NGN NCLEX RN Exams Test Bank with All Questions and 100% Correct Answers Updated 2023, Exams of Nursing

Download NGN NCLEX RN Exams Test Bank with All Questions and 100% Correct Answers Updated 2023 and more Exams Nursing in PDF only on Docsity! NGN NCLEX RN Exams Test Bank with All Questions and 100% Correct Answers Updated 2023-2024 New Latest Version Question 1 A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Ngeles rule is: A. March 27 B. February 1 C. February 27 D. January 3 Correct Answer: C (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 Nageles rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result. (D) January 3 is a miscalculation. Question 2 The nurse practitioner determines that a client is approximately 9 weeks gestation. During the visit, the practitioner informs the client about symptoms of physical changes that she will experience during her first trimester, such as: A. Nausea and vomiting B. Quickening C. A 6-8 lb weight gain D. Abdominal enlargement Correct Answer: A (A) Nausea and vomiting are experienced by almost half of all pregnant women during the first 3 months of pregnancy as a result of elevated human chorionic gonadotropin levels and changed carbohydrate metabolism. (B) Quickening is the mothers perception of fetal movement and generally does not occur until 1820 weeks after the last menstrual period in primigravidas, but it may occur as early as 16 weeks in multigravidas. (C) During the first trimester there should be only a modest weight gain of 24 Ib. It is not uncommon for women to lose weight during the first trimester owing to nausea and/or vomiting. (D) Physical changes are not apparent until the second trimester, when the uterus rises out of the pelvis. Question 8 When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take? A. Continue monitoring because this is a normal occurrence. B. Turn client on right side. C. Decrease IV fluids. D. Report to physician or midwife. Correct Answer: D (A) This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery. (B) To increase 02 perfusion to the unborn infant, the mother should be placed on her left side. (C) IV fluids should be increased, not decreased. (D) Immediate action is warranted, such as reporting findings, turning mother on left side, administering 02, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client. Question 9 A client has been diagnosed as being preeclamptic. The physician orders magnesium sulfate. Magnesium sulfate (MgS0O4) is used in the management of preeclampsia for: A. Prevention of seizures B. Prevention of uterine contractions C. Sedation D. Fetal lung protection Correct Answer: A (A) MgS04 is classified as an anticonvulsant drug. In preeclampsia management, MgS04 is used for prevention of seizures. (B) MgSO4 has been used to inhibit hyperactive labor, but results are questionable. (C) Negative side effects such as respiratory depression should not be confused with generalized sedation. (D) MgS04 does not affect lung maturity. The infant should be assessed for neuromuscular and respiratory depression. Question 10 The predominant purpose of the first Apgar scoring of a newborn is to: A. Determine gross abnormal motor function B. Obtain a baseline for comparison with the infant's future adaptation to the environment C. Evaluate the infant's vital functions D. Determine the extent of congenital malformations Correct Answer: C (A) Apgar scores are not related to the infants care, but to the infants physical condition. (B) Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation. (C) The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. (D) Congenital malformations are not one of the areas assessed with Apgar scores. Question 11 Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above 100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry Color: Body pink, blue extremities A.7 B. 10 C.8 D.9 Correct Answer: A (A) Seven out of a possible perfect score of 10 is correct. Two points are given for heart rate above 100; 1 point is given for slow, irregular respiratory effort; 1 point is given for some flex- ion of extremities in assessing muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed for color when the body is pink with blue extremities (acrocyanosis). (B) For a perfect Apgar score of 10, the infant would have a heart rate over 100 but would also have a good cry, active motion, and be completely pink. (C) For an Apgar score of 8 the respiratory rate, muscle tone, or color would need to fall into the 2-point rather than the 1-point category. (D) For this infant to receive an Apgar score of 9, four of the areas evaluated would need ratings of 2 points and one area, a rating of 1 point. Question 12 A pregnant woman at 36 weeks gestation is followed for PIH and develops proteinuria. To increase protein in her diet, which of the following foods will provide the greatest amount of protein when added to her intake of 100 mL of milk? A. Fifty milliliters light cream and 2 tbsp corn syrup B. Thirty grams powdered skim milk and 1 egg C. One small scoop (90 g) vanilla ice cream and 1 tbsp chocolate syrup D. One package vitamin-fortified gelatin drink Correct Answer: B (A) This choice would provide more unwanted fat and sugar than protein. (B) Skim milk would add protein. Eggs are good sources of protein while low in fat and calories. (C) The benefit of protein from ice cream would be outweighed by the fat content. Chocolate syrup has caffeine, which is contraindicated or limited in pregnancy. (D) Although most animal proteins are higher in protein than plant proteins, gelatin is not. It loses protein during the processing for food consumption. Question 13 The physician recommends immediate hospital admission for a client with PIH. She says to the nurse, "It’s not so easy for me to just go right to the hospital like that." After acknowledging her feelings, which of these approaches by the nurse would probably be best? A. Stress to the client that her husband would want her to do what is best for her health. B. Explore with the client her perceptions of why she is unable to go to the hospital. C. Repeat the physician’s reasons for advising immediate hospitalization. D. Explain to the client that she is ultimately responsible for her own welfare and that of her baby. Correct Answer: B (A) This answer does not hold the client accountable for her own health. (B) The nurse should explore potential reasons for the clients anxiety: are there small children at home, is the husband out of town? The nurse should aid the client in seeking support or interventions to decrease the anxiety of hospitalization. (C) Repeating the physicians reason for recommending hospitalization may not aid the client in dealing with her reasons for anxiety. (D) The concern for self and welfare of baby may be secondary to a woman who is in a crisis situation. The nurse should explore the clients potential reasons for anxiety. For example, is there another child in the home who is ill, or is there a husband who is overseas and not able to return on short notice? Question 14 Which of the following findings would be abnormal in a postpartal woman? A. Chills shortly after delivery B. Pulse rate of 60 bpm in morning on first postdelivery day C. Urinary output of 3000 mL on the second day after delivery D. An oral temperature of 101F (38.3C) on the third day after delivery Correct Answer: D (A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. (B) The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. (C) Urinary output increases during the early postpartal period (1224 hours) owing to diuresis. The kidneys must eliminate an estimated 20003000 mL of extracellular fluid associated with a normal pregnancy. (D) A temperature of 100.4F (38C) may occur after delivery as a result of exertion Correct Answer: A (A) Chlamydia trachomatis infection is the most common STD in the United States. The Centers for Disease Control and Prevention recommend screening of all high-risk women, such as adolescents and women with multiple sex partners. (B) Herpes simplex genitalia is estimated to be found in 520 million people in the United States and is rising in occurrence yearly. (C) Syphilis is a chronic infection caused by Treponema pallidum. Over the last several years the number of people infected has begun to increase. (D) Gonorrhea is a bacterial infection caused by the organism Neisseria gonorrhoeae. Although gonorrhea is common, chlamydia is still the most common STD. Question 20 A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes him as being "on the move," sleeping 3-4 hours nightly, spending lots of money, and losing approximately 10 Ib. During the initial assessment with the client, the nurse would expect him to exhibit which of the following? A. Short, polite responses to interview questions B. Introspection related to his present situation C. Exaggerated self-importance D. Feelings of helplessness and hopelessness Correct Answer: C (A) During the manic phase of bipolar disorder, clients have short attention spans and may be abusive toward authority figures. (B) Introspection requires focusing and concentration; clients with mania experience flight of ideas, which prevents concentration. (C) Grandiosity and an inflated sense of self-worth are characteristic of this disorder. (D) Feelings of helplessness and hopelessness are symptoms of the depressive stage of bipolar disorder. Question 21 The therapeutic blood-level range for lithium is: A. 0.25-1.0 mEq/L B. 0.5-1.5 mEq/L C. 1.0-2.0 mEq/L D. 2.0-2.5 mEq/L Correct Answer: B (A) This range is too low to be therapeutic. (B) This is the therapeutic range for lithium. (C) This range is above the therapeutic level. (D) This range is toxic and may cause severe side effects. Question 22 A client with bipolar disorder taking lithium tells the nurse that he has ringing in his ears, blurred vision, and diarrhea. The nurse notices a slight tremor in his left hand and a slurring pattern to his speech. Which of the following actions by the nurse is appropriate? A. Administer a stat dose of lithium as necessary. B. Recognize this as an expected response to lithium. C. Request an order for a stat blood lithium level. D. Give an oral dose of lithium antidote. Correct Answer: C (A) These symptoms are indicative of lithium toxicity. A stat dose of lithium could be fatal. (B) These are toxic effects of lithium therapy. (C) The client is exhibiting symptoms of lithium toxicity, which may be validated by lab studies. (D) There is no known lithium antidote. Question 23 Which of the following activities would be most appropriate during occupational therapy for a client with bipolar disorder? A. Playing cards with other clients B. Working crossword puzzles C. Playing tennis with a staff member D. Sewing beads on a leather belt Correct Answer: C (A) This activity is too competitive, and the manic client might become abusive toward the other clients. (B) During mania, the clients attention span is too short to accomplish this task. (C) This activity uses gross motor skills, eases tension, and expands excess energy. A staff member is better equipped to interact therapeutically with clients. (D) This activity requires the use of fine motor skills and is very tedious. Question 24 A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time? A. Small, frequent feedings of foods that can be carried B. Tube feedings with nutritional supplements C. Allowing him to eat when and what he wants D. Giving him a quiet place where he can sit down to eat meals Correct Answer: A (A) The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with finger foods allow him to eat during periods of activity. (B) This type of therapy should be implemented when other methods have been exhausted. (C) The manic client should not be in control of his treatment plan. This type of client may forget to eat. (D) The manic client is unable to sit down to eat full meals. Question 25 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, "| wish | were dead because | am worthless