primary problem related to near-drowning victims. The first organ that sustains irreversible damage after submersion in water is the: A. Kidney (urinary system) B. Brain (nervous system) C. Heart (circulatory system) D. Lungs (respiratory system) Answer: B Explanation: (A) The kidney can survive after 30 minutes of water submersion. (B) The cerebral neurons sustain irreversible damage after 4-6 minutes of water submersion. (C) The heart can survive up to 30 minutes of water submersion. (D) The lungs can survive up to 30 minutes of water submersion. NO.190 A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of 71 spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be: A. November 23rd B. December 26th C. September 14th D. December 9th Answer: A Explanation: (A) Naele's rule is as follows: add 7 days to the 1st day of the last menstrual period, subtract 3 months, and then add 1 year. (B) Naele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naele's rule. (C) Naele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurringon the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naele's rule. (D) Naele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14thday of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naele's rule. NO.191 Following a fracture of the left femur, a client develops symptoms of osteomyelitis. During the acute phase of osteomyelitis, nursing care is directed toward: A. Moving or turning the client's left leg carefully to minimize pain and discomfort B. Allowing the client out of bed only in a wheelchair or gurney to minimize weight bearing on the left leg C. Providing the client with a high-protein, high-fiber diet to promote healing D. Instituting physical therapy to ensure restoration of optimal functioning of the leg Answer: A Explanation: (A) Any movement of his affected limb will cause discomfort to the child. (B) No weight bearing will be allowed until healing is well underway to avoid pathological fractures. (C) The child will be anorexic and may experience vomiting. Diet should be simple and high caloric until appetite returns and symptoms subside. (D) Physical therapy is instituted only after infection subsides. NO.192 After several days, an IDDM client's serum glucose stabilizes, and the registered nurse continues client teaching in preparation for his discharge. The nurse helps him plan an American Diabetes Association diet and explains how foods can be substituted on the exchange list. He can substitute 1 oz of poultry for: A. One frankfurter B. One ounce of ham C. Two slices of bacon D. One-fourth cup dry cottage cheese Answer: D Explanation: (A) A frankfurter is a high-fat meat on the diabetic exchange list. (B) Ham is a medium-fat meat on 72 the diabetic exchange list, unless it is a center-cut slice. (C) One strip of bacon equals onefatexchange rather than ameatexchange. Dietary substitutions should occur within exchange lists and not between exchange lists. (D) Diabetic meat-exchange lists are categorized into leanmeat foods, medium-fat meats, and high-fat meats. Cottage cheese (dry, 2% butterfat), one-fourth cup, can substitute for one lean-meat exchange. NO.193 The client tells the nurse, "I have pain in my left shoulder." This is considered: A. Evaluation process B. Objective information C. Subjective information D. Complaining Answer: C Explanation: (A) Evaluation process follows a nursing intervention. (B) Objective information can be measured. (C) Subjective information is provided by a person. (D) Client is reporting a symptom that needs to be assessed. NO.194 Endotracheal tube cuff pressure should never exceed: A. 10 mm Hg B. 20 mm Hg C. 45 mm Hg D. 60 mm Hg Answer: B Explanation: (A) Pressure<10 mm Hg places the client at risk for aspiration. (B) Pressure in the endotracheal tube cuff should never exceed 20 mm Hg, because higher pressure places the client at risk for tracheal erosion. (C) A pressure of 45 mm Hg is an extremely high pressure in the endotracheal tube cuff. This places the client at great risk for tracheal erosion. (D) A pressure of 60 mm Hg is an extremely high pressure in the endotracheal tube cuff. This places the client at great risk for tracheal erosion. NO.195 A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm. The nurse caring for the client establishes the following priority nursing diagnosis-Alteration in comfort, pain related to: A. Increased excretion of lactic acid due to myocardial hypoxia B. Increased blood flow through the coronary arteries C. Decreased stimulation of the sympathetic nervous system D. Decreased secretion of catecholamines secondary to anxiety Answer: A Explanation: (A) Anaerobic metabolism results because the