Test for all specialty in nursing FILL IN THE BLANKS

Test for all specialty in nursing

FILL IN THE BLANKS

Fill in the blank spaces with the correct word or phrase to complete each statement.

1. The three most basic causes of cell injury are a. b. c.

2. The five classic signs of infection are a. b. c. d. e.

3. The two major components of the inflammatory response are a. b.

4. The three types of exudates are a. b. c.

5. The four components of the healing process are a. b. c. d.

6. Collagen fibers in scar tissue are weak for days.

7. The four most common sites of nosocomial infection are a. b. c. d.

8. Cancers arising in tissues derived from mesoderm such as muscles, bones, or connective tissue are called

.

9. The two distinct processes involved in carcinogenesis are a. b.

10. Another name for the contractile force of the heart is .

1058 PART II: Content Review

TRUE & FALSE QUESTIONS

Mark each of the following statements True or False. Correct all false statements in the space provided.

1. Calcification occurs only in necrotic tissue.

2. Chronic inflammation progressively destroys tissue and results in loss of function and scarring.

3. Once regeneration occurs, function is restored to damaged organs.

4. If a child cuts his hand on a piece of broken glass and has eight sutures to close the wound, healing will occur by second intention.

5. To facilitate healing of a wound across the middle knuckle of the index finger, the joint needs to be immobilized.

6. Signs of systemic infection include swollen lymph nodes, fever, and elevated ESR.

7. Total length of the cell cycle is the same for all cells; what differs is the length of time spent in each phase.

8. A characteristic of a benign tumor is that it is composed of cells that resemble the tissue of origin.

9. Malignant tumors cause systemic symptoms such as altered taste and weight loss.

10. The initial effect of an increase in heart rate is a decrease in cardiac output.

MATCHING QUESTIONS

Match the following:

T F

T F

T F

T F

T F

1. Adhesions a. Type of nosocomial infection, which is the direct result of a diagnostic or therapeutic procedure

2. Hypertrophy b. Angioneogenesis

3. Serous exudates c. Ability of a microorganism to produce infection

4. Dehiscence d. Enlargement of cells and organs as a result of increased demand

5. Apoptosis e. Number of cells increased through cell division in response to demand

6. Contracture f. Fluid in blisters of a mild sunburn

7. Suppurative exudate g. Microorganism that causes infection only in a susceptible person

T F

T F

T F

T F

T F

CHAPTER 33 Physiological Integrity 1059

8. Necrosis h. Tissue death

9. Granuloma i. Process by which strains of microorganisms become resident flora in an area of the body

10. Keloid j. Tissue is disordered and cells vary in size and shape

11. Hyperplasia k. Shrinking of cells and organs as a result of decreased demand

12. Phagocytosis l. Lack of organ development

13. Revascularization m. Exaggerated contraction of maturing collagen, mostly affecting large wounds which results in distortion and limited mobility

14. Colonization n. Joining of serous membranes which normally move freely against each other due to organization of inflammatory exudates. Risk is greatest with trauma to abdominal organs, heart, and lungs

15. Atrophy o. Breaking open of a healing wound usually a result of pressure on the wound

16. Opportunistic p. Irregular masses of scar tissue protruding from the skin that result from pathogen overproduction of collagen

17. Iatrogenic infection q. Decreased number of cells as a result of self-destruction

18. Virulence r. Round masses of transformed macrophages surrounded by lymphocytes and fibroblasts

19. Aplastic s. Shortening of a muscle or scar tissue causing distortion or deformity

20. Dysplasia t. Ingestion of particles by cells u. Material that passes through vessels into adjacent tissues in inflammation

(continued)

APPLICATION QUESTIONS

1. Of which process is gangrene an example?

a. Coagulation necrosis b. Liquefaction necrosis c. Autolysis d. Phagocytosis

2. Which is the primary factor that determines the time interval that can elapse between removal of an organ from a donor and its transplantation into a recipient? a. Time an organ can survive ischemia b. Ability of the organ to withstand temperature change c. Amount of DNA present in the organ ’ s cells d. Number of organelles in the organ ’ s cells

3. Which factors can initiate an inflammatory response?

(Select all that apply.) a. Heat or cold b. Trauma c. Infection d. Antigen – antibody-complex deposition e. Complement activation


4. What type of diet should be encouraged for a client having radiation through an abdominal port who complains of nausea and vomiting? (Select all that apply.) a. High-protein b. High-carbohydrate

c. High-fat d. High-residue e. High-calorie f. Low-protein g. Low-calorie h. Low-carbohydrate i. Low-residue j. Low-fat

5. When caring for a client having radiation therapy the nurse receives a report that the client ’ s laboratory values are normal and there are no signs of anemia, infection, or bleeding. Which conclusion should the nurse draw from this information? a. Radiation has not yet reached a therapeutic level. b. The client is free of side effects of radiation. c. Nutritional status is normal. d. Bone-marrow suppression is not a problem.

6. The father of a 9-month-old boy just diagnosed with a primary immune deficiency says to the nurse “ I don ’ t understand it. Why did my son seem healthy until he was 6-months old and then start getting all these infections?

” On which fact should the nurse ’ s response be based? a. Under 6-months of age, most babies do not show signs of active infection.

b. It takes about 6 months for babies to be exposed to enough pathogens for infection to readily occur. c. Until about 6 months, babies are protected from infection by immunity from their mothers. d. Before 6 months, babies are only susceptible to bacterial infections.

7. When assessing skin of a client having external radiation therapy, which fact should the nurse keep in mind? a. Skin damage is preceded by changes in oral mucous membranes. b. Most skin changes occur 4 – 8 weeks after the start of radiation. c. Skin areas with poor blood flow are at greatest risk for injury. d. Intertriginous areas are at particular risk for skin reactions.