to everyone; | guess | am just no good." Which response by the nurse is most appropriate at this time? A. "| 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. "| know with your wife and new baby that you do have a lot to live for." D. "You've been feeling sad and alone for some time now?" Correct Answer: D (A) This response does not acknowledge the clients feelings. (B) This is a closed question and does not encourage communication. (C) This response negates the clients feelings and does not require a response from the client. (D) This acknowledges the clients implied thoughts and feelings and encourages a response. Question 26 Which of the following statements relevant to a suicidal client is correct? A. The more specific a client's plan, the more likely he or she is to attempt suicide. B. A client who is unsuccessful at a first suicide attempt is not likely to make future attempts. C. A client who threatens suicide is just seeking attention and is not likely to attempt suicide. D. Nurses who care for a client who has attempted suicide should not make any reference to the word "suicide" in order to protect the client's ego. Correct Answer: A (A) This is a high-risk factor for potential suicide. (B) A previous suicide attempt is a definite risk factor for subsequent attempts. (C) Every threat of suicide should be taken seriously. (D) The client should be asked directly about his or her intent to do bodily harm. The client is never hurt by direct, respectful questions. Question 27 Correct Answer: Explanation (A) These delusions are related to the belief that an individual has an incurable illness. (B) These delusions are related to feelings of self-importance and uniqueness. (C) These delusions are related to feelings of being conspired against. (D) These delusions are related to denial of self-existence. Question 33 A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination? A. Auditory B. Gustatory C. Olfactory D. Visceral Correct Answer: B (A) Auditory hallucinations involve sensory perceptions of hearing. (B) Gustatory hallucinations involve sensory perceptions of taste. (C) Olfactory hallucinations involve sensory perceptions of smell. (D) Visceral hallucinations involve sensory perceptions of sensation. Question 34 A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, "My doctor is in love with me and wants to marry me." This client is using which of the following defense mechanisms? A. Displacement B. Projection C. Reaction formation D. Suppression B Correct Answer: Explanation (A) Displacement involves transferring feelings to a more acceptable object. (B) Projection involves attributing ones thoughts or feelings to another person. (C) Reaction formation involves transforming an unacceptable impulse into the opposite behavior. (D) Suppression involves the intentional exclusion of unpleasant thoughts or experiences. Question 35 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) Correct Answer: 8 (A) The kidney can survive after 30 minutes of water submersion. (B) The cerebral neurons sustain irreversible damage after 46 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. Question 36 One of the most dramatic and serious complications associated with bacterial meningitis is Waterhouse- Friderichsen syndrome, which is: A. Peripheral circulatory collapse B. Syndrome of inappropriate antiduretic hormone C. Cerebral edema resulting in hydrocephalus D. Auditory nerve damage resulting in permanent hearing loss A Correct Answer: Explanation (A) Waterhouse-Friderichsen syndrome is peripheral circulatory collapse, which may result in extensive and diffuse intravascular coagulation and thrombocytopenia resulting in death. (B) Syndrome of inappropriate antidiuretic hormone is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (C) Cerebral edema resulting in hydrocephalus is a complication of meningitis, but it is not Waterhouse- Friderichsen syndrome. (D) Auditory nerve damage resulting in permanent hearing loss is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. Question 37 An 8-year-old child comes to the physician's office complaining of swelling and pain in the knees. His mother says, "The swelling occurred for no reason, and it keeps getting worse." The initial diagnosis is Lyme disease. When talking to the mother and child, questions related to which of the following would be important to include in the initial history? A. A decreased urinary output and flank pain B. A fever of over 103F occurring over the last 2-3 weeks C. Rashes covering the palms of the hands and the soles of the feet D. Headaches, malaise, or sore throat Correct Answer: D (A) Urinary tract symptoms are not commonly associated with Lyme disease. (B) A fever of 103F is not characteristic of Lyme disease. (C) The rash that is associated with Lyme disease does not appear on the palms of the hands and the soles of the feet. (D) Classic symptoms of Lyme disease include headache, malaise, fatigue, anorexia, stiff neck, generalized lymphadenopathy, splenomegaly, conjunctivitis, sore throat, abdominal pain, and cough. Question 38 The most commonly known vectors of Lyme disease are: A. Mites B. Fleas C. Ticks D. Mosquitoes Correct Answer: C (A) Mites are not the common vector of Lyme disease. (B) Fleas are not the common vector of Lyme disease. (C) Ticks are the common vector of Lyme disease. (D) Mosquitoes are not the common vector of Lyme disease. Question 39 A laboratory technique specific for diagnosing Lyme disease is: A. Polymerase chain reaction B. Heterophil antibody test C. Decreased serum calcium level D. Increased serum potassium level Correct Answer: A (A) Polymerase chain reaction is the laboratory technique specific for Lyme disease. (B) Heterophil antibody test is used to diagnose mononucleosis. (C) Lyme disease does not decrease the serum calcium level. (D) Lyme disease does not increase the serum potassium level. Question 40 The nurse would expect to include which of the following when planning the management of the client with Lyme disease? A. Complete bed rest for 6-8 weeks B. Tetracycline treatment C. IV amphotericin B D. High-protein diet with limited fluids (A) The temperature elevation related to febrile seizures generally exceeds 101F, and seizures occur during the temperature rise rather than after a prolonged elevation. (B) Febrile seizures may recur and are more likely to do so when the first seizure occurs in the 1st year of life. (C) There is little risk of neurological deficit, mental retardation, or altered behavior secondary to febrile seizures. (D) Febrile seizures are associated with disease of the central nervous system. Question 46 When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal signs of: A. Anemia and vomiting B. Polyuria and polydipsia C. Irritability relieved by feeding formula D. Hypothermia and azotemia Correct Answer: B (A) Anemia and vomiting are not cardinal signs of diabetes insipidus. (B) Polyuria and polydipsia are the cardinal signs of diabetes insipidus. (C) Irritability relieved by feeding water, not formula, is a common sign, but not the cardinal sign, of diabetes insipidus. (D) Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus. Question 47 The usual treatment for diabetes insipidus is with IM or SC injection of vasopressin tannate in oil. Nursing care related to the client receiving IM vasopressin tannate would include: A. Weigh once a week and report to the physician any weight gain of 10 lb. B. Limit fluid intake to 500 mL/day. C. Store the medication in a refrigerator and allow to stand at room temperature for 30 minutes prior to administration. D. Hold the vial under warm water for 10-15 minutes and shake vigorously before drawing medication into the syringe. Correct Answer: D (A) Weight should be obtained daily. (B) Fluid is not restricted but is given according to urine output. (C) The medication does not have to be stored in a refrigerator. (D) Holding the vial under warm water for 1015 minutes or rolling between your hands and shaking vigorously before drawing medication into the syringe activates the medication in the oil solution. Question 48 A child is admitted to the emergency room with her mother. Her mother states that she has been exposed to chickenpox. During the assessment, the nurse would note a characteristic rash: A. That is covered with vesicular scabs all in the macular stage B. That appears profusely on the trunk and sparsely on the extremities C. That first appears on the neck and spreads downward D. That appears especially on the cheeks, which gives a'slapped-cheek" appearance Correct Answer: B (A) A rash with vesicular scabs in all stages (macule, papule, vesicle, and crusts). (B) A rash that appears profusely on the trunk and sparsely on the extremities. (C) Arash that first appears on the neck and spreads downward is characteristic of rubeola and rubella. (D) A rash, especially on the cheeks, that gives a "slapped-cheek" appearance is characteristic of roseola. Question 49 Discharge teaching was effective if the parents of a child with atopic dermatitis could state the importance of: A. Maintaining a high-humidified environment B. Furry, soft stuffed animals for play C. Showering 3-4 times a day D. Wrapping hands in soft cotton gloves Correct Answer: D (A) Maintaining a low-humidified environment. (B) Avoiding furry, soft stuffed animals for play, which may increase symptoms of allergy. (C) Avoiding showering, which irritates the dermatitis, and encouraging bathing 4 times a day in colloid bath for temporary relief. (D) Wrapping hands in soft cotton gloves to prevent skin damage during scratching. Question 50 The priority nursing goal when working with an autistic child is: A. To establish trust with the child B. To maintain communication with the family C. To promote involvement in school activities D. To maintain nutritional requirements Correct Answer: A (A) The priority nursing goal when working with an autistic child is establishing a trusting relationship. (B) Maintaining a relationship with the family is important but having the trust of the child is a priority. (C) To promote involvement in school activities is inappropriate for a child who is autistic. (D) Maintaining nutritional requirements is not the primary problem of the autistic child. Question 51 The child with iron poisoning is given lV deforoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria. The initial nursing intervention would be to: A. Discontinue the IV B. Stop the medication, and begin a normal saline infusion C. Take all vital signs, and report to the physician D. Assess urinary output, and if it is 30 mL an hour, maintain current treatment Correct Answer: B (A) The IV line should not be discontinued because other IV medications will be needed. (B) Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction and could go into shock if the medication is not stopped. The line should be kept opened for other medication. (C) Taking vital signs and reporting to the physician is not an adequate intervention because the IV medication continues to flow. (D) Assessing urinary output and, if it is 30 mL an hour, maintaining current treatment is an inappropriate intervention owing to the childs obvious allergic reaction. Question 52 As the nurse assesses a male adolescent with chlamydia, the nurse determines that a sign of chlamydia is: A. Enlarged penis B. Secondary lymphadenitis C. Epididymitis D. Hepatomegaly Correct Answer: C (A) An enlarged penis is not a sign of chlamydia. (B) Secondary lymphadenitis is a complication of lymphogranuloma venereum. (C) Untreated chlamydial infection can spread from the urethra, causing epididymitis, which presents as a tender, scrotal swelling. (D) Hepatomegaly is not a complication. Question 53 When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child: A. Fruit juices B. Diluted carbonated drinks C. Soy-based, lactose-free formula D. Regular formulas mixed with electrolyte solutions Correct Answer: C Question 58 The following medications were noted on review of the