decreased blood supply to the myocardium causes a release of lactic acid. Lactic acid is an irritant to the myocardial neural receptors, producing chest pain. (B) Chest pain is caused by a decrease in the O2 supply to the myocardial cells. Treatment 75 conflicts of everyday life C. Client is able to verbalize effects of substance abuse on the body D. Client has remained substance free during hospitalization and is discharged Answer: B Explanation: (A) This client response does not address stress reduction techniques. Verbal response focuses only on the problem. (B) Exercise or physical activity is a common strategy or coping technique used to reduce stress and anxiety. (C) Verbalizing effects of substance abuse on the body may help with insight and break through denial, but it is not a strategy to reduce anxiety. (D)Remaining substance- free does indicate motivation to change lifestyle of substance abuse or dependence, and it is not a stress reduction strategy in itself. NO.201 A child receiving chemotherapeutic drugs experiences a loss of appetite directly related to the therapy. Which of the following strategies should be most effective in encouraging the child to eat? A. Provide a well-balanced diet at usual times, and restrict dessert if the child fails to eat well. B. Schedule procedures immediately after eating so that the child will not be tired or in pain at mealtime. C. Offer the child a diet with a wider variety of foods and with more seasoning than her usual diet. D. Offer the child smaller meals more frequently than usual, and include as many of her favorite foods as possible. Answer: D Explanation: (A) Because the child's appetite is capricious at best, regular servings may be overwhelming. Praise the child for what is eaten. (B) The child will soon learn that procedures follow meals and may play with food rather than eat it to avoid or delay the procedure. (C) Young children usually do not like highly seasoned foods and may need the security of usual foods. Such a change may actually increase anorexia. (D) Small servings appear more achievable to the child, and the inclusion of favorite foods can add a sense of security. NO.202 A 14-year-old teenager is hospitalized for anorexia nervosa. She is admitted to the adolescent mental health unit and placed on a behavior modification program. Nursing interventions for the teenager will most likely include: A. Establishing routine tasks and activities around mealtimes B. Administering medications such as lithium C. Requiring the client to eat more during meals D. Checking the client's room frequently Answer: A Explanation: (A) Providing a more structured, supportive environment addresses safety and comfort needs, thereby helping the anorexic client develop more internal control. (B) Medications (commonly antidepressants) are frequently ordered for the anorexic client. However, lithium (used primarily with 76 bipolar disorder) is not commonly used to treat the anorexic client. (C) Requiring and/or demanding that the anorexic client "eat more" at mealtimes increases the client's feelings of powerlessness. (D) Like the previous strategy, checking the client's room frequently contributes to the client's feelings of powerlessness. NO.203 The nurse has been assigned a client who delivered a 6- lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client would be: A. Length of her labor B. Type of episiotomy C. Amount of IV fluid to be infused D. Character of the fundus Answer: D Explanation: The length of labor has little bearing on the fourth stage of labor. The type of labor and delivery is significant. (B) The type of episiotomy will affect the client's comfort level. However, the nurse's assessment and implementations center on prevention of hemorrhage during the fourthstage of labor. The amount of bleeding from the episiotomy or hematoma formation is of higher priority than the type of episiotomy. (C) The amount of IV fluid to be infused is a nursing function to be attended to; however, it is lower in priority than determining if hemorrhaging is occurring. (D) Character of the fundus would be the priority nursing assessment because changes in uterine tone may identify possible postpartum hemorrhage. NO.204 A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty- eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications? A. Fluid volume deficit B. Fluid volume excess C. Decreased cardiac output D. Severe hypotension Answer: B Explanation: (A) Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. (B) Forty-eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. (C) Increased cardiac output results as fluids shift back to the vascular compartment. (D) Hypertension