Post-Operative Nursing Care, Exams of Nursing

Download Post-Operative Nursing Care and more Exams Nursing in PDF only on Docsity! = Practice Questions | So | NCLEX-PN ® Practice Questions Third Edition Wilda Rinehart Diann Sloan Clara Hurd 800 East 96th Street, Indianapolis, Indiana 46240 USA Contents at a Glance Introduction 1 CHAPTER 1 Practice Exam 1 and Rationales 5 CHAPTER 2 Practice Exam 2 and Rationales 73 CHAPTER 3 Practice Exam 3 and Rationales 145 CHAPTER 4 Practice Exam 4 and Rationales 209 CHAPTER 5 Practice Exam 5 and Rationales 275 APPENDIX A Things You Forgot 341 APPENDIX B Need to Know More? 349 APPENDIX C Alphabetical Listing of Nursing Boards in the 359 United States and Protectorates Table of Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Welcome to the NCLEX-PN® Practice Questions Exam Cram . . . . . . 1 Taking the Computerized Adaptive Test . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 The Cost of the Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 How to Prepare for the Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 What Will You Find in This Book? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Hints for Using This Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Need Further Study? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Contact the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Chapter 1: Practice Exam 1 and Rationales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Quick Check Answer Key . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Answers and Rationales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Chapter 2: Practice Exam 2 and Rationales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Quick Check Answer Key . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Answers and Rationales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Chapter 3: Practice Exam 3 and Rationales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Quick Check Answer Key . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Answers and Rationales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 Chapter 4: Practice Exam 4 and Rationales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 Quick Check Answer Key . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 Answers and Rationales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Chapter 5: Practice Exam 5 and Rationales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275 Quick Check Answer Key . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318 Answers and Rationales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 Appendix A: Things You Forgot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341 Therapeutic Drug Levels. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341 vi NCLEX-PN Practice Questions Vital Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341 Intrapartal Normal Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342 Anticoagulant Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342 Standard Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343 Airborne Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343 Droplet Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344 Contact Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344 Revised Life Support Guidelines (American Heart Association) . . . . . 344 Defense Mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345 Nutrition Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345 Immunization Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347 Appendix B: Need to Know More? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349 Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349 Care of the Client with Respiratory Disorders. . . . . . . . . . . . . . . 349 Care of the Client with Genitourinary Disorders . . . . . . . . . . . . 350 Care of the Client with Hematological Disorders . . . . . . . . . . . . 350 Care of the Client with Fluid and Electrolytes and Acid/Base Balance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351 Care of the Client with Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351 Care of the Client with Sensory Disorders . . . . . . . . . . . . . . . . . . 352 Care of the Client with Neoplastic Disorders . . . . . . . . . . . . . . . 352 Care of the Client with Gastrointestinal Disorders . . . . . . . . . . . 353 Care of the Client with Musculoskeletal and Connective Tissue Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353 Care of the Client with Endocrine Disorders. . . . . . . . . . . . . . . . 354 Care of the Client with Cardiac Disorders . . . . . . . . . . . . . . . . . . 354 Care of the Client with Neurological Disorders . . . . . . . . . . . . . 355 Care of the Client with Psychiatric Disorders . . . . . . . . . . . . . . . 355 Care of the Client with Maternal-Newborn Care . . . . . . . . . . . . 356 Care of the Pediatric Client . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356 Cultural Practices Influencing Nursing Care . . . . . . . . . . . . . . . . 356 Legal Issues in Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . 357 Appendix C: Alphabetical Listing of Nursing Boards in the United States and Protectorates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359 Dedication We would like to thank our families for tolerating our late nights and long hours. Also, thanks to Gene Sloan for his help without pay. Special thanks to all the gradu- ates who have attended Rinehart and Associates Review Seminars. Thanks for allowing us to be a part of your success. We are also delighted that Jessica Rinehart Wentz, RN, Whitney Hurd Miller, RN, and Brad Sloan, RN, chose nursing as their profession above so many other professions. Acknowledgments Our special thanks to our editors, support staff, and nurse reviewers for helping us to organize our thoughts and experiences into a text for students and practic- ing professionals. You made the task before us challenging and enjoyable. We Want to Hear from You! As the reader of this book, you are our most important critic and commentator. We value your opinion and want to know what we’re doing right, what we could do better, what areas you’d like to see us publish in, and any other words of wis- dom you’re willing to pass our way. As an associate publisher for Pearson, I welcome your comments. You can email or write me directly to let me know what you did or didn’t like about this book— as well as what we can do to make our books better. Please note that I cannot help you with technical problems related to the topic of this book. We do have a User Services group, however, where I will forward specific technical ques- tions related to the book. When you write, please be sure to include this book’s title and author as well as your name, email address, and phone number. I will carefully review your com- ments and share them with the author and editors who worked on the book. Email: [email protected] Mail: David Dusthimer Associate Publisher Pearson 800 East 96th Street Indianapolis, IN 46240 USA Reader Services Visit our website and register this book at www.pearsonitcertification.com/reg- ister for convenient access to any updates, downloads, or errata that might be available for this book. Introduction Welcome to the NCLEX-PN® Practice Questions Exam Cram This book helps you get ready to take and pass the Licensure Exam for Practical Nurses. This chapter discusses the NCLEX® exam in general and how the Exam Cram books can help you prepare for the test. It doesn’t matter whether this is the first time you’re going to take the exam or whether you have taken it previ- ously; this book gives you the necessary information and techniques to obtain licensure. The NCLEX-PN® Practice Questions Exam Cram helps you practice taking ques- tions written in the NCLEX® format. Used with the Exam Cram review book NCLEX-PN® Exam Cram, it helps you understand and appreciate the subjects and materials you need to pass. The books are aimed at test preparation and review. They do not teach you everything you need to know about the subject of nursing. Instead, they present you with materials that you are likely to encounter on the exam. Using a simple approach, we help you understand the “need to know” information. To pass the NCLEX®, you must understand how the exam is developed. The NCLEX-PN® consists of questions from the cognitive levels of knowledge, comprehension, application, and analysis. The majority of questions are written at the application and analysis level. Questions incorporate the five stages of the nursing process (assessment, diagnosis, planning, implementation, and evalua- tion) and the four categories of client needs. Client needs are divided into sub- categories that define the content within each of the four major categories. These categories and subcategories are . A. Safe, effective care environment: . Coordinated care: 13%-19% . Safety and infection control: 11%-17% . B. Health promotion and maintenance: 7%–13% . C. Psychosocial integrity: 7%-13% 4 NCLEX-PN Practice Questions You also will find a Cram Sheet at the beginning of this book specifically written for this exam. This is a very popular element that is also found in NCLEX-PN® Exam Cram (Que Publishing, ISBN 0-7897-3267-X). This item condenses all the necessary facts found in this exam into one easy-to-handle tearcard. The Cram Sheet is something you can carry with you to the exam location and use as a last- second study aid. Be aware that you can’t take it into the exam room, though. Hints for Using This Book Because this book is a paper practice product, you might want to take advantage of the answer sheets in each chapter. These can be copied for multiple practice sessions. We suggest that you score your exam by subtracting the missed items from the total and then dividing the total answered correctly by the total num- ber of questions. This gives you the percentage answered correctly. We also sug- gest that you achieve a score of at least 77% before you schedule your exam. If you do not, take the exam again until you do. The higher the score, the better your chance to do well on the NCLEX® exam! You also will want to take advantage of the CD exam engine; it provides you with a computer-adaptive test very similar to the one you will experience during the NCLEX® exam. Every question in this book is on the CD, including the answer rationales. Aside from being a test-preparation book, this book is useful if you are brushing up on your nursing knowledge. It is an excellent quick reference for the licensed nurse. Need Further Study? If you are having a hard time correctly answering questions, be sure to see this book’s companion volume, the NCLEX-PN® Exam Cram (Que Publishing, ISBN 0-7897-3706-X). If you still need further study, you might want to take a class or look at one of the many other books available at your local bookstore. Contact the Authors The authors