NCSBN TEST BANK for NCLEX RN & NCLEX PN UPDATED QUESTIONS AND ANSWERS, Exams of Nursing

Download NCSBN TEST BANK for NCLEX RN & NCLEX PN UPDATED QUESTIONS AND ANSWERS and more Exams Nursing in PDF only on Docsity! NCSBN TEST BANK for NCLEX RN & NCLEX PN UPDATED QUESTIONS AND ANSWERS Question 1 A c. What document should be in guiding the care of this client? A) Client Self Determination Act B) Physician's treatment orders C) Advance Directives. D) Clinical Pathway protocols Review Information: The correct answer is: C) Advance Directives. This document specifies the client's wishes Question 2 You are the of a health care team that consists of one licensed practical/vocational nurse, one nursing assistant, a nursing student and yourself. To whom is it appropriate to assign complete care for A) Yourself B) The nursing student C) The licensed vocational nurse D) The nursing assistant Review Information: The correct answer is:A) Yourself. While the nurse may delegate a bed bath for a stable client, this care should be performed by an RN for a new admission. Only tasks that do not require independent judgment should be delegated. Question 3 A mother brings her the clinic, complaining that the child seems to be .The nurse expects to find which of the following on the initial history and physical assessment? A) Increased temperature and lethargy B) Rash and restlessness C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor Review Information: The correct answer is: B) Rash and restlessness. Question 4 As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? A) "The child has been listless and has lost weight." B) "Her urine is dark yellow and small in amounts." C) "Clothes are becoming tighter across her abdomen." D+) "We notice muscle weakness and some unsteadiness." Review Information: The correct answer is:C) "Clothes are becoming tighter across her abdomen.". One of the most common signs of neuroblastoma is increasing abdominal girth. The parents'' report that clothing is tight is significant, and should be followed by additional assessments. Question 5 A 16 year-old presents to the emergency department. The triage nurse finds that this teenager is legally married and signed the consent form for treatment. What would be the appropriate INITIAL action by the nurse? C) Treatment for ear infection two months ago D) Episode of fungal skin infection last week Review Information: The correct answer is:B) Exposure to strep throat in daycare last month. Evidence supports a strong relationship between infection with Group A streptococci and subsequent rheumatic fever (usually within 2-6 weeks). Therefore, the history of playmates recovering from strep throat would indicate that the child diagnosed with rheumatic fever most likely also had strep throat. Sometimes, such an infection has no clinical symptoms. Question 8 When the nurse becomes aware of feeling reluctant to interact with a manipulative client, the BEST action by the nurse is to A) Discuss the feeling of reluctance with an objective peer or supervisor B) Limit contacts with the client to avoid reinforcing the manipulative behavior C) Confront the client regarding the negative effects of his/her behavior on others D) Develop a behavior modification plan that will promote more functional behavior Review Information: The correct answer is:A) Discuss the feeling of reluctance with an objective peer or supervisor. The nurse who is experiencing stress in the therapeutic relationship can gain objectivity through supervision. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse-client relationship. Question 9 A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action A)May result in charges of unlawful seclusion and restraint B) Leaves the nurse vulnerable for charges of assault and battery C)Was appropriate in view of the client's history of violence D)Was necessary to maintain the therapeutic milieu of the unit Review Information: The correct answer is:A) May result in charges of unlawful seclusion and restraint. Seclusion should only be used when there is an immediate threat of violence or threatening behavior. Question 10 A client has been admitted to the Coronary Care Unit with a Myocardial Infarction. Which of the following nursing diagnosis should have PRIORITY? A) Pain related to ischemia B) Risk for altered elimination: constipation C) Risk for complication: dysrhythmias D) Anxiety Review Information: The correct answer is:A) Pain related to ischemia. Pain is related to ischemia, and relief of pain will decrease myocardial oxygen demands, reduce blood pressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system and increased preload, further increasing myocardial demands. Question 11 The nurse manager who is responsible for hiring professional nursing staff is required to comply with the Americans with Disabilities Act. The provisions of the law require the nurse manager to A) Maintain an environment free from hazards B) Provide reasonable accommodations for disabled individuals C) Make all necessary accommodations for disabled individuals Time management strategies must include setting priorities and meeting goals. Question 14 The clinic nurse assesses a toddler with a tentative diagnosis of neuroblastoma. Symptoms the nurse observes that suggest this problem include A) Lymphedema and nerve palsy B) Hearing loss and ataxia C) Headaches and vomiting D) Abdominal mass and weakness Review Information: The correct answer is:D) Abdominal mass and weakness. Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline, weakness, pallor, anorexia, weight loss and irritability. Question 15 A fifteen year-old client has been placed in a Milwaukee Brace. Which one of the following statements from the client indicates the need for additional teaching? A) "I will only have to wear this for six months." B) "I should inspect my skin daily." C) "The brace will be worn day and night." D) "I can take it off when I shower." Review Information: The correct answer is:A) "I will only have to wear this for six months.". The brace must be worn long-term, usually for 1-2 years. Question 16 The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that A) Quality of care will improve B) Staff turnover should decrease C) Flexible scheduling will occur D) Team morale will improve Review Information: The correct answer is:D) Team morale will improve. Nurses are more satisfied with autonomy and control. The nurse manager becomes the facilitator of scheduling rather than the decision- maker of the schedule. Question 17 A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? A) Diffuse expiratory wheezing B) Loose, productive cough C) No relief from inhalant D) Fever and chills Review Information: The correct answer is:A) Diffuse expiratory wheezing. In asthma, the airways are narrowed - creating difficulty getting air in and a wheezing sound. Question 18 The nurse manager hears a physician loudly criticizing one of the staff nurses in the hearing of others. The employee does not respond to the physician's complaints. The nurse manager's FIRST action should be A)Walk up to the physician and quietly ask that this unacceptable behavior stop B) Heart murmur C) Macular rash D) Hemorrhage Review Information: The correct answer is:B) Heart murmur. Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. These emboli produce symptoms of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli. Furthermore, the vegetations may travel to various organs such as spleen, kidney, coronary artery, brain and lungs and obstruct blood flow. Question 21 A nurseadmits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the MOST likely cause of this problem stems from the infant's inability to A) Stabilize thermoregulation B)Maintain alveolar surface tension C) Begin normal pulmonary blood flow D) Regulate intracardiac pressure Review Information: The correct answer is:B) Maintain alveolar surface tension. Respiratory distress syndrome is primarily a disease related to developmental delay in lung maturation. Although many factors lead to the development of the problem, the central factor relates to the lack of a normally functioning surfactant system due to immaturity in lung development. Question 22 An 18 year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's PRIORITY assessment should be A) Response to stimuli B) Bladder control C) Respiratory function D) Muscle weakness Review Information: The correct answer is: C) Respiratory function. Spinal injury at the C-2 level results in quadriplegia. While the client will experience all of the problems identified, respiratory assessment is a priority. Question 23 The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care? A) Hourly urine output B) White blood count C) Blood glucose every four hours D) Temperature every two hours Review Information: The correct answer is:A) Hourly urine output. Clients who have had an episode of decreased glomerular perfusion are at risk for pre- renal failure. This is caused by any abnormal decline in kidney perfusion that reduces glomerular perfusion. Pre-renal failure occurs when the effective arterial blood volume falls. Examples of this phenomena include a drop in circulating blood volume as in a cardiac arrest state or in low cardiac perfusion states such as congestive heart failure associated with a cardiomyopathy. Close observation of hourly urinary output is necessary for early detection of this condition. Question 24 C) Regression D) Pinworms Review Information: The correct answer is:D) Pinworms. Signs of pinworm infection include intense perianal itching, poor sleep patterns, general irritability, restlessness, bed-wetting, distractibility and short attention span. Question 29 A 72 year-old client with osteomyelitis requires a six week course of intravenous antibiotics. In planning for home care, the MOST important action by the nurse is A) Investigating the client's insurance coverage for home IV antibiotic therapy B) Determining if there are adequate hand washing facilities in the home C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver D) Selecting the appropriate venous access device Review Information: The correct answer is:C) Assessing the client''s ability to participate in self care and/or the reliability of a caregiver. The cognitive ability of the client as well as the availability and reliability of a caregiver must be assessed to determine if home care is a feasible option. Question 30 The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. The BEST response by the nurse is A) "Folic acid should be taken before and after conception." B) "Multivitamin supplements are recommended during pregnancy." C) "A well balanced diet promotes normal fetal development." D) "Increased dietary iron improves the health of mother and fetus." Review Information: The correct answer is:A) "Folic acid should be taken before and after conception.". The American Academy of Pediatrics recommends that all childbearing women increase folic acid from dietary sources and/or supplements. There is evidence that increased amounts of folic acid prevents neural tube defects. Question 31 The nurse is caring for a newborn with a neural tube defect. The BEST covering for the lesion is A) Telfa dressing with antibiotic ointment B) Moist sterile nonadherent dressing C) Dry sterile dressing D) Sterile occlusive pressure dressing Review Information: The correct answer is:B) Moist sterile nonadherent dressing. Before surgical closure the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist. Question 32 A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning? A) Use ready-to-feed commercial infant formula B) Boil the tap water for 10 minutes prior to preparing the formula C) Let tap water run for 2 minutes before adding to concentrate D) Buy bottled water labeled "lead free" to mix the formula Review Information: The correct answer is:C) Let tap water run for 2 minutes before adding to concentrate. A) Teaching relaxation techniques B) Implementing a daily exercise routine C) Improving daily nutritional intake D) Suggesting communication strategies Review Information: The correct answer is:D) Suggesting communication strategies. Since Alzheimer''s disease is a progressive chronic illness that greatly challenges caregivers, the nurse can be of greatest assistance in helping family to identify language changes, and select verbal and nonverbal communication strategies to minimize aberrant behavior. Question 38 The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to A) Maintain previous calorie intake B) Keep a candy bar available at all times C) Reduce carbohydrates intake to 25% of total calories D) Keep a regular schedule of meals and snacks Review Information: The correct answer is:D) Keep a regular schedule of meals and snacks. Currently, calorie-controlled diets with strict mealplans are rarely suggested for clients who have diabetes. Try to incorporate schedule or food changes into clients'' existing dietary patterns. Help clients learn to read labels and identify specific canned foods, frozen entrees, or other foods which are acceptable and those which should be avoided. Question 39 The mother of a two month-old baby calls the nurse at a well-baby clinic two days after the first DTaP immunization. She reports that the baby feels very warm, has cried inconsolably for as long as three hours, and has had several shaking spells. The response of the nurse should be to A) instruct the mother to call 911 for an ambulance to transport the infant B) suggest that these are expected reactions and to begin every 4 hour antipyretics C) tell the mother to take the infant immediately to the nearest emergency room D) give instructions to bring the infant to the clinic now Review Information: The correct answer is:A)instruct the mother to call 911 for an ambulance to transport the infant The exhibited findings of the infant indicate a severe