is the result of hypervolemia. NO.205 A schizophrenic is admitted to the psychiatric unit. What affect would the nurse expect to observe? A. Anger B. Apathy and flatness C. Smiling 77 D. Hostility Answer: B Explanation: (A) Anger is an emotion that is not necessarily present in schizophrenia. (B) Lack of response to or involvement with environment and distancing are characteristic of schizophrenia. (C) Euphoria is more characteristic of manic-depressive disorder (bipolar disorder). (D) Hostility is an emotion that is not necessarily present in schizophrenia. NO.206 A primigravida with a blood type A negative is at 28 weeks' gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy? A. "I'm getting this shot so that my baby won't develop antibodies against my blood, right?" B. "I understand that if my baby is Rh positive I'll be getting another one of these injections." C. "This shot should help to protect me in future pregnancies if this baby is Rh positive, like my husband." D. "This shot will prevent me from becoming sensitized to Rh-positive blood." Answer: A Explanation: (A) RhoGAM is given to Rh-negative mothers to prevent the maternal Rh immune response to fetal Rh-positive antigens. (B) If the infant is Rh positive, the mother will receive another dose postdelivery to prevent maternal sensitization. (C) Prevention of maternal sensitization will protect future pregnancies because the mother's blood will be free of antibodies against her fetus. (D) RhoGAM prevents maternal sensitization to Rh-positive blood. NO.207 A client who has gout is most likely to form which type of renal calculi? A. Struvite stones B. Staghorn calculi C. Uric acid stones D. Calcium stones Answer: C Explanation: (A) The presence of urinary tract infection is a factor in the formation of struvite stones. (B) Staghorn calculi is the other name for struvite stones associated with urinary tract infection. (C) Clients who have gout form uric acid stones. (D) Clients who have increased urinary excretion of calcium form calcium stones. NO.208 A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay-colored stools. His admitting diagnosis is "rule out hepatitis." Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposure to hepatitis. Which of the following represents a high-risk group for contracting this disease? 80 cardinal symptoms of PIH. NO.214 The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig's sign. The nurse expects her to react to discomfort if she: A. Dorsiflexes her ankle B. Flexes her spine C. Plantiflexes her wrist D. Turns her head to the side Answer: B Explanation: (A) Discomfort with ankle dorsiflexion is not expected with meningitis. (B) Spinal flexion, flexing the neck or the hips with legs extended, causes discomfort if the meninges are irritated. (C) Discomfort with wrist flexion is not expected with meningitis. (D) Rotating the cervical spine may cause discomfort with meningitis, but pain with flexion is more indicative of meningeal irritation. NO.215 A client suspects that she is pregnant. She reports two missed menstrual periods. The first day of her last menstrual period was August 3. Her estimated date of confinement would be: A. November 7 B. November 10 C. May 7 D. May 10 Answer: D Explanation: (A) Wrong calculation (B) Wrong calculation (C) Wrong calculation (D) Nagele's rule is: Expected Date of Confinement = Last Menstrual Period - 3 months + 7 days + 1 year NO.216 A 10-year-old boy has been diagnosed with Legg-Calve Perthes disease. Which of the client's responses would indicate compliance during initial therapy? A. Drinking large amounts of milk B. Not bearing weight on affected extremity C. Walking short distances 3 times/day D. Putting self on weight reduction diet Answer: B Explanation: (A) This condition causes aseptic necrosis of the head of the femur in the acetabulum. Drinking large quantities of milk at this time cannot hasten recovery. (B) The aim of treatment is to keep the head of the femur in the acetabulum. Non-weight-bearing is essential. Activity causes microfractures of the epiphysis. (C) In addition to non-weightbearing, clients are often placed on bedrest, which helps to reduce inflammation. Later, active motion is encouraged. (D) Weight is not generally an issue with this disease. Slipped femoral capital epiphysis, which is most frequently observed in obese pubescent children, usually requires a weight reduction diet. 81 NO.217 A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, "Why did this happen to my baby?" is: A. "It's God's will. It was probably for the best. There was something probably wrong with your baby." B. "You're young. You can have other children later." C. "I