of this text are interested in you and want you to pass on the first attempt. If after reviewing with this text you would like to contact the authors, you may do so at Rinehart and Associates, PO Box 124, Booneville, MS 38829, or by visiting www.nclexreview.net. 3C H A P T E R T H R E E Practice Exam 3 and Rationales 1. A client hospitalized with severe depression and suicidal ideation refuses to talk with the nurse. The nurse recognizes that the suici- dal client has difficulty: ❍ A. Expressing feelings of low self-worth ❍ B. Discussing remorse and guilt for actions ❍ C. Displaying dependence on others ❍ D. Expressing anger toward others 2. A client receiving HydroDIURIL (hydrochlorothiazide) is instructed to increase her dietary intake of potassium. The best snack for the client requiring increased potassium is: ❍ A. Pear ❍ B. Apple ❍ C. Orange ❍ D. Banana 3. The nurse is caring for a client following removal of the thyroid. Immediately post-op, the nurse should: ❍ A. Maintain the client in a semi-Fowler’s position with the head and neck supported by pillows ❍ B. Encourage the client to turn her head side to side, to promote drainage of oral secretions ❍ C. Maintain the client in a supine position with sandbags placed on either side of the head and neck ❍ D. Encourage the client to cough and breathe deeply every 2 hours, with the neck in a flexed position Quick Answers: 187 Detailed Answer: 190 Quick Answers: 187 Detailed Answer: 190 Quick Answers: 187 Detailed Answer: 190 ✓Quick Check 146 Chapter 3 4. A client hospitalized with chronic dyspepsia is diagnosed with gastric cancer. Which of the following is associated with an increased incidence of gastric cancer? ❍ A. Dairy products ❍ B. Carbonated beverages ❍ C. Refined sugars ❍ D. Luncheon meats 5. A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial per- sonality disorder. In reviewing the client’s record, the nurse could expect to find: ❍ A. A history of consistent employment ❍ B. A below-average intelligence ❍ C. A history of cruelty to animals ❍ D. An expression of remorse for his actions 6. The licensed vocational nurse may not assume the primary care for a client: ❍ A. In the fourth stage of labor ❍ B. Two days post-appendectomy ❍ C. With a venous access device ❍ D. With bipolar disorder 7. The physician has ordered dressings with mafenide acetate (Sulfamylon) cream for a client with full-thickness burns of the hands and arms. Before dressing changes, the nurse should give priority to: ❍ A. Administering pain medication ❍ B. Checking the adequacy of urinary output ❍ C. Requesting a daily complete blood count ❍ D. Obtaining a blood glucose by finger stick 8. The nurse is teaching a group of parents about gross motor devel- opment of the toddler. Which behavior is an example of the nor- mal gross motor skill of a toddler? ❍ A. She can pull a toy behind her. ❍ B. She can copy a horizontal line. ❍ C. She can build a tower of eight blocks. ❍ D. She can broad-jump. Quick Answers: 187 Detailed Answer: 190 ✓Quick Check Quick Answers: 187 Detailed Answer: 190 Quick Answers: 187 Detailed Answer: 190 Quick Answers: 187 Detailed Answer: 190 Quick Answers: 187 Detailed Answer: 190 Practice Exam 3 and Rationales 149 19. An 8-year-old admitted with an upper-respiratory infection has an order for O2 saturation via pulse oximeter. To ensure an accurate reading, the nurse should: ❍ A. Place the probe on the child’s abdomen ❍ B. Recalibrate the oximeter at the beginning of each shift ❍ C. Apply the probe and wait 15 minutes before obtaining a reading ❍ D. Place the probe on the child’s finger 20. An infant with Tetralogy of Fallot is discharged with a prescription for lanoxin elixir. The nurse should instruct the mother to: ❍ A. Administer the medication using a nipple ❍ B. Administer the medication using the calibrated drop- per in the bottle ❍ C. Administer the medication using a plastic baby spoon ❍ D. Administer the medication in a baby bottle with 1oz. of water 21. The client scheduled for electroconvulsive therapy tells the nurse, “I’m so afraid. What will happen to me during the treatment?” Which of the following statements is most therapeutic for the nurse to make? ❍ A. “You will be given medicine to relax you during the treatment.” ❍ B. “The treatment will produce a controlled grand mal seizure.” ❍ C. “The treatment might produce nausea and headache.” ❍ D. “You can expect to be sleepy and confused for a time after the treatment.” 22. Which of the following skin lesions is associated with Lyme’s dis- ease? ❍ A. Bull’s eye rash ❍ B. Papular crusts ❍ C. Bullae ❍ D. Plaques Quick Answers: 187 Detailed Answer: 191 ✓Quick Check Quick Answers: 187 Detailed Answer: 191 Quick Answers: 187 Detailed Answer: 191 Quick Answers: 187 Detailed Answer: 191 150 Chapter 3 23. Which of the following snacks would be suitable for the child with gluten-induced enteropathy? ❍ A. Soft oatmeal cookie ❍ B. Buttered popcorn ❍ C. Peanut butter and jelly sandwich ❍ D. Cheese pizza 24. A client with schizophrenia is receiving chlorpromazine (Thorazine) 400mg twice a day. An adverse side effect of the med- ication is: ❍ A. Photosensitivity ❍ B. Elevated temperature ❍ C. Weight gain ❍ D. Elevated blood pressure 25. Which information should be given to the client taking phenytoin (Dilantin)? ❍ A. Taking the medication with meals will increase its effectiveness. ❍ B. The medication can cause sleep disturbances. ❍ C. More frequent dental appointments will be needed for special gum care. ❍ D. The medication decreases the effects of oral contra- ceptives. 26. A client has returned to his room following an esophagoscopy. Before offering fluids, the nurse should give priority to assessing the client’s: ❍ A. Level of consciousness ❍ B. Gag reflex ❍ C. Urinary output ❍ D. Movement of extremities 27. Which instruction should be included in the discharge teaching for the client with cataract surgery? ❍ A. Over-the-counter eyedrops can be used to treat red- ness and irritation. ❍ B. The eye shield should be worn at night. ❍ C. It will be necessary to wear special cataract glasses. ❍ D. A prescription for medication to control post-operative pain will be needed. Quick Answers: 187 Detailed Answer: 192 ✓Quick Check Quick Answers: 187 Detailed Answer: 192 Quick Answers: 187 Detailed Answer: 192 Quick Answers: 187 Detailed Answer: 192 Quick Answers: 187 Detailed Answer: 192 Practice Exam 3 and Rationales 151 28. An 8-year-old is admitted with drooling, muffled phonation, and a temperature of 102°F. The nurse should immediately notify the doctor because the child’s symptoms are suggestive of: ❍ A. Strep throat ❍ B. Epiglottitis ❍ C. Laryngotracheobronchitis ❍ D. Bronchiolitis 29. Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should: ❍ A. Offer the baby sterile water between feedings of for- mula ❍ B. Apply an emollient to the baby’s skin to prevent drying ❍ C. Wear a gown, gloves, and a mask while caring for the infant ❍ D. Place the baby on enteric isolation 30. A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client’s plan of care? ❍ A. Weighing the client after she eats ❍ B. Having a staff member remain with her for 1 hour after she eats ❍ C. Placing high-protein foods in the center of the client’s plate ❍ D. Providing the client with child-size utensils 31. According to Erickson’s stage of growth and development, the developmental task associated with middle childhood is: ❍ A. Trust ❍ B. Initiative ❍ C. Independence ❍ D. Industry 32. The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is: ❍ A. Tinnitus ❍ B. Nausea ❍ C. Ataxia ❍ D. Hypotension Quick Answers: 187 Detailed Answer: 192 ✓Quick Check Quick Answers: 187 Detailed Answer: 192 Quick Answers: 187 Detailed Answer: 192 Quick Answers: 187 Detailed Answer: 192 Quick Answers: 187 Detailed Answer: 192 154 Chapter 3 43. The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephotic syndrome. The nurse should: ❍ A. Encourage the client to drink extra fluids ❍ B. Request a low-protein diet for the client ❍ C. Bathe the client using only mild soap and water ❍ D. Provide additional warmth for swollen, inflamed joints 44. The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal? ❍ A. Antabuse (disulfiram) ❍ B. Romazicon (flumazenil) ❍ C. Dolophine (methodone) ❍ D. Ativan (lorazepam) 45. A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at: ❍ A. 8 a.m. ❍ B. 10 a.m. ❍ C. 3 p.m. ❍ D. 5 a.m. 46. The licensed practical nurse is assisting the charge nurse in plan- ning care for a client with a detached retina. Which of the follow- ing nursing diagnoses should receive priority? ❍ A. Alteration in comfort ❍ B. Alteration in mobility ❍ C. Alteration in skin integrity ❍ D. Alteration in O2 perfusion 47. The primary purpose for using a CPM machine for the client with a total knee repair is to help: ❍ A. Prevent contractures ❍ B. Promote flexion of the artificial joint ❍ C. Decrease the pain associated with early ambulation ❍ D. Alleviate lactic acid production in the leg muscles Quick Answers: 187 Detailed Answer: 193 ✓Quick Check Quick Answers: 187 Detailed Answer: 194 Quick Answers: 187 Detailed Answer: 194 Quick Answers: 187 Detailed Answer: 194 Quick Answers: 187 Detailed Answer: 194 Practice Exam 3 and Rationales 155 48. Which of the following statements reflects Kohlberg’s theory of the moral development of the preschool-age child? ❍ A. Obeying adults is seen as correct behavior. ❍ B. Showing respect for parents is seen as important. ❍ C. Pleasing others is viewed as good behavior. ❍ D. Behavior is determined by consequences. 