reaction to the immunizations. Immediate attention is needed & an ambulance with trained staff needs to transport because of the risk of grand mal seizures from potential encephalopathy which is a critical reaction. The mother would need to be instructed after this acute reaction to inform the provider of this reaction to the first dose of DTaP. Based on the need and risk involved to the infant, the health care provider may decide that further DTaP immunizations are contraindicated for life. The clinic nurse would need to document in the notes for this infant: the instructions given, findings reported by the mother and specific follow-up needs for the next clinic visit in relation to teaching and evaluation of the outcome of this event. Question 40 The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? A) Donating blood B) Using public bathrooms C) Unprotected sex D) Touching a person with AIDS Review Information: The correct answer is:C) Unprotected sex. Because HIV is spread through exposure to bodily fluids, unprotected intercourse and shared drug paraphernalia remain the highest risk for infection. Question 45 The nurse planning care for a 12 year-old child with sickle cell disease in a vaso- occlusive crisis of the elbow should include which one of the following as a PRIORITY? A) Limit fluids B) Client controlled analgesia C) Cold compresses to elbow D) Passive range of motion exercise Review Information: The correct answer is:B) Client controlled analgesia. Management of a crisis is directed towards supportive and symptomatic treatment. The priority of care is pain relief. In a 12 year-old child, client controlled analgesia promotes maximum comfort. Question 46 As the nurse provides discharge teaching to the parents of a 15 month- old child with Kawasaki Disease who has received immunoglobulin therapy, which one of the following instructions would be MOST appropriate? A) High doses of aspirin will be continued for some time B) Complete recovery is expected within several days C) Active range of motion exercises should be done frequently D) The measles, mumps and rubella vaccine should be delayed Review Information: The correct answer is:D) The measles, mumps and rubella vaccine should be delayed. Discharge instructions for a child with Kawasaki Disease should include immunoglobulin therapy may interfere with the body''s ability to form appropriate amounts of antibodies and live immunizations should be delayed. Question 47 The nurse is giving instructions to the parents of a child with Cystic Fibrosis. The nurse would emphasize that pancreatic enzymes should be taken A) Once each day B) Three times daily after meals C) With each meal or snack D) Each time carbohydrates are eaten Review Information: The correct answer is:C) With each meal or snack. Pancreatic enzymes should be taken with each meal and every snack to allow for digestion of all foods that are eaten. Question 48 The nurse is assessing an eight month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be MOST likely to exhibit? A) Lethargy B) Irritability C) Negative Moro D) Depressed fontanel Review Information: The correct answer is:B) Irritability. Signs of IICP (increased intracranial pressure) in infants include bulging fontanel, instability, high-pitched cry, and cries when held. Vital sign changes include pulse that is variable, i.e., rapid, slow and bounding, or feeble. Respirations are more often slow, deep, and irregular. Question 49 The nurse is performing a physical assessment on a toddler. Which of the following should be the FIRST action? A) Perform traumatic procedures B) Use minimal physical contact C) Proceed from head to toe Question 52 The nurse is explaining the proper use of syrup of ipecac to a group of parents. For which of the following accidental poisonings is the treatment appropriate? A) Oven cleaner B) Drain cleaner C) Kerosene D) Chewable vitamins Review Information: The correct answer is:D) Chewable vitamins. Of the above choices, poisoning with vitamins is the only case in which it is safe to induce vomiting with syrup of ipecac. Question 53 A two year-old child is brought to the pediatrician's office with a chief complaint of mild diarrhea for two days. Nutritional counseling by the nurse should include which one of the following statements? A) Place the child on clear liquids and gelatin for 24 hours B) Continue with the regular diet and include oral rehydration fluids C) Give bananas, apples, rice and toast as tolerated D) Place NPO for 24 hours, then rehydrate with milk and water Review Information: The correct answer is:B) Continue with the regular diet and include oral rehydration fluids. Current recommendations for mild to moderate diarrhea are to maintain a normal diet with rehydration fluids. Question 54 The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. The nurse's BEST recommendation for the client is A) Nebulized treatments for home care B) Adding a spacer device to the MDI canister C) Asking a family member to assist the client with the MDI D) Request a visiting nurse to follow the client at home Review Information: The correct answer is:B) Adding a spacer device to the MDI canister. The majority of pulmonary medications for COPD are delivered by inhalation.This is often preferred over oral administration because a lower drug dose is needed and systemic side effects are reduced. In addition, the onset of action of bronchodilator medication given via inhalation is faster. Question 55 Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? A) Scratching the head more than usual B) Flakes evident on a student's shoulders C) Oval pattern occipital hair loss D) Whitish oval specks sticking to the hair Review Information: The correct answer is:D) Whitish oval specks sticking to the hair. Diagnosis of pediculosis capitis is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment includes shampoo application, such as lindane for children over 2 years of age, and meticulous combing and removal of all nits. Question 56 When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the BEST action the nurse would suggest to the parents is A) Administer syrup of ipecac B) Offer small amounts of water C) Have the child drink milk D) Give ginger ale or cola Review Information: The correct answer is:B) Offer small amounts of water. Small amounts of water will dilute the corrosive substance prior to gastric lavage. Question 57 A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client's history indicate a potential hazard for this test? A) Reflex incontinence B) Allergic to shellfish C) Claustrophobia D) Hypertension Review Information: The correct answer is:B) Allergic to shellfish. It is important to know if the client has an allergy to iodine or shellfish. If the client does, they may have an allergic reaction to the IVP contrast dye injected during the procedure. Question 58 A high school nurse is advising a class of unwed pregnant students that the MOST