know your other children will be a great comfort to you." D. "I can see you're upset. Would you like to see and hold your baby?" Answer: D Explanation: (A) The mother and the father require support; the nurse should not minimize their grief in this situation. (B) Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. (C) Attachment to this infant occurs during the pregnancy for both the mother and father. Siblings will not replace their feelings or minimize their loss of this infant. (D) Holding and viewing the infant decreases denial and may facilitate the grief process. The nurse should prepare family members for how the infant appears ("she is bruised") and provide support. NO.218 A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy: A. Establish a structured environment with routine tasks and activities. Also, serve meals at the same time each day. B. Distract the client during meals to get her to eat because she must take in sufficient amounts to keep from starving. C. Do frequent room checks to be sure that the client is not hiding food or throwing it away. D. Listen attentively and participate in in-depth discussions about food, because these actions may encourage her to eat. Answer: A Explanation: (A) Anorexia nervosa clients feel out of control. Providing a structured environment offers safety and comfort and can help them to develop internal control, thus reducing their need to control by self- starvation. (B) Distraction does not focus on the client's need for control. (C) Doing frequent room checks reinforces feelings of powerlessness and the need to continue with the dysfunctional behavior. (D) Participating in long discussions about food does not make the client want to eat, but rather this strategy allows her to indulge in her preoccupation and to continue with the dysfunctional behavior. NO.219 The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should: A. Call the doctor immediately 82 B. Help her to blow her nose carefully C. Test the discharge for sugar D. Turn her to her side Answer: C Explanation: (A) The nasal discharge could be due to a cold. It is necessary to gather additional assessment data to identify a possible cerebrospinal fluid leak. (B) If the discharge is cerebrospinal fluid, it would not be safe to encourage the girl to blow her nose. (C) Cerebrospinal fluid is positive for sugar; mucus is not. (D) Turning her to her side will have no effect on her "runny nose." It is necessary to gather further assessment data. NO.220 Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels? A. Broiled fish with rice B. Bran flakes with fresh peaches C. Lasagna with garlic bread D. Cauliflower and lettuce salad Answer: A Explanation: (A) Broiled fish and rice are both excellent sources of protein. (B) Fresh fruits are not a good source of protein. (C) Foods in the bread group are not high in protein. (D) Most vegetables are not high in protein; peas and beans are the major vegetables higher in protein. NO.221 The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include: A. Blurred vision and dizziness B. Eye pain and itching C. Feeling of eye pressure and headache D. Eye discharge and hemoptysis Answer: B Explanation: (A) Although blurred vision may occur, dizziness would not be associated with an infection or hemorrhage. (B) Eye pain is a symptom of hemorrhage within the eye, and itching is associated with infection. (C) Nausea and headache would not be usual symptoms of eye hemorrhage or infection. (D) Some eye discharge might be anticipated if an infection is present; hemoptysis would not. NO.222 A client has ascites, which is caused by: A. Decreased plasma proteins B. Electrolyte imbalance C. Decreased renal function D. Portal hypertension Answer: A Explanation: C. Pericardial friction rub and pain on deep inspiration 85 NO.228 A 4 year old has an imaginary playmate, which concerns the mother. The nurse's best response would be: A. "I understand your concern and will assist you with a referral." B. "Try not to worry because you will just upset your child." C. "Just ignore the behavior and it should disappear by age 8." D. "This is appropriate behavior for a preschooler and should not be a concern." Answer: D Explanation: (A) This is normal for a preschooler, and a referral is not appropriate. (B) Telling a parent not to worry is unhelpful. This response does not address the mother's concern. (C) This response is incorrect. The behavior is normal and will usually disappear by the time the child enters school. (D) This behavior is normal development for a preschooler. NO.229 Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication? A. "I would notify my physician immediately if I