49. A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to: ❍ A. Determine whether the ear infection has affected her hearing ❍ B. Make sure that she has taken all the antibiotic ❍ C. Document that the infection has completely cleared ❍ D. Obtain a new prescription in case the infection recurs 50. A factory worker is brought to the nurse’s office after a metal frag- ment enters his right eye. The nurse should: ❍ A. Cover the right eye with a sterile 4×4 ❍ B. Attempt to remove the metal with a cotton-tipped applicator ❍ C. Flush the eye for 10 minutes with running water ❍ D. Cover both eyes and transport the client to the ER 51. The nurse is caring for a client with systemic lupus erythematosis (SLE). The major complication associated with systemic lupus erythematosis is: ❍ A. Nephritis ❍ B. Cardiomegaly ❍ C. Desquamation ❍ D. Meningitis 52. Which diet is associated with an increased risk of colorectal cancer? ❍ A. Low protein, complex carbohydrates ❍ B. High protein, simple carbohydrates ❍ C. High fat, refined carbohydrates ❍ D. Low carbohydrates, complex proteins Quick Answers: 187 Detailed Answer: 194 ✓Quick Check Quick Answers: 187 Detailed Answer: 194 Quick Answers: 187 Detailed Answer: 194 Quick Answers: 187 Detailed Answer: 194 Quick Answers: 187 Detailed Answer: 194 156 Chapter 3 53. The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid: ❍ A. Holding the infant ❍ B. Offering a pacifier ❍ C. Providing a mobile ❍ D. Offering sterile water 54. The physician has ordered Amoxil (amoxicillin) 500mg capsules for a client with esophageal varices. The nurse can best care for the client’s needs by: ❍ A. Giving the medication as ordered ❍ B. Providing extra water with the medication ❍ C. Giving the medication with an antacid ❍ D. Requesting an alternate form of the medication 55. The nurse is providing dietary instructions for a client with iron- deficiency anemia. Which food is a poor source of iron? ❍ A. Tomatoes ❍ B. Legumes ❍ C. Dried fruits ❍ D. Nuts 56. The nurse is teaching a client with Parkinson’s disease ways to prevent curvatures of the spine associated with the disease. To prevent spinal flexion, the nurse should tell the client to: ❍ A. Periodically lie prone without a neck pillow ❍ B. Sleep only in dorsal recumbent position ❍ C. Rest in supine position with his head elevated ❍ D. Sleep on either side but keep his back straight 57. The nurse is planning dietary changes for a client following an episode of pancreatitis. Which diet is suitable for the client? ❍ A. Low calorie, low carbohydrate ❍ B. High calorie, low fat ❍ C. High protein, high fat ❍ D. Low protein, high carbohydrate Quick Answers: 187 Detailed Answer: 194 ✓Quick Check Quick Answers: 187 Detailed Answer: 195 Quick Answers: 187 Detailed Answer: 195 Quick Answers: 187 Detailed Answer: 195 Quick Answers: 187 Detailed Answer: 195 Practice Exam 3 and Rationales 159 68. A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is: ❍ A. Loss of sensation in the lower extremities ❍ B. Back pain that lessens when standing ❍ C. Decreased urinary output ❍ D. Pulsations in the periumbilical area 69. A client is admitted with acute adrenal crisis. During the intake assessment, the nurse can expect to find that the client has: ❍ A. Low blood pressure ❍ B. Slow, regular pulse ❍ C. Warm, flushed skin ❍ D. Increased urination 70. An elderly client is hospitalized for a transurethral prostatectomy. Which finding should be reported to the doctor immediately? ❍ A. Hourly urinary output of 40–50cc ❍ B. Bright red urine with many clots ❍ C. Dark red urine with few clots ❍ D. Requests for pain med q 4 hrs. 71. A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of polymigratory arthritis? ❍ A. Irregular movements of the extremities and facial gri- macing ❍ B. Painless swelling over the extensor surfaces of the joints ❍ C. Faint areas of red demarcation over the back and abdomen ❍ D. Swelling, inflammation, and effusion of the joints 72. A child with croup is placed in a cool, high-humidity tent connect- ed to room air. The primary purpose of the tent is to: ❍ A. Prevent insensible water loss ❍ B. Provide a moist environment with oxygen at 30% ❍ C. Prevent dehydration and reduce fever ❍ D. Liquefy secretions and relieve laryngeal spasm Quick Answers: 187 Detailed Answer: 196 ✓Quick Check Quick Answers: 187 Detailed Answer: 196 Quick Answers: 187 Detailed Answer: 196 Quick Answers: 187 Detailed Answer: 196 Quick Answers: 187 Detailed Answer: 196 160 Chapter 3 73. A client is admitted with a diagnosis of hypothyroidism. An initial assessment of the client would reveal: ❍ A. Slow pulse rate, weight loss, diarrhea, and cardiac fail- ure ❍ B. Weight gain, lethargy, slowed speech, and decreased respiratory rate ❍ C. Rapid pulse, constipation, and bulging eyes ❍ D. Decreased body temperature, weight loss, and increased respirations 74. Which statement describes the contagious stage of varicella? ❍ A. The contagious stage is 1 day before the onset of the rash until the appearance of vesicles. ❍ B. The contagious stage lasts during the vesicular and crusting stages of the lesions. ❍ C. The contagious stage is from the onset of the rash until the rash disappears. ❍ D. The contagious stage is 1 day before the onset of the rash until all the lesions are crusted. 75. A client admitted to the psychiatric unit claims to be the Son of God and insists that he will not be kept away from his followers. The most likely explanation for the client’s delusion is: ❍ A. A religious experience ❍ B. A stressful event ❍ C. Low self-esteem ❍ D. Overwhelming anxiety 76. The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately? ❍ A. Reluctance to swallow ❍ B. Drooling of blood-tinged saliva ❍ C. An axillary temperature of 99°F ❍ D. Respiratory stridor Quick Answers: 187 Detailed Answer: 196 ✓Quick Check Quick Answers: 187 Detailed Answer: 197 Quick Answers: 187 Detailed Answer: 197 Quick Answers: 187 Detailed Answer: 197 Practice Exam 3 and Rationales 161 77. The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort lessens when he: ❍ A. Skips a meal ❍ B. Rests in recumbent position ❍ C. Eats a meal ❍ D. Sits upright after eating 78. Which of the following meal selections is appropriate for the client with celiac disease? ❍ A. Toast, jam, and apple juice ❍ B. Peanut butter cookies and milk ❍ C. Rice Krispies bar and milk ❍ D. Cheese pizza and Kool-Aid 79. A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client’s medication? ❍ A. The client complains of blurred vision. ❍ B. The client complains of increased thirst and increased urination. ❍ C. The client complains of increased weight gain over the past year. ❍ D. The client complains of changes in taste. 80. A 2-month-old infant has just received her first Tetramune injec- tion. The nurse should tell the mother that the immunization: ❍ A. Will need to be repeated when the child is 4 years of age ❍ B. Is given to determine whether the child is susceptible to pertussis ❍ C. Is one of a series of injections that protects against dpt and Hib ❍ D. Is a one-time injection that protects against MMR and varicella Quick Answers: 187 Detailed Answer: 197 ✓Quick Check Quick Answers: 187 Detailed Answer: 197 Quick Answers: 187 Detailed Answer: 197 Quick Answers: 187 Detailed Answer: 197 164 Chapter 3 91. Before administering a client’s morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to: ❍ A. Record the pulse rate and administer the medication ❍ B. Administer the medication and monitor the heart rate ❍ C. Withhold the medication and notify the doctor ❍ D. Withhold the medication until the heart rate increases 92. What information should the nurse give a new mother regarding the introduction of solid foods for her infant? ❍ A. Solid foods should not be given until the extrusion reflex disappears, at 8–10 months of age. ❍ B. Solid foods should be introduced one at a time, with 4- to 7-day intervals. ❍ C. Solid foods can be mixed in a bottle or infant feeder to make feeding easier. ❍ D. Solid foods should begin with fruits and vegetables. 93. A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to: ❍ A. Withholding all morning medications ❍ B. Ordering a CBC and CPK ❍ C. Administering prescribed anti-Parkinsonian medication ❍ D. Transferring the client to a medical unit 94. A client with human immunodeficiency syndrome has gastroin- testinal symptoms, including diarrhea. The nurse should teach the client to avoid: ❍ A. Calcium-rich foods ❍ B. Canned or frozen vegetables ❍ C. Processed meat ❍ D. Raw fruits and vegetables 95. A 4-year-old is admitted with acute leukemia. It will be most important to monitor the child for: ❍ A. Abdominal pain and anorexia ❍ B. Fatigue and bruising ❍ C. Bleeding and pallor ❍ D. Petechiae and mucosal ulcers Quick Answers: 188 Detailed Answer: 198 ✓Quick Check Quick Answers: 188 Detailed Answer: 198 Quick Answers: 188 Detailed Answer: 198 Quick Answers: 188 Detailed Answer: 198 Quick Answers: 188 Detailed Answer: 199 Practice Exam 3 and Rationales 165 96. A 5-month-old is diagnosed with atopic dermatitis. Nursing inter- ventions will focus on: ❍ A. Preventing infection ❍ B. Administering antipyretics ❍ C. Keeping the skin free of moisture ❍ D. Limiting oral fluid intake 97. The nurse is caring for a client with a history of diverticulitis. The client complains of abdominal pain, fever, and diarrhea. Which food was responsible for the client’s symptoms? ❍ A. Mashed potatoes ❍ B. Steamed carrots ❍ C. Baked fish ❍ D. Whole-grain cereal 98. The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client’s cancer is located in: ❍ A. The tail of the pancreas ❍ B. The head of the pancreas ❍ C. The body of the pancreas ❍ D. The entire pancreas 99. A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is: ❍ A. Weight gain ❍ B. Hair loss ❍ C. Sore throat ❍ D. Brittle nails 100. The doctor has ordered Percocet (oxycodone) for a client follow- ing abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is to: ❍ A. Prevent addiction ❍ B. Alleviate pain ❍ C. Facilitate mobility ❍ D. Prevent nausea Quick Answers: 188 Detailed Answer: 199 ✓Quick Check Quick Answers: 188 Detailed Answer: 199 Quick Answers: 188 Detailed Answer: 199 Quick Answers: 188 Detailed Answer: 199 Quick Answers: 188 Detailed Answer: 199 166 Chapter 3 101. Which finding is the best indication that a client with ineffective airway clearance needs suctioning? ❍ A. Oxygen saturation ❍ B. Respiratory rate ❍ C. Breath sounds ❍ D. Arterial blood gases 102. A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices: ❍ A. Gastric distress ❍ B. Changes in hearing ❍ C. Red discoloration of bodily fluids ❍ D. Changes in color vision 103. The primary cause of anemia in a client with chronic renal failure is: ❍ A. Poor iron absorption ❍ B. Destruction of red blood cells ❍ C. Lack of intrinsic factor ❍ D. Insufficient erythropoietin 104. Which of the following nursing interventions has the highest prior- ity for the client scheduled for an intravenous pyelogram? ❍ A. Providing the client with a favorite meal for dinner ❍ B. Asking if the client has allergies to shellfish ❍ C. Encouraging fluids the evening before the test ❍ D. Telling the client what to expect during the test 105. The doctor has prescribed aspirin 325mg daily for a client with transient ischemic attacks. The nurse knows that aspirin was pre- scribed to: ❍ A. Prevent headaches ❍ B. Boost coagulation ❍ C. Prevent cerebral anoxia ❍ D. Keep platelets from clumping together Quick Answers: 188 Detailed Answer: 199 ✓Quick Check Quick Answers: 188 Detailed Answer: 199 Quick Answers: 188 Detailed Answer: 199 Quick Answers: 188 Detailed Answer: 199 Quick Answers: 188 Detailed Answer: 199 Practice Exam 3 and Rationales 169 116. The nurse is preparing to discharge a client following a laparo- scopic cholecystectomy. The nurse should: ❍ A. Tell the client to avoid a tub bath for 5 to 7 days ❍ B. Tell the client to expect clay-colored stools ❍ C. Tell the client that she can expect lower abdominal pain for the next week ❍ D. Tell the client that she can resume a regular diet imme- diately 117. A high school student returns to school following a 3-week absence due to mononucleosis. The school nurse knows it will be important for the client: ❍ A. To drink additional fluids throughout the day ❍ B. To avoid contact sports for 