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A client is admitted postcraniotomy. Decadron 4 mg IV is ordered

every six hours. The nurse understands the Decadron is ordered to

1. Incorrect prevent seizures.
2. Incorrect maintain the integrity of the gastric mucosa.
3. Correct decrease cerebral edema.
4. Incorrect stabilize the blood sugar. Answer Rationale:
5. Cerebral edema is common after surgery. Decadron (a corticosteroid) is given to decrease the edema. Question 102 of 385 A client is admitted with a C7 complete transection. In the immediate postinjury period, the nurse must plan for
6. Correct possible ventilatory support.
7. Incorrect bladder and bowel training.
8. Incorrect complications of autonomic dysreflexia.
9. Incorrect diaphragmatic pacing. Answer Rationale:
10. Edema above the area of the lesion can cause respiratory depression and arrest. Question 103 of 385 A client fell backward over a stair rail to the floor below, and is not breathing. After calling for assistance, how should the nurse proceed?
11. Incorrect After determining pulselessness, administer five chest compressions at the rate of 60 per minute.
12. Correct Initiate rescue breathing by performing a jaw thrust maneuver and administering two breaths.
13. Incorrect Initiate rescue breathing by performing a chin tilt maneuver and administering two breaths.
14. Incorrect After determining absence of breathing, administer 15 chest compressions at the rate

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of 60 per minute. Answer Rationale:

2. When initiating rescue breathing for a client with a suspected spinal

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injury, the jaw thrust maneuver is used with rescue breathing at the rate of 12 breaths per minute. Question 104 of 385 A client with a cervical spine injury was placed in Halo traction yesterday. When the client complains of discomfort around the pins, what action should the nurse take?

1. Incorrect Loosen the pins immediately and maintain the head in a neutral position.
2. Correct Give the ordered analgesic and reassure the client that the pain is temporary.
3. Incorrect Carefully loosen the pins and notify the physician immediately.
4. Incorrect Cleanse the skin around the pin sites and dry the area thoroughly. Answer Rationale:
5. Discomfort at the pin sites is expected for several days after application of the Halo device. The pain can be controlled with mild analgesic medication. The client can benefit from the reassurance that the pain will not continue for the weeks that the traction will be in place. Question 105 of 385 A client with a C6 spinal cord injury two months ago now complains of a pounding headache. The pulse is 64 and the blood pressure is 220/110 mmHg. Which of the following actions should the nurse take first?
6. Incorrect Notify the physician.
7. Correct Elevate the client's head and lower the legs.
8. Incorrect Give the analgesic as ordered.
9. Incorrect Check for fecal impaction. Answer Rationale:
10. The client is showing signs of autonomic dysreflexia. Placing the client in a sitting position will allow blood to pool in the legs, which should lower the blood pressure and prevent possible hypertensive hemorrhage.

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Question 106 of 385 The nurse is evaluating the ability of a client with trigeminal neuralgia to implement the treatment that has been suggested. Which of the following

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behaviors by the client will be most effective in controlling manifestations? The client

1. Incorrect puts the affected arm through full range of motion daily.
2. Incorrect uses proper body mechanics in sitting and bending.
3. Correct avoids extremes in temperature of food and drink.
4. Incorrect exercises the facial muscles at least twice daily. Answer Rationale:
5. Extremes of temperature of food or drink can trigger paroxysms of severe facial pain along the pathways of the trigeminal nerve. Meals are better tolerated if served at room temperature. Question 107 of 385 A client with Bell's palsy asks the nurse why artificial tears were ordered by the physician. Select the best reply by the nurse.
6. Incorrect "Because your eye remains closed, foreign matter can be trapped beneath the lid."
7. Incorrect "Artificial tears will remove the purulent drainage from your eye, which speeds healing."
8. Correct "Because you cannot blink the affected eye, it can become dry and irritated."
9. Incorrect "When your affected eye fails to make tears, the eye can become irritated and ulcerated." Answer Rationale:
10. Bell's palsy may cause paralysis of the eyelid and loss of the blink reflex on the affected side. The eye may not close completely. These problems render the eye susceptible to drying and irritation from dust or other debris. Question 108 of 385 A nurse is caring for a client with Guillain-Barré syndrome. Which of the following strategies is of the most importance in the plan of care?
11. Incorrect Use of artificial tears.
12. Incorrect Starting an enteral feeding.
13. Correct Frequent measurement of vital capacity.
14. Incorrect Range of motion exercises three to four

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times per day. Answer Rationale:

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3. Clients with Guillain-Barré have respiratory muscle weakness and respiratory failure. Question 109 of 385 The nurse has presented information about amyotrophic lateral sclerosis (ALS) to a newly diagnosed client. Which question by the client indicates that he understands the nature of the disease?
4. Incorrect "How can I avoid infecting my family with the virus?"
5. Incorrect "How can I prevent an exacerbation of the disease?"
6. Incorrect "How many people achieve remission with chemotherapy?"
7. Correct "How can I execute a living will?" Answer Rationale:
8. Clients with ALS often experience respiratory failure as the disease progresses, and need to communicate their wishes regarding ventilator support. The nurse should explore the client's wishes and facilitate discussion within the family. Arranging for the client to sign a living will, if the client wishes to do so, is also a nursing responsibility. Question 110 of 385 A client reports gradual painless blurring of vision. On assessment, the nurse notes a cloudy opaque lens. Based on this assessment, the nurse suspects the client has
9. Incorrect retinal detachment.
10. Correct cataracts.
11. Incorrect diabetic retinopathy.
12. Incorrect glaucoma. Answer Rationale:
13. These are the assessment findings of cataracts. Question 111 of 385 Which of the following risk factors would the nurse assess for in a

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client with glaucoma?

1. Correct Family history, increased intraocular pressure, and age of 45–

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2. Incorrect Myopia, history of diabetes, and sudden severe physical exertion.
3. Incorrect History of diabetes and age greater than 50.
4. Incorrect Female gender, cigarette smoking, age greater than 65. Answer Rationale:
5. These are common risk factors for glaucoma. Question 112 of 385 The nurse has been planning for home care with the family of a client who will undergo extracapsular lens extraction with an intraocular lens implant. Because the client and family speak very little English, the nurse takes extra care to evaluate their understanding. Which behavior by the client and/or family shows progress in understanding post-op home care instructions?
6. Incorrect The family demonstrates that the eye should be cleaned with a washcloth, soap, and water.
7. Correct The family shows the nurse the sunglasses they have purchased for the client to wear post-op.
8. Incorrect The client demonstrates medication instillation by carefully dropping the solution on the cornea.
9. Incorrect Using a chart showing various sleeping positions, the client points to a person lying on the affected side. Answer Rationale:
10. Sunglasses should be worn post-op for comfort and protection when outdoors. Question 113 of 385 A nurse is admitting a client who reports vision loss. To determine if a client has glaucoma or a detached retina, the nurse understands that a client with glaucoma will report
11. Incorrect seeing floating spots.
12. Incorrect seeing flashing lights.

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3. Correct eye pain.
4. Incorrect sudden loss of vision. Answer Rationale:
5. Eye pain is present with open and narrow angle glaucoma, but not with a detached retina.

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Question 114 of 385 Which of the following techniques should the nurse use to evaluate a client's understanding of self-care for chronic (primary) open angle glaucoma?

1. Correct The nurse observes the client's administration of eye drops.
2. Incorrect The nurse observes the client's technique for monitoring blood glucose.
3. Incorrect The nurse measures the client's blood pressure at each visit.
4. Incorrect The nurse measures hearing acuity at each visit. Answer Rationale:
5. Glaucoma is usually treated with eye drops, such as betaxolol (Timoptic), a beta- adrenergic antagonist. The eye can be damaged when eye drops are used incorrectly. Question 115 of 385 A client is admitted with a detached retina of the left eye. The nurse patches both eyes. What is the rationale for patching both eyes?
6. Incorrect To prevent photophobia.
7. Correct To decrease eye movement.
8. Incorrect To prevent nystagmus.
9. Incorrect To prevent eye infections. Answer Rationale:
10. Eye movements can increase the amount of detachment. Question 116 of 385 A neighbor splashes chlorine bleach in her eyes and calls the nurse for immediate help. The first action the nurse should take is to
11. Incorrect lift the upper lid over the lower lid of each eye.
12. Incorrect close and patch both eyes with a loose bandage.
13. Correct continuously flush the eyes with tap water for 20 minutes.
14. Incorrect instill an over-the-counter anti-irritant solution, such as Visine. Answer Rationale:
15. Immediate irrigation with copious amounts of water or normal

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saline solution may reduce alkaline burns of the cornea and conjunctiva. Any

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delay in initiating the irrigation can result in serious damage to eye structures. Question 117 of 385 A client reports bilateral hearing loss. On assessment of the ear, the nurse observes chalky white plaques on the eardrum and the eardrum appears pinkish orange in color. The Rinne test favors bone conduction. Based on this assessment, the nurse suspects the client has (a)