experience nausea, vomiting, and double vision." B. "I could stop taking this medication when I begin to feel better." C. "I should only take the medication if my heart rate is greater than 100 bpm." D. "I should always take this medication with an antacid." Answer: A Explanation: (A) The first signs of digoxin toxicity include abdominal pain, anorexia, nausea, vomiting, and visual disturbances. The physician should be notified if any of these symptoms are experienced. (B) The positive inotropic effects of digoxin increase cardiac output and result in an enhanced activity tolerance. "Feeling better" indicates the drug is working and medication therapy must be continued. (C) Clients should be taught to take their pulse prior to taking the digoxin. If their pulse rate becomes irregular, slows significantly, or is >100 bpm the physician should be notified. (D) Antacids decrease the effectiveness of digoxin. NO.230 Assessment of the client with pericarditis may reveal which of the following? A. Ventricular gallop and substernal chest pain B. Narrowed pulse pressure and shortness of breath D. Pericardial tamponade and widened pulse pressure Answer: C Explanation: (A) No S3 or S4 are noted with pericarditis. (B) No change in pulse pressure occurs. (C) The symptoms of pericarditis vary with the cause, but they usually include chest pain, dyspnea, tachycardia, rise in temperature, and friction rub caused by fibrin or other deposits. The pain seen with pericarditis typically worsens with deep inspiration. (D) Tamponade is not typically seen early on, and no change in pulse pressure occurs. 86 NO.231 A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours? A. Position on side or abdomen. B. Maintain elbow restraints in place unless she is being directly supervised. C. Clean suture line every shift. D. Offer pacifier when she cries. Answer: B Explanation: (A) Placing the infant on her abdomen may allow for injury to the suture line. (B) Elbow restraints prevent the infant from touching the suture line and yet leaves hands free. (C) The suture line is cleaned as often as every hour to prevent crusting and scarring. (D) Sucking of a bottle or pacifier places pressure on the suture line and may delay healing and cause scarring. NO.232 An expected response to sodium polystyrene sulfonate (Kayexalate) is: A. Increase in serum magnesium B. Increase in serum HCO3 C. Decrease in serum potassium D. Decrease in serum calcium Answer: C Explanation: (A) Sodium polystyrene sulfonate administration will not increase serum magnesium. Hypermagnesemia is virtually unknown except for clients in renal failure. (B) Sodium polystyrene sulfonate administration is not known to increase serum bicarbonate. (C) Decrease in serum potassium, the expected response of sodium polystyrene sulfonate, is secondary to the binding of this drug and potassium in the colon, and potassium is removed through the feces. (D) Serum calcium may actually increase with sodium polystyrene sulfonate administration, especially if calcium chloride is administered concurrently with this drug. NO.233 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 Answer: D Explanation: (A) 87 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 can maintain his own respirations once the umbilical cord is severed at birth. NO.234 The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client's pneumonia is caused by a gram-positive bacteria, the nurse experts to find the sputum to be: A. Bright red with streaks B. Rust colored C. Green colored D. Pink-tinged and frothy Answer: B Explanation: (A) Bright red sputum with streaks is associated with pneumonia caused by gram-negative bacteria, such asKlebsiellapneumonia. (B) Pneumococcal pneumonia, caused by gram-positive bacteria, has a characteristic productive cough with green or rust-colored sputum. (C) Green-colored sputum is more characteristic ofPseudomonasthan of gram-positive bacterial pneumonia. (D) Pink-tinged and frothy sputum is more characteristic of pulmonary edema than of gram-positive bacterial pneumonia. NO.235 Primary nursing diagnoses for the antisocial client are: A. Alteration in perception and altered self-concept B. Impaired social interaction, ineffective individual coping, and altered self-concept C. Altered communication processes and altered recreational patterns D. Altered body image and altered thought processes Answer: B Explanation: 90 studies have not demonstrated the efficacy of this practice. (D) Fluid intake needs to be in the 2000-2500 mL range if possible to help irrigate the bladder and prevent infection. NO.241 A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, "I know that alcohol is a problem for