NCLEX New Generation Exam Test Bank Updated 2023-2024 with All Questions, Exams of Nursing

Download NCLEX New Generation Exam Test Bank Updated 2023-2024 with All Questions and more Exams Nursing in PDF only on Docsity! NCLEX New Generation Exam Test Bank Updated 2023-2024 with All Questions and 100% Correct Answers New Version Question 1 A c. What document should be in guiding the care of this client? A) Client Self Determination Act B) Physician's treatment orders C) Advance Directives. D) Clinical Pathway protocols Review Information: The correct answer is: C) Advance Directives. This document specifies the client's wishes Question 2 You are the of a health care team that consists of one licensed practical/vocational nurse, one nursing assistant , a nursing student and yourself. To whom is it appropriate to assign complete care for A) Yourself B) The nursing student C) The licensed vocational nurse D) The nursing assistant Review Information: The correct answer is:A) Yourself. While the nurse may delegate a bed bath for a stable client, this care should be performed by an RN for a new admission. Only tasks that do not require independent judgment should be delegated. 3Question 3 A mother brings her the clinic, complaining that the child seems to be The nurse expects to find which of the following on the initial history and physical assessment? A) Increased temperature and lethargy B) Rash and restlessness C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor Review Information: The correct answer is:B) Rash and restlessness. Question 9 A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action A) May result in charges of unlawful seclusion and restraint B) Leaves the nurse vulnerable for charges of assault and battery C) Was appropriate in view of the client's history of violence D) Was necessary to maintain the therapeutic milieu of the unit Review Information: The correct answer is:A) May result in charges of unlawful seclusion and restraint. Seclusion should only be used when there is an immediate threat of violence or threatening behavior. Question 10 A client has been admitted to the Coronary Care Unit with a Myocardial Infarction. Which of the following nursing diagnosis should have PRIORITY? A) Pain related to ischemia B) Risk for altered elimination: constipation C) Risk for complication: dysrhythmias D) Anxiety Review Information: The correct answer is:A) Pain related to ischemia. Pain is related to ischemia, and relief of pain will decrease myocardial oxygen demands, reduce blood pressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system and increased preload, further increasing myocardial demands. Question 11 The nurse manager who is responsible for hiring professional nursing staff is required to comply with the Americans with Disabilities Act. The provisions of the law require the nurse manager to A) Maintain an environment free from hazards B) Provide reasonable accommodations for disabled individuals C) Make all necessary accommodations for disabled individuals D) Consider only physical disabilities in making employment decisions Review Information: The correct answer is:B) Provide reasonable accommodations for disabled individuals. The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant's ability to perform the job and not discriminate on the basis of a disability. Employers also must make "reasonable accommodations. Question 12 The mother of a school-aged child in a long leg cast asks the nurse how to relieve itching inside the cast. Which of the following is appropriate for the nurse to suggest as a remedy? A) Scratching the outside of the cast vigorously, applying pressure over the area B) Blowing a hair dryer or heat lamp on the cast over the area that is itching C) Using a long, smooth piece of wood to gently scratch the affected area D) Applying an ice pack over the area of the cast that is affected Review Information: The correct answer is:D) Applying an ice pack over the area of the cast that is affected. Applying ice is a safe method of relieving the itching. Question 13 Which of the following BEST describes the application of time management strategies in the role of the nurse manager? A) Scheduling staff efficiently to cover client needs B) Assuming a fair share of the client care as a role model C) Setting daily goals to prioritize work D) Delegating tasks to reduce work load Review Information: The correct answer is:C) Setting daily goals to prioritize work. Time management strategies must include setting priorities and meeting goals. Question 14 The clinic nurse assesses a toddler with a tentative diagnosis of neuroblastoma. Symptoms the nurse observes that suggest this problem include A) Lymphedema and nerve palsy B) Hearing loss and ataxia C) Headaches and vomiting D) Abdominal mass and weakness Review Information: The correct answer is:D) Abdominal mass and weakness. Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline, weakness, pallor, anorexia, weight loss and irritability. Question 15 A fifteen year-old client has been placed in a Milwaukee Brace. Which one of the following statements from the client indicates the need for additional teaching? A) "I will only have to wear this for six months." B) "I should inspect my skin daily." C) "The brace will be worn day and night." D) "I can take it off when I shower." Review Information: The correct answer is:A) "I will only have to wear this for six months.". The brace must be worn long-term, usually for 1-2 years. Question 16 The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that A) Quality of care will improve B) Staff turnover should decrease C) Flexible scheduling will occur D) Team morale will improve Review Information: The correct answer is:D) Team morale will improve. Nurses are more satisfied with autonomy and control. The nurse manager becomes the facilitator of scheduling rather than the decision-maker of the schedule. Question 17 A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? A) Diffuse expiratory wheezing Review Information: The correct answer is: C) Respiratory function. Spinal injury at the C-2 level results in quadriplegia. While the client will experience all of the problems identified, respiratory assessment is a priority. Question 23 The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care? A) Hourly urine output B) White blood count C) Blood glucose every four hours D) Temperature every two hours Review Information: The correct answer is:A) Hourly urine output. Clients who have had an episode of decreased glomerular perfusion are at risk for pre-renal failure. This is caused by any abnormal decline in kidney perfusion that reduces glomerular perfusion. Pre-renal failure occurs when the effective arterial blood volume falls. Examples of this phenomena include a drop in circulating blood volume as in a cardiac arrest state or in low cardiac perfusion states such as congestive heart failure associated with a cardiomyopathy. Close observation of hourly urinary output is necessary for early detection of this condition. Question 24 The nurse admitting a 5 month-old who vomited nine times in the past six hours should observe for signs of A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis Review Information: The correct answer is:B) Metabolic alkalosis. Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss and lead to metabolic alkalosis. Question 25 A child is injured on the school playground and appears to have a fractured leg. The FIRST action the school nurse should take is A) Call for emergency transport to the hospital B) Immobilize the limb and joints above and below the injury C) Assess the child and the extent of the injury D) Apply cold compresses to the injured area Review Information: The correct answer is:C) Assess the child and the extent of the injury. When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis). Question 26 As the nurse interviews the parents of a child with asthma, it is a PRIORITY to ask about A) Household pets B) New furniture C) Lead based paint D) Plants such as cactus Review Information: The correct answer is:A) Household pets. Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting and household dust. Question 27 An 80 year-old client was admitted with a diagnosis of possible cerebral vascular accident. Blood pressure has ranged from 180/110 to 160/100. Over the past several hours, the nurse noted increasing lethargy. Which of the following assessments should the nurse report IMMEDIATELY to the physician? A) Slurred speech B) Incontinence C) Muscle weakness D) Rapid pulse Review Information: The correct answer is:A) Slurred speech. Changes in speech patterns and level of conscious can be indicators of continued intercranial bleeding. Treatment options may change based on further diagnostic tests. Question 28 A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would INITIALLY assess for A) Allergies B) Hyperactivity C) Regression D) Pinworms Review Information: The correct answer is:D) Pinworms. Signs of pinworm infection include intense perianal itching, poor sleep patterns, general irritability, restlessness, bed-wetting, distractibility and short attention span. Question 29 A 72 year-old client with osteomyelitis requires a six week course of intravenous antibiotics. In planning for home care, the MOST important action by the nurse is A) Investigating the client's insurance coverage for home IV antibiotic therapy B) Determining if there are adequate hand washing facilities in the home C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver D) Selecting the appropriate venous access device Review Information: The correct answer is:C) Assessing the client''s ability to participate in self care and/or the reliability of a caregiver. The cognitive ability of the client as well as the availability and reliability of a caregiver must be assessed to determine if home care is a feasible option. Question 30 The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. The BEST response by the nurse is A) "Folic acid should be taken before and after conception." B) "Multivitamin supplements are recommended during pregnancy." C) "A well balanced diet promotes normal fetal development." D) "Increased dietary iron improves the health of mother and fetus." Review Information: The correct answer is:A) "Folic acid should be taken before and after conception.". A) Promote the client's comfort B) Reduce the drying time C) Decrease irritation to the skin D) Improve venous return Review Information: The correct answer is:D) Improve venous return. Elevating the leg both improves venous return and reduces swelling. Question 37 A nurse is working with family members of a newly diagnosed client with Alzheimer's disease. Which of the following interventions is MOST helpful? A) Teaching relaxation techniques B) Implementing a daily exercise routine C) Improving daily nutritional intake D) Suggesting communication strategies Review Information: The correct answer is:D) Suggesting communication strategies. Since Alzheimer''s disease is a progressive chronic illness that greatly challenges caregivers, the nurse can be of greatest assistance in helping family to identify language changes, and select verbal and nonverbal communication strategies to minimize aberrant behavior. Question 38 The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to A) Maintain previous calorie intake B) Keep a candy bar available at all times C) Reduce carbohydrates intake to 25% of total calories D) Keep a regular schedule of meals and snacks Review Information: The correct answer is:D) Keep a regular schedule of meals and snacks. Currently, calorie-controlled diets with strict mealplans are rarely suggested for clients who have diabetes. Try to incorporate schedule or food changes into clients'' existing dietary patterns. Help clients learn to read labels and identify specific canned foods, frozen entrees, or other foods which are acceptable and those which should be avoided. Question 39 The mother of a two month-old baby calls the nurse at a well-baby clinic two days after the first DTaP immunization. She reports that the baby feels very warm, has cried inconsolably for as long as three hours, and has had several shaking spells. The response of the nurse should be to A) instruct the mother to call 911 for an ambulance to transport the infant B) suggest that these are expected reactions and to begin every 4 hour antipyretics C) tell the mother to take the infant immediately to the nearest emergency room D) give instructions to bring the infant to the clinic now Review Information: The correct answer is:A)instruct the mother to call 911 for an ambulance to transport the infant The exhibited findings of the infant indicate a severe reaction to the immunizations. Immediate attention is needed & an ambulance with trained staff needs to transport because of the risk of grand mal seizures from potential encephalopathy which is a critical reaction. The mother would need to be instructed after this acute reaction to inform the provider of this reaction to the first dose of DTaP. Based on the need and risk involved to the infant, the health care provider may decide that further DTaP immunizations are contraindicated for life. The clinic nurse would need to document in the notes for this infant: the instructions given, findings reported by the mother and specific follow-up needs for the next clinic visit in relation to teaching and evaluation of the outcome of this event. Question 40 The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? A) Donating blood B) Using public bathrooms C) Unprotected sex D) Touching a person with AIDS Review Information: The correct answer is:C) Unprotected sex. Because HIV is spread through exposure to bodily fluids, unprotected intercourse and shared drug paraphernalia remain the highest risk for infection. Question 41 A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has short palpebral fissures, thinned upper lip, and hypoplastic philtrum of the upper lip. The mother states that the child seems to have problems in learning to count and recognizing basic colors. Based on this data, the nurse suspects that the child is MOST likely showing the effects of A) Congenital abnormalities B) Chronic toxoplasmosis C) Fetal alcohol syndrome D) Lead poisoning Review Information: The correct answer is:C) Fetal alcohol syndrome. Major features of fetal alcohol syndrome consist of facial and associated physical features, such as short palpebral fissure, hypoplastic philtrum, thinned upper lip, short, upturned nose. Behavioral problems, cognitive impairment and psychosocial deficits are also associated with this syndrome. Question 42 The nurse is performing the admission assessment of a client with an acute episode of asthma. Which of the following assessments would the nurse anticipate finding? A) Prolonged inspiration B) Expiratory wheezes C) Expectorating large amounts of purulent mucous D) Lethargy Review Information: The correct answer is:B) Expiratory wheezes. Asthma is characterized by expiratory wheezes caused by obstruction of the airways. Wheezes are a high pitched musical sounds produced by air moving through narrowed airways. Clients often associate wheezes with the feeling of tightness in the chest. Question 43 The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which of the following dinner menus would be BEST? A) Fish sticks, french fries, banana, cookies, milk B) Ground beef patty, lima beans, wheat roll, raisins, milk C) Chicken nuggets, macaroni, peas, cantaloupe, milk D) Peanut butter and jelly sandwich, apple slices, milk Review Information: The correct answer is:B) Ground beef patty, lima beans, wheat roll, raisins, milk. Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, dried fruits such as raisins. This dinner is the best choice, high in iron and is appropriate for a toddler. Question 44 A ten year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The BEST approach for the nurse to use is to The nurse should approach the toddler slowly and use minimal physical contact initially so as to gain the toddler''s cooperation. Be flexible in the sequence of the exam, and give only brief simple explanations just prior to the action. Question 50 A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of the following symptoms noted on the initial nursing assessment is expected? A) Recent weight gain B) Physical growth delay C) Protruding eyeballs D) Sudden onset of irritability Review Information: The correct answer is:C) Protruding eyeballs. Exophthalmos or protruding eyeballs is a distinctive characteristic of Graves'' Disease. Question 51 When assessing a client admitted to the hospital for diabetic acidosis, which of the following clinical manifestations would the nurse expect? A) A blood pH level above 7.5 B) Arterial blood PCO2 above 40 C) Blood pH level below 7.3 D) Arterial blood PCO2 below 10 Review Information: The correct answer is:C) Blood pH level below 7.3. In the absence of insulin, which facilitates the transport of glucose into the cell, the body breaks down fats and proteins to supply energy ketones, a by-product of fat metabolism. These accumulate causing metabolic acidosis (pH < 7.3). Question 52 The nurse is explaining the proper use of syrup of ipecac to a group of parents. For which of the following accidental poisonings is the treatment appropriate? A) Oven cleaner B) Drain cleaner C) Kerosene D) Chewable vitamins Review Information: The correct answer is:D) Chewable vitamins. Of the above choices, poisoning with vitamins is the only case in which it is safe to induce vomiting with syrup of ipecac. Question 53 A two year-old child is brought to the pediatrician's office with a chief complaint of mild diarrhea for two days. Nutritional counseling by the nurse should include which one of the following statements? A) Place the child on clear liquids and gelatin for 24 hours B) Continue with the regular diet and include oral rehydration fluids C) Give bananas, apples, rice and toast as tolerated D) Place NPO for 24 hours, then rehydrate with milk and water Review Information: The correct answer is:B) Continue with the regular diet and include oral rehydration fluids. Current recommendations for mild to moderate diarrhea are to maintain a normal diet with rehydration fluids. Question 54 The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. The nurse's BEST recommendation for the client is A) Nebulized treatments for home care B) Adding a spacer device to the MDI canister C) Asking a family member to assist the client with the MDI D) Request a visiting nurse to follow the client at home Review Information: The correct answer is:B) Adding a spacer device to the MDI canister. The majority of pulmonary medications for COPD are delivered by inhalation.This is often preferred over oral administration because a lower drug dose is