1–2 months ❍ C. To have a snack twice a day to prevent hypoglycemia ❍ D. To continue antibiotic therapy for 6 months 118. A 6-year-old with cystic fibrosis has an order for pancreatic replacement. The nurse knows that the medication will be given: ❍ A. At bedtime ❍ B. With meals and snacks ❍ C. Twice daily ❍ D. Daily in the morning 119. The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia. Which foods are highest in B12? ❍ A. Meat, eggs, dairy products ❍ B. Peanut butter, raisins, molasses ❍ C. Broccoli, cauliflower, cabbage ❍ D. Shrimp, legumes, bran cereals 120. A client with hypertension has begun an aerobic exercise program. The nurse should tell the client that the recommended exercise regimen should begin slowly and build up to: ❍ A. 20–30 minutes three times a week ❍ B. 45 minutes two times a week ❍ C. 1 hour four times a week ❍ D. 1 hour two times a week Quick Answers: 188 Detailed Answer: 200 ✓Quick Check Quick Answers: 188 Detailed Answer: 200 Quick Answers: 188 Detailed Answer: 201 Quick Answers: 188 Detailed Answer: 201 Quick Answers: 188 Detailed Answer: 201 170 Chapter 3 121. A client with breast cancer is returned to the room following a right total mastectomy. The nurse should: ❍ A. Elevate the client’s right arm on pillows ❍ B. Place the client’s right arm in a dependent sling ❍ C. Keep the client’s right arm on the bed beside her ❍ D. Place the client’s right arm across her body 122. A neurological consult has been ordered for a pediatric client with suspected absence seizures. The client with absence seizures can be expected to have: ❍ A. Short, abrupt muscle contraction ❍ B. Quick, bilateral severe jerking movements ❍ C. Abrupt loss of muscle tone ❍ D. A brief lapse in consciousness 123. A client with schizoaffective disorder is exhibiting Parkinsonian symptoms. Which medication is responsible for the development of Parkinsonian symptoms? ❍ A. Zyprexa (olanzapine) ❍ B. Cogentin (benzatropine mesylate) ❍ C. Benadryl (diphenhydramine) ❍ D. Depakote (divalproex sodium) 124. Which activity is best suited to the 12-year-old with juvenile rheumatoid arthritis? ❍ A. Playing video games ❍ B. Swimming ❍ C. Working crossword puzzles ❍ D. Playing slow-pitch softball 125. The glycosylated hemoglobin of a 40-year-old client with diabetes mellitus is 2.5%. The nurse understands that: ❍ A. The client can have a higher-calorie diet. ❍ B. The client has good control of her diabetes. ❍ C. The client requires adjustment in her insulin dose. ❍ D. The client has poor control of her diabetes. Quick Answers: 188 Detailed Answer: 201 ✓Quick Check Quick Answers: 188 Detailed Answer: 201 Quick Answers: 188 Detailed Answer: 201 Quick Answers: 188 Detailed Answer: 201 Quick Answers: 188 Detailed Answer: 201 Practice Exam 3 and Rationales 171 126. The physician has ordered Stadol (butorphanol) for a post- operative client. The nurse knows that the medication is having its intended effect if the client: ❍ A. Is asleep 30 minutes after the injection ❍ B. Asks for extra servings on his meal tray ❍ C. Has an increased urinary output ❍ D. States that he is feeling less nauseated 127. The mother of a child with cystic fibrosis tells the nurse that her child makes “snoring” sounds when breathing. The nurse is aware that many children with cystic fibrosis have: ❍ A. Choanal atresia ❍ B. Nasal polyps ❍ C. Septal deviations ❍ D. Enlarged adenoids 128. A client is hospitalized with hepatitis A. Which of the client’s regu- lar medications is contraindicated due to the current illness? ❍ A. Prilosec (omeprazole) ❍ B. Synthroid (levothyroxine) ❍ C. Premarin (conjugated estrogens) ❍ D. Lipitor (atorvastatin) 129. The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indi- cates that the client understands his new diet? ❍ A. Cornflakes, whole milk, banana, and coffee ❍ B. Scrambled eggs, bacon, toast, and coffee ❍ C. Oatmeal, apple juice, dry toast, and coffee ❍ D. Pancakes, ham, tomato juice, and coffee 130. An 18-month-old is being discharged following hypospadias repair. Which instruction should be included in the nurse’s dis- charge teaching? ❍ A. The child should not play on his rocking horse. ❍ B. Applying warm compresses to decrease pain. ❍ C. Diapering should be avoided for 1–2 weeks. ❍ D. The child will need a special diet to promote healing. Quick Answers: 188 Detailed Answer: 201 ✓Quick Check Quick Answers: 188 Detailed Answer: 202 Quick Answers: 188 Detailed Answer: 202 Quick Answers: 188 Detailed Answer: 202 Quick Answers: 188 Detailed Answer: 202 174 Chapter 3 140. A client with AIDS complains of a weight loss of 20 pounds in the past month. Which diet is suggested for the client with AIDS? ❍ A. High calorie, high protein, high fat ❍ B. High calorie, high carbohydrate, low protein ❍ C. High calorie, low carbohydrate, high fat ❍ D. High calorie, high protein, low fat 141. The nurse is caring for a 4-year-old with cerebral palsy. Which nursing intervention will help ready the child for rehabilitative services? ❍ A. Patching one of the eyes to strengthen the muscles ❍ B. Providing suckers and pinwheels to help strengthen tongue movement ❍ C. Providing musical tapes to provide auditory training ❍ D. Encouraging play with a video game to improve mus- cle coordination 142. At the 6-week check-up, the mother asks when she can expect the baby to sleep all night. The nurse should tell the mother that most infants begin to sleep all night by age: ❍ A. 1 month ❍ B. 2 months ❍ C. 3–4 months ❍ D. 5–6 months 143. Which of the following pediatric clients is at greatest risk for latex allergy? ❍ A. The child with a myelomeningocele ❍ B. The child with epispadias ❍ C. The child with coxa plana ❍ D. The child with rheumatic fever 144. The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to: ❍ A. Use the heel of her hand during percussion ❍ B. Change the child’s position every 20 minutes ❍ C. Do percussion after the child eats and at bedtime ❍ D. Use cupped hands during percussion Quick Answers: 188 Detailed Answer: 203 ✓Quick Check Quick Answers: 188 Detailed Answer: 203 Quick Answers: 188 Detailed Answer: 203 Quick Answers: 188 Detailed Answer: 203 Quick Answers: 188 Detailed Answer: 203 Practice Exam 3 and Rationales 175 145. The nurse calculates the amount of an antibiotic for injection to be given to an infant. The amount of medication to be administered is 1.25mL. The nurse should: ❍ A. Divide the amount into two injections and administer in each vastus lateralis muscle ❍ B. Give the medication in one injection in the dorsog- luteal muscle ❍ C. Divide the amount in two injections and give one in the ventrogluteal muscle and one in the vastus later- alis muscle ❍ D. Give the medication in one injection in the ventrog- luteal muscle 146. A client with schizophrenia is receiving depot injections of Haldol Deconate (haloperidol decanoate). The client should be told to return for his next injection in: ❍ A. 1 week ❍ B. 2 weeks ❍ C. 4 weeks ❍ D. 6 weeks 147. A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents? ❍ A. Keep the bed flat, with a small pillow beneath the cast ❍ B. Provide crayons and a coloring book for play activity ❍ C. Increase her intake of high-calorie foods for healing ❍ D. Tuck a disposable diaper beneath the cast at the per- ineal opening 148. The nurse is caring for a client following the reimplantation of the thumb and index finger. Which finding should be reported to the physician immediately? ❍ A. Temperature of 100°F ❍ B. Coolness and discoloration of the digits ❍ C. Complaints of pain ❍ D. Difficulty moving the digits Quick Answers: 188 Detailed Answer: 203 ✓Quick Check Quick Answers: 188 Detailed Answer: 203 Quick Answers: 188 Detailed Answer: 204 Quick Answers: 188 Detailed Answer: 204 176 Chapter 3 149. When assessing the urinary output of a client who has had extra- corporeal lithotripsy, the nurse can expect to find: ❍ A. Cherry-red urine that gradually becomes clearer ❍ B. Orange-tinged urine containing particles of calculi ❍ C. Dark red urine that becomes cloudy in appearance ❍ D. Dark, smoky-colored urine with high specific gravity 150. The physician has prescribed Cognex (tacrine) for a client with dementia. The nurse should monitor the client for adverse reac- tions, which include: ❍ A. Hypoglycemia ❍ B. Jaundice ❍ C. Urinary retention ❍ D. Tinnitus 151. The physician has ordered a low-potassium diet for a child with acute glomerulonephritis. Which snack is suitable for the child with potassium restrictions? ❍ A. Raisins ❍ B. Oranges ❍ C. Apricots ❍ D. Bananas 152. The physician has ordered a blood test for H. pylori. The nurse should prepare the client by: ❍ A. Withholding intake after midnight ❍ B. Telling the client that no special preparation is needed ❍ C. Explaining that a small dose of radioactive isotope will be used ❍ D. Giving an oral suspension of glucose 1 hour before the test 153. The nurse is preparing to give an oral potassium supplement. The nurse should: ❍ A. Give the medication without diluting it ❍ B. Give the medication with 4oz. of juice ❍ C. Give the medication with water only ❍ D. Give the medication on an empty stomach Quick Answers: 188 Detailed Answer: 204 ✓Quick Check Quick Answers: 188 Detailed Answer: 204 Quick Answers: 188 Detailed Answer: 204 Quick Answers: 188 Detailed Answer: 204 Quick Answers: 188 Detailed Answer: 204 Practice Exam 3 and Rationales 179 164. The physician has ordered aspirin therapy for a client with severe rheumatoid arthritis. A sign of acute aspirin toxicity is: ❍ A. Anorexia ❍ B. Diarrhea ❍ C. Tinnitus ❍ D. Pruritis 165. A client is admitted to the emergency room with symptoms of delirium tremens. After admitting the client to a private room, the priority nursing intervention is to: ❍ A. Obtain a history of his alcohol use ❍ B. Provide seizure precautions ❍ C. Keep the room cool and dark ❍ D. Administer thiamine and zinc 166. The nurse is providing dietary teaching for a client with gout. Which dietary selection is suitable for the client with gout? ❍ A. Broiled liver, macaroni and cheese, spinach ❍ B. Stuffed crab, steamed rice, peas ❍ C. Baked chicken, pasta salad, asparagus casserole ❍ D. Steak, baked potato, tossed salad 167. A newborn has been diagnosed with exstrophy of the bladder. The nurse should position the newborn: ❍ A. Prone ❍ B. Supine ❍ C. On either side ❍ D. With the head elevated 168. The mother of a 3-month-old with esophageal reflux asks the nurse what she can do to lessen the baby’s reflux. The nurse should tell the mother to: ❍ A. Feed the baby only when he is hungry ❍ B. Burp the baby after the feeding is completed ❍ C. Place the baby supine with head elevated ❍ D. Burp the baby frequently throughout the feeding Quick Answers: 188 Detailed Answer: 205 ✓Quick Check Quick Answers: 188 Detailed Answer: 205 Quick Answers: 188 Detailed Answer: 205 Quick Answers: 188 Detailed Answer: 205 Quick Answers: 188 Detailed Answer: 205 180 Chapter 3 169. A child is hospitalized with a fractured femur involving the epiph- ysis. Epiphyseal fractures are serious because: ❍ A. Bone marrow is lost through the fracture site. ❍ B. Normal bone growth is affected. ❍ C. Blood supply to the bone is obliterated. ❍ D. Callus formation prevents bone healing. 