some people, but I can stop whenever I want to. I'm never sick or miss work, and no one can complain about me." During the initial assessment, the best response by the nurse would be: A. "The fact is you are an alcoholic or you wouldn't be here." B. "I understand it took strength to admit yourself to the unit, and I will do my part to help you to stay alcohol- free." C. "If you can stop drinking when you want to, why don't you stop?" D. "It's good that you can stop drinking when you want to." Answer: B Explanation: (A) Direct confrontation initially is nontherapeutic and may result in the client becoming frustrated and wanting to leave. (B) A positive, supportive attitude builds trust, and identifying positive strength raises self-esteem. Offering help allows the client to feel that he is not alone in dealing with problems. (C) Asking the client why or to give an explanation for his behavior puts him in a position of having to justify his behavior to the nurse. (D) Giving approval or placing a value on feelings or a behavior may limit the client's freedom to behave in a way that may displease another. This response may lead to seeking praise instead of progress. NO.242 A client is experiencing mucosal cell damage secondary to chemotherapy. Because of mucosal ulcers, eating has become increasingly uncomfortable for her. Which of the following interventions would be most effective in getting her to eat? A. Local anesthetics or mouth washes applied to ulcers 30 minutes prior to meals B. A bland, moist, soft diet C. Staying with the client and providing distraction during meals D. Cleaning the mouth carefully with lemon glycerin swabs and milk of magnesia before meals Answer: B Explanation: (A) Local anesthetics do temporarily relieve the pain but leave an unpleasant taste and numb feeling that are not conductive to eating. (B) Such a diet is less irritating to the damaged mucosa and is easier for the child to tolerate. (C) This intervention is helpful if the child has only anorexia. It does not work if the type and texture of the food increase oral discomfort. (D) Lemon glycerin swabs and milk of magnesia dry the oral mucosa and should be avoided. NO.243 A client's prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant. The best time to immunize her is: A. In the immediate postpartum period B. After the first trimester 91 C. At 28 weeks' gestation D. Within 72 hours postpartum Answer: A Explanation: (A) The rubella vaccine is made with attenuated virus and is given in the immediate postpartal period to prevent infection during pregnancy and subsequent adverse fetal and neonatal sequelae. Mothers are advised to prevent pregnancy for 3 months following immunization. (B) Rubella infection during the second trimester may result in permanent hearing loss for the fetus. (C) RhoGam is the drug generally administered at 28 weeks' gestation to Rh-negative women. It is contraindicated to administer rubella vaccine during pregnancy. (D) RhoGam is the drug administered within 72 hours postpartum to Rh-negative women to prevent the development of antibodies to fetal cells. NO.244 A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, "The doctor said I have stones that need to be removed; where are they?" The nurse knows that the best explanation for this is to tell her that: A. There are stones present in her gallbladder B. There are stones present in her kidneys C. There are stones present in her common bile duct D. There are no stones, but her gallbladder is irritated and caused her nausea, vomiting, and pain Answer: C Explanation: (A)Cholelithiasisis the correct term used to describe the presence of stones in the gallbladder. (B)Nephrolithiasis,orrenal calculi,is the correct term used to describe the presence of stones in the kidney. (C)Choledocholithiasisis the correct term used to describe the presence of stones in the common bile duct. (D)Cholecystitisis the correct term used to describe inflammation of the gallbladder and can be associated with cystic duct obstructions from impacted stones. NO.245 On the third postpartum day, the nurse would expect the lochia to be: A. Rubra B. Serosa C. Alba D. Scant Answer: A Explanation: (A) This discharge occurs from delivery through the 3rd day. There is dark red blood, placental debris, and clots. (B) This discharge occurs from days 4-10. The lochia is brownish, serous, and thin. (C) This discharge occurs from day 10 through the 6thweek. The lochia is yellowish white. (D) This is not a classification of lochia but relates to the amount of discharge. NO.246 Clients receiving antipsychotic drug therapy will often exhibit extrapyramidal side effects that are reversible with which of