1. Correct otosclerosis.
2. Incorrect external otitis.
3. Incorrect cholesteatoma.
4. Incorrect actinic keratosis. Answer Rationale:
5. These are classic signs of otosclerosis. Question 118 of 385 The nurse is teaching a post-op stapedectomy client. What should be included in the teaching?
6. Correct Blow the nose gently one side at a time.
7. Incorrect Resume exercise in one week.
8. Incorrect Work can be resumed the next day.
9. Incorrect Gently sneeze or cough with the mouth closed. Answer Rationale:
10. The client should blow the nose gently one side at a time to prevent pressure changes in the ear. Question 119 of 385 A client reports very loud, overpowering ringing in the ears, fluctuating hearing loss on the right side with severe vertigo accompanied by nausea and vomiting, and a feeling of fullness in the right ear. The nurse suspects the client has (a)
11. Incorrect acoustic neuroma.
12. Incorrect otosclerosis.

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3. Correct Ménière's disease.

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4. Incorrect cholesteatoma. Answer Rationale:
5. These are classic signs of Ménière's disease. Question 120 of 385 What is the priority nursing diagnosis for a client with very loud overpowering ringing in his ears, fluctuating hearing loss on the right side with severe vertigo accompanied by nausea and vomiting and a feeling of fullness in the right ear?
6. Incorrect Pain.
7. Incorrect Anxiety.
8. Incorrect Impaired physical mobility.
9. Correct Knowledge deficit related to the disease process. Answer Rationale:
10. This client most likely has Ménière's disease. In Ménière's disease, patient education is paramount. The client needs to be taught that with the increased volume of hydrolymph, excessive fluid intake increases the volume even more and exacerbates the disease. They should also be taught not to ambulate or make extreme movements during the acute attacks. Question 121 of 385 A client is being assessed to rule out cardiovascular problems. The nurse understands that some of the common symptoms associated with cardiovascular disease are
11. Incorrect fatigue, weight changes, mood swings.
12. Correct shortness of breath, chest discomfort, palpitations.
13. Incorrect mood swings, headaches, fainting.
14. Incorrect dyspnea, chest discomfort, sputum production. Answer Rationale:
15. Some of the most common clinical manifestations of cardiovascular disease are shortness of breath, chest pain or

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discomfort, dyspnea, palpitations, fainting, and peripheral skin changes such as edema.

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Question 122 of 385 Which of the following assessment findings by the nurse is abnormal?

1. Correct S 4 heard at the apex in an 80-year-old male.
2. (^) Incorrect S 3 heard at the apex in a 15-year-old female.
3. (^) Incorrect S 1 heard at the fourth-fifth left intercostal space in a 35-year-old (^) man.
4. (^) Incorrect S 2 heard at the second-third left intercostal space in a 40- year-old (^) female. Answer Rationale:
5. (^) S 4 is an abnormal heart sound. It is indicative of decreased ventricular compliance. Question 123 of 385 Which of the following instructions should the nurse give to a client prior to an exercise electrocardiogram?
6. Incorrect Smoking is permitted up to the time of the test.
7. Incorrect Allow only three hours of sleep the night prior to the test.
8. Correct Avoid coffee, tea, and alcohol the day of the test.
9. Incorrect Take all medications as prescribed prior to the test. Answer Rationale:
10. Avoid any stimulants such as coffee, tea, or a depressant such as alcohol. Question 124 of 385 To prevent possible complication, which of the following questions should a nurse ask a client prior to a cardiac catheterization?
11. Incorrect "Do you understand the procedure?"
12. Correct "Can you eat shellfish?"
13. Incorrect "Have you ever had a heart attack?"
14. Incorrect "Have you ever had a cardiac catheterization before?" Answer Rationale:
15. Shellfish contains iodine, which is also in the contrast media used during a catheterization. It is imperative to

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obtain information regarding iodine allergies.

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Question 125 of 385 Which of the following should the nurse include in the plan of care for a post-op coronary arteriogram client?

1. Incorrect Monitor vital signs every eight hours.
2. Incorrect Assess lung sounds.
3. Incorrect Provide early ambulation.
4. Correct Assess pedal pulses. Answer Rationale:
5. Assessment of pedal pulses is imperative after a cardiac catheterization. Evaluation of presence and quality of pulses indicates blood flow to the catheterized extremity. A client has the following rhythm. The client has no pulse or blood pressure. The nurse interprets the rhythm as
6. Correct ventricular tachycardia.
7. Incorrect supraventricular tachycardia.
8. Incorrect ventricular fibrillation.
9. Incorrect sinus tachycardia. Answer Rationale:
10. The above rhythm is ventricular tachycardia. Question 126 of 385 A client has the following rhythm. The client has no pulse or blood pressure. The nurse interprets the rhythm as
11. Incorrect supraventricular tachycardia.
12. Incorrect ventricular tachycardia.
13. Incorrect sinus tachycardia.