170. Before administering a nasogastric feeding to a client hospitalized following a CVA, the nurse aspirates 40mL of residual. The nurse should: ❍ A. Replace the aspirate and administer the feeding ❍ B. Discard the aspirate and withhold the feeding ❍ C. Discard the aspirate and begin the feeding ❍ D. Replace the aspirate and withhold the feeding 171. A client has an order for Dilantin (phenytoin) .2g orally twice a day. The medication is available in 100mg capsules. For the morn- ing medication, the nurse should administer: ❍ A. 1 capsule ❍ B. 2 capsules ❍ C. 3 capsules ❍ D. 4 capsules 172. The LPN is reviewing the lab results of an elderly client when she notes a specific gravity of 1.025. The nurse recognizes that: ❍ A. The client has impaired renal function. ❍ B. The client has a normal specific gravity. ❍ C. The client has mild to moderate dehydration. ❍ D. The client has diluted urine from fluid overload. 173. A client with acute pancreatitis has requested pain medication. Which pain medication is indicated for the client with acute pan- creatitis? ❍ A. Demerol (meperidine) ❍ B. Toradol (ketorolac) ❍ C. Morphine (morphine sulfate) ❍ D. Codeine (codeine) Quick Answers: 188 Detailed Answer: 206 ✓Quick Check Quick Answers: 188 Detailed Answer: 206 Quick Answers: 188 Detailed Answer: 206 Quick Answers: 188 Detailed Answer: 206 Quick Answers: 188 Detailed Answer: 206 Practice Exam 3 and Rationales 181 174. A client with a hiatal hernia has been taking magnesium hydroxide for relief of heartburn. Overuse of magnesium-based antacids can cause the client to have: ❍ A. Constipation ❍ B. Weight gain ❍ C. Anorexia ❍ D. Diarrhea 175. When performing a newborn assessment, the nurse measures the circumference of the neonate’s head and chest. Which assessment finding is expected in the normal newborn? ❍ A. The head and chest circumference are the same. ❍ B. The head is 2cm larger than the chest. ❍ C. The head is 3cm smaller than the chest. ❍ D. The head is 4cm larger than the chest. 176. A client with a history of clots is receiving Lovenox (enoxaparin). Which drug is given to counteract the effects of enoxaparin? ❍ A. Calcium gluconate ❍ B. Aquamephyton ❍ C. Methergine ❍ D. Protamine sulfate 177. The nurse is formulating a plan of care for a client with a cognitive disorder. Which activity is most appropriate for the client with confusion and short attention span? ❍ A. Taking part in a reality-orientation group ❍ B. Participating in unit community goal setting ❍ C. Going on a field trip with a group of clients ❍ D. Meeting with an assertiveness training group 178. The mother of a child with hemophilia asks the nurse which over- the-counter medication is suitable for her child’s joint discomfort. The nurse should tell the mother to purchase: ❍ A. Advil (ibuprofen) ❍ B. Tylenol (acetaminophen) ❍ C. Aspirin (acetylsalicytic acid) ❍ D. Naproxen (naprosyn) Quick Answers: 188 Detailed Answer: 206 ✓Quick Check Quick Answers: 188 Detailed Answer: 206 Quick Answers: 188 Detailed Answer: 206 Quick Answers: 188 Detailed Answer: 206 Quick Answers: 188 Detailed Answer: 206 184 Chapter 3 188. The nurse is caring for a client who is unconscious following a fall. Which comment by the nurse will help the client become reoriented when he regains consciousness? ❍ A. “I am your nurse and I will be taking care of you today.” ❍ B. “Can you tell me your name and where you are?” ❍ C. “I know you are confused right now, but everything will be alright.” ❍ D. “You were in an accident that hurt your head. You are in the hospital.” 189. Following a generalized seizure, the nurse can expect the client to: ❍ A. Be unable to move the extremities ❍ B. Be drowsy and prone to sleep ❍ C. Remember events before the seizure ❍ D. Have a drop in blood pressure 190. A client with oxylate renal calculi should be taught to limit his intake of foods such as: ❍ A. Strawberries ❍ B. Oranges ❍ C. Apples ❍ D. Pears 191. A 6-year-old is diagnosed with Legg-Calve Perthes disease of the right femur. An important part of the child’s care includes instruct- ing the parents: ❍ A. To increase the amount of dietary protein ❍ B. About exercises to strengthen affected muscles ❍ C. About relaxation exercises to minimize pain in the joints ❍ D. To prevent weight bearing on the affected leg 192. The nurse is assessing an infant with Hirschsprung’s disease. The nurse can expect the infant to: ❍ A. Weigh less than expected for height and age ❍ B. Have infrequent bowel movements ❍ C. Exhibit clubbing of the fingers and toes ❍ D. Have hyperactive deep tendon reflexes Quick Answers: 189 Detailed Answer: 207 ✓Quick Check Quick Answers: 189 Detailed Answer: 207 Quick Answers: 189 Detailed Answer: 208 Quick Answers: 189 Detailed Answer: 208 Quick Answers: 189 Detailed Answer: 208 Practice Exam 3 and Rationales 185 193. The physician has prescribed supplemental iron for a prenatal client. The nurse should tell the client to take the medication with: ❍ A. Milk, to prevent stomach upset ❍ B. Tomato juice, to increase absorption ❍ C. Oatmeal, to prevent constipation ❍ D. Water, to increase serum iron levels 194. The nurse is teaching a client with a history of obesity and hyper- tension regarding dietary requirements during pregnancy. Which statement indicates that the client needs further teaching? ❍ A. “I need to reduce my daily intake to 1,200 calories a day.” ❍ B. “I need to drink at least a quart of milk a day.” ❍ C. “I shouldn’t add salt when I am cooking.” ❍ D. “I need to eat more protein and fiber each day.” 195. An elderly client is admitted to the psychiatric unit from the nurs- ing home. Transfer information indicates that the client has become confused and disoriented, with behavioral problems. The client will also likely show a loss of ability in: ❍ A. Speech ❍ B. Judgment ❍ C. Endurance ❍ D. Balance 196. The physician has ordered an external monitor for a laboring client. If the fetus is in the left occipital posterior (LOP) position, the nurse knows that the ultrasound transducer will be located: ❍ A. Near the symphysis pubis ❍ B. Near the umbilicus ❍ C. Over the fetal back ❍ D. Over the fetal abdomen 197. A client develops tremors while withdrawing from alcohol. Which medication is routinely administered to lessen physiological effects of alcohol withdrawal? ❍ A. Dolophine (methodone) ❍ B. Klonopin (clonazepam) ❍ C. Narcan (naloxone) ❍ D. Antabuse (disulfiram) Quick Answers: 189 Detailed Answer: 208 ✓Quick Check Quick Answers: 189 Detailed Answer: 208 Quick Answers: 189 Detailed Answer: 208 Quick Answers: 189 Detailed Answer: 208 Quick Answers: 189 Detailed Answer: 208 186 Chapter 3 198. A client with Type II diabetes has an order for regular insulin 10 units SC each morning. The client’s breakfast should be served within: ❍ A. 15 minutes ❍ B. 20 minutes ❍ C. 30 minutes ❍ D. 45 minutes 199. A 10-year-old has an order for Demerol (meperidine) 35mg IM for pain. The medication is available as Demerol 50mg per mL. How much should the nurse administer? ❍ A. .5mL ❍ B. .6mL ❍ C. .7mL ❍ D. .8mL 200. Which antibiotic is contraindicated for the treatment of infections in infants and young children? ❍ A. Tetracyn (tetracycline) ❍ B. Amoxil (amoxicillin) ❍ C. Cefotan (cefotetan) ❍ D. E-Mycin (erythromycin) Quick Answers: 189 Detailed Answer: 208 Quick Answers: 189 Detailed Answer: 208 Quick Answers: 189 Detailed Answer: 208 ✓Quick Check 184. B 185. A 186. D 187. C 188. D 189. B 190. A 191. D 192. B 193. B 194. A 195. B 196. C 197. B 198. C 199. C 200. A Practice Exam 3 and Rationales 189 190 Chapter 3 Answers and Rationales 1. Answer D is correct. The suicidal client has difficulty expressing anger toward others. The depressed suicidal client frequently expresses feelings of low self-worth, feelings of remorse and guilt, and a dependence on others; therefore, answers A, B, and C are incorrect. 2. Answer D is correct. Answers A, B, and C are incorrect because they contain lower amounts of potassium. (Note that the banana contains 450mg K+, the orange contains 235mg K+, the pear contains 208mg K+, and the apple contains 165mg K+.) 3. Answer A is correct. Following a thyroidectomy, the client should be placed in semi- Fowler’s position to decrease swelling that would place pressure on the airway. Answers B, C, and D are incorrect because they would increase the chances of post- operative complications that include bleeding, swelling, and airway obstruction. 4. Answer D is correct. Luncheon meats contain preservatives such as nitrites that have been linked to gastric cancer. Answers A, B, and C have not been found to increase the risk of gastric cancer; therefore, they are incorrect. 5. Answer C is correct. A history of cruelty to people and animals, truancy, setting fires, and lack of guilt or remorse are associated with a diagnosis of conduct disorder in children, which becomes a diagnosis of antisocial personality disorder in adults. Answer A is incorrect because the client with antisocial personality disorder does not hold consistent employment. Answer B is incorrect because the IQ is usually higher than average. Answer D is incorrect because of a lack of guilt or remorse for wrong- doing. 6. Answer C is correct. The licensed vocational nurse may not assume primary care of the client with a central venous access device. The licensed vocational nurse may care for the client in labor, the client post-operative client, and the client with bipolar disor- der; therefore, answers A, B, and D are incorrect. 7. Answer A is correct. Sulfamylon (mafenide acetate) produces a painful sensation when applied to the burn wound; therefore, the client should receive pain medication before dressing changes. Answers B, C, and D do not pertain to dressing changes for the client with burns, so they are incorrect. 8. Answer A is correct. According to the Denver Developmental Screening Test, the child can pull a toy behind her by age 2 years. Answers B, C, and D are not accomplished until ages 4–5 years; therefore, they are incorrect. 9. Answer A is correct. The client with a fractured mandible should keep a pair of wire cutters with him at all times to release the device in case of choking or aspiration. Answer B is incorrect because the wires would prevent insertion of an oral airway. Answer C is incorrect because it would be of no use in releasing the wires. Answer D is incorrect because it would be used only as a last resort in case of airway obstruc- tion. 10. Answer B is correct. The infant’s apical heart rate is within the accepted range for administering the medication. Answers A, C, and D are incorrect because the apical heart rate is suitable for giving the medication. Practice Exam 3 and Rationales 191 11. Answer B is correct. Chelating agents are used to treat the client with poisonings from heavy metals such as lead and iron. Answers A and D are used to remove non- corrosive poisons; therefore, they are incorrect. Answer C prevents vomiting; there- fore, it is an incorrect response. 