important action they can perform to deliver a healthy child is A) Maintaining good nutrition B) Staying in school B) Ingestion of raw shellfish last week C) Multiple sex partners D) Blood transfusion 15 years ago Review Information: The correct answer is:D) Blood transfusion 15 years ago. The client who was transfused prior to blood screening for hepatitis C may show symptoms many years later. Question 63 A client is recovering from a thyroidectomy. While monitoring the client's initial post operative condition, which of the following should the nurse report immediately? A) Tetany and paresthesia B) Mild stridor and hoarseness C) Irritability and insomnia D) Headache and nausea Review Information: The correct answer is: A) Tetany and paresthesia. Because the parathyroid gland may be damaged in this surgery, secondary hypocalcemia may occur. Symptoms of hypoparathyroidism include tetany, paresthesia, muscle cramps and seizures. Question 64 A client is admitted with a right upper lobe infiltrate, and also to rule out tuberculosis. The isolation precautions the nurse would institute include A) Positive pressure ventilation B) Gown and gloves C) Particulate respirator mask D) Barrier precautions Review Information: The correct answer is:C) Particulate respirator mask. Tight fitting, high-efficiency masks are required when caring for clients who have suspected communicable disease of the airborne variety. Question 65 A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report? A) The client lost 2 pounds B) The client's potassium level is 4 mEq/liter. C) The client's urine output was 1500 cc in five hours D) The client is to receive another dose of Lasix at 10 PM Review Information: The correct answer is:C) The client's urine output was 1500 cc in five hours. Although all of these may be correct information to include in report, the essential piece would be the urine output. Question 66 The nurse is caring for a client with a colostomy. During a teaching session, the nurse recommends that the pouch be emptied A) When it is one third to one half full B) Prior to meals C) After each fecal elimination D) At the same time each day Review Information: The correct answer is:A) When it is one third to one half full. If the pouch becomes more than half full it may separate from the flange. Question 67 A couple asks the nurse about risks of several birth control methods. The MOST appropriate response by the nurse would be A) Norplant is safe and may be removed easily B) Oral contraceptives should not be used by smokers C) Depo-Provera is convenient with few side effects D) The IUD gives protection from pregnancy and infection Review Information: The correct answer is:B) Oral contraceptives should not be used by smokers. The use of oral contraceptives in a pregnant woman who smokes increases her risk of cardiovascular problems. Question 68 Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment? A) An increase in appetite B) A decrease in fluid retention C) A decrease in lethargy D) A reduction in jaundice Review Information: The correct answer is:C) A decrease in lethargy. Lactulose produces and acid environment in the bowel and trapsammonia in the gut; the laxative effect then aids in removing the ammonia from the body. This decreases the effects of hepatic encephalopathy, including lethargy and confusion. The appropriate INITIAL nursing action is to A) Assess lochia for color and amount B) Monitor pulse and blood pressure C) Call the physician immediately D) Ask the woman to empty her bladder Review Information: The correct answer is:D) Ask the woman to empty her bladder. A full bladder can displace the uterus and prevent contraction. After the woman empties the bladder, the fundus should be assessed again. Question 74 An 8 year-old client is admitted to the hospital for surgery. The child's parent reports several allergies. Which of the following should all health care personnel be aware of? A) Shellfish B) Molds C) Balloons D) Perfumed soap Review Information: The correct answer is:C) Balloons. Allergy to balloons indicates a latex allergy. All personnel in contact with the child will need to be aware of this condition and use non-latex gloves. Question 75 The nurse is caring for a client who is post-op following a thoracotomy. The client has two chest tubes in place,connected to one chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the MOST appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Continue to monitor the client to see if the bubbling increases D) Instruct the client to try to avoid coughing Review Information: The correct answer is:C) Continue to monitor the client to see if the bubbling increases. Bubbling associated with coughing after lung surgery is to be expected as small amounts of air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only nursing action required. Question 76 The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. The nurse should instruct the client to A) Complete the entire course of the medication for an effective cure B) Begin treatment with acyclovir at the onset of symptoms of recurrence C) Stop treatment if she thinks she may be pregnant to prevent birth defects D) Continue to take prophylactic doses for at least five years after the diagnosis Review Information: The correct answer is:B) Begin treatment with acyclovir at the onset of symptoms of recurrence. When the client is aware of early symptoms, such as pain, itching or tingling, treatment is very effective. Question 77 An eight year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in Review Information: The correct answer is:C) Rash, blood dyscrasias, severe depression. Rash and blood dyscrasias are side effects of anti- psychotic drugs. A history of severe depression is a contraindication to the use of neuroleptics. Question 80 The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which of the following actions should receive PRIORITY in the plan? A) Antibiotic therapy for 10 days B) Teach client isometric exercises for legs C) Assess movement and sensation of extremities D) Assist to stand up at bedside within the first 24 hours Review Information: The correct answer is:C) Assess movement and sensation of extremities. Following corrective surgery for scoliosis, neurological status requires special attention and assessment, especially that of the extremities. Question 81 A three year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack? A) Cheese crackers B) Peanut butter sandwich C) Potato chips D) Vanilla cookies Review Information: The correct answer is:C) Potato chips. Children with celiac disease should eat a gluten free diet. Gluten is found mainly in grains of wheat and rye and in smaller quantities in barley and oats. Corn, rice, soybeans and potatoes are digestible in persons with celiac disease. Question 82 The nurse is caring for a 14 month-old just diagnosed with Cystic Fibrosis. The parents state this is the first child in either family