needed and systemic side effects are reduced. In addition, the onset of action of bronchodilator medication given via inhalation is faster. Question 55 Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? A) Scratching the head more than usual B) Flakes evident on a student's shoulders C) Oval pattern occipital hair loss D) Whitish oval specks sticking to the hair Review Information: The correct answer is:D) Whitish oval specks sticking to the hair. Diagnosis of pediculosis capitis is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment includes shampoo application, such as lindane for children over 2 years of age, and meticulous combing and removal of all nits. Question 56 When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the BEST action the nurse would suggest to the parents is A) Administer syrup of ipecac B) Offer small amounts of water C) Have the child drink milk D) Give ginger ale or cola Review Information: The correct answer is:B) Offer small amounts of water. Small amounts of water will dilute the corrosive substance prior to gastric lavage. Question 57 A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client's history indicate a potential hazard for this test? A) Reflex incontinence B) Allergic to shellfish C) Claustrophobia D) Hypertension Review Information: The correct answer is:B) Allergic to shellfish. It is important to know if the client has an allergy to iodine or shellfish. If the client does, they may have an allergic reaction to the IVP contrast dye injected during the procedure. Question 58 C) Irritability and insomnia D) Headache and nausea Review Information: The correct answer is: A) Tetany and paresthesia. Because the parathyroid gland may be damaged in this surgery, secondary hypocalcemia may occur. Symptoms of hypoparathyroidism include tetany, paresthesia, muscle cramps and seizures. Question 64 A client is admitted with a right upper lobe infiltrate, and also to rule out tuberculosis. The isolation precautions the nurse would institute include A) Positive pressure ventilation B) Gown and gloves C) Particulate respirator mask D) Barrier precautions Review Information: The correct answer is:C) Particulate respirator mask. Tight fitting, high-efficiency masks are required when caring for clients who have suspected communicable disease of the airborne variety. Question 65 A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report? A) The client lost 2 pounds B) The client's potassium level is 4 mEq/liter. C) The client's urine output was 1500 cc in five hours D) The client is to receive another dose of Lasix at 10 PM Review Information: The correct answer is:C) The client's urine output was 1500 cc in five hours. Although all of these may be correct information to include in report, the essential piece would be the urine output. Question 66 The nurse is caring for a client with a colostomy. During a teaching session, the nurse recommends that the pouch be emptied A) When it is one third to one half full B) Prior to meals C) After each fecal elimination D) At the same time each day Review Information: The correct answer is:A) When it is one third to one half full. If the pouch becomes more than half full it may separate from the flange. Question 67 A couple asks the nurse about risks of several birth control methods. The MOST appropriate response by the nurse would be A) Norplant is safe and may be removed easily B) Oral contraceptives should not be used by smokers C) Depo-Provera is convenient with few side effects D) The IUD gives protection from pregnancy and infection Review Information: The correct answer is:B) Oral contraceptives should not be used by smokers. The use of oral contraceptives in a pregnant woman who smokes increases her risk of cardiovascular problems. Question 68 Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment? A) An increase in appetite B) A decrease in fluid retention C) A decrease in lethargy D) A reduction in jaundice Review Information: The correct answer is:C) A decrease in lethargy. Lactulose produces and acid environment in the bowel and trapsammonia in the gut; the laxative effect then aids in removing the ammonia from the body. This decreases the effects of hepatic encephalopathy, including lethargy and confusion. Question 69 The mother of a 3 month-old infant tells the nurse that she wants to change from formula towhole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? A) Solid foods should be introduced at 3-4 months B) Whole milk is difficult for a young infant to digest C) Fluoridated tap water should be used to dilute milk D) Supplemental apple juice can be used between feedings Review Information: The correct answer is:B) Whole milk is difficult for a young infant to digest. Cow''s milk is not given to infants younger than 1 year because the tough, hard curd is difficult to digest. Also it contains little iron and creates a high renal solute load. Question 70 The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombusformation in the post-operative period? A) Estrogen replacement therapy B) 10% less than ideal body weight C) Hypersensitivity to heparin D) History of hepatitis Review Information: The correct answer is:A) Estrogen replacement therapy. Estrogen increases the hypercoagualability of the blood and increased the risk for development of thrombophlebitis. Question 71 The nurse is planning discharge for a 90 year-old client with musculo-skeletal weakness. Which of the following interventions would be MOST effective in preventing falls? A) Place nightlights in bedroom B) Wear eyeglasses at all times C) Install grab bars in the bathroom D) Teach muscle strengthening exercises When the client is aware of early symptoms, such as pain, itching or tingling, treatment is very effective. Question 77 An eight year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which one of the following is the BEST choice? A) Bologna sandwich, pudding, milk B) Frankfurter, baked potato, milk C) Chicken strips, corn on the cob, milk D) Grilled cheese sandwich, apple, milk Review Information: The correct answer is:C) Chicken strips, corn on the cob, milk. This menu is lowest in sodium. Ideally, low fat milk would be available. Question 78 The nurse is teaching parents about accidental poisoning in children. Which of the following should be emphasized? A) Start treatment before calling the Poison Control Center B) Empty the child's mouth in any case of possible poisoning C) Do not move the child if a toxic substance was inhaled D) Induce vomiting if the poison is a hydrocarbon Review Information: The correct answer is:B) Empty the child''s mouth in any case of possible poisoning. Emptying the mouth of poison interferes with further ingestion and should be done first to limit contact with the substance. Question 79 Which of the following symptoms contraindicate the use of haloperidol (Haldol) and warrant withholding the dose? A) Drowsiness, lethargy, and inactivity B) Dry mouth, nasal congestion, and blurred vision C) Rash, blood dyscrasias, severe depression D) Hyperglycemia, weight gain, and edema Review Information: The correct answer is:C) Rash, blood dyscrasias, severe depression. Rash and blood dyscrasias are side effects of anti-psychotic drugs. A history of severe depression is a contraindication to the use of neuroleptics. Question 80 The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which of the following actions should receive PRIORITY in the plan? A) Antibiotic therapy for 10 days B) Teach client isometric exercises for legs C) Assess movement and sensation of extremities D) Assist to stand up at bedside within the first 24 hours Review Information: The correct answer is:C) Assess movement and sensation of extremities. Following corrective surgery for scoliosis, neurological status requires special attention and assessment, especially that of the extremities. Question 81 A three year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack? A) Cheese crackers B) Peanut butter sandwich C) Potato chips D) Vanilla cookies Review Information: The correct answer is:C) Potato chips. Children with celiac disease should eat a gluten free diet. Gluten is found mainly in grains of wheat and rye and in smaller quantities in barley and oats. Corn, rice, soybeans and potatoes are digestible in persons with celiac disease. Question 82 The nurse is caring for a 14 month-old just diagnosed with Cystic Fibrosis. The parents state this is the first child in either family with this disease, and ask about the risk to future children. The BEST response by the nurse is based on the knowledge that there is a A) 1 in 4 chance for each child to carry that trait B) 1 in 4 risk for each child to have the disease C) 1 in 2 chance of avoiding the trait and disease D) 1 in 2 chance that each child will have the disease Review Information: The correct answer is:B) 1 in 4 risk for each child to have the disease. Cystic Fibrosis is an autosomal recessive transmission pattern. In this situation, both parents must be carriers of the trait for the disease since neither one of them has the disease. Therefore, for each pregnancy, there is a 25% chance of the child having the disease, 50% chance of carrying the trait and a 25% chance of having neither the trait or the disease. Question 83 A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do FIRST? A) Notify the physician B) Administer the prn dose of Albuterol C) Apply oxygen at 2 liters per nasal cannula D) Repeat the peak flow reading in 30 minutes Review Information: The correct answer is: B) Administer the prn dose of Albuterol. Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-to-severe persistent asthma to determine the severity of the exacerbation and to guide the treatment. A peak flow reading of less than 50% of the client''s baseline reading is a medical alert condition and a short-acting beta-agonist must be taken immediately. Question 84 What nursing observation signifies that a client has attained the stage of concrete operations (Piaget)? A) Explores his environment using sight and movement B) Can think in mental images or word pictures C) Makes the moral judgment that "stealing is wrong" D) Reasons that homework is time-consuming but necessary Review Information: The correct answer is:C) Makes the moral judgment that "stealing is wrong". The stage of concrete operations is depicted by logical thinking and moral judgments. Question 85 Coumadin is ordered daily, based on the client''s prothrombin time (PT). This test evaluates the adequacy of the extrinsicsystem and common pathway in the clotting cascade; Coumadin affects the Vitamin K dependent clotting factors. Question 91 The nurse is caring for a four year-old two hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported IMMEDIATELY? A) Vomiting of dark emesis B) Complaints of throat pain C) Apical heart rate of 110 D) Increased restlessness Review Information: The correct answer is:D) Increased restlessness. Restlessness and increased respiratory and heart rates are often early signs of hemorrhage. care of infants and children. Question 92 The nurse admits a 7 year-old to the emergency room following a leg injury. X-rays show that there is a femur fracture near the epiphysis. The nurse should be aware that at this age, the injury MOST likely will A) Heal quickly because of thin periosteum B) Result in retarded bone growth C) Stimulate bone growth in the affected leg D) Show more rapid union than that of a younger child Review Information: The correct answer is: B) Result in retarded bone growth. An epiphyseal (growth) plate fracture in a 7 year-old often results in retarded bone growth. Limbs will be different in length. Question 93 A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse assesses this as A) Dystonia B) Akathesia C) Brady dysknesia D) Tardive dyskinesia Review Information: The correct answer is:D) Tardive dyskinesia. Signs of tardive dyskinesia include smacking lips, grinding of teeth and "fly catching" tongue movements. Question 94 While the nurse assesses a 2 month-old infant, the mother expresses concern because a flat pink birthmark on the baby's forehead and eyelid has not gone away. The nurse should tell the parents that A) Mongolian spots are a normal finding in dark-skinned children B) Port wine stains are often associated with other malformations C) Telangiectatic nevi are normal and will disappear as the baby grows D) The child is too young for surgical removal at this time Review Information: The correct answer is:C) Telangiectatic nevi are normal and will disappear as the baby grows. Telangiectatic nevi, salmon patch or stork bite birthmarks are a normal variation and the facial nevi will generally disappear by ages 1-2 years. Question 95 A client has returned to the unit following a renal biopsy. Which of the following nursing interventions is appropriate? A) Ambulate the client 4 hours after procedure B) Maintain client on NPO status for 24 hours C) Monitor vital signs D) Change dressing every eight hours Review Information: The correct answer is:C) Monitor vital signs. The potential complication of this procedure is internal hemorrhage. Monitoring vital signs is critical to detect early indications of bleeding. Question 96 The nurse assessing a newborn notices that the breasts are enlarged bilaterally with a white, thin discharge. The INITIAL action of the nurse should be to A) Notify the attending practitioner B) Ask about medications taken in pregnancy C) Record the findings as "normal" D) Obtain fluid to send for culture Review Information: The correct answer is:C) Record the findings as "normal". Newborn infants of both sexes may have engorged breasts and may secrete milk during the first few days and weeks following birth. Question 97 A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive PRIORITY? A) Maintaining proper body alignment B) Frequent neurovascular assessments of the affected leg C) Inspection of pin sites for evidence of drainage or inflammation D) Applying an over-bed trapeze to assist the client with movement in bed Review Information: The correct answer is:B) Frequent neurovascular assessments of the affected leg. The most important activity for the nurse is to assess neurovascular status. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular problem and early intervention may prevent permanent limb damage. Question 98 The nurse is teaching a client newly diagnosed with asthma how to use the metered-dose inhaler (MDI). The client asks when they will know the canister is empty. The BEST response is A) Drop the canister in water to observe floating B) Estimate how many doses are usually in the canister C) Count the number of doses as the inhaler is used D) Shake the canister to detect any fluid movement Review Information: The correct answer is:A) Drop the canister in water to observe floating. A mother telephones the clinic and tells the nurse she is concerned because her breastfed 1 month-old has soft, yellow stoolsafter each feeding. The nurse's BEST response would be based on the knowledge that A) This type of stool is normal for breast fed infants B) The stool should have turned to light brown by now C) Formula supplements will add bulk to the stools D) Water should be offered several times each day Review Information: The correct answer is:A) This type of stool is normal for breast fed infants. In breast-fed infants, stools are frequent and yellow to golden and vary from soft to thick liquid in consistency. No change in feedings is indicated. Question 105 The nurse caring for a 9 year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which of the following nursing diagnoses is a PRIORITY at this time? A) Risk for fluid volume deficit related to morphine overdose B) Decreased gastrointestinal mobility related to mucosal irritation C) Ineffective breathing patterns related to central nervous system depression D) Altered nutrition related to inability to control nausea and vomiting Review Information: The correct answer is:C) Ineffective breathing patterns related to central nervous system depression. Respiratory depression is a life-threatening risk in this overdose. Question 106 A pregnant client asks the nurse about the scheduled blood test for alpha-fetoprotein (AFP). The nurse's BEST explanation i A) "It tells us how far along your pregnancy is." B) "The results help determine if the baby is growing normally." C) "Placental exchange of oxygen is measured." D) "Possible neurological defects may be identified." Review Information: The correct answer is:D) "Possible neurological defects may be identified.". A fetus with neural tube defects loses alfa-fetoprotein (AFP) to the amniotic fluid and hence the maternal blood. High levels indicate the possibility of defects such as spina bifida and meningocele. Further assessments are indicated if a test is positive. Question 107 The nurse notes that a 2 year-old child recovering from a tonsillectomy has an temperature of 98.2 degrees F at 8:00 AM. At 10:00 AMthe child's mother reports that the child "feels very warm" to touch. The FIRST action by the nurse should be to A) Reassure the mother that this is normal B) Offer the child cold oral fluids C) Reassess the child's temperature D) Administer the prescribed acetaminophen Review Information: The correct answer is:C) Reassess the child''s temperature. A child''s temperature may have rapid fluctuations. The nurse should listen to and show respect for what parents say. Question 108 The nurse is assessing an eight month-old child. The nurse would anticipate that the child would be able to A) Say two words B) Pull up to stand C) Sit without support D) Use a spoon Review Information: The correct answer is:C) Sit without support. The age at which the normal child develops the ability to sit steadily without support is 8 months. Question 109 The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used to A) Determine oxygen saturation B) Measure forced expiratory volume C) Monitor atmosphere for presence of allergens D) Provide metered doses for inhaled bronchodilator Review Information: The correct answer is:B) Measure forced expiratory volume. The peak flow meter is used to measure peak expiratory flow volume. It provides useful information about the presence and/or severity of airway obstruction. Question 110 The nurse is performing a pre-kindergarten physical on a five year-old. The last series of vaccines will be administered. What is the preferred site for injection by the nurse? A) Vastus intermedius B) Gluteus rainlinus C) Vastus lateralis D) DorsogluteaI Review Information: The correct answer is:C) Vastus lateralis. Vastus lateralis, a large and well developed muscle, is the preferred site, since it is removed from major nerves and blood vessels. Question 111 A client experienced the loss of a seven month fetus. The nurse planning for discharge should emphasize A) Discussing