client’s home medication profile. Which of the medications would most likely potentiate or elevate serum digoxin levels? A. KCl B. Thyroid agents C. Quinidine D. Theophylline Correct Answer: C (A) Hypokalemia can cause digoxin toxicity. Administration of KCI would prevent this. (B) Thyroid agents decrease digoxin levels. (C) Quinidine increases digoxin levels dramatically. (D) Theophylline is not noted to have an effect on digoxin levels. Question 59 In the client with a diagnosis of coronary artery disease, the nurse would anticipate the complication of bradycardia with occlusion of which coronary artery? A. Right coronary artery B. Left main coronary artery C. Circumflex coronary artery D. Left anterior descending coronary artery Correct Answer: A (A) Sinus bradycardia and atrioventricular (AV) heart block are usually a result of right coronary artery occlusion. The right coronary artery perfuses the sinoatrial and AV nodes in mostindividuals. (B) Occlusion of the left main coronary artery causes bundle branch blocks and premature ventricular contractions. (C) Occlusion of the circumflex artery does not cause bradycardia. (D) Sinus tachycardia occurs primarily with left anterior descending coronary artery occlusion because this form of occlusion impairs left ventricular function. Question 60 When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. This behavior is most indicative of: A. Pericarditis B. Anxiety C. Congestive heart failure D. Angina Correct Answer: C (A) Pericarditis can cause dyspnea but primarily causes chest pain. (B) Anxiety can cause dyspnea resulting in SOB, yet it is not typically influenced by degree of head elevation. (C) The inability to oxygenate well without being upright is most indicative of congestive heart failure, due to alveolar drowning. (D) Angina causes primarily chest pain; any SOB associated with angina is not influenced by body position. Question 61 When a client questions the nurse as to the purpose of exercise electrocardiography (ECG) in the diagnosis of cardiovascular disorders, the nurses response should be based on the fact that: A. The test provides a baseline for further tests B. The procedure simulates usual daily activity and myocardial performance C. The client can be monitored while cardiac conditioning and heart toning are done D. Ischemia can be diagnosed because exercise increasesO2 consumption and demand Correct Answer: D (A) The purpose of the study is not to provide a baseline for further tests. (B) The test causes an increase in 02 demand beyond that required to perform usual daily activities. (C) Monitoring does occur, but the test is not for the purpose of cardiac toning and conditioning. (D) Exercise ECG, or stress testing, is designed to elevate the peripheral and myocardial needs for 02 to evaluate the ability of the myocardium and coronary arteries to meet the additional demands. Question 62 In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware that there is typically: A. Decreased pulmonary blood flow and cyanosis B. Increased pressure in the pulmonary veins and pulmonary edema C. Systemic venous engorgement D. Increased left ventricular systolic pressures and hypertrophy Correct Answer: D (A) These signs are seen in pulmonic stenosis or in response to pulmonary congestion and edema and mitral stenosis. (B) These signs are seen primarily in mitral stenosis or as a late sign in aortic stenosis after left ventricular failure. (C) These signs are seen primarily in right-sided heart valve dysfunction. (D) Left ventricular hypertrophy occurs to increase muscle mass and overcome the stenosis; left ventricular pressures increase as left ventricular volume increases owing to insufficient emptying. Question 63 The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to: A. Digoxin (Lanoxin) B. Lidocaine (Xylocaine) C. Quinidine gluconate or sulfate (Quinaglute,Quinidex) D. Nitroglycerin IV (Tridil) Correct Answer: B (A) Side effects of digoxin include headache, hypotension, AV block, blurred vision, and yellow-green halos. (B) Side effects of lidocaine include heart block, headache, dizziness, confusion, tremor, lethargy, and convulsions. (C) Side effects of quinidine include heart block, hepatotoxicity, thrombocytopenia, and respiratory depression. (D) Side effects of nitroglycerin include postural hypotension, headache, dizziness, and flushing. Question 64 Which of the following ECG changes would be seen as a positive myocardial stress test response? A. Hyperacute T wave B. Prolongation of the PR interval C. ST-segment depression D. Pathological Q wave Correct Answer: C (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 is definitely a positive criterion on the exercise ECG test. (D) Patho-logical Q waves occur with MI. Question 65 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 C. Pericardial friction rub and pain on deep inspiration D. Pericardial tamponade and widened pulse pressure Correct Answer: C (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. Question 71 Which of the following signs and symptoms indicates a tension pneumothorax as compared to an open pneumothorax? A. Ventilation-perfusion (V./Q.) mismatch B. Hypoxemia and respiratory acidosis C. Mediastinal tissue and organ shifting D. Decreased tidal volume and tachypnea Correct Answer: C (A, B, D) These occur in both tension pneumothorax and open pneumothorax. (C) The tension pneumothorax acts like a one- way valve so that the pneumothorax increases with each breath. Eventually, it occupies enough space to shift mediastinal tissue toward the unaffected side away from the midline. Tracheal deviation, movement of point of maximum impulse, and decreased cardiac output will occur. The other three options will occur in both types of pneumothorax. Question 72 Hematotympanum and otorrhea are associated with which of the following head injuries? A. Basilar skull fracture B. Subdural hematoma C. Epidural hematoma D. Frontal lobe fracture Correct Answer: A (A) Basilar skull fractures are fractures of the base of the skull. Blood behind the eardrum or blood or cerebrospinal fluid (CSF) leaking from the ear are indicative of a dural laceration. Basilar skull fractures are the only type with these symptoms. (B, C, D) These do not typically cause dural lacerations and CSF leakage. Question 73 A client with a C-3-4 fracture has just arrived in the emergency room. The primary nursing intervention is: A. Stabilization of the cervical spine B. Airway assessment and stabilization C. Confirmation of spinal cord injury D. Normalization of intravascular volume Correct Answer: B (A) If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also protects the cervical spine. (B) Primary intervention is protection of the airway and adequate ventilation. (C, D) All other interventions are secondary to adequate ventilation. Question 74 In a client with chest trauma, the nurse needs to evaluate mediastinal position. This can best be done by: A. Auscultating bilateral breath sounds B. Palpating for presence of crepitus C. Palpating for trachial deviation D. Auscultating heart sounds Correct Answer: C (A) No change in the breath sounds occurs as a direct result of the mediastinal shift. (B) Crepitus can occur owing to the primary disorder, not to the mediastinal shift. (C) Mediastinal shift occurs primarily with tension pneumothorax, but it can occur with very large hemothorax or pneumothorax. Mediastinal shift causes trachial deviation and deviation of the hearts point of maximum impulse. (D) No change in the heart sounds occurs as a result of the mediastinal shift. Question 75 Priapism may be a sign of: A. Altered neurological function B. Imminent death C. Urinary incontinence D. Reproductive dysfunction Correct Answer: A (A) Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. (B) Priapism is not associated with death. (C) Urinary retention, rather than incontinence, may occur. (D) Reproductive dysfunction may be a secondary problem. Question 76 When evaluating a client with symptoms of shock, it is important for the nurse to differentiate between neurogenic and hypovolemic shock. The symptoms of neurogenic shock differ from hypovolemic shock in that: A. In neurogenic shock, the skin is warm and dry B. In hypovolemic shock, there is a bradycardia C. In hypovolemic shock, capillary refill is less than 2 seconds D. In neurogenic shock, there is delayed capillary refill Correct Answer: A (A) Neurogenic shock is caused by injury to the cervical region, which leads to loss of sympathetic control. This loss leads to vasodilation of the vascular beds, bradycardia resulting from the lack of sympathetic balance to parasympathetic stimuli from the vagus nerve, and the loss of the ability to sweat below the level of injury. In neurogenic shock, the client is hypotensive but bradycardiac with warm, dry skin. (B) In hypovolemic shock, the client is hypotensive and tachycardiac with cool skin. (C) In hypovolemic shock, the capillary refill would be>5 seconds. (D) In neurogenic shock, there is no capillary delay, the vascular beds are dilated, and peripheral flow is good. Question 77 Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)? A. Increased core body temperature B. Decreased serum osmolality C. Administration of hypo-osmolar fluids D. Decreased PaCO2 Correct Answer: D (A) An increase in core body temperature increases metabolism and results in an increase in ICP. (B) Decreased serum osmolality indicates a fluid overload and may result in an increase in ICP. (C) Hypo-osmolar fluids are generally voided in the neurologically compromised. Using IV fluids such as D5W results in the dextrose being metabolized, releasing free water that is absorbed by the brain cells, leading to cerebral edema. (D) Hypercapnia and hypoventilation, which cause retention of CO2 and lead to respiratory acidosis, both increase ICP. CO2 is the most potent vasodilator known. Question 78 A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental 02, and establishing IV access, the next nursing intervention would be to: A. Pass a nasogastric tube through the left nostril B. Place a 4 X 4 gauze in the nares to impede the flow C. Gently suction the nasal drainage to protect the airway D. Perform a halo test and glucose level on the drainage Correct Answer: D (A) Mafenide acetate is bacteriostatic against gram-positive and gram-negative organisms and is the agent that best penetrates eschar. (B) Silver sulfadiazine poorly penetrates eschar. (C) Neomycin sulfate does not penetrate eschar. (D) Povidoneiodine does not penetrate eschar. Question 84 When the nurse is evaluating lab data for a client 1824 hours after a major thermal burn, the expected physiological changes would include which of the following? A. Elevated serum sodium B. Elevated serum calcium C. Elevated serum protein D. Elevated hematocrit Correct Answer: D (A) Sodium enters the edema fluid in the burned area, lowering the sodium content of the vascular fluid. Hyponatremia may continue for days to several weeks because of sodium loss to edema, sodium shifting into the cells, and later, diuresis. (B) Hypocalcemia occurs because of calcium loss to edema fluid at the burned site (third space fluid). (C) Protein loss occurs at the burn site owing to increased capillary permeability. Serum protein levels remain low until healing occurs. (D) Hematocrit level is elevated owing to hemoconcentration from hypovolemia. Anemia is present in the postburn stage owing to blood loss and hemolysis, but it cannot be assessed until the client is adequately hydrated. Question 85 The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts? A. Neosporin sulfate B. Mafenide acetate C. Silver sulfadiazine D. Povidone-iodine Correct Answer: B (A) The side effects of neomycin sulfate include rash, urticaria, nephrotoxicity, and ototoxicity. (B) The side effects of mafenide acetate include bone marrow suppression, hemolytic anemia, eosinophilia, and metabolic acidosis. The hyperventilation is a compensatory response to the metabolic acidosis. (C) The