12. Answer A is correct. The least restrictive restraint for the infant with cleft lip and cleft palate repair is elbow restraints. Answers B, C, and D are more restrictive and unnec- essary; therefore, they are incorrect. 13. Answer C is correct. Beta blockers such as timolol (Timoptic) can cause bron- chospasms in the client with chronic obstructive lung disease. Timoptic is not con- traindicated for use in clients with diabetes, gastric ulcers, or pancreatitis; therefore, answers A, B, and C are incorrect. 14. Answer D is correct. Leaving a nightlight on during the evening and night shifts helps the client remain oriented to the environment and fosters independence. Answers A and B will not decrease the client’s confusion. Answer C will increase the likelihood of confusion in an elderly client. 15. Answer B is correct. Pruritis or itching is caused by the presence of uric acid crystals on the skin, which is common in the client with end-stage renal failure. Answers A, C, and D are not associated with end-stage renal failure. 16. Answer C is correct. There is no specified time or frequency for the ordered medica- tion. Answers A, B, and D contain specified time and frequency, therefore they do not require further clarification. 17. Answer B is correct. A low-sodium diet is best for the client with Meniere’s syndrome. Answers A, C, and D do not relate to the care of the client with Meniere’s syndrome; therefore, they are incorrect. 18. Answer B is correct. Increased voiding at night is a symptom of right-sided heart fail- ure. Answers A and D are incorrect because they are symptoms of left-sided heart fail- ure. Answer C does not relate to the client’s diagnosis; therefore, it is incorrect. 19. Answer D is correct. The pulse oximeter should be placed on the child’s finger or ear- lobe because blood flow to these areas is most accessible for measuring oxygen con- centration. Answer A is incorrect because the probe cannot be secured to the abdomen. Answer B is incorrect because it should be recalibrated before application. Answer C is incorrect because a reading is obtained within seconds, not minutes. 20. Answer B is correct. The medication should be administered using the calibrated dropper that comes with the medication. Answers A and C are incorrect because part or all of the medication could be lost during administration. Answer D is incorrect because part or all of the medication will be lost if the child does not finish the bottle. 21. Answer A is correct. The client will receive medication that relaxes skeletal muscles and produces mild sedation. Answers B and D are incorrect because such statements increase the client’s anxiety level. Nausea and headache are not associated with ECT; therefore, answer C is incorrect. 22. Answer A is correct. Lyme’s disease produces a characteristic annular or circular rash sometimes described as a “bull’s eye” rash. Answers B, C, and D are incorrect because they are not symptoms associated with Lyme’s disease. 194 Chapter 3 44. Answer D is correct. Benzodiazepines are ordered for the client in alcohol withdrawal to prevent delirium tremens. Answer A is incorrect because it is a medication used in aversive therapy to maintain sobriety. Answer B is incorrect because it is used for the treatment of benzodiazepine overdose. Answer C is incorrect because it is the treat- ment for opiate withdrawal. 45. Answer C is correct. The client taking NPH insulin should have a snack midafternoon to prevent hypoglycemia. Answers A and B are incorrect because the times are too early for symptoms of hypoglycemia. Answer D is incorrect because the time is too late and the client would be in severe hypoglycemia. 46. Answer B is correct. The client with a detached retina will have limitations in mobility before and after surgery. Answer A is incorrect because a detached retina produces no pain or discomfort. Answers C and D do not apply to the client with a detached retina; therefore, they are incorrect. 47. Answer B is correct. The primary purpose for the continuous passive-motion machine is to promote flexion of the artificial joint. The device should be placed at the foot of the client’s bed. Answers A, C, and D do not describe the purpose of the CPM machine; therefore, they are incorrect. 48. Answer D is correct. According to Kohlberg, in the preconventional stage of develop- ment, the behavior of the preschool child is determined by the consequences of the behavior. Answers A, B, and C describe other stages of moral development; therefore, they are incorrect. 49. Answer C is correct. The client should be assessed following completion of antibiotic therapy to determine whether the infection has cleared. Answer A would be done if there are repeated instances of otitis media; therefore, it is incorrect. Answer B is incorrect because it will not determine whether the child has taken the medication. Answer D is incorrect because the purpose of the recheck is to determine whether the infection is gone. 50. Answer D is correct. The nurse should cover both of the client’s eyes and transport him immediately to the ER or the doctor’s office. Answers A, B, and D are incorrect because they increase the risk of further damage to the eye. 51. Answer A is correct. The major complication of SLE is lupus nephritis, which results in end-stage renal disease. SLE affects the musculoskeletal, integumentary, renal, nervous, and cardiovascular systems, but the major complication is renal involvement; therefore, answers B and D are incorrect. Answer C is incorrect because the SLE pro- duces a “butterfly” rash, not desquamation. 52. Answer C is correct. A diet that is high in fat and refined carbohydrates increases the risk of colorectal cancer. High fat content results in an increase in fecal bile acids, which facilitate carcinogenic changes. Refined carbohydrates increase the transit time of food through the gastrointestinal tract and increase the exposure time of the intes- tinal mucosa to cancer-causing substances. Answers A, B, and D do not relate to the question; therefore, they are incorrect. 53. Answer B is correct. The nurse should avoid giving the infant a pacifier or bottle because sucking is not permitted. Holding the infant cradled in the arms, providing a Practice Exam 3 and Rationales 195 mobile, and offering sterile water using a Breck feeder are permitted; therefore, answers A, C, and D are incorrect. 54. Answer D is correct. The client with esophageal varices can develop spontaneous bleeding from the mechanical irritation caused by taking capsules; therefore, the nurse should request the medication in a suspension. Answer A is incorrect because it does not best meet the client’s needs. Answer B is incorrect because it is not the best means of preventing bleeding. Answer C is incorrect because the medications should not be given with milk or antacids. 55. Answer A is correct. Tomatoes are a poor source of iron, although they are an excel- lent source of vitamin C, which increases iron absorption. Answers B, C, and D are good sources of iron; therefore, they are incorrect. 56. Answer A is correct. Periodically lying in a prone position without a pillow will help prevent the flexion of the spine that occurs with Parkinson’s disease. Answers B and C flex the spine; therefore, they are incorrect. Answer D is not realistic because of posi- tion changes during sleep; therefore, it is incorrect. 57. Answer B is correct. The client recovering from pancreatitis needs a diet that is high in calories and low in fat. Answers A, C, and D are incorrect because they can increase the client’s discomfort. 58. Answer B is correct. Dressing in layers and using extra covering will help decrease the feeling of being cold that is experienced by the client with hypothyroidism. Decreased sensation and decreased alertness are common in the client with hypothy- roidism; therefore, the use of electric blankets and heating pads can result in burns, making answers A and C incorrect. Answer D is incorrect because the client with hypothyroidism has dry skin, and a hot bath morning and evening would make her condition worse. 59. Answer D is correct. A history of frequent alcohol and tobacco use is the most signifi- cant factor in the development of cancer of the larynx. Answers A, B, and C are also factors in the development of laryngeal cancer, but they are not the most significant; therefore, they are incorrect. 60. Answer B is correct. Numbness and tingling in the extremities is common in the client with pernicious anemia, but not those with other types of anemia. Answers A, C, and D are incorrect because they are symptoms of all types of anemia. 61. Answer B is correct. The client with echolalia repeats words or phrases used by oth- ers. Answer A is incorrect because it refers to clang association. Answer C is incorrect because it refers to circumstantiality. Answer D is incorrect because it refers to neolo- gisms. 62. Answer C is correct. Holding a cup of coffee or hot chocolate helps to relieve the pain and stiffness of the hands. Answers A, B, and D do not relieve the symptoms of rheumatoid arthritis; therefore, they are incorrect. 63. Answer A is correct. The infant’s birth weight should double by 6 months of age. Answers B, C, and D are incorrect because they are greater than the expected weight gain by 6 months of age. 196 Chapter 3 64. Answer C is correct. Symptoms associated with nontropical sprue and celiac disease are caused by the ingestion of gluten, which is found in wheat, oats, barley, and rye. Creamed soup and crackers contain gluten. Answers A, B, and D do not contain gluten; therefore, they are incorrect. 65. Answer A is correct. Lanoxin (digoxin) slows and strengthens the contraction of the heart. An increase in urinary output shows that the medication is having a desired effect by eliminating excess fluid from the body. Answer B is incorrect because the weight would decrease. Answer C might occur but is not directly related to the ques- tion; therefore, it is incorrect. Answer D is incorrect because pedal edema would decrease, not increase. 66. Answer B is correct. The toddler has gross motor skills suited to playing with a ball, which can be kicked forward or thrown overhand. Answers A and C are incorrect because they require fine motor skills. Answer D is incorrect because the toddler lacks gross motor skills for play on the swing set. 67. Answer A is correct. Antacids containing aluminum and calcium tend to cause consti- pation. Answer A refers to the side effects of anticholinergic medications used to treat ulcers; therefore, it is incorrect. Answer C refers to antacids containing magnesium; therefore, it is incorrect. Answer D refers to dopamine antagonists used to treat ulcers; therefore, it is incorrect. 