the following agents ordered by the physician? A. Phenothiazines 92 B. Anticholinergics C. Anti-Parkinsonian drugs D. Tricyclic agents Answer: B Explanation: (A) This answer is incorrect. Phenothiazines are antipsychotic drugs and produce the symptoms. (B) This answer is correct. Anticholinergic agents are often used prophylactically for extrapyramidal symptoms. They balance cholinergic activity in the basal ganglia of the brain. (C) This answer is incorrect. Anti- Parkinsonian drugs would increase the symptoms. (D) This answer is incorrect. Tricyclic agents are used for symptoms of depression. NO.247 A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor. The nurse knows she has included the appropriate information in her teaching when the client tells her: A. "He should remove the electrodes for bathing." B. "Damage to his heart muscle will be recorded by the monitor." C. "He is to keep a record of everything he does during the day." D. "He is to refrain from activities that cause chest pain." Answer: C Explanation: (A) The client should leave the electrodes in place during the entire time the test is ordered. He should not even remove the electrodes for bathing. (B) The Holter monitor will record cardiac electrical activity but will not record damage to his myocardium. (C) The client should keep a record of all of his activities so the physician can correlate the ECG findings with his activities. (D) The client should continue doing his regular activities. The purpose of the Holter monitor is to record heart activity during routine activities. NO.248 A 1000-mL dose of D5W 12 normal saline is to be infused in 8 hours. The drop factor for the tubing is 60 gtt/min. How many drops per minute should the nurse administer? A. 75 gtt/min B. 100 gtt/min C. 125 gtt/min D. 150 gtt/min Answer: C Explanation: (A) This answer is a miscalculation. (B) This answer is a miscalculation. (C)125 gtt/min. (D) This answer is a miscalculation. NO.249 A client tells the nurse that he has been hearing voices that tell him to kill his girlfriend because she is a spy. He further states that he is having difficulty not obeying the voices because, if he does not, his house will be burned down. The highest priority nursing diagnosis for him at this time is: A. Sensory-perceptual alteration: auditory command hallucinations 95 NO.255 A client is being discharged on warfarin (Coumadin), an oral anticoagulant. The nurse instructs him about using this drug. Which following response by the client indicates the need for further teaching? A. "I should shave with my electric razor while on Coumadin." B. "I will inform my dentist that I am on anticoagulant therapy before receiving dental work." C. "I will continue with my usual dosage of aspirin for my arthritis when I return home." D. "I will wear an ID bracelet stating that I am on anticoagulants." Answer: C Explanation: (A) Using an electric razor prevents the risk of cuts while shaving. (B) Any physician or dentist should be informed of anticoagulant therapy because of the risk of bleeding due to a prolonged PT. (C) The client should be instructed to consult with his physician. Aspirin is avoided because it potentiates the affects of oral anticoagulants by interfering with platelet aggregation. (D) Identification bracelets are necessary to direct treatment, especially in an emergency situation. NO.256 The physician is preparing to induce labor on a 40-week multigravida. The nurse should anticipate the administration of: A. Oxytocin (Pitocin) B. Progesterone C. Vasopressin (Pitressin) D. Ergonovine maleate Answer: A Explanation: (A) Oxytocin is a hormone secreted by the neurohypophysis during suckling and parturition that produces strong uterine contractions. (B) Progesterone has a quiescence effect on the uterus. (C) Vasopressin is an antidiuretic hormone that promotes water reabsorption by the renal tubules. (D) Ergonovine produces dystocia as a result of sustained uterine contractions. NO.257 The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to: A. Wear gloves for the procedure B. Place and adjust the pad from back to front C. Cleanse and wipe the perineum from front to back D. Protect the outer surface of the pad from contamination Answer: C Explanation: (A) Perineal hygiene is a clean procedure and does not require the client to wear gloves. A care provider should wear gloves to adhere to universal precautions. (B) The pad should be applied from front to back to prevent contamination of the birth canal or urinary tract from rectal bacteria. (C) Wiping from front to back and discarding the wipe prevents contamination of the urinary tract and birth canal from rectal bacteria. (D) The inner surface of the pad should not be touched to maintain asepsis. 