side effects of silver sulfadiazine include rash, itching, leukopenia, and decreased renal function. (D) The primary side effect of povidone- iodine is decreased renal function. Question 86 The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment: A. Decreases hypertrophic scar formation B. Assists with ambulation C. Covers burn scars and decreases the psychological impact during recovery D. Increases venous return and cardiac output by normalizing fluid status Correct Answer: A (A) Tubular support, such as that received with a Jobst garment, applies tension of 1020 mm Hg. This amount of uniform pressure is necessary to prevent or reduce hypertrophic scarring. Clients typically wear a pressure garment for 612 months during the recovery phase of their care. (B) Pressure garments have no ambulatory assistive properties. (C) Pressure garments can worsen the psychological impact of burn injury, especially if worn on the face. (D) Pressure garments do not normalize fluid status. Question 87 A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect of the drug therapy, which of the following foods should be included in his diet? A. Celery B. Potatoes C. Tomatoes D. Liver Correct Answer: B (A) Celery is high in sodium. (B) Potatoes are high in potassium. (C) Tomatoes are high in sodium. (D) Liver is high in iron. Question 88 Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema? A. Distant breath sounds B. Increased heart sounds C. Decreased anteroposterior chest diameter D. Collapsed neck veins Correct Answer: A (A) Distant breath sounds are found in clients with emphysema owing to increased anteroposterior chest diameter, overdistention, and air trapping. (B) Deceased heart sounds arepresent because of the increased anteroposterior chest diameter. (C) A barrel- shaped chest is characteristic of emphysema. (D) Increased distention of neck veins is found owing to right-sided heart failure, which may be present in advanced emphysema. Question 89 The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should: A. Increase his nasal 02 to 6 L/min B. Place him in a lateral Sims’ position C. Encourage pursed-lip breathing D. Have him breathe into a paper bag Correct Answer: C (A) Giving too high a concentration of 02 to a client with emphysema may remove his stimulus to breathe. (B) The client should sit forward with his hands on his knees or an overbed table and with shoulders elevated. (C) Pursed-lip breathing helps the client to blow off CO2 and to keep air passages open. (D) Covering the face of a client extremely short of breath may cause anxiety and further increase dyspnea. Question 90 Signs and symptoms of an allergy attack include which of the following? A. Wheezing on inspiration B. Increased respiratory rate C. Circumoral cyanosis D. Prolonged expiration Correct Answer: D (A) Wheezing occurs during expiration when air movement is impaired because of constricted edematous bronchial lumina. (B) Respirations are difficult, but the rate is frequently normal. (C) The circumoral area is usually pale. Cyanosis is not an early sign of hypoxia. (D) Expiration is prolonged because the alveoli are greatly distended and air trapping occurs. Question 91 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." lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of "not feeling well." At 4:30 PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to: A. Give him 3 tbsp of sugar dissolved in 4 oz of grape juice to drink B. Ask him to dissolve three pieces of hard candy in his mouth C. Have him drink 4 oz of orange juice D. Monitor him closely until dinner arrives Correct Answer: C (A) The combination of sugar and juice will increase the blood sugar beyond the normal range. (B) Concentrated sweets are not absorbed as fast as juice; consequently, they elevate the blood sugar beyond the normal limit. (C) Four ounces of orange juice will act immediately to raise the blood sugar to a normal level and sustain it for 30 minutes until supper is served. (D) There is an increased potential for the clients blood sugar to decrease even further, resulting in diabetic coma. Question 97 A male client receives 10 U of regular human insulin SC at 9:00 AM. The nurse would expect peak action from this injection to occur at: A. 9:30 AM B. 10:30 AM C. 12 noon D. 4:00 PM Correct Answer: C (A) This is too early for peak action to occur. (B) This is too early for peak action to occur. (C) Regular insulin peak action occurs 24 hours after administration. (D) This is too late for peak action to occur. Question 98 A type | 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. Anormal blood sugar level B. A decreased blood sugar level C. An increased blood sugar level D. Fluctuating levels with a predawn increase Correct Answer: C (A) Blood sugar levels increase when the body responds to stress and illness. (B) Blood sugar levels increase when the body responds to stress and illness. (C) Hyperglycemia occurs because glucose is produced as the body responds to the stress and illness of cellulitis. (D) Blood sugar levels remain elevated as long as the body responds to stress and illness. Question 99 The physician has ordered that a daily exercise program be instituted by a client with type | diabetes following his discharge from the hospital. Discharge instructions about exercise should include which of the following? A. Exercise should be performed 30 minutes before meals. B. A snack may be needed before and/or during exercise. C. Hyperglycemia may occur 2-4 hours after exercise. D. The blood glucose level should be 100 mg or below before exercise is begun. Correct Answer: B (A) Exercise should not be performed before meals because the blood sugar is usually lower just prior to eating; therefore, there is an increased risk for hypoglycemia. (B) Exercise lowers blood sugar levels; therefore, a snack may be needed to maintain the appropriate glucose level. (C) Exercise lowers blood sugar levels. (D) Exercise lowers blood sugar levels. If the blood glucose level is 100 mg or below at the start of exercise, the potential for hypoglycemia is greater. Question 100 Dietary planning is an essential part of the diabetic client’s regimen. The American Diabetes Association recommends which of the following caloric guidelines for daily meal planning? A. 50% complex carbohydrate, 20%-25% protein, 20%-25% fat B. 45% complex carbohydrate, 25%-30% protein, 30%-35% fat C. 70% complex carbohydrate, 20%-30% protein, 10%-20% fat D. 60% complex carbohydrate, 12%-15% protein, 20%-25% fat Correct Answer: D (A) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney as it is metabolized. (B) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney. (C) The percentage of carbohydrates is too high; the percent range of protein is too high, and of fat, too low. (D) This combination provides enough carbohydrates to maintain blood glucose levels, enough protein to maintain body repair, and enough fat to ensure palatability. Question 101 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, | feel like | have to urinate again!" Which of the following is the most appropriate initial nursing response? A. Assure her that this is most likely the result of bladder spasms. B. Check the collection bag and tubing to verify that the catheter is draining properly. C. Instruct her to do Kegel exercises to diminish the urge to void. D. Ask her if she has felt this way before. Correct Answer: B (A) Although this may be an appropriate response, the initial response would be to assure the patency of the catheter. (B) The most frequent reason for an urge to void with an indwelling catheter is blocked tubing. This response would be the best initial response. (C) Kegel exercises while a retention catheter is in place would not help to prevent a voiding urge and could irritate the urethral sphincter. (D) Though the nurse would want to ascertain whether the client has felt the same urge to void before, the initial response should be to assure the patency of the catheter. Question 102 In cleansing the perineal area around the site of catheter insertion, the nurse would: A. Wipe the catheter toward the urinary meatus B. Wipe the catheter away from the urinary meatus C. Apply a small amount of talcum powder after drying the perineal area D. Gently insert the catheter another '/2 inch after cleansing to prevent irritation from the balloon Correct Answer: B (A) Wiping toward the urinary meatus would transport microorganisms from the external tubing to the urethra, thereby increasing the risk of bladder infection. (B) Wiping away from the urinary meatus would remove microorganisms from the point of insertion of the catheter, thereby decreasing the risk of bladder infection. (C) Talcum powder should not be applied following catheter care, because powders contribute to moisture retention and infection likelihood. (D) The catheter should never be inserted further into the urethra, because this would serve no useful purpose and would increase the risk of infection. hours, when he is especially at high risk for falls. (B) This option would result in the need to get up during the night to urinate and would thus increase the risk of falls. This option also does not take into consideration the clients usual daily routine. (C) Taking this medication with at least one glass of water would not have an impact on the risk of falls. (D) This option would result in the need to get up during the night to urinate and would thus increase the risk of falls. Question 108 The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching? A. "I'll be sure to rise slowly and sit for a few minutes after lying down." B. "I'll be sure to walk at least 2-3 blocks every day." C. "I'll be sure to restrict my fluid intake to four or five glasses a day." D. "I'll be sure not to take any more aspirin while | amon this drug." Correct Answer: A (A) This response will help to prevent the occurrence of postural hypotension, a common side effect of this drug and a common reason for falls. (B) Although walking is an excellent exercise, it is not specific to the reduction of risks associated with diuretic therapy. (C) Clients on diuretic therapy are generally taught to ensure that their fluid intake is at least 20003000 mL daily, unless contraindicated. (D) Aspirin is a safe drug to take along with furosemide. Question 109 A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful? A. Pork chop, baked acorn squash, brussel sprouts B. Chicken breast, rice, and green beans C. Roast beef, baked potato, and diced carrots D. Tuna casserole, noodles, and spinach Correct Answer: A (A) Both acorn squash and brussels sprouts are potassium-rich foods. (B) None of these foods is considered potassium rich. (C) Only the baked potato is a potassium-rich food. (D) Spinach is the only potassium-rich food in this option. Question 110 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 Correct Answer: B (A) Although blurred vision may occur, dizziness would not be associated with an infection or hemorrhage. (B) Eye pain is a symptom of hemorrhage within the eye, and itching is associated with infection. (C) Nausea and headache would not be usual symptoms of eye hemorrhage or infection. (D) Some eye discharge might be anticipated if an infection is present; hemoptysis would not. Question 111 The nurse would teach a male client ways to minimize the risk of infection after eye surgery. Which of the following indicates the client needs further teaching? A. "| will wash my hands before instilling eye medications." B. "| will wear sunglasses when going outside." C. "| will wear an eye patch for the first 3 postoperative days." D. "| will maintain the sterility of the eye medications." Correct Answer: C (A) Hand washing would be an important action designed to prevent transmission of pathogens from the hands to the eye. (B) Wearing sunglasses when going outside will prevent airborne pathogens from entering the eye. (C) Eye patches are most frequently ordered to be worn while the client sleeps or naps, not