8. How should the care of a client undergoing brachytherapy be assigned? a. To male nurses whenever possible b. On a rotating basis among nonpregnant nursing staff c. Consistently to the same nurses d. Never to a nurse with a history of cancer

9. A client having radiation therapy asks the nurse if his

blood cells are going to be affected. Which fact should form the basis of the nurse ’ s answer? a. Bone marrow and therefore blood cells is affected with almost all ports of radiation. b. If radiation is delivered to the hip or leg, no effect should occur. c. It depends on whether or not medications are being taken that sensitize blood cells to radiation. d. Speed and volume of blood to tissues of the port will determine the effect.

10. Which direction should be given to a client with a platelet count of 45,000 mm3, a WBC count of

1250/mm3, and an RBC count of 4.8 million/mm3? a. Cook vegetables well. b. Use an electric razor. c. Rest at regular intervals. d. Increase vitamin B12 intake.

11. A client having chemotherapy for breast cancer reports a temperature of 101.4 F. How should the nurse interpret this fact? a. Sign of infection, which needs to be reported right away b. Side effect of chemotherapy, not requiring intervention c. Sign of infection, which needs monitoring and reporting if it persists for 48 hours

d. Indicator of dehydration requiring client teaching regarding fluid intake

12. A client who had a dose of chemotherapy at 8 a.m. calls the clinic at 2:30 p.m. complaining of nausea and vomiting despite having taken the prescribed medication. She asks how much worse the nausea and vomiting is going to get. On which fact should the nurse ’ s answer be based? a. Nausea and vomiting is totally unpredictable. b. Nausea and vomiting typically peak in the first

12 hours. c. Nausea and vomiting will ease on going to bed. d. Vomiting should cease in about 36 hours but nausea may persist for 7 – 10 days.


13. For which type of toxicity would the nurse plan to monitor a client who is being treated with cisplatin? a. Neurotoxicity b. Cardiotoxicity c. Nephrotoxicity d. Hepatotoxicity

14. Which class of chemotherapy drugs is most likely to affect fertility? a. Alkylating agents b. Antimetabolytes

c. Cytotoxic antibiotics d. Mitotic inhibitors

15. Which information could be correctly included in the teaching plan for a client receiving chemotherapy? a. Scalp hair may be lost but body hair is unaffected. b. Hair loss usually occurs 6 – 8 weeks after chemotherapy starts. c. Regrowth usually starts 1 – 2 months after chemotherapy is completed. d. Hair regrowth can be expected to take 24 – 36 months.

16. Which comment about measuring pulmonary artery wedge pressure indicates a correct understanding of at least one aspect of the procedure? a. The pressure-monitoring system must be calibrated at least every 12 hours. b. Normal mean pressure is 15 mmHg. c. The balloon must be completely deflated after each pressure measurement is obtained. d. The catheter is passed through the right heart and into the right pulmonary artery.

17. Which statement is an appropriate practice guideline when CVP is being monitored? a. A pressure greater than 6 mmHg must be reported immediately.

b. A CVP of greater than 10 mmHg indicates the need for immediate fluid. c. Overall trend is more important than any individual measure. d. A CVP of 1 – 3 mmHg requires immediate intervention to prevent pulmonary edema.

18. Which statement made by a client receiving radiation therapy indicates a need for further teaching? a. “ Today is my last treatment so by next week I will know if I am going to have any side effects from the radiation.

” b. “ I ’ m tired of having blood drawn but I know I need it to check my bone marrow.

” c. “ I need to check my skin for redness, especially in the skin folds.

” d. “ I ’ m awfully fatigued all the time but I understand it is expected.

”

19. When caring for a client with a Swan – Ganz catheter, for which complications would the nurse monitor?

(Select all that apply.) a. Heart failure b. Thromboembolism c. Hypervolemia d. Cardiac dysrhythmia e. Infection

20. A client who has received a biopsy report indicating dysplasia asks the nurse if this means she has cancer.

Which is the most appropriate response? a. “ Yes, it is cancer but an early form that is usually treatable.

” b. “ It may be cancer. More tests have to be done and you will know in about 5 days.

” c. “ No, it is not cancer but the tissue is abnormal and sometimes it becomes cancerous.

” d. “ No, it is not cancer and it doesn ’ t turn into cancer.

”

21. Which complication must the nurse be alert for when caring for a client on intra-arterial blood pressure monitoring? a. Ventricular tachycardia b. Myocardial infarct c. Pulmonary artery rupture d. Hemorrhage

Think Smart/Test Smart

This question is looking for a correct statement because it asks which statement shows that the person making it correctly understands some aspect of the procedure. Thus, three distractors are going to be incorrect statements about the procedure and one is going to be correct and will be the answer.

(continued)


22. The spouse of a client who is to have intra-arterial blood pressure monitoring initiated, tells the nurse he heard someone say that an Allen test would be done and asks what it is for. Which fact should form the basis of the nurse ’ s response? a. To make sure there is collateral circulation sufficient to keep tissue supplied with oxygenated blood. b. To check for abnormal clotting because of the risk of thromboembolism. c. To check if the volume of bloodflow is sufficient to provide an accurate measurement. d. To determine if the artery has a diameter great enough to allow passage of the catheter.

23. When measuring CVP, which is the reference point or the zero point of the manometer or the transducer? a. Fourth intercostal space at the left midclavicular line b. Fourth intercostal space at the left sternal border c. Sixth intercostal space at the right sternal border d. Sixth intercostal space at the left midclavicular