68. Answer D is correct. The client with an abdominal aortic aneurysm frequently com- plains of pulsations or “feeling my heart beat” in the abdomen. Answers A and C are incorrect because they occur with rupture of the aneurysm. Answer B is incorrect because back pain is not affected by changes in position. 69. Answer A is correct. The client with acute adrenal crisis has symptoms of hypov- olemia and shock; therefore, the blood pressure would be low. Answer B is incorrect because the pulse would be rapid and irregular. Answer C is incorrect because the skin would be cool and pale. Answer D is incorrect because the urinary output would be decreased. 70. Answer B is correct. Bright red bleeding with many clots indicates arterial bleeding that requires surgical intervention. Answer A is within normal limits; therefore, it is incorrect. Answer C indicates venous bleeding, which can be managed by nursing intervention; therefore, it is incorrect. Answer D does not indicate excessive need for pain management that requires the doctor’s attention; therefore, it is incorrect. 71. Answer D is correct. The child with polymigratory arthritis will exhibit swollen, painful joints. Answer B is incorrect because it describes subcutaneous nodules. Answer C is incorrect because it describes erythema marginatum. Answer A is incorrect because it describes Syndeham’s chorea. 72. Answer D is correct. The primary reason for placing a child with croup under a mist tent is to liquefy secretions and relieve laryngeal spasms. Answer A is incorrect because it does not prevent insensible water loss. Answer B is incorrect because the oxygen concentration is too high. Answer C is incorrect because the mist tent does not prevent dehydration or reduce fever. 73. Answer B is correct. Symptoms of hypothyroidism include weight gain, lethargy, slow speech, and decreased respirations. Answers A and D do not describe symptoms Practice Exam 3 and Rationales 199 95. Answer C is correct. The child with leukemia has low platelet counts, which contribute to spontaneous bleeding. Answers A, B, and D, common in the child with leukemia, are not life-threatening. 96. Answer A is correct. The nurse should prevent the infant with atopic dermatitis (eczema) from scratching, which can lead to skin infections. Answer B is incorrect because fever is not associated with atopic dermatitis. Answers C and D are incorrect choices because they increase dryness of the skin, which worsens the symptoms of atopic dermatitis. 97. Answer D is correct. Symptoms associated with diverticulitis are usually reported after eating popcorn, celery, raw vegetables, whole grains, and nuts. Answers A, B, and C are incorrect because they are allowed in the diet of the client with diverticulitis. 98. Answer B is correct. The Whipple procedure is performed for cancer located in the head of the pancreas. Answers A, C, and D are not correct because of the location of the cancer. 99. Answer C is correct. Side effects of Pulmozyme include sore throat, hoarseness, and laryngitis. Answers A, B, and D are not associated with the use of Pulmozyme; therefore, they are incorrect. 100. Answer B is correct. The nurse should be concerned with alleviating the client’s pain. Answers A, C, and D are not primary objectives in the care of the client receiving an opiate analgesic; therefore, they are incorrect. 101. Answer C is correct. Changes in breath sounds are the best indication of the need for suctioning in the client with ineffective airway clearance. Answers A, B, and D are incorrect because they can be altered by other conditions. 102. Answer D is correct. An adverse reaction to Myambutol is change in visual acuity or color vision. Answer A is incorrect because it does not relate to the medication. Answer C is incorrect because it is an adverse reaction to Streptomycin. Answer C is incorrect because it is a side effect of Rifampin. 103. Answer D is correct. Insufficient erythropoietin production is the primary cause of anemia in the client with chronic renal failure. Answers A, B, and C do not relate to the anemia seen in the client with chronic renal failure; therefore, they are incorrect. 104. Answer C is correct. The contrast media used during an intravenous pyelogram con- tains iodine, which can result in an anaphylactic reaction. Answers A, B, and D do not relate specifically to the test; therefore, they are incorrect. 105. Answer D is correct. Aspirin prevents the platelets from clumping together to prevent clots. Answer A is incorrect because the low-dose aspirin will not prevent headaches. Answers B and C are untrue statements; therefore, they are incorrect. 106. Answer C is correct. The usual course of treatment using a combined therapy with INH and Rifampin is 6 months. Answers A and D are incorrect because the treatment time is too brief. Answer B is incorrect because the medication is not needed for life. 107. Answer D is correct. At 4 months of age, the infant can roll over, which makes it vul- nerable to falls from dressing tables or beds without rails. Answer A is incorrect 200 Chapter 3 because it does not prove a threat to safety. Answers B and C are incorrect choices because the 4-month-old is not capable of crawling or standing. 108. Answer C is correct. Adverse side effects of Dilantin include agranulocytosis and aplastic anemia; therefore, the client will need frequent CBCs. Answer A is incorrect because the medication does not cause dental staining. Answer B is incorrect because the medication does not interfere with the metabolism of carbohydrates. Answer D is incorrect because the medication does not cause drowsiness. 109. Answer A is correct. The infant with hypospadias should not be circumcised because the foreskin is used in reconstruction. Answer B and C are incorrect because recon- struction is done between 16 and 18 months of age, before toilet training. Answer D is incorrect because the infant with hypospadias should not be circumcised. 110. Answer C is correct. Coconut oil is high in saturated fat and is not appropriate for the client on a low-cholesterol diet. Answers A, B, and D are incorrect because they are suggested for the client with elevated cholesterol levels. 111. Answer B is correct. In stage III of Alzheimer’s disease, the client develops agnosia, or failure to recognize familiar objects. Answer A is incorrect because it appears in stage I. Answer C is incorrect because it appears in stage II. Answer D is incorrect because it appears in stage IV. 112. Answer D is correct. The client taking steroid medication should receive an annual influenza vaccine. Answer A is incorrect because the medication should be taken with food. Answer B is incorrect because increased appetite and weight gain are expected side effects of the medication. Answer C is incorrect because wearing sunglasses will not prevent cataracts. 113. Answer A is correct. The client with an above-the-knee amputation should be placed prone 15–30 minutes twice a day to prevent contractures. Answers B and D are incor- rect choices because elevating the extremity after the first 24 hours will promote the development of contractures. Use of a trochanter roll will prevent rotation of the extremity but will not prevent contractures; therefore, answer D is incorrect. 114. Answer D is correct. All 20 primary, or deciduous, teeth should be present by age 30 months. Answers A, B, and C are incorrect because the ages are wrong. 115. Answer C is correct. The radioactive implant should be picked up with tongs and returned to the lead-lined container. Answer A is incorrect because radioactive materi- als are placed in lead-lined containers, not plastic ones, and are returned to the radia- tion department, not the lab. Answer B is incorrect because the client should not touch the implant or try to reinsert it. Answer D is incorrect because the implant should not be placed in the commode for disposal. 116. Answer A is correct. Following a laparoscopic cholecystectomy, the client should avoid a tub bath for 5 to 7 days. Answer B is incorrect because the stools should not be clay colored. Answer C is incorrect because pain is usually located in the shoulders. Answer D is incorrect because the client should not resume a regular diet until clear liquids have been tolerated. 117. Answer B is correct. The client recovering from mononucleosis should avoid contact sports and other activities that could result in injury or rupture of the spleen. Answer A Practice Exam 3 and Rationales 201 is incorrect because the client does not need additional fluids. Hypoglycemia is not associated with mononucleosis; therefore, answer C is incorrect. Answer D is incorrect because antibiotics are not usually indicated in the treatment of mononucleosis. 118. Answer B is correct. Pancreatic enzyme replacement is given with each meal and each snack. Answers A, C, and D do not specify a relationship to meals; therefore, they are incorrect. 119. Answer A is correct. Meat, eggs, and dairy products are foods high in vitamin B12. Answer B is incorrect because peanut butter, raisins, and molasses are sources rich in iron. Answer C is incorrect because broccoli, cauliflower, and cabbage are all sources rich in vitamin K. Answer D is incorrect because shrimp, legumes, and bran cereals are high in magnesium. 120. Answer A is correct. The client’s aerobic workout should be 20–30 minutes long three times a week. Answers B, C, and D exceed the recommended time for the client begin- ning an aerobic program; therefore, they are incorrect. 121. Answer A is correct. A total mastectomy involves removal of the entire breast and some or all of the axillary lymph nodes. Following surgery, the client’s right arm should be elevated on pillows, to facilitate lymph drainage. Answers B, C, and D are incorrect because they would not help facilitate lymph drainage and would create increased edema in the affected extremity. 122. Answer D is correct. Absence seizures, formerly known as petit mal seizures, are characterized by a brief lapse in consciousness accompanied by rapid eye blinking, lip smacking, and minor myoclonus of the upper extremities. Answer A refers to myoclonic seizures; therefore, it is incorrect. Answer B refers to tonic clonic, formerly known as grand mal, seizures; therefore, it is incorrect. Answer C refers to atonic seizures; therefore, it is incorrect. 123. Answer A is correct. A side effect of antipsychotic medication, such as Zyprexa, is the development of Parkinsonian symptoms. Answers B and C are incorrect choices because they are used to reverse Parkinsonian symptoms in the client taking antipsy- chotic medication. Answer D is incorrect because the medication is an anticonvulsant used to stabilize mood. Parkinsonian symptoms are not associated with anticonvulsant medication. 