constantly for this length of time. (D) Eye medications are sterile; clients need to be taught how to maintain this sterility. Question 112 With a geriatric client, the nurse should also assess whether he has been obtaining a yearly vaccination against influenza. Why is this assessment important? A. Influenza is growing in our society. B. Older clients generally are sicker than others when stricken with flu. C. Older clients have less effective immune systems. D. Older clients have more exposure to the causative agents. Correct Answer: C (A) Although influenza is common, the elderly are more at risk because of decreased effectiveness of their immune system, not because the incidence is increasing. (B) Older clients have the same degree of illness when stricken as other populations. (C) As people age, their immune system becomes less effective, increasing their risk for influenza. (D) Older clients have no more exposure to the causative agents than do school-age children, for example. Question 113 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. Correct Answer: A (A) Serum albumin levels indicate the adequacy of protein stores available for tissue repair. (B) Serum albumin does not measure iron stores. (C) Serum albumin levels do not measure kidney function. (D) A decreased serum albumin level would cause fluid movement out of blood vessels, not into them. Question 114 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 C. Metabolic acidosis D. Metabolic alkalosis Correct Answer: D (A) Sodium level is within normal limits. (B) Sodium level is within normal limits. (C) pH level is consistent with alkalosis. (D) With an NG tube attached to low, intermittent suction, acids are removed and a client will develop metabolic alkalosis. Question 120 A client is experiencing muscle weakness and lethargy. His serum Ktis 3.2. What other symptoms might he exhibit? A. Tetany B. Dysrhythmias C. Numbness of extremities D. Headache Correct Answer: B (A) Tetany is seen with low calcium. (B) Low potassium causes dysrhythmias because potassium is responsible for cardiac muscle activity. (C) Numbness of extremities is seen with high potassium. (D) Headache is not associated with potassium excess or deficiency. Question 121 Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome? A. Eating three large meals a day B. Drinking small amounts of liquids with meals C. Taking a long walk after meals D. Eating a low-carbohydrate diet Correct Answer: D (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. Question 122 Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug? A. Limit fluids to 500 mL/day. B. Administer 2 hours before meals. C. Observe for skin rash and diarrhea. D. Monitor blood pressure, pulse. Correct Answer: C (A) Fluids up to 25003000 mL/day are needed to prevent kidney stones. (B) The client should be instructed to take oral preparations with meals or snacks to lessen gastric irritation. (C) Sulfasalazine causes skin rash and diarrhea. (D) Blood pressure and pulse are not altered by sulfasalazine. Question 123 Other drugs may be ordered to manage a client's ulcerative colitis. Which of the following medications, if ordered, would the nurse question? A. Methylprednisolone sodium succinate (Solu-Medrol) B. Loperamide (Imodium) C. Psyllium D. 6-Mercaptopurine Correct Answer: D (A) Methylprednisolone sodium succinate is used for its anti-inflammatory effects. (B) Loperamide would be used to control diarrhea. (C) Psyllium may improve consistency of stools by providing bulk. (D) An immunosuppressant such as 6- mercaptopurine is used for chronic unrelenting Crohns disease. Question 124 A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should: A. Explain that he will be kept NPO for 24 hours before the exam B. Practice with him so he will be able to hold his breath for 1 minute C. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver D. Explain that his vital signs will be checked frequently after the test Correct Answer: D (A) There is no NPO restriction prior to a liver biopsy. (B) The client would need to hold his breath for 510 seconds. (C) There is no pretest laxative given. (D) Following the test, the client is watched for hemorrhage and shock. Question 125 After a liver biopsy, the best position for the client is: A. High Fowler B. Prone C. Supine D. Right lateral Correct Answer: D (A) This position does not help to prevent bleeding. (B) This position does not help to prevent bleeding. (C) This position does not help to prevent bleeding. (D) The right lateral position would allow pressure on the liver to prevent bleeding. Question 126 A complication for which the nurse should be alert following a liver biopsy is: A. Hepatic coma B. Jaundice C. Ascites D. Shock Correct Answer: D (A) Hepatic coma may occur in liver disease due to the increased NH3levels, not due to liver biopsy. (B) Jaundice may occur due to increased bilirubin levels, not due to liver biopsy. (C) Ascites would occur due to portal hypertension, not due to liver biopsy. (D) Hemorrhage and shock are the most likely complications after liver biopsy because of already existing bleeding tendencies in the vascular makeup of the liver. Question 127 Which nursing implication is appropriate for a client undergoing a paracentesis? A. Have the client void before the procedure. B. Keep the client NPO. C. Observe the client for hypertension following the procedure. D. Place the client on the right side following the procedure. Question 132 A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record: A. 3-2-0-0-2 B. 2-2-0-2-2 C. 3-1-1-0-2 D. 2-1-1-0-2 Correct Answer: C (A) This answer is an incorrect application of the GTPAL method. One prior pregnancy was a preterm birth at 36 weeks (T =1, P= 1; not T = 2). (B) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G = 3, not 2), one prior pregnancy was preterm (T= 1, P= 1; not T= 2), and she has had no prior abortions (A =0). (C) This answer is the correct application of GTPAL method. The client is currently pregnant for the third time (G =3), her first pregnancy ended at term (>37 weeks) (T =1), her second pregnancy ended preterm 2033 weeks) (P = 1), she has no history of abortion (A=0), and she has two living children (L = 2). (D) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G =3, not 2). Question 133 A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the gravida and para system to record the clients obstetrical history, the nurse should record: A. Gravida 3 para 1 B. Gravida 3 para 2 C. Gravida 2 para 1 D. Gravida 2 para 2 Correct Answer: B (A) This answer is an incorrect application of gravida and para. The client has had two prior deliveries of more than 20 weeks gestation; therefore, para equals 2, not 1. (B) This answer is the correct application of gravida and para. The client is currently pregnant for the third time (G = 3), regardless of the length of the pregnancy, and has had two prior pregnancies with birth after the 20th week (P = 2), whether infant was alive or dead. (C) This answer is an incorrect application of gravida and para. The client is currently pregnant for the third time (G = 3, not 2); prior pregnancies lasted longer than 20 weeks (therefore, P = 2, not 1). (D) This is an incorrect application of gravida and para. Client is currently pregnant for third time (G = 3, not 2). Question 134 A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate (MgS04) therapy, the nurse knows it is safe to repeat the dosage if: A. Deep tendon reflexes are absent B. Urine output is 20 mL/hr C. MgSO4serum levels are>15 mg/dL D. Respirations are>16 breaths/min Correct Answer: D (A) MgSO4is a central nervous system depressant. Loss of reflexes is often the first sign of developing toxicity. (B) Urinary output at <25 mL/hr or 100 mL in 4 hours may result in the accumulation of toxic levels of magnesium. (C) The therapeutic serum range for MgSO4is 68 mg/dL. Higher levels indicate toxicity. (D) Respirations of>16 breaths/min indicate that toxic levels of magnesium have not been reached. Medication administration would be safe. Question 135 Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH? A. 136/88 to 144/93 B. 132/78 to 124/76 C. 114/70 to 140/88 D. 140/90 to 148/98 Correct Answer: C (A) These blood pressure changes reflect only an 8 mm Hg systolic and a 5 mm Hg diastolic increase, which is insufficient for blood pressure changes indicating PIH. (B) These blood pressure changes reflect a decrease in systolic pressure of 8 mm Hg and diastolic pressure of 2 mm Hg; these values are not indicative of blood pressure increases reflecting PIH. (C) The definition of PIH is an increase in systolic blood pressure of 30 mm Hg and/or diastolic blood pressure of 15 mm Hg. These blood pressures reflect a change of 26 mm Hg systolically and 18mm Hg diastolically. (D) These blood pressures reflect a change of only 8 mm Hg systolically and 8 mm Hg diastolically, which is insufficient for blood pressure changes indicating PIH. Question 136 In assisting preconceptual clients, the nurse should teach that the corpus luteum secretes progesterone, which thickens the endometrial lining in which of the phases of the menstrual cycle? A. Menstrual phase B. Proliferative phase C. Secretory phase D. Ischemic phase Correct Answer: C (A) Menses occurs during the menstrual phase, during which levels of both estrogen and progesterone are decreased. (B) The ovarian hormone responsible for the proliferative phase, during which the uterine endometrium enlarges, is estrogen. (C) The ovarian hormone responsible for the secretory phase is progesterone, which is secreted by the corpus luteum and causes marked swelling in the uterine endometrium. (D) The corpus luteum begins to degenerate in the ischemic phase, causing a fall in both estrogen and progesterone. Question 137 A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full- term girl and is now progressing toward the establishment of successful lactation. To remove the baby from her breast, she should be instructed to: A. Gently pull the infant away B. Withdraw the breast from the infant's mouth C. Compress the areolar tissue until the infant drops the nipple from her mouth D. Insert a clean finger into the baby’s mouth beside the nipple Correct Answer: D (A) In pulling the infant away from the breast without breaking suction, nipple trauma is likely to occur. (B) In pulling the breast away from the infant without breaking suction, nipple trauma is likely to occur. (C) Compressing the maternal tissue does not break the suction of the infant on the breast and can cause nipple trauma. (D) By inserting a finger into the infants mouth beside the nipple, the lactating mother can break the suction and the nipple can be removed without trauma. Question 142 A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20-minute examination, the nurse notes three fetal movements accompanied by accelerations of the fetal heart rate, each 15 bpm, lasting 15 seconds. The nurse interprets this test to be: A. Nonreactive B. Reactive C. Positive D. Negative Correct Answer: B (A) In a nonreactive NST, the criteria for reactivity are not met. (B) A reactive NST shows at least two accelerations of FHR with fetal movements, each 15 bpm, lasting 15 seconds or more, over 20 minutes. (C, D) This term is used to interpret a contraction stress test (CST), or oxytocin challenge test, not an NST. Question 143 The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 1-2 minutes; strong, large amount of "bloody show." The most appropriate nursing goal for this client would be: A. Maintain client’s privacy. B. Assist with assessment procedures. C. Provide strategies to maintain client control. D. Enlist additional caregiver support to ensure client's safety. Correct Answer: C (A) Privacy may help the laboring client feel safer, but measures that enhance coping take priority. (B) The frequency of assessments do increase in transition, but helping the client to maintain control and cope with this phase of labor takes on importance. (C) This laboring