feelings with support persons B) Focusing on the other healthy children C) Seeking causes for the fetal death D) Planning another pregnancy very soon Review Information: The correct answer is:A) Discussing feelings with support persons. In communicating therapeutically, the nurse helps the couple begin the grief process by suggesting they seek family, friends and support groups to listen to their feelings. Question 112 The parents of a 4 year-old hospitalized child tell the nurse they will leave for a time and return at 6 PM. When the child asks when the parents will come again, the nurse can BEST respond by saying The nurse is assessing a client with a stage 2 skin ulcer. Which of the following treatments is most effective to promote healing? A) Covering the wound with a dry dressing B) Using hydrogen peroxide soaks C) Leaving the area open to dry D) Applying a transparent film cover Review Information: The correct answer is:D) Applying a transparent film cover. For this type of ulcer, the most effective treatment is a transparent cover. Question 119 A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my husband will never come near me." The nurse's BEST response would be A) "You are underestimating your husband's ability to love you." B) "Are you concerned that your husband will reject you?" C) "Are you wondering about the effect on your sexual relations?" D) "Are you worried that the surgery will change you?" Review Information: The correct answer is:D) "Are you worried that the surgery will change you?" This is a response that encourages further discussion without focusing on an area that the nurse, but possibly not the client, feels is a problem. Question 120 When teaching suicide prevention to the parents of a 15 year-old who recently attempted suicide, the nurse describes the following behavioral cue A) Angry outbursts at significant others B) Fears of being left alone C) Giving away valued personal items D) Experiencing the loss of a boyfriend Review Information: The correct answer is:C) Giving away valued personal items. 80% of all potential suicide victims give some type of clue. These clues might lead one to suspect that a client is holding suicidal thoughts or is developing a plan. Question 121 The nurse is caring for a 4 year-old admitted after receiving burns to more than 50% of his body. Which laboratory data should be reviewed by the nurse as a PRIORITY in the first 24 hours? A) Blood urea nitrogen B) Hematocrit C) Blood glucose D) White blood count Review Information: The correct answer is:A) Blood urea nitrogen. Glomerular filtration is decreased in the initial response to severe burns, with fluid shift. Kidney function must be monitored closely, or renal failure may follow in a few days. Question 122 The nurse is caring for a client in a Coronary Care Unit two days following a Myocardial Infarction. The client has many questions about his condition. The nurse should focus teaching about A) Immediate needs and concerns B) Post discharge rehabilitation C) Medication therapy at home D) Activity and rest schedule Review Information: The correct answer is:A) Immediate needs and concerns. Client education of the post MI client should be limited to immediate needs and concerns. Question 123 The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test? A) Client should be NPO after midnight B) Client should receive a sedative medication prior to the test C) Discontinue anti-coagulant therapy prior to the test D) No special preparation is necessary Review Information: The correct answer is:D) No special preparation is necessary. This is a non-invasive procedure and does not require preparation. Question 124 While interviewing a client, the nurse notices that the client is shifting positions, wringing her hands, and avoiding eye contact. It is important for the nurse to A) Ask the client what she is feeling B) Assess the client for auditory hallucinations C) Recognize the behavior as a side effect of medication D) Re-focus the discussion on a less anxiety provoking topic Review Information: The correct answer is:A) Ask the client what she is feeling. The initial step in anxiety intervention is observing, identifying, and assessing anxiety. Question 125 Parents of a 4 year-old boy have just been informed that their son has a congenital neurologic demyelinating disorder that is terminal. The nurse evaluates their reaction as which phase of the crisis process? A) Pre-crisis phase B) Impact phase C) Crisis phase D) Resolution phase Review Information: The correct answer is:B) Impact phase. The impact of crisis is indicative of high levels of stress, sense of helplessness, confusion, disorganization, and the inability to apply problem solving behavior. Question 126 A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's BEST initial intervention is to A) Discuss with the mother sharing parenting responsibilities B) Help the mother to express her feelings and concerns C) Arrange for the parents to attend infant care classes An 8 year-old client is admitted to the child mental health unit for evaluation. Following his mother's departure, the client cries and refuses his dinner. The BEST approach by the nurse is to A) Offer to play with him B) Remind him that he is expected to eat his meals C) Tell him that he will be denied privileges for uncooperative behavior D) Tell him that his mother will be upset with him if he does not cooperate Review Information: The correct answer is:A) Offer to play with him. Play is both distracting and an avenue for a child's communication. Play facilitates mastery of feelings. Question 133 A client is admitted to a psychiatric unit with delusions. The nurse can expect which of the following signs and symptoms? A) Flight of ideas and hyperactivity B) Suspiciousness and resistance to therapy C) Anorexia and hopelessness D) Panic and multiple physical complaints Review Information: The correct answer is:B) Suspiciousness and resistance to therapy. Clinical features of delusional disorder include extreme suspiciousness, jealousy, distrust, belief that others intend to harm. Question 134 A client states, "People think I'm no good, you know what I mean?" Which of the following nursing responses would be MOST therapeutic for this client? A) "Well people often take their own feelings of inadequacy out on others." B) "I think you're good. So you see, there's one person who likes you." C) "I'm not sure what you mean. Tell me a bit more about that." D) "Have you done something to create this impression on people?" Review Information: The correct answer is:C) "I'm not sure what you mean. Tell me a bit more about that." Therapeutic communication technique that elicits more information is delivered in an open non-judgmental fashion. Question 135 A client who is a former actress enters the day room wearing a sheer nightgown, high heels, numerous bracelets, bright red lipstick and heavily rouged cheeks. Which of the following is the BEST nursing action in response to the client's attire? A) Gently remind her that she is no longer on stage B) Directly assist client to her room for appropriate apparel C) Quietly point out to her the dress of other clients on the unit D) Tactfully explain to her the clothing appropriate for the hospital Review Information: The correct answer is:B) Directly assist client to her room for appropriate apparel. Allows the client to maintain self-esteem while modifying behavior. Question 136 An appropriate goal for a client with anxiety would be to A) Ventilate her feelings to the nurse B) Establish contact with reality C) Learn self-help techniques for reducing anxiety D) Become desensitized to past trauma Review Information: The correct answer is:C) Learn self-help techniques for reducing anxiety. Exploring alternative coping mechanisms will decrease present anxiety to a manageable level. Assisting the client to learn self-help techniques will assist in learning to cope with anxiety. Question 137 Handshaking is the preferred form of touch or contact used with clients in a psychiatric setting. The rationale behind this limited touch practice is that A) Some clients misconstrue hugs as an invitation to sexual advances B) Handshaking keeps the gesture on a professional level C) Refusal to touch a client denotes lack of concern D) Inappropriate touch often results in charges of assault and battery Review Information: The correct answer is: A) Some clients misconstrue hugs as an invitation to sexual advances. Touch denotes positive feelings for another person. The client may interpret hugging and holding hands as a sexual advance. Question 138 A client with paranoid delusions stares at the nurse for several days. The client suddenly walks up to the nurse and shouts "You think you're so perfect and pure and good." An appropriate response for the nurse is A) "Is that why you've been starring at me?" B) "You seem to be in a really bad mood." C) "Perfect? I don't quite understand." D) "You are angry right now." Review Information: The correct answer is: D) "You are angry right now.". The nurse recognizes the underlying emotion with matter of fact attitude. Question 139 A client being treated for hypertension returns to the clinic for follow up.He says, "I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." The MOST appropriate nursing diagnosis would be A) Noncompliance related to medication side effects B) Knowledge deficit related to misunderstanding of disease state