124. Answer B is correct. Exercises that provide light passive resistance are best for the child with rheumatoid arthritis. Answers A and C require movement of the hands and fingers that might be too painful for the child with juvenile rheumatoid arthritis; there- fore, they are incorrect. Answer D is incorrect because it requires the use of larger joints affected by the disease. 125. Answer B is correct. The client’s diabetes is well under control. Answer A is incorrect because it will lead to elevated blood sugar levels and poorer control of the client’s diabetes. Answer C is incorrect because the diet and insulin dose are appropriate for the client. Answer D is incorrect because the desired range for glycosylated hemoglo- bin in the adult client is 2.5%–5.9%. 126. Answer A is correct. Stadol reduces the perception of pain, which allows the post- operative client to rest. Answers B and C are not affected by the medication; therefore, 204 Chapter 3 147. Answer D is correct. Tucking a disposable diaper at the perineal opening will help pre- vent soiling of the cast by urine and stool. Answer A is incorrect because the head of the bed should be elevated. Answer B is incorrect because the child can place the crayons beneath the cast, causing pressure areas to develop. Answer C is incorrect because the child does not need high-calorie foods that would cause weight gain while she is immobilized by the cast. 148. Answer B is correct. Coolness and discoloration of the reimplanted digits indicates compromised circulation, which should be reported immediately to the physician. The temperature should be monitored, but the client would receive antibiotics to prevent infection; therefore, answer A is incorrect. Answers C and D are expected following amputation and reimplantation; therefore, they are incorrect. 149. Answer A is correct. Following extracorporeal lithotripsy, the urine will appear cherry red in color but will gradually change to clear urine. Answer B is incorrect because the urine will be red, not orange. Answer C is incorrect because the urine will be not be dark red or cloudy in appearance. Answer D is incorrect because it describes the uri- nary output of the client with acute glomerulonephritis. 150. Answer B is correct. An adverse reaction to Cognex (tacrine) is drug-induced hepati- tis. The nurse should monitor the client for signs of jaundice. Answers A, C, and D are incorrect because they are not associated with the use of Cognex (tacrine). 151. Answer C is correct. Apricots are low in potassium; therefore, it is a suitable snack of the client on a potassium-restricted diet. Raisins, oranges, and bananas are all good sources of potassium; therefore, answers A, B, and C are incorrect choices. 152. Answer B is correct. No special preparation is needed for the blood test for H. pylori. Answer A is incorrect because the client is not NPO before the test. Answer C is incor- rect because it refers to preparation for the breath test. Answer D is incorrect because glucose is not administered before the test. 153. Answer B is correct. Oral potassium supplements should be given in at least 4oz. of juice or other liquid, to prevent gastric upset and to disguise the unpleasant taste. Answers A, C, and D are incorrect because they cause gastric upset. 154. Answer D is correct. Fresh specimens are essential for accurate diagnosis of CMV. Answer A is incorrect because cultures of urine, sputum, and oral swab are preferred. Answer B is incorrect because pregnant caregivers should not be assigned to care for clients with suspected or known infection with CMV. Answer C is incorrect because a convalescent culture is obtained 2–4 weeks after diagnosis. 155. Answer D is correct. The client should receive pain medication 30 minutes before the application of Sulfamylon. Answer A is incorrect because it refers to silver nitrate. Answer B is incorrect because it refers to Silvadene. Answer C is incorrect because it refers to Betadine. 156. Answer D is correct. Gingival hyperplasia is a side effect of Dilantin; therefore, the nurse should provide oral hygiene and gum care every shift. Answers A, B, and C do not apply to the medication; therefore, they are incorrect. 157. Answer C is correct. Zofran is given before chemotherapy to prevent nausea. Answers A, B, and D are not associated with the medication; therefore, they are incorrect. Practice Exam 3 and Rationales 205 158. Answer A is correct. When administering ear drops to a child under 3 years of age, the nurse should pull the ear down and back to straighten the ear canal. Answers B and D are incorrect positions for administering ear drops. Answer C is used for admin- istering ear drops to an adult client. 159. Answer C is correct. The nurse should carefully monitor the client taking Thorazine for signs of infection that can quickly become overwhelming. Answers A, B, and D are incorrect because they are expected side effects of the medication. 160. Answer A is correct. Iron is better absorbed when taken with ascorbic acid. Orange juice is an excellent source of ascorbic acid. Answer B is incorrect because the med- ication should be taken with orange juice or tomato juice. Answer C is incorrect because iron should not be taken with milk because it interferes with absorption. Answer D is incorrect because apple juice does not contain high amounts of ascorbic acid. 161. Answer B is correct. Burn injury of the arm (9%), chest (9%), and head (9%) accounts for burns covering 27% of the total body surface area. Answers A, C, and D are incorrect percentages. 162. Answer B is correct. With standing orders, the nurse can administer oxygen at 6L per minute via mask. Answer A is incorrect because the amount is too low to help the client with chest pain and shortness of breath. Answers C and D have oxygen levels requiring a doctor’s order. 163. Answer A is correct. Stool from the ileostomy contains digestive enzymes that can cause severe skin breakdown. Answer B contains contradictory information; therefore, it is incorrect. Answers C and D contain inaccurate statements; therefore, they are incorrect. 164. Answer C is correct. Tinnitus is a sign of aspirin toxicity. Answers A, B, and D are not related to aspirin toxicity; therefore, they are incorrect. 165. Answer B is correct. The client with delirium tremens has an increased risk for seizures; therefore, the nurse should provide seizure precautions. Answer A is not a priority in the client’s care; therefore, it is incorrect. Answer C is incorrect because the client should be kept in a dimly lit, not dark, room. Answer D is incorrect because thi- amine and multivitamins are given to prevent Wernicke’s encephalopathy, not delirium tremens. 166. Answer D is correct. Steak, baked potato, and tossed salad are lower in purine than the other choices. Liver, crab, and chicken are high in purine; therefore, answers A, B, and C are incorrect. 167. Answer C is correct. Placing the newborn in a side-lying position helps the urine to drain from the exposed bladder. Answer A is incorrect because it would position the child on the exposed bladder. Answers B and D are incorrect choices because they would allow the urine to pool. 168. Answer D is correct. Burping the baby frequently throughout the feeding will help pre- vent gastric distention that contributes to esophageal reflux. Answers A and B are incorrect because they allow air to collect in the baby’s stomach, which contributes to reflux. Answer C is incorrect because the baby should be placed side-lying with the head elevated, to prevent aspiration. 206 Chapter 3 169. Answer B is correct. Growth plates located in the epiphysis can be damaged by epi- physeal fractures. Answers A, C, and D are untrue statements; therefore, they are incorrect. 170. Answer A is correct. The nurse should replace the aspirate and administer the feeding because the amount aspirated was less than 50mL. Answers B and C are incorrect choices because the aspirate should not be discarded. Answer D is incorrect because the feeding should not be withheld. 171. Answer B is correct. The nurse should administer two capsules. Answers A, C, and D contain inaccurate amounts; therefore, they are incorrect. 172. Answer B is correct. The normal specific gravity is 1.010 to 1.025. Answers A, C, and D are inaccurate statements; therefore, they are incorrect. 173. Answer A is correct. To prevent spasms of the sphincter of Oddi, the client with acute pancreatitis should receive non-opiate analgesics for pain. Answer B is incorrect because the client with acute pancreatitis might be prone to bleed; therefore, Toradol is not a drug of choice for pain control. Morphine and codeine, opiate analgesics, are contraindicated for the client with acute pancreatitis; therefore, answers C and D are incorrect. 174. Answer D is correct. Overuse of magnesium-containing antacids results in diarrhea. Antacids containing calcium and aluminum cause constipation; therefore, answer A is incorrect. Answers B and C are not associated with the use of magnesium antacids; therefore, they are incorrect. 175. Answer B is correct. The head circumference of the normal newborn is approximately 33 cm, while the chest circumference is 31cm. Answer A is incorrect because the head and chest are not the same circumference. Answer C is incorrect because the head is larger in circumference than the chest. Answer D is incorrect because the difference in head circumference and chest circumference is too great. 176. Answer D is correct. Protamine sulfate is given to counteract the effects of enoxaprin as well as heparin. Calcium gluconate is given to counteract the effects of magnesium sulfate; therefore, answer A is incorrect. Answer B is incorrect because aquamephyton is given to counteract the effects of sodium warfarin. Answer C is incorrect because methergine is given to increase uterine contractions following delivery. 177. Answer A is correct. Participating in reality orientation is the most appropriate activity for the client who is confused. Answers B, C, and D are incorrect because they are not suitable activities for a client who is confused. 178. Answer B is correct. The nurse should recommend acetaminophen for the child’s joint discomfort because it will have no effect on the bleeding time. Answers A, C, and D are all nonsteroidal anti-inflammatory medications that can prolong bleeding time; therefore, they are not suitable for the child with hemophilia. 179. Answer D is correct. Applying a paste of baking soda and water soothes the itching and helps to dry the vesicles. The use of baby powder is not recommended because inhalation of the powder is detrimental to the client; therefore, answer A is incorrect. Answers B and C are incorrect choices because hydrogen peroxide and saline will not relieve the itching and will prevent the vesicles from crusting.