client is in transition, the most difficult part of the first stage of labor because of decreased frequency, increased duration and intensity, and decreased resting phase of the uterine contraction. The clients ability to cope is most threatened during this phase of labor, and nursing actions are directed toward helping the client to maintain control. (D) Safety is a concern throughout labor, but helping the client to cope takes on importance in transition. Question 144 A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station 12 means that the: A. Presenting part is 2 cm above the level of the ischial spines B. Biparietal diameter is at the level of the ischial spines C. Presenting part is 2 cm below the level of the ischial spines D. Biparietal diameter is 5 cm above the ischial spines Correct Answer: C (A) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is above the ischial spines, the station is negative. (B) When the biparietal diameter is at the level of the ischial spines, the presenting part is generally at a +4 or +5 station. (C) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is below the ischial spines, the station is positive. Thus, 2 cm below the ischial spines is the station +2. (D) When the biparietal diameter is above the ischial spines by 5 cm, the presenting part is usually engaged or at station 0. Question 145 A pregnant client is at the clinic for a third trimester prenatal visit. During this examination, it has been determined that her fetus is in a vertex presentation with the occiput located in her right anterior quadrant. On her chart this would be noted as: A. Right occipitoposterior B. Right occipitoanterior C. Right sacroanterior D. LOA Correct Answer: B (A) The fetus in the right occipitoposterior position would be presenting with the occiput in the maternal right posterior quadrant. (B) Fetal position is defined by the location of the fetal presenting part in the four quadrants of the maternal pelvis. The right occipitoanterior is a fetus presenting with the occiput in mothers right anterior quadrant. (C) The fetus in right sacroanterior position would be presenting a sacrum, not an occiput. (D) The fetus in left occipitoanterior position would be presenting with the occiput in the mothers left anterior quadrant. Question 146 Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, "Begin oxytocin induction at 1 mU/min." The nurse should: A. Begin the oxytocin induction as ordered B. Increase the dosage by 2 mU/min increments at15-minute intervals C. Maintain the dosage when duration of contractions is 40-60 seconds and frequency is at 2‘/2-4 minute intervals D. Question the order Correct Answer: D (A) Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. (B) This answer is the correct protocol for oxytocin administration, but the medication should not be used until CPD is ruled out. (C) This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used until CPD is ruled out. (D) This answer is the appropriate nursing action because the scenario presents a dysfunctional labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD. Question 147 A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse? A. "Keep breathing with your abdominal muscles as long as you can." B. "Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breathe about 16-20 times a minute with shallow chest breaths." C. "Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles." D. "If a woman in labor listens to her body and takes rapid, deep breaths, she will be able to deal with her contractions quite well." Correct Answer: B (A) Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. (B) In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. (C) It is important to assume a comfortable position in labor, but the Lamazeprepared laboring woman is taught to breathe with her chest, not abdominal, muscles. (D) When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 69 breaths/min. Question 152 A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD). She is started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline level is drawn. Which of the following values represents a therapeutic level? A. 144 g/mL B. 25 p g/mL C.4 g/mL D. 30 pg/mL Correct Answer: A (A) The therapeutic blood level range of theophylline is 1020 mg/mL. Therapeutic drug monitoring determines effective drug dosages and prevents toxicity. (B, D) This value is a toxic level of the drug. (C) This value is a nontherapeutic level of the drug. Question 153 A client is being discharged with albuterol (Proventil) and beclomethasone dipropionate (Vanceril) to be administered via inhalation three times a day and at bedtime. Client teaching regarding the sequential order in which the drugs should be administered includes: A. Glucocorticoid followed by the bronchodilator B. Bronchodilator followed by the glucocorticoid C. Alternate successive administrations D. According to the client’s preference Correct Answer: B (A) The client would not receive therapeutic effects of the glucocorticoid when it is inhaled through constricted airways. (B) Bronchodilating the airways first allows for the glucocorticoid to be inhaled through open airways and increases the penetration of the steroid for maximum effectiveness of the drug. (C) Inac- Inaccurate use of the inhalers will lead to decreased effectiveness of the treatment. (D) Client teaching regarding the use and effects of inhalers will promote client understanding and compliance. Question 154 To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to: A. Rinse the plastic holder that aerosolizes the drug with hydrogen peroxide every other day B. Rinse the mouth and gargle with warm water after each use of the inhaler C. Take antacids immediately before inhalation to neutralize mucous membranes and prevent infection D. Rinse the mouth before each use to eliminate colonization of bacteria Correct Answer: B (A) It is sufficient to rinse the plastic holders with warm water at least once per day. (B) It is important to rinse the mouth after each use to minimize the risk of fungal infections by reducing the droplets of the glucocorticoid left in the oral cavity. (C) Antacids act by neutralizing or reducing gastric acid, thus decreasing the pH of the stomach. "Neutralizing" the oral mucosa prior to inhalation of a steroid inhaler does not minimize the risk of fungal infections. (D) Rinsing prior to the use of the glucocorticoid will not eliminate the droplets left on the oral mucous membranes following the use of the inhaler. Question 155 Which of the following would indicate the need for further teaching for the client with COPD? The client verbalizes the need to: A. Eat high-calorie, high-protein foods B. Take vitamin supplementation C. Eliminate intake of milk and milk products D. Eat small, frequent meals Correct Answer: C (A) Protein is vital for the maintenance of muscle to aid in breathing. A high-calorie diet using higher fat than carbohydrate content is given because clients are unable to breathe off the excess CO2that is an end product of carbohydrate metabolism. (B) Inadequate nutritional status, in particular, deficiencies in vitamins A and C, decreases resistance to infection. (C) Milk does not make mucus thicker. It may coat the back of the throat and make it feel thicker. Rinsing the mouth with water after drinking milk will prevent this problem. (D) Small, frequent meals minimize a fullness sensation and reduce pressure on the diaphragm. The work of breathing and SOB are also reduced. Question 156 A dose of theophylline may need to be altered if a client with COPD: A. ls allergic to morphine B. Has a history of arthritis C. Operates machinery D. Is concurrently on cimetidine for ulcers Correct Answer: D (A) The effects of morphine or an allergic response to the drug will not affect theophylline clearance. (B) Xanthines are used cautiously in clients with severe cardiac disease, liver disease, cor pulmonale, hypertension, or hyperthyroidism. Arthritis does not influence the dosage of theophylline. (C) Theophylline does not cause sedation or drowsiness. Conversely, its side effects may be exhibited by central nervous system stimulation. (D) Cimetidine decreases theophylline clearance from the system and increases theophylline levels in the blood, thus increasing the risk of toxicity. Question 157 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 Correct Answer: D (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. Question 158 Which of the following changes in blood pressure readings should be of greatest concern to the nurse when assessing a prenatal client? A. 130/88 to 144/92 B. 136/90 to 148/100 C. 150/96 to 160/104 C. Noise or bright lights may precipitate a convulsion. D. External stimuli are annoying to the client with PIH. Correct Answer: C (A) The client may be anxious and hyperresponsive to stimuli but not necessarily restless. (B) This is not a physiological response to an elevated blood pressure in PIH. (C) The nurse must know the nursing measures that decrease the potential for convulsions. A quiet, darkened room decreases stimuli and promotes rest. (D) External stimuli might induce a convulsion but are not annoying to the client with PIH. Question 164 A 26-year-old client is admitted to the labor, delivery, recovery, postpartum unit. The nurse completes her assessment and determines the client is in the first stage of labor. The nurse should instruct her: A. To hold her breath during contractions B. To be flat on her back C. Not to push with her contractions D. To push before becoming fully dilated Correct Answer: C (A) This nursing action may cause hyperventilation. (B) This nursing action could cause inferior vena cava syndrome. (C) The client is allowed to push only after complete dilation during the second stage of labor. The nurse needs to know the stages of labor. (D) If the client pushes before dilation, it could cause cervical edema and/or edema to the fetal scalp; both of these could contribute to increased risk of complications. Question 165 In addition to changing the mothers position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina: A. Immediately pour sterile saline on the cord, and repeat this every 15 minutes to prevent drying. B. Cover the cord with a wet sponge. C. Apply a cord clamp to the exposed cord, and cover with a sterile towel. D. Keep the cord warm and moist by continuous applications of warm, sterile saline compresses. Correct Answer: D (A) Saline should be warmed; waiting 15 minutes may not keep the cord moist. (B) This choice does not specify what the sponge was "wet" with. (C) This measure would stop circulation to the fetus. (D) The cord should be kept warm and moist to maintain fetal circulation. This measure is an accepted nursing action. Question 166 Which of the following signs might indicate a complication during the labor process with vertex presentation? A. Fetal tachycardia to 170 bpm during a contraction B. Nausea and vomiting at 8-10 cm dilation C. Contraction lasting 60 seconds D. Appearance of dark-colored amniotic fluid Correct Answer: D (A) Fetal tachycardia may indicate fetal hypoxia; however, 170 bpmis only mild tachycardia. (B) Nausea and vomiting occur frequently during transition and are not a complication. (C) Contractions frequently last 6090 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. (D) Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part. Question 167 A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurses first intervention should be to: A. Check FHT B. Notify the attending physician C. Turn off the IV oxytocin D. Prepare for the delivery because the client is probably in transition Correct Answer: C (A) FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. (B) The physician should be notified, but this is not the first intervention the nurse should do. (C) The standard of care for an induction according to the Association of Womens Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. (D) Contractions lasting 6090 