C) Defensive coping related to chronic illness D) Altered health maintenance related to occupation Review Information: The correct answer is: A) Noncompliance related to medication side effects. The client kept his appointment, and stated he knew the pills were important. He is unable to comply with the regimen due to side effects, not a lack of knowledge about his disease. D) Explores his feelings of resentment to identify causes Review Information: The correct answer is: C) Provides opportunity to discuss concerns without presence of parents. This intervention provides the teen with the opportunity to have control and encourages decision making. Question 145 A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance and cardiac dysrhythmias. Additional assessment findings that the nurse would expect to observe are A) Brittle hair, lanugo, amenorrhea B) Diarrhea, nausea, vomiting, dental erosion C) Hyperthermia, tachycardia, increased metabolic rate D) Excessive anxiety about symptoms Review Information: The correct answer is: A) Brittle hair, lanugo, amenorrhea. Physical findings associated with anorexia are brittle hair, lanugo, and dehydration, lowered metabolic rate and vital signs. Question 146 A depressed client in an assisted living facility tells the nurse that "life isn't worth living anymore." What is the BEST response to this statement? A) "Come on, it is not that bad." B) "Have you thought about hurting yourself?" C) "Did you tell that to your family?" D) "Think of the many positive things in life." Review Information: The correct answer is: B) "Have you thought about hurting yourself?". It is appropriate and necessary to determine if someone who has voiced suicidal ideation is considering a suicidal act. This response is most therapeutic in the circumstances. Question 147 A client, recovering from alcoholism, asks the nurse, "What can I do when I start recognizing relapse triggers within myself?" How might the nurse BEST respond? A) "When you have the impulse to stop in a bar, contact a sober friend and talk with him." B) "Go to an AA meeting when you feel the urge to drink." C) "It is important to exercise daily and get involved in activities that will cause you not to think about drug use." D) "Identify your relapse triggers as part of getting better." Review Information: The correct answer is: D) "Identify your relapse triggers as part of getting better.". This option encourages the process of self evaluation and problem solving. Question 148 A client was admitted to the eating disorder unit with bulimia nervosa. When the nurse assesses for a history of complications of this disorder, the following are expected A) Respiratory distress, dyspnea B) Bacterial gastrointestinal infections, overhydration C) Metabolic acidosis, constricted colon D) Dental erosion, parotid gland enlargement Review Information: The correct answer is: D) Dental erosion, parotid gland enlargement. Dental erosion related to purging and parotid gland enlargement due to purging are common complications. Question 149 A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states," This is not my baby, and I do not want it." The nurse's BEST response is A) "This is a common occurrence after birth, but you will come to accept the baby." B) "Many women have postpartum blues and need some time to love the baby." C) "What a beautiful baby! Her eyes are just like yours." D) "You seem upset; tell me what the pregnancy and birth were like for you." Review Information: The correct answer is: D) "You seem upset; tell me what the pregnancy and birth were like for you.". A non-judgmental, open ended response facilitates dialogue between the client and nurse. Question 150 Which of the following times is a depressed client at highest risk for attempting suicide? A) Immediately after admission, during one-to-one observation B) 7 to 14 days after initiation of antidepressant medication and psychotherapy when energy increases C) Following an angry outburst with family D) When the client is removed from the security room Review Information: The correct answer is: B) 7 to 14 days after initiation of antidepressant medication and psychotherapy when energy increases. As the depression lessens, the depressed client acquires energy to follow the plan. Question 1 The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of A) Anonymity B) Beneficence Several studies have been conducted in pregnant women where oral anticoagulation agents are contraindicated. Warfarin (Coumadin) is known to cross the placenta and is therefore reported to be teratogenic. Question 6 Which of the following BEST describes the goal of total quality management or continuous quality improvement in a health care setting? A) Observing reactive service and product problem solving B) Improving processes in a proactive, preventive mode C) Conducting chart audits to find common errors D) Creating a flow chart to organize daily tasks Review Information: The correct answer is: B) Improving processes in a proactive, preventive mode. Total Quality Management and Continuous Quality Improvement have a major goal of identifying ways to do the right thing at the right time in the right way by proactive problem- solving. Question 7 A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which of the following interview strategies is the BEST? A) Vary the interview style for each candidate to learn different techniques B) Use simple questions requiring "yes" and "no" answers to gain definitive information C) Develop an interview guide for consistency in interviewing each candidate D) Ask personal information of each applicant to assure meeting of job demands Review Information: The correct answer is: C) Develop an interview guide for consistency in interviewing each candidate. An interview guide used for each candidate enables the nurse manager to be more objective in the decision making. Question 8 The nurse is caring for a client who has altered cerebral tissue perfusion related to a subarachnoid hemorrhage. To reduce the risk of rebleeding, the nurse should plan to A) Restrict visitors to immediate family B) Arouse the client frequently C) Keep client's hips flexed at 120 degrees D) Apply warming blankets Review Information: The correct answer is: A) Restrict visitors to immediate family. Maintaining a quiet environment will assist in decreasing cerebral swelling and rebleeding. Question 9 The nurse is caring for a client with renal calculi. Which physician order would be a PRIORITY? A) Morphine sulfate as client controlled analgesia B) Push oral fluids and keep vein open C) Continuous warm compresses to the flank area D) Intravenous antibiotics Review Information: The correct answer is: A) Morphine sulfate as client controlled analgesia. Administering narcotic analgesics provide prompt relief of the severe pain caused by kidney stones. Question 10 The nurse is teaching parents of a 7 month-old about adding table foods. Which of the following is an APPROPRIATE finger food? A) Hot dog pieces B) Sliced bananas C) Whole grapes D) Popcorn Review Information: The correct answer is: B) Sliced bananas. Finger foods should be bite-size pieces of soft food such as bananas. Question 11 While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about A) One year of age B) Two years of age C) Three years of age D) Four years of age Review Information: The correct answer is: B) Two years of age. A child should be at least 2 years of age to use the radial pulse to assess heart rate. Question 12 A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses her at home two days later and finds the weight to be 6 pounds 7 ounces. When the parents question this loss, the nurse explains that A) The newborn needs additional assessments B) The mother should breast feed more often C) A change to formula is indicated D) The loss is within normal limits A) Encourage child to engage in activities in the playroom B) Promote independence in activities of daily living C) Talk with the child and allow him to express his opinions D) Provide frequent reassurance and cuddling Review Information: The correct answer is: A) Encourage child to engage in activities in the playroom. According to Erikson, the school age child is in the stage of industry versus inferiority. To help them achieve industry, the nurse should encourage them to carry out tasks and activities in their room or in the playroom. Question 18 The nurse is preparing to administer a tube feeding to a post-operative client. To accurately assess for a gastostomy tube placement, the PRIORITY is to A) Auscultate the abdomen while instilling 10 cc of air into the tube B) Place the end of the tube in water to check for air bubbles C) Retract the tube several inches to check for resistance D) Measure the length of tubing from nose to epigastrium Review Information: The correct answer is: A) Auscultate the abdomen while instilling 10 cc of air into the tube. If a swoosh of air is heard over the abdominal cavity while instilling air into the gastric tube, this indicates that it is accurately placed in the stomach. The feeding can begin after assessing the client for bowel sounds. Question 19 You are caring for a client with Parkinson's disease who has developed hallucinations. Which of the following medications that the client is receiving may have been a contributing factor? A) L-Dopa B) Cogentin C) Baclofen D) Benadryl Review Information: The correct answer is: A) L-Dopa. While