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Question 127 of 385

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4. Correct ventricular fibrillation. Answer Rationale:
5. The above rhythm is ventricular fibrillation. Question 128 of 385 A client had a myocardial infarction yesterday. His cardiac monitor shows six to eight PVCs per minute, with occasional couplets. The best action by the nurse at this time is to
6. Incorrect initiate manual chest compressions.
7. Incorrect monitor the client for development of ventricular tachycardia.
8. Incorrect perform a precordial thump.
9. Correct administer the ordered prn dose of lidocaine. Answer Rationale:
10. Lidocaine, a class I antidysrhythmic drug, is indicated when the client has six or more PVCs per minute, multifocal PVCs, couplets or triplets, or PVCs occurring on the downslope of the T wave. Any of these situations is likely to progress to the more dangerous ventricular tachycardia or ventricular fibrillation if not treated immediately. Question 129 of 385 A client is admitted in cardiogenic shock. To best evaluate the heart's hemodynamic performance, the nurse anticipates the insertion of a(n)
11. Incorrect intra-arterial line.
12. Incorrect intra-aortic balloon pump (IABP).
13. Correct pulmonary artery catheter.
14. Incorrect central venous pressure line (CVP). Answer Rationale:
15. A pulmonary artery catheter will show all right and left heart hemodynamic pressures and provide for cardiac output measurements. Question 130 of 385 Which of the following statements by a client to the nurse

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indicates a risk factor for coronary artery disease?

1. Incorrect "No one in my family has heart problems."
2. Correct "I smoke 1 1/2 packs of cigarettes per day."

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3. Incorrect "My cholesterol is 189."
4. Incorrect "I exercise four times a week." Answer Rationale:
5. Smoking has been determined to increase the risk of coronary heart disease. Question 131 of 385 An adult female has a history of coronary artery disease and angina pectoris. After walking to the bathroom, she complains of aching substernal pain that radiates to her left shoulder. The nurse should
6. Incorrect use pillows to support and immobilize the left shoulder.
7. Correct administer a prn dose of nitroglycerin sublingually.
8. Incorrect administer a prn dose of aspirin or acetaminophen (Tylenol).
9. Incorrect assist her to lie down and elevate her legs. Answer Rationale:
10. Nitroglycerin dilates peripheral veins, reducing venous return to the heart. This immediately decreases cardiac workload, relieving ischemia and chest pain. It also dilates coronary arteries, improving oxygen supply to the heart. Question 132 of 385 A nitroglycerin transdermal patch was prescribed six weeks ago for an adult to treat angina pectoris. The nurse knows that the patch has been effective if
11. Correct the client reports no episodes of chest pain.
12. Incorrect pulse oximetry shows the client's oxygen saturation is improved.
13. Incorrect the client's serum cholesterol level has decreased.
14. Incorrect the client's pressure is within normal limits. Answer Rationale:
15. Nitroglycerin reduces cardiac workload and improves myocardial oxygenation. This prevents episodes of anginal pain. Question 133 of 385 Ms. F. has developed angina pectoris secondary to coronary

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artery disease. A low fat, low cholesterol diet is prescribed for her. The nurse should praise Ms. F. for a wise choice if she selected which of the following for an

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evening snack?

1. Incorrect Half tuna salad sandwich.
2. Incorrect Yogurt with fresh strawberries.
3. Incorrect Cheese cubes and crackers.
4. Correct Jello mold with fruit slices. Answer Rationale:
5. Most fruits and vegetables are low in fat and cholesterol-free. Jello also has no fat or cholesterol. Question 134 of 385 Lidocaine is mixed 2 g in 500 ml D 5 W. The nurse prepared to start an infusion at 2^ mg/h^ using a 60-drop tubing. Which of the following is the correct rate to start the infusion on a pump?
6. Correct 30 ml.
7. Incorrect 45 ml.
8. Incorrect 15 ml.
9. Incorrect 60 ml. Answer Rationale:
10. 30 ml is 2 mg/h. 1000 mg = 1 g. 2 g is 200 mg. 2000mg:500ml::2mg: x ml 2000 x = 1000 x = 0.5 ml/hr 60 drops = 1 ml. 60 drops × 0.5 ml. = 30 ml/hr. Question 135 of 385 An adult male is transferred to the step-down unit on the third day after a myocardial infarction. Which of the following should the nurse include in his care plan at this time?
11. Correct Supervising short walks in the hallway.
12. Incorrect Performing passive range of motion exercises.
13. Incorrect Enforcing complete bedrest.
14. Incorrect Having him sit on the side of the bed and

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