with this disease, and ask about the risk to future children. The BEST response by the nurse is based on the knowledge that there is a A) 1 in 4 chance for each child to carry that trait B) 1 in 4 risk for each child to have the disease C) 1 in 2 chance of avoiding the trait and disease D) 1 in 2 chance that each child will have the disease Review Information: The correct answer is:B) 1 in 4 risk for each child to have the disease. Cystic Fibrosis is an autosomal recessive transmission pattern. In this situation, both parents must be carriers of the trait for the disease since neither one of them has the disease. Therefore, for each pregnancy, there is a 25% chance of the child having the disease, 50% chance of carrying the trait and a 25% chance of having neither the trait or the disease. Question 83 A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do FIRST? A) Notify the physician B) Administer the prn dose of Albuterol C) Apply oxygen at 2 liters per nasal cannula D) Repeat the peak flow reading in 30 minutes Review Information: The correct answer is: B) Administer the prn dose of Albuterol. Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-to-severe persistent asthma to determine the severity of the exacerbation and to A) Assess for abdominal distention B) Maintain infant in an upright position C) Begin formula feedings when infant is alert D) Pump the shunt to assess for proper function Review Information: The correct answer is:A) Assess for abdominal distention. The child is observed for abdominal distention because cerebrospinal fluid may cause peritonitis or a postoperative ileus as a complication of distal catheter placement. Question 89 The mother of a two year-old hospitalized child asksthe nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The BEST response of the nurse would be to A) Request the mother to remain with the child at all times B) Explain that this behavior will stop with in a few days C) Help the mother understand this is a normal response to hospitalization D) Suggest that the mother "sneak out" of the child's room when he sleep Review Information: The correct answer is:C) Help the mother understand this is a normal response to hospitalization. The protest phase of separation anxiety is a normal response for a child this age. Question 90 When caring for a client receiving warfarin sodium (Coumadin), the nurse would monitor the results of the client's A) Bleeding time B) Coagulation time C) Prothrombin time D) Partial thromboplastin time Review Information: The correct answer is:C) Prothrombin time. Coumadin is ordered daily, based on the client''s prothrombin time (PT). This test evaluates the adequacy of the extrinsicsystem and common pathway in the clotting cascade; Coumadin affects the Vitamin K dependent clotting factors. Question 91 The nurse is caring for a four year-old two hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported IMMEDIATELY? A) Vomiting of dark emesis B) Complaints of throat pain C) Apical heart rate of 110 D) Increased restlessness Review Information: The correct answer is:D) Increased restlessness. Restlessness and increased respiratory and heart rates are often early signs of hemorrhage. care of infants and children. Question 92 The nurse admits a 7 year-old to the emergency room following a leg injury. X-rays show that there is a femur fracture near the epiphysis. The nurse should be aware that at this age, the injury MOST likely will A) Heal quickly because of thin periosteum B) Result in retarded bone growth C) Stimulate bone growth in the affected leg D) Show more rapid union than that of a younger child Question 97 A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive PRIORITY? A) Maintaining proper body alignment B) Frequent neurovascular assessments of the affected leg C) Inspection of pin sites for evidence of drainage or inflammation D) Applying an over-bed trapeze to assist the client with movement in bed Review Information: The correct answer is:B) Frequent neurovascular assessments of the affected leg. The most important activity for the nurse is to assess neurovascular status. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular problem and early intervention may prevent permanent limb damage. Question 98 The nurse is teaching a client newly diagnosed with asthma how to use the metered-dose inhaler (MDI). The client asks when they will know the canister is empty. The BEST response is A) Drop the canister in water to observe floating B) Estimate how many doses are usually in the canister C) Count the number of doses as the inhaler is used D) Shake the canister to detect any fluid movement Review Information: The correct answer is:A) Drop the canister in water to observe floating. Dropping the canister into a bowl of water assesses the amount of medications remaining in a metered-dose inhaler. The client should obtain a refill when the inhaler rises to the surface and begins to tip over. Question 99 While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is MOST important for the nurse to teach them to A) Maintain good oral hygiene and dental care B) Omit medication if the child is seizure free C) Administer acetaminophen to promote sleep D) Serve a diet that is high in iron Review Information: The correct answer is:A) Maintain good oral hygiene and dental care. Swollen and tender gums occur often with use of phenytoin. Oral hygiene and regular visits to the dentist should be emphasized. Question 100 A two year-old child has just been diagnosed with Cystic Fibrosis. The child's father asks the nurse "What are the chances that another child of ours will have Cystic Fibrosis?" Which of the following is the BEST response? A) "The probability of recurrence is unknown." B) "Cystic Fibrosis is more common in Asians." C) "Each of your children have a 25% chance of having Cystic Fibrosis." D) "The incidence of Cystic Fibrosis is approximately 1: 14,000 live births." Review Information: The correct answer is:C) "Each of your children have a 25% chance of having Cystic Fibrosis.". Cystic Fibrosis is an autosomal recessive disease. There is a 25% chance of each pregnancy of these parents resulting in a child with Cystic Fibrosis. Question 101 A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate A) Non stress test B) Abdominal ultrasound C) Pelvic exam D) X-ray of abdomen Review Information: The correct answer is:B) Abdominal ultrasound. The standard for diagnosis of placenta previa, which is suggested in the client''s history, is abdominal ultrasound. Question 102 The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate? A) Increased serum glucose B) Decreased albumin C) Decreased potassium D) Increased sodium retention Review Information: The correct answer is:C) Decreased potassium. In bulimia, loss of electrolytes can occur in addition to signs and symptoms of starvation and dehydration. Question 103 An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze FIRST? A) Potassium