it is unclear whether some 1/3 of clients with Parkinson's disease have a dementia, the nurse should ask about hallucinations because the Parkinson's disease medications will cause hallucinations when they are at too high a dose. This should be asked at each client visit in home care or clinic visits. Question 20 A nurse admits a client transferred from the emergency room. The client, diagnosed with a myocardial infarction, is complaining of substernal chest pain, diaphoresis and nausea. The FIRST action by the nurse should be A) Order an EKG B) Administer pain medication as ordered C) Start an IV D) Measure vital signs Review Information: The correct answer is: B) Administer pain medication as ordered. Decreasing the clients pain is the most important priority at this time. As long as pain is present there is danger in extending the infarcted area. Question 21 Decentralized scheduling is used on a nursing unit. A CHIEF advantage of this management strategy is that it A) Considers client and staff needs B) Conserves time for planning C) Frees the nurse manager from this task D) Allows for requests for special privileges Review Information: The correct answer is: A) Considers client and staff needs. Decentralized staffing takes into consideration specific client needs and staff interests and abilities. Question 22 A client with angina has been instructed about the use of sublingual nitroglycerin. Which of the following statements made to the nurse indicates a need for FURTHER teaching? A) "I will rest briefly right after taking one tablet." B) "I can take 2-3 tablets at once if I have severe pain." C) "I'll call the doctor if pain continues after 3 tablets 5 minutes apart." D) "I understand that the medication should be kept in the dark bottle." Review Information: The correct answer is: B) "I can take 2-3 tablets at once if I have severe pain." Clients must understand that just one sublingual tablet should be taken at a time. After rest and a five minute interval, a second and then a third tablet may be necessary. Question 23 The nurse is talking with the family of an 18 month-old newly diagnosed with retinoblastoma. A PRIORITY in communicating with the parents is A) Discussing the need for genetic counseling B) Informing them that combined therapy is seldom effective C) Preparing for the child's permanent disfigurement D) Suggesting that total blindness may follow surgery Review Information: The correct answer is: A) Discussing the need for genetic counseling. The hereditary aspects of this disease are well documented. While the parents focus on the needs of this child, they should be aware that the risk is high for future offspring. Question 29 A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which of the following client statements from the assessment data is likely to explain his noncompliance? A) "I have problems with diarrhea." B) "I have difficulty falling asleep." C) "I have diminished sexual function." D) "I often feel jittery." Review Information: The correct answer is: C) "I have diminished sexual function." Inderal beta-blocks cells prohibiting the release of epinephrine into the cells; this may result in hypotension which results in decreased libido and impotence. Question 30 The nurse is instructing a client with moderate persistent asthma on the proper method for using MDI's (multi-dose inhalers). Which medication should be administered FIRST? A) Steroid B) Anticholinergic C) Mast cell stabilizer D) Beta agonist Review Information: The correct answer is: D) Beta agonist. The beta-agonist is taken first to open the airway. Dettenrneier, .A. (1992). Pulmonary Nursing Care. St. Louis: Mosby. Lewis, S., Collier, I., & Heitkemper, M.M. (1996). Medical-Surgical Nursing. (4th ed.). St. Louis: Mosby. Question 31 A nurse assessing the newborn of a diabetic mother understands that hypoglycemia is related to A) Disruption of fetal glucose supply B) Pancreatic insufficiency C) Maternal insulin dependency D) Reduced glycogen reserves Review Information: The correct answer is: A) Disruption of fetal glucose supply. After delivery, the high glucose levels which crossed the placenta to the fetus are suddenly stopped. The newborn continues to secrete insulin in anticipation of glucose. When oral feedings begin, the newborn will adjust insulin production within a day or two. Lowdermilk, D., Perry, S., Bobak, I. (1997). Maternal and Women's Health Care. (6th ed.). St. Louis, Mosby. Wong, D. (1999). Whaley and Wong's Nursing Care of Infants and Children. (5th ed.). St. Louis: Mosby. Question 32 The nurse is administering an intravenous piggyback infusion of penicillin. Which of the following client statements would require the nurse's IMMEDIATE attention? A) "I have a burning sensation when I urinate." B) "I have soreness and aching in my muscles." C) "I am itching all over." D) "I have cramping in my stomach." Review Information: The correct answer is: C) "I am itching all over." Complaints of itching, feeling hot all over and/or the appearance of raised, red welts on the skin are symptoms of an allergic reaction to the penicillin infusion. Therefore, the drug administration should be stopped immediately. Carroll, P. (1994). Speed: The Essential Response to Anaphylaxis. RN 57(6), 26-31. Ignatavicius, D.D., Workman, M.L., Mishler, M.A. (1995). Medical-Surgical Nursing. Philadelphia: WB Saunders. Review Information: The correct answer is: A) The client's self-report is the most important consideration. Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is. Luckmann, Joan. (1997). Saunders Manual of Nursing Care. Philadelphia: W.B. Saunders Company. Springhouse. (1997). Diseases. (2nd ed.). Springhouse, PA: Springhouse Corporation. Question 36 The nurse is performing an assessment of the motor function in a client with a head injury. The BEST technique is A) A firm touch to the trapezius muscle or arm B) Pinching any body part C) Sternal rub D) Gentle pressure on eye orbit Review Information: The correct answer is: D) Gentle pressure on eye orbit. This is an acceptable stimuli. Urden, L., Davie, J. & Thelan, L. (1997). Essentials of Critical Care. (2nd ed.). St. Louis: Mosby-Yearbook. Barker, E. (1994). Neuro-Science Nursing. St. Louis: Mosby. Question 37 A 3 year-old child has tympanostomy tubes in place. The child's mother asks the nurse if he can swim in the family pool. The BEST response from the nurse is A) "Your child should not swim at all while the tubes are in place." B) "Your child may swim in your own pool but not in a lake or ocean." C) "Your child may swim if he wears ear plugs." D) "Your child may swim anywhere." Review Information: The correct answer is: C) "Your child may swim if he wears ear plugs.". Water should not enter the ears. Children should use ear plugs when bathing or swimming and should not put their head under the water. Ashwill, J. W. & Droske, S. C. (1997). Nursing Care of Children: Principles and Practice. Philadelphia: W. B. Saunders. Ball, J. & Bindler, R. (2000). Pediatric Nursing: Caring for Children. Norwalk: Appleton & Lange. Question 38 The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects? A) Neurotoxicity B) Hepatomegaly C) Nephrotoxicity D) Ototoxicity Review Information: The correct answer is: C) Nephrotoxicity. Nephrotoxicity is a common side effect of calcium disodium edetate, in addition to lead poisoning in general. McHenry & Salerno. (2000). Mosby Pharmacology in Nursing. St. Louis: Mosby-Yearbook. Wong, D. (1999). Whaley & Wong's Nursing Care of Infants and Children.. St. Louis: Mosby. Question 39 The nurse admits a two year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure? A) "He has been taking long naps for a week." Medical-Surgical Nursing, Clinical Management for Continuity of Care. (5th ed.). Philadelphia: Saunders. Lewis, S., Collier, I., & Heitkemper, M. (1996). Medical-Surgical Nursing; Assessment and Management of Clinical Problems. (4th ed.). St. Louis: Mosby. Question 2 In providing care to a 14 year-old adolescent with scoliosis, which of the following will be MOST difficult for this client? A) Compliance with treatment regimens B) Looking different from their peers C) Lacking independence in activities D) Reliance on family for their social support Review Information: The correct answer is: B) Looking different from their peers. Conformity to peer influences peaks at around age 14. Since many persons view any disability as deviant, the client will need help in learning how to deal with reactions of others. Treatment of scoliosis is long-term and involves bracing and/or surgery. Wong, D. (1999). Whaley & Wong''s Nursing Care of Infants and Children.. St. Louis: Mosby. Ashwill, J. W. & Droske, S. C. (1997). Nursing Care of Children: Principles and Practice. Philadelphia: W. B. Saunders. Question 3 When counseling parents of a child who has recently been diagnosed with hemophilia, the nurse must know that in the offspring of a normal father and a carrier mother A) It is likely that all sons are affected B) There is a 50% probability that sons will have the disease C) Every daughter is likely to be a carrier D) There is a 25% chance a daughter will be a carrier Review Information: The correct answer is: D) There is a 25% chance a daughter will be a carrier. Hemophilia A is a sex-linked recessive traitseen almost exclusively in males. With a normal father and carrier mother, affected individuals are male. There is a 25% chance of having