96 NO.258 A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of: A. Depression B. Agitation C. Psychotic ideation D. Anhedonia Answer: B Explanation: (A) Signs of depression would include withdrawal, sadness, morbid thoughts, insomnia, early awakening, etc. (B) These clinical features are classic signs of agitation. (C) Psychotic ideation includes delusional thoughts, bizarre behavior, disorganized thinking, etc. (D) Anhedonia is the inability to experience pleasure. NO.259 A 52-year-old client's abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration for which she is especially at risk is: A. Air embolus B. Circulatory overload C. Hypocalcemia D. Hypokalemia Answer: C Explanation: (A) Air embolism is a potential complication of blood administration, but it is fairly rare and can be prevented by using good IV technique. (B) Circulatory overload is a potential complication of blood administration, but because this client is actively bleeding, she is not at high risk for overload. (C) Hypocalcemia is a potential complication of blood administration that occurs in situations where massive transfusion has occurred over a short period of time. It occurs because the citrate in stored blood binds with the client's calcium. Another potential complication for which this client is especially at risk is hypothermia, which can be prevented by using a blood warmer to administer the blood. (D) Hypokalemia is not a complication of blood administration. NO.260 In evaluating the laboratory results of a client with severe pressure ulcers, the nurse finds that her albumin level is low. A decrease in serum albumin would contribute to the formation of pressure ulcers because: A. The proteins needed for tissue repair are diminished. B. The iron stores needed for tissue repair are inadequate. C. A decreased serum albumin level indicates kidney disease. D. A decreased serum albumin causes fluid movement into the blood vessels, causing dehydration. Answer: A Explanation: (A) 97 Serum albumin levels indicate the adequacy of protein stores available for tissue repair. (B) Serum albumin does not measure iron stores. (C) Serum albumin levels do not measure kidney function. (D) A decreased serum albumin level would cause fluid movement out of blood vessels, not into them. NO.261 A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be: A. Accepting her present body image B. Verbalizing realistic feelings about her body C. Having an improved perception of her body image D. Exhibiting increased self-esteem Answer: B Explanation: (A) This outcome criterion is inadequate because the term "accepts" is not directly measurable. (B) This outcome criterion is directly measurable because specific goal-related verbalizations can be heard and verified by the nurse. (C) "Improved perception of body image" is not directly measurable and is therefore open to many interpretations. (D) Although long-term goals for the anorexic client should focus on increased self-esteem, this outcome criterion (as stated) does not include specific indicators or behaviors for which to observe. NO.262 A client was admitted to the hospital for a TURP. Within 48 hours of admission and 12 hours postoperatively, both the blood pressure and pulse increased. He became agitated, thought snakes were crawling on his arms and legs, and generally became unmanageable. He pulled out his IV and urinary catheter in attempt to rid himself of the snakes. He was sweating profusely. The admission nurse's notes indicated that the client admitted to "having a few drinks now and then." He is probably experiencing which of the following? A. Major psychotic depression B. Delirium tremens C. Generalized anxiety disorder D. Adjustment disorder with mixed features Answer: B Explanation: (A) Symptoms of psychotic depression must exist for at least 2 weeks, and the symptoms must represent a change from previous functioning. (B) Delirium tremens occur approximately on the second or third day following cessation or reduction of alcohol intake. Symptoms would be all those described in the situation. (C) Symptoms exhibited by this client are not exhibited in clients with anxiety disorders, who manifest excessive or unrealistic worry about life circumstances for at least 6 months. (D) Symptoms for adjustment disorders with mixed emotional features (e.g., depression and anxiety) are different from those exhibited by the client in this situation. NO.263 Except for initial explosiveness on admission, a client diagnosed with schizophrenia stays in her room. She continues to believe other people are out to get her. A nursing intervention basic to