levels B) Blood pH C) Magnesium levels Review Information: The correct answer is:C) Ineffective breathing patterns related to central nervous system depression. Respiratory depression is a life-threatening risk in this overdose. Question 106 A pregnant client asks the nurse about the scheduled blood test for alpha-fetoprotein (AFP). The nurse's BEST explanation i A) "It tells us how far along your pregnancy is." B) "The results help determine if the baby is growing normally." C) "Placental exchange of oxygen is measured." D) "Possible neurological defects may be identified." Review Information: The correct answer is:D) "Possible neurological defects may be identified.". A fetus with neural tube defects loses alfa-fetoprotein (AFP) to the amniotic fluid and hence the maternal blood. High levels indicate the possibility of defects such as spina bifida and meningocele. Further assessments are indicated if a test is positive. Question 107 The nurse notes that a 2 year-old child recovering from a tonsillectomy has an temperature of 98.2 degrees F at 8:00 AM. At 10:00 AMthe child's mother reports that the child "feels very warm" to touch. The FIRST action by the nurse should be to A) Reassure the mother that this is normal B) Offer the child cold oral fluids C) Reassess the child's temperature D) Administer the prescribed acetaminophen Review Information: The correct answer is:C) Reassess the child''s temperature. A child''s temperature may have rapid fluctuations. The nurse should listen to and show respect for what parents say. Question 108 The nurse is assessing an eight month-old child. The nurse would anticipate that the child would be able to A) Say two words B) Pull up to stand C) Sit without support D) Use a spoon Review Information: The correct answer is:C) Sit without support. The age at which the normal child develops the ability to sit steadily without support is 8 months. Question 109 The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used to A) Determine oxygen saturation B) Measure forced expiratory volume C) Monitor atmosphere for presence of allergens D) Provide metered doses for inhaled bronchodilator Review Information: The correct answer is:B) Measure forced expiratory volume. The peak flow meter is used to measure peak expiratory flow volume. It provides useful information about the presence and/or severity of airway obstruction. Question 110 The nurse is performing a pre-kindergarten physical on a five year-old. The last series of vaccines will be administered. What is the preferred site for injection by the nurse? A) Vastus intermedius B) Gluteus rainlinus C) Vastus lateralis D) DorsogluteaI Review Information: The correct answer is:C) Vastus lateralis. Vastus lateralis, a large and well developed muscle, is the preferred site, since it is removed from major nerves and blood vessels. Question 111 A client experienced the loss of a seven month fetus. The nurse planning for discharge should emphasize A) Discussing feelings with support persons B) Focusing on the other healthy children C) Seeking causes for the fetal death D) Planning another pregnancy very soon Review Information: The correct answer is:A) Discussing feelings with support persons. In communicating therapeutically, the nurse helps the couple begin the grief process by suggesting they seek family, friends and support groups to listen to their feelings. Question 112 Restlessness, confusion, irritability and disorientation may be the first signs of fat embolism syndrome followed by a very high temperature. The nurse needs to confirm hypoxia first. Question 117 Which nursing intervention will be MOST effective in helping a withdrawn client to develop relationship skills? A) Offer the client frequent opportunities to interact with you B) Remind the client frequently to interact with other clients C) Assist the client to analyze the meaning of her behavior D) Identify for her other clients who have similar problems Review Information: The correct answer is:A) Offer the client frequent opportunities to interact with you. The withdrawn client is uncomfortable in social interaction. The nurse client relationship is a corrective relationship in which the client learns both tolerance and skills for relationships. Question 118 The nurse is assessing a client with a stage 2 skin ulcer. Which of the following treatments is most effective to promote healing? A) Covering the wound with a dry dressing B) Using hydrogen peroxide soaks C) Leaving the area open to dry D) Applying a transparent film cover Review Information: The correct answer is:D) Applying a transparent film cover. For this type of ulcer, the most effective treatment is a transparent cover. Question 119 A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my husband will never come near me." The nurse's BEST response would be A) "You are underestimating your husband's ability to love you." B) "Are you concerned that your husband will reject you?" C) "Are you wondering about the effect on your sexual relations?" D) "Are you worried that the surgery will change you?" Review Information: The correct answer is:D) "Are you worried that the surgery will change you?" This is a response that encourages further discussion without focusing on an area that the nurse, but possibly not the client, feels is a problem. Question 120 When teaching suicide prevention to the parents of a 15 year-old who recently attempted suicide, the nurse describes the following behavioral cue A) Angry outbursts at significant others B) Fears of being left alone C) Giving away valued personal items D) Experiencing the loss of a boyfriend Review Information: The correct answer is:C) Giving away valued personal items. 80% of all potential suicide victims give some type of clue. These clues might lead one to suspect that a client is holding suicidal thoughts or is developing a plan. Question 121 The nurse is caring for a 4 year-old admitted after receiving burns to more than 50% of his body. Which laboratory data should be reviewed by the nurse as a PRIORITY in the first 24 hours? A) Blood urea nitrogen B) Hematocrit C) Blood glucose D) White blood count Review Information: The correct answer is:A) Blood urea nitrogen. Glomerular filtration is decreased in the initial response to severe burns, with fluid shift. Kidney function must be monitored closely, or renal failure may follow in a few days. Question 122 The nurse is caring for a client in a Coronary Care Unit two days following a Myocardial Infarction. The client has many questions about his condition. The nurse should focus teaching about A) Immediate needs and concerns B) Post discharge rehabilitation C) Medication therapy at home D) Activity and rest schedule Review Information: The correct answer is:A) Immediate needs and concerns. Client education of the post MI client should be limited to immediate needs and concerns. Question 123 The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test? A) Client