an affected male, 25% chance of having a carrier female, 25% chance of having a normal female and 25% chance of having a normal male. Ball, J. & Bindler, R. (2000). Pediatric Nursing: Caring for Children. Norwalk: Appleton & Lange. Wong, D. (1999). Whaley & Wong''s Nursing Care of Infants and Children.. St. Louis: Mosby. Question 4 A three year-old child is treated in the emergency room after ingesting an ounce of a liquid narcotic. What FIRST action should the nurse take? A) Provide humidified oxygen B) Suction mouth and nose C) Assess airway and circulation D) Start intravenous fluids Review Information: The correct answer is: C) Assess airway and circulation. The first step in treatment of a toxic exposure or ingestion is to assess the airway, breathing and circulation; then stabilize the client. Other nursing actions will follow. Wong, D. (1999). Whaley & Wong''s Nursing Care of Infants and Children.. St. Louis: Mosby. Ashwill, J. W. & Droske, S. C. (1997). Nursing Care of Children: Principles and Practice. Philadelphia: W. B. Saunders. Question 5 The nurse is caring for a client who is receiving total parenteral nutrition (hyperalimentation and lipids). What is the PRIORITY nursing action on every eight hour shift? A) Monitor blood pressure, temperature and weight B) Change the tubing under sterile conditions C) Check urine glucose, acetone and specific gravity National Institutes of Health. Springhouse. (1998). Nursing 98 Drug Handbook Question 8 The nurse measures the head and chest circumferences of a 20 month-old infant. After comparing the measurements, the nurse finds that they are approximately the same. The appropriate action for the nurse to take would be to A) Notify the physician B) Palpate the anterior fontanel C) Feel the posterior fontanel D) Record these normal findings Review Information: The correct answer is: D) Record these normal findings. The rate of increase in head circumference slows by the end of infancy, and the head circumference is usually equal to chest circumference at 1 to 2 years of age. Wong, D. (1999). Whaley & Wong''s Nursing Care of Infants and Children.. St. Louis: Mosby. Ashwill, J. W. & Droske, S. C. (1997). Nursing Care of Children: Principles and Practice. Philadelphia: W. B. Saunders. Question 9 A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse informs the child and family that the MOST important reason for this diet is to A) Promote healing and strengthen the immune system B) Provide a well balanced nutritional intake C) Stimulate increased peristalsis absorption D) Spare protein catabolism to meet metabolic needs Review Information: The correct answer is: D) Spare protein catabolism to meet metabolic needs. Because of the burn injury, the child has increased metabolism and catabolism. By providing a high carbohydrate diet, the breakdown of protein for energy is avoided. Proteins are then used to restore tissue. Betz, C., Hunsberger, M. & Wright, S. (1994). Family-Centered Nursing Care of Children. (2nd ed.). Philadelphia: Saunders. Wong, D. (1999). Whaley & Wong''s Nursing Care of Infants and Children.. St. Louis: Mosby. Question 10 The nurse prepares to give a one year-old child an intramuscular injection. The BEST site for this injection would be in the A) Deltoid muscle B) Ventrogluteal muscle C) Dorsogluteal muscle D) Vastus lateralis muscle Review Information: The correct answer is: D) Vastus lateralis muscle. The preferred site for an injection for an infant is the vastus lateralis muscle which lies along the lateral aspect of the thigh. This site is able to tolerate larger volumes, and it is not located near any nerves or blood vessels. Ashwill, J. W. & Droske, S. C. (1997). Nursing Care of Children: Principles and Practice. Philadelphia: W. B. Saunders. Ball, J. & Bindler, R. (2000). Pediatric Nursing: Caring for Children. Norwalk: Appleton & Lange. Question 11 A client is unconscious following a tonic-clonic seizure. What should the nurse do FIRST? A) Check the pulse B) Administer Valium C) Place the client in a side-lying position D) Place a tongue blade in the mouth Ball, J. & Bindler, R. (2000). Pediatric Nursing: Caring for Children. Norwalk: Appleton & Lange. Question 14 In teaching parents about the lifestyle of their child with sickle cell disease, the nurse should emphasize that their child should A) Avoid overheating B) Maintain normal activity C) Be cautious of addiction D) Delay routine immunizations Review Information: The correct answer is: A) Avoid overheating. Fluid loss caused by overheating can trigger a crisis. Ashwill, J. W. & Droske, S. C. (1997). Nursing Care of Children: Principles and Practice. Philadelphia: W. B. Saunders. Ball, J. & Bindler, R. (2000). Pediatric Nursing: Caring for Children. Norwalk: Appleton & Lange. Question 15 The nurse is caring for a newborn who has just been diagnosed with hypospadias. After discussing the defect with the parents, the nurse should expect that A) Circumcision can be performed at any time B) Initial repair is delayed until ages 6-8 C) Post-operative appearance will be normal D) Surgery will be performed in stages Review Information: The correct answer is: D) Surgery will be performed in stages. Hypospadias, a condition in which the urethral opening is located on the ventral surface or below the penis, is corrected in stages as soon as the infant can tolerate surgery. Wong, D. (1999). Whaley & Wong''s Nursing Care of Infants and Children.. St. Louis: Mosby. Ball, J. & Bindler, R. (2000). Pediatric Nursing: Caring for Children. Norwalk: Appleton & Lange. Question 16 One reason that domestic violence remains extensively undetected is A) Few battered victims seek medical care B) As few as one in twenty battered victims are accurately identified C) Expenses due to police and court costs D) Very little knowledge is currently known about batterers and battering relationships Review Information: The correct answer is: B) As few as one in twenty battered victims are accurately identified. Signs of abuse may not be clearly manifested and a series a minor complaints such as headache, abdominal pain, insomnia, back pain, and dizziness may be covert indications of abuse undetected. Complaints may be vague. Fontaine, K. & Fletcher, J. (1998). Essentials of Mental Health Nursing. Menlo Park, CA: Addison- Wesley. Varcarolis, E. (1998). Foundations of Psychiatric Mental Health Nursing. Philadelphia: W.B. Saunders. Question 17 The nurse is caring for a client with COPD who suddenly complains of sharp pains in the right side of his chest, is cyanotic and has a tracheal deviation toward the right side. The nurse recognizes that these symptoms are probably due to A) Atelectasis B) Respiratory acidosis C) Tension pneumothorax D) Bronchospasm Review Information: The correct answer is: C) Tension pneumothorax. Question 20 The parents of a 7 year-old tell the nurse their child has started to "tattle" on siblings. In interpreting this new behavior to the mother, the nurse should explain the child acts this way because A) The ethical sense and feelings of justice are developing B) Attempts to control the family use new coping styles C) Insecurity and attention getting are common motives D) Complex thought processes help to resolve conflicts Review Information: The correct answer is: A) The ethical sense and feelings of justice are developing. The child is developing a sense of justice and a desire to do what is right. At seven, the child is increasingly aware of family roles and responsibilities. They also do what is right because of parental direction or to avoid punishment. Pillitteri, A. (1995). Maternal Child Health Nursing. Philadelphia: Lippincott-Raven Publishers. Boynton, R. et al. (1994). Manual of Ambulatory Pediatrics. Philadelphia: Lippincott-Raven Publishers. Question 21 In assessing the healing of a client's wound during a home visit, which of the following is the BEST indicator of good healing? A) White patches B) Green drainage C) Reddened tissue D) Eschar development Review Information: The correct answer is: C) Reddened tissue. As the wound granulates, redness indicates healing. Beuscher, T. (1997). Wound Care. In Martin, K., Larson, B., Gorski, L. & Hayko, D. Mosby''s Home Health Client Teaching Guides: Rx for Teaching, IV F 2, 1-6. St. Louis: Mosby. Troia, C. & Black, J. (1997). Preventing Pressure Ulcers. In Martin, K., Larson, B., Gorski, L., & Hayko, D. Mosby''s Home Health Client Teaching Guides: Rx for Teaching, IV F 1, 1-6. St. Louis: Mosby. Question 22 Clients taking which of the following drugs are at risk for depression? A) Steroids B) Diuretics C) Folic acid D) Aspirin Review Information: The correct answer is: A) Steroids. Adverse medication effects can cause a syndrome that may or may not remit when the medication is discontinued. Examples include: phenothiazines, steroids, and reserpine. Shives, L. (1998). Basic Concepts of Psychiatric-Mental Health Nursing. New York: J.B. Lippincott Co. Varcarolis, E. (1998). Foundations of Psychiatric Mental Health Nursing. Philadelphia: W.B. Saunders. Question 23 The nurse is assessing a 4 year-old for possible developmental dysplasia of the right hip. Which of the following would the nurse expect to find? A) Pelvic tip downward B) Right leg lengthening C) Ortolani sign D) Characteristic limp Review Information: The correct answer is: D) Characteristic limp. Developmental dysplasia produces a characteristic limp in children who are walking.