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor. Question 168 During a clients 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 D. Urine retention or a distended bladder Correct Answer: D (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. affected resulting in fat, foul, frothy, bulky stools. (C) Dark brown stools indicate normal passage through the colon. (D) Blood-tinged stools indicate dysfunction of the gastrointestinal (Gl) tract. Question 174 A group of nursing students at a local preschool day care center are going to screen each childs fine and gross motor, language, and social skills. The students will use which one of the most widely used screening tests? A. Revised Prescreening Developmental Questionnaire B. Goodenough Draw-a-Person Screening Test C. Denver Development Screening Test D. Caldwell Home Inventory Correct Answer: C (A) The Revised Prescreening Developmental Questionnaire is more age appropriate and offers simplified parent scoring and easier comparison. It is used by parents instead of professionals. (B) The Goodenough Draw-a-Person test is used to assess intellectual development. (C) The Denver Developmental Screening Test is one of the most widely used screening tests. It offers a concise, easy-to-administer, systematic approach to assessing the preschool child. It is widely used because of its reliability and validity. (D) The Caldwell Home Inventory is used to assess the home environment in area of social, emotional, and cognitive supports. Question 175 A mother came to the pediatric clinic with her 17- month-old child. The mother would like to begin toilet training. What should the nurse teach her about implementing toilet training? A. Take two or three favorite toys with the child. B. Have a child-sized toilet seat or training potty on hand. C. Explain to the child she is going to "void" and "defecate." D. Show disapproval if she does not void or defecate. Correct Answer: B (A) Giving her toys will distract her and interfere with toilet training because of inappropriate reinforcement. (B) A child-sized toilet seat or training potty gives a child a feeling of security. (C) She should use words that are age appropriate for the child. (D) Children should be praised for cooperative behavior and/or successful evacuation. Question 176 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 Correct Answer: A (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 612 months of age to help visual stimulation. Question 177 A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention? A. Increased pulse rate B. Increased expectorate of secretions C. Decreased inspiratory difficulty D. Increased respiratory rate Correct Answer: C (A) A side effect of epinephrine is fatal ventricular fibrillation owing to its effects on cardiac stimulation. (B) Medications used to treat asthma are designed to decrease bronchospasm, not to increase expectorate of secretions. (C) Epinephrine decreased inspiratory difficulty by stimulating -, 1, and 2-receptors causing sympathomimetic stimulation (e.g., bronchodilation). (D) The person with asthma fights to inspire sufficient air thus increasing respiratory rate. Question 178 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 C. Increased airway resistance D. Continuous changes in respiratory rate and depth Correct Answer: C (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) Asthma is characterized by spasm and constriction of the airways resulting in increased resistance to airflow. (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. Question 179 A mother frantically calls the emergency room (ER) asking what to do about her 3-year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to: A. Give the child 15 mL of syrup of ipecac. B. Give the child 10 mL of syrup of ipecac with a sip of water. C. Give the child 1 cup of water to induce vomiting. D. Bring the child to the ER immediately. Correct Answer: D (A) Before giving any emetic, the substance ingested must be known. (B) At least 8 oz of water should be administered along with ipecac syrup to increase volume in the stomach and facilitate vomiting. (C) Water alone will not induce vomiting. An emetic is necessary to facilitate vomiting. (D) Vomiting should never be induced in an unconscious client because of the risk of aspiration. Question 180 A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate? Question 184 An 8-week-old infant has been diagnosed with gastroesophageal reflux. The nurse is teaching the infant’s mother to care for the infant at home. Which one of the following statements by the nurse is appropriate regarding the infant’s home care? A. "Lay the infant flat on her left side after feeding." B. "Feed the infant every 4 hours with half-strength formula." C. "Antacids need to be given an hour before feeding." D. "Play activities should be carried out before instead of after feedings." Correct Answer: D (A) Elevating the childs head to a 30-degree angle is the recommended position for gastroesophageal reflux. The supine position predisposes the child to aspiration. (B) Small, frequent feedings with thickened formula are recommended to minimize vomiting. (C) Antacids should be given at the same time as the feeding to improve their buffering action. (D) The infant should be kept still after feedings to reduce the risk of vomiting and aspiration. Vigorous activities should be carried out before feedings. Question 185 The nurse is preparing a 6-year-old child for an IV insertion. Which one of the following statements by the nurse is appropriate when preparing a child for a potentially painful procedure? A. "Some say this feels like a pinch or a bug bite. You tell me what it feels like." B. "This is going to hurt a lot; close your eyes and hold my hand." C. "This is a terrible procedure, so don’t look." D. "This will hurt only a little; try to be a big boy." Correct Answer: A (A) Educating the child about the pain may lessen anxiety. The child should be prepared for a potentially painful procedure but avoid suggesting pain. The nurse should allow the child his own sensory perception and evaluation of the procedure. (B) The nurse should avoid absolute descriptive statements and allow the child his own perception of the procedure. (C) The nurse should avoid evaluative statements or descriptions and give the child control in describing his reactions. (D) False statements regarding a painful procedure will cause a loss of trust between the child and the nurse. Question 186 The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take? A. Place a tongue blade in the child’s mouth. B. Restrain the child so he will not injure himself. C. Go to the nurses station and call the physician. D. Move furniture out of the way and place a blanket under his head. Correct Answer: D (A) The nurse should not put anything in the childs mouth during a seizure; this action could obstruct the airway. (B) Restraining the childs movements could cause constrictive injury. (C) Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. (D) The nurse should provide safety for the child by moving objects and protecting the head. Question 187 A six-month-old infant is receiving ribavirin for the treatment of respiratory syncytial virus. Ribavirin is administered via which one of the following routes? A. Oral B.IM C.IV D. Aerosol Correct Answer: D (A) Ribavirin is not supplied in an oral form. (B) Ribavirin is administered by aerosol in order to decrease the duration of viral shedding within the infected tissue. (C) Ribavirin is not approved for IV use to treat respiratory syncytial virus. (D) Ribavirin is a synthetic antiviral agent supplied as a crystalline powder that is reconstituted with sterile water. A Small Aerosol Particle Generator unit aerosolizes the medication for delivery by oxygen hood, croup tent, or aerosol mask. Question 188 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 Correct Answer: B (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. Question 189 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 full thickness burns to 25% of her body? A. Urine output B. Edema C. Hypertension D. Bulging fontanelle Correct Answer: A (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. Question 190 A 4-year-old child is being discharged from the hospital after being treated for severe croup. Which one of the following instructions should the nurse give to the childs mother for the home treatment of croup? A. Take him in the bathroom, turn on the hot water, and close the door. B. Give him a dose of antihistamine. C. Give large amounts of clear liquids if drooling occurs. D. Place him near a cool mist vaporizer and encourage crying. Correct Answer: A (A) Initial home treatment of croup includes placing the child in an environment of high humidity to liquefy and mobilize secretions. (B) Antihistamines should be avoided because they can cause thickening of secretions. (C) Drooling is a characteristic sign of airway obstruction and the child should be taken directly to the emergency room. (D) Crying increases respiratory distress and hypoxia in the child with croup. The nurse should promote methods that will calm the child. Question 194 A 26-year-old client is in a treatment center for aprazolam (Xanax) abuse and continues to manifest moderate levels of anxiety 3 weeks into the rehabilitation program, often requesting medication for "his nerves." Included in the client’s plan of care is to identify alternate methods of coping with stress and anxiety other than use of medication. After intervening with assistance in stress reduction techniques, identifying feelings and past coping, the nurse evaluates the outcome as being met if: A. Client promises that he will not abuse aprazolam after discharge B. Client demonstrates use of exercise or physical activity to handle nervous energy following conflicts of everyday life C. Client is able to verbalize effects of substance abuse on the body D. Client has remained substance free during hospitalization and is discharged Correct Answer: B (A) This client response does not address stress reduction techniques. Verbal response focuses only on the problem. (B) Exercise or physical activity is a common strategy or coping technique used to reduce stress and anxiety. (C) Verbalizing effects of substance abuse on the body may help with insight and break through denial, but it is not a strategy to reduce anxiety. (D)Remaining substance-free does indicate motivation to change lifestyle of substance abuse or dependence, and it is not a stress reduction strategy in itself. Question 195 A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by: A. Placing her in seclusion until the behavior is under control B. Walking up to the client and touching her on the arm to get her attention C. Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet area D. Confronting the client, letting her know the consequences for getting angry and disrupting the unit Correct Answer: C (A) Threatening a client with punitive action is violating a clients rights and could escalate the clients anger. (B) Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. (C) Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance from staff. (D) Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry. Question 196 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 Correct Answer: D (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 lifes 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. Question 197 A 56-year-old psychiatric inpatient has had recurring episodes of depression and chronic low self- esteem. She feels that her family does not want her around, experiences a sense of helplessness, and has a negative view of herself. To assist the client in focusing on her strengths and positive traits, a strategy used by the nurse would be to: A. Tell the client to attend all structured activities on the unit B. Encourage or direct client to attend activities that offer simple methods to attain success C. Increase the client’s self-esteem by asking that she make all decisions regarding attendance in group activities D. Not allow any dependent behaviors by the client because she must learn independence and will have to ask for any assistance from staff Correct Answer: B (A) The nurse should encourage activities gradually, as clients energy level and tolerance for shared activities improve. (B) Activities that focus on strengths and accomplishments, with uncomplicated tasks, minimize failure and increase self-worth. (C) Asking a client to set a goal to make all decisions about attending group activities is unrealistic, and such decisions are not always under the clients control; this sets up the client for further failure and possibly decreased self-worth. (D) Encouragement toward independence does promote increased feelings of selfworth; however, clients may need assistance with decision making and problem solving for various situations and on an individual basis. Question 198 A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, "I just couldn't take it anymore." The nurse's best response to this disclosure would be: A. "You shouldn't do things like that, just tell someone you feel bad." B. "Tell me more about what you couldn't take anymore." C. "I’m sure you probably didn’t mean to kill yourself." D. "How long have you been in the hospital." Correct Answer: B (A) Disapproving gives the impression that the nurse has a right to pass judgment on the clients thoughts, actions, or ideas. (B) Giving a broad opening gives the client encouragement to continue with verbalization. (C) Failing to acknowledge the clients feelings conveys a lack of understanding and empathy. (D) Changing the subject takes the conversation away from the client and is indicative of the nurses anxiety or insensitivity. Question 199 A 42-year-old client with bipolar disorder has been hospitalized on the inpatient psychiatric unit. She is dancing around, talking incessantly, and singing. Much of the time the client is anorexic and eats very little from her tray before she is up and about again. The nurses intervention would be to: A. Confront the client with the fact that she will have to eat more from her tray to sustain her B. Try to get the client to focus on her eating by offering a detailed discussion on the importance of nutrition C. Let her have snacks and drinks anytime that she wants them because she will not eat at regular meal times D. Not expect the client to sit down for complete meals; monitor intake, offering snacks and juice frequently Correct Answer: D (A) Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. (B) Clients experiencing delusions of persecution believe that others in the environment are plotting against them. (C) Clients experiencing thought broadcasting perceive that others can hear their thoughts. (D) Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers. Question 204 A client experiencing delusions states, "| came here because there were people surrounding my house that wanted to take me away and use my body for science." The best response by the nurse would be: A. "Describe the people surrounding your house that want to take you away." B. "| need more information on why you think others want to use your body for science." C. "There were no people surrounding your house, your relatives brought you here, and no one really wants your body for science." D. "| know that must be frightening for you; let the staff know when you are having thoughts that trouble you." Correct Answer: D (A) Focusing on the delusional content does not reinforce reality. (B) Pursuing details or more information on the delusion reinforces the false belief and further distances the client from reality. (C) Challenging the clients delusional system may force the client to defend it, and you cannot change the delusion through logic. (D) Focusing on the feeling can reinforce reality and discourage the false belief. Seeking out staff when thoughts are troublesome can help to decrease anxiety. Question 205 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. Correct Answer: A (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 clients 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. Question 206 A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, "| know that alcohol is a problem for some people, but | can stop whenever | 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. "| understand it took strength to admit yourself to the unit, and | 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." Correct Answer: B (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 clients freedom to behave in a way that may displease another. This response may lead to seeking praise instead of progress. Question 207 A 79-year-old client with Alzheimer’s disease is exhibiting significant memory impairment, cognitive impairment, extremely impaired judgment in social situations, and agitation when placed in a new situation or around unfamiliar people. The nurse should include the following strategy in the client’s care: A. Maintain routines and usual structure and adhere to schedules. B. Encourage the client to attend all structured activities on the unit, whether she wants to or not. C. Ask the client to go to an activity once. If she gives no response right away, change the question around, asking the same thing. D. Give the client two or three choices to decide what she wants to do. Correct Answer: A (A) Alzheimers clients cope poorly with changes in routine because of memory deficits. Schedule changes cause confusion and frustration, whereas adhering to schedules is helpful and supports orientation. (B) Insisting that the client go to all unit activities may antagonize her and increase her agitation because of cognitive impairments. It may be better to allow the client time for calming down or distraction rather than to insist that she attend every activity. (C) When repeating a question, allow time first for a response; then use the same words the second time to avoid further confusion. (D) The nurse should avoid giving several choices at once. Cognitively impaired clients will become more frustrated with making decisions. Question 208 The nurse working with a client who is out of control should follow a model of intervention that includes which of the following? A. Approach the client on a continuum of least restrictive care. B. Challenge client’s behavior immediately with steps to prevent injury to self or others. C. Leave the aggressive client to himself or herself, and take other clients away. D. To ensure safety of other clients, place client in seclusion immediately when he or she begins shouting. Correct Answer: A (A) Approaching a clients aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). (B) Approaching a client in a challenging manner is threatening and inappropriate. A nonchallenging and calm approach reflects staff in control and may increase clients internal control. (C) It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. (D) Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention. closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, "What is the greatest risk to my baby if it is born prematurely?" The RN’s answer should be: A. Hyperglycemia B. Hypoglycemia C. Lack of development of the intestines D. Lack of development of the lungs Correct Answer: D (A) Any infant would be at risk for hyperglycemia because the infants 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 infants 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 infants 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. Question 214 At 30 weeks gestation, a client is admitted to the unit in premature labor. Her physician orders that an IV be started with 500 mL D5W mixed with 150 mg of ritodrine stat. The RN prepares the IV solution with the medication. The RN knows that clients receiving the medication ritodrine IV should be observed closely for which one of the following side effects: A. Hypoglycemia B. Hyperkalemia C. Tachycardia D. Increase in hematocrit and hemoglobin Correct Answer: C (A) Ritodrine is a sympathomimetic 2-adrenergic agonist that can cause an elevation of blood glucose and plasma insulin in pregnant women. Hyperglycemia can occur in women with abnormal carbohydrate metabolism because of their inability to release more insulin. (B) Hypokalemia can occur resulting from the action of the _-mimetics. It results from a displacement of the extracellular potassium into the intracellular space. (C) Ritodrine causes vasodilation of vessel walls, which can lead to hypotension. The body compensates by increasing heart rate and pulse pressure. (D) There is a lowering of serum iron resulting from the action of _- mimetics to activate hematopoiesis. Question 215 At 32 weeks’ gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, "How do | prepare for the test | am scheduled for?" The RN will most likely inform her of the following instructions to help prepare her for the test: A. "You need to know that an IV is always started before the test." B. "You will need to drink 6 to 8 glasses of water to fill your bladder." C. "Do not eat any food or drink any liquids before the test is started." D. "You will have to remain as still as you possibly can." Correct Answer: D (A) An IV line is not started in a nonstress test, because this test is used as an indicator of fetal well- being. This test measures fetal activity and heart rate acceleration. (B) The bladder does not have to be full prior to this test. It is not a sonogram test where a full bladder enables other structures to be scanned. (C) It has been proved that eating or drinking liquids prior to the test can assist in increasing fetal activity. (D) Any maternal activity will interfere with the results of the test. Question 216 After the fetal activity test (nonstress test) is completed, the RN is looking at the test results on the monitor strip. The RN observes that the fetal heart accelerated 5 beats/min with each fetal movement. The accelerations lasted 15 seconds and occurred 3 times during the 20- minute test. The RN knows that these test results will be interpreted as: A. A reactive test B. A nonreactive test C. An unsatisfactory test D. A negative test Correct Answer: A (A) A nonstress test that shows at least two accelerations of the fetal heart rate of 15 bpm with fetal activity, lasting 15 seconds over a 20- minute period. (B) Reactive criteria are not met. The accelerations of the fetal heart rate are not at least 15 bpm and do not last 15 seconds. This could mean fetal well-being is compromised. Usually a contraction stress test is ordered if the nonstress test results are negative. (C) An unsatisfactory test means the data cannot be interpreted, or there was inadequate fetal activity. If this happens, usually the test is ordered to be done at a later date. (D) A negative test is a term used to describe the results of a contraction stress test. Question 217 At 38 weeks gestation, a client is in active labor. She is using her Lamaze breathing techniques. The RN is coaching her breathing and encouraging her to relax and work with her contractions. Which one of the following complaints by the client will alert the RN that she is beginning to hyperventilate with her breathing? A. "lam cold." B. "| have a backache." C. "| feel dizzy." D. "| am nauseous.” Correct Answer: C (A) Cold is not a symptom of hyperventilation. This could be due to the temperature of the room. (B) Backache is not a symptom of hyperventilation. This is probably due to the gravid uterus and its effect on the back muscles, or it may be due to the clients position in bed. (C) Dizziness is the first symptom of hyperventilation. It occurs because the body is eliminating too much C02. (D) Nausea is not a symptom of hyperventilation. It could be a symptom of pain. Question 218 After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis? A. One centimeter below the ischial spines B. One centimeter above the ischial spines C. Has not entered the pelvic inlet yet D. Located in the pelvic outlet Correct Answer: B