should be NPO after midnight The impact of crisis is indicative of high levels of stress, sense of helplessness, confusion, disorganization, and the inability to apply problem solving behavior. Question 126 A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's BEST initial intervention is to A) Discuss with the mother sharing parenting responsibilities B) Help the mother to express her feelings and concerns C) Arrange for the parents to attend infant care classes D) Talk with the father and help him accept the wife's decision Review Information: The correct answer is:B) Help the mother to express her feelings and concerns. Non-judgmental support for expressed feelings may lead to resolution of competitive feelings in a new family. Cultural influences may also be revealed. Question 127 Which of the following statements made by a female client indicate to the nurse that she may have a thought disorder? A) "I'm so angry about this. Wait until my husband hears about this." B) "I'm a little confused. What time is it?" C) "I can't find my 'mesmer' shoes. Have you seen them?" D) "I'm fine. It's my daughter who has the problem." Review Information: The correct answer is:C) "I can''t find my ''mesmer'' shoes. Have you seen them?". A Neologism is a new word self invented by a person and not readily understood by another that is often associated with a thought disorder. Question 128 The nurse is aware that which of the following psychosocial needs are BEST described in the adolescent when hospitalized? A) Independence, confidence, narcissism B) Group sports, competition, being right C) Privacy, autonomy, peer interactions D) School performance, reading, journal writing Review Information: The correct answer is:C) Privacy, autonomy, peer interactions. Adolescents display the need for privacy, autonomy and peer interaction concurrent with an evolving sense of identity. Question 129 The nurse is observing a client with an obsessive-compulsive disorder in an in-patient setting. Which of the following behaviors is consistent with this diagnosis? A) Repeatedly checking that the door is locked B) Verbalized suspicions about thefts C) Preference for consistent care givers D) Repetitive, involuntary movements Review Information: The correct answer is:A) Repeatedly checking that the door is locked. Behaviors that are repeated are symptomatic of obsessive-compulsive disorders. These behaviors often interfere with normal function and employment. Question 130 A young adult seeks treatment in an out-patient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the MOST therapeutic approach by the nurse? A) Listen quietly without comment B) Ask for further information on the spies C) Confront the client on a delusion D) Contact the government agency Review Information: The correct answer is:A) Listen quietly without comment. The client''s comments demonstrate grandiose ideas. The most therapeutic response is to listen but avoid incorporation into the delusion. Question 131 The client's self-esteem is MOST damaged by the nurse's A) Anger B) Indifference C) Disapproval D) Fear Review Information: The correct answer is:B) Indifference. Positive connectedness/caring objectivity characterizes therapeutic relationships and is incongruent with indifference. Question 132 An 8 year-old client is admitted to the child mental health unit for evaluation. Following his mother's departure, the client cries and refuses his dinner. The BEST approach by the nurse is to A) Offer to play with him Exploring alternative coping mechanisms will decrease present anxiety to a manageable level. Assisting the client to learn self-help techniques will assist in learning to cope with anxiety. Question 137 Handshaking is the preferred form of touch or contact used with clients in a psychiatric setting. The rationale behind this limited touch practice is that A) Some clients misconstrue hugs as an invitation to sexual advances B) Handshaking keeps the gesture on a professional level C) Refusal to touch a client denotes lack of concern D) Inappropriate touch often results in charges of assault and battery Review Information: The correct answer is: A) Some clients misconstrue hugs as an invitation to sexual advances. Touch denotes positive feelings for another person. The client may interpret hugging and holding hands as a sexual advance. Question 138 A client with paranoid delusions stares at the nurse for several days. The client suddenly walks up to the nurse and shouts "You think you're so perfect and pure and good." An appropriate response for the nurse is A) "Is that why you've been starring at me?" B) "You seem to be in a really bad mood." C) "Perfect? I don't quite understand." D) "You are angry right now." Review Information: The correct answer is: D) "You are angry right now.". The nurse recognizes the underlying emotion with matter of fact attitude. Question 139 A client being treated for hypertension returns to the clinic for follow up.He says, "I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." The MOST appropriate nursing diagnosis would be A) Noncompliance related to medication side effects B) Knowledge deficit related to misunderstanding of disease state C) Defensive coping related to chronic illness D) Altered health maintenance related to occupation Review Information: The correct answer is: A) Noncompliance related to medication side effects. The client kept his appointment, and stated he knew the pills were important. He is unable to comply with the regimen due to side effects, not a lack of knowledge about his disease. Question 140 A spouse is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that A) Such fantasies can gratify unconscious wishes or prepare for anticipated future events B) Detaching or dissociating in this way postpones painful feelings C) This conversion or transferring of a mental conflict to a physical symptom can lead to marital conflict D) Isolating her feelings in this way reduces conflict Review Information: The correct answer is: A) Such fantasies can gratify unconscious wishes or prepare for anticipated future events. Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratifying unconscious wishes. Question 141 An important goal in the development of a therapeutic in-patient milieu is A) Providing a businesslike atmosphere where clients can work on individual goals B) Providing a group forum in which clients decide on unit rules, regulations, and policies C) Providing a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions D) Discouraging expressions of anger because they can be disruptive to other clients Review Information: The correct answer is: C) Providing a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions. A therapeutic milieu is purposeful and planned to provide safety and a testing ground for new patterns of behavior. Question 142 D) Excessive anxiety about symptoms Review Information: The correct answer is: A) Brittle hair, lanugo, amenorrhea. Physical findings associated with anorexia are brittle hair, lanugo, and dehydration, lowered metabolic rate and vital signs. Question 146 A depressed client in an assisted living facility tells the nurse that "life isn't worth living anymore." What is the BEST response to this statement? A) "Come on, it is not that bad." B) "Have you thought about hurting yourself?" C) "Did you tell that to your family?" D) "Think of the many positive things in life." Review Information: The correct answer is: B) "Have you thought about hurting yourself?". It is appropriate and necessary to determine if someone who has voiced suicidal ideation is considering a suicidal act. This response is most therapeutic in the circumstances. Question 147 A client, recovering from alcoholism, asks the nurse, "What can I do when I start recognizing relapse triggers within myself?" How might the nurse BEST respond? A) "When you have the impulse to stop in a bar, contact a sober friend and talk with him." B) "Go to an AA meeting when you feel the urge to drink." C) "It is important to exercise daily and get involved in activities that will cause you not to think about drug use." D) "Identify your relapse triggers as part of getting better." Review Information: The correct answer is: D) "Identify your relapse triggers as part of getting better.". This option encourages the process of self evaluation and problem solving. Question 148 A client was admitted to the eating disorder unit with bulimia nervosa. When the nurse assesses for a history of complications of this disorder, the following are expected A) Respiratory distress, dyspnea B) Bacterial gastrointestinal infections, overhydration C) Metabolic acidosis, constricted colon D) Dental erosion, parotid gland enlargement Review Information: The correct answer is: D) Dental erosion, parotid gland enlargement. Dental erosion related to purging and parotid gland enlargement due to purging are common complications. Question 149 A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states," This is not my baby, and I do not want it." The nurse's BEST response is A) "This is a common occurrence after birth, but you will come to accept the baby." B) "Many women have postpartum blues and need some time to love the baby." C) "What a beautiful baby! Her eyes are just like yours." D) "You seem upset; tell me what the pregnancy and birth were like for you." Review Information: The correct answer is: D) "You seem upset; tell me what the pregnancy and birth were like for you.". A non-judgmental, open ended response facilitates dialogue between the client and nurse. Question 150 Which of the following times is a depressed client at highest risk for attempting suicide? A) Immediately after admission, during one-to-one observation B) 7 to 14 days after initiation of antidepressant medication and psychotherapy when energy increases C) Following an angry outburst with family D) When the client is removed from the security room Review Information: The correct answer is: B) 7 to 14 days after initiation of antidepressant medication and psychotherapy when energy increases. As the depression lessens, the depressed client acquires energy to follow the plan. Question 1 system available is A) The venturi mask B) Nasal cannula C) Partial non-rebreather mask D) Simple face mask Review Information: The correct answer is: A) The venturi mask. The most accurate way to deliver oxygen to the client is through a venturi system such as the Venti Mask. The Venti Mask is a high flow device that entrains room air into a reservoir device on the mask and mixes the room air with 100% oxygen. The size of the opening to the reservoir determines the concentration of oxygen. The client's respiratory rate and respiratory pattern do not affect the concentration of oxygen delivered. The maximum amount of oxygen that can be delivered by this system is 55%. Question 4 The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an IMMEDIATE response from the nurse? A) Decreased breath sounds in right lower lobe B) Aspiration of a residual of 100cc of formula C) Decrease in bowel sounds D) Urine output of 250 cc in past eight hours Review Information: The correct answer is: A) Decreased breath sounds in right lower lobe. The most common problem associated with enteral feedings is atelectasis. Maintain client at 30 degrees during feedings and monitor for signs of aspiration. Check for tube placement prior to each feeding or every four to eight hours if continuous feeding. Question 5 A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). The nurse would anticipate the physician ordering A) Oral Coumadin therapy B) Heparin 5000 units subcutaneously b.i.d. C) Heparin infusion to maintain the PTT at 1.5-2.5 times the control value D) Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value Review Information: The correct answer is: D) Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value. Several studies have been conducted in pregnant women where oral anticoagulation agents are contraindicated. Warfarin (Coumadin) is known to cross the placenta and is therefore reported to be teratogenic. Question 6 Which of the following BEST describes the goal of total quality management or continuous quality improvement in a health care setting? A) Observing reactive service and product problem solving Question 8 The nurse is caring for a client who has altered cerebral tissue perfusion related to a subarachnoid hemorrhage. To reduce the risk of rebleeding, the nurse should plan to A) Restrict visitors to immediate family B) Arouse the client frequently C) Keep client's hips flexed at 120 degrees D) Apply warming blankets Review Information: The correct answer is: A) Restrict visitors to immediate family. Maintaining a quiet environment will assist in decreasing cerebral swelling and rebleeding. Question 9 The nurse is caring for a client with renal calculi. Which physician order would be a PRIORITY? A) Morphine sulfate as client controlled analgesia B) Push oral fluids and keep vein open C) Continuous warm compresses to the flank area D) Intravenous antibiotics Review Information: The correct answer is: A) Morphine sulfate as client controlled analgesia. Administering narcotic analgesics provide prompt relief of the severe pain caused by kidney stones. Question 10 The nurse is teaching parents of a 7 month-old about adding table foods. Which of the following is an APPROPRIATE finger food? A) Hot dog pieces B) Sliced bananas C) Whole grapes D) Popcorn Review Information: The correct answer is: B) Sliced bananas. Finger foods should be bite-size pieces of soft food such as bananas. Question 11 While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about A) One year of age B) Two years of age C) Three years of age D) Four years of age Review Information: The correct answer is: B) Two years of age. A child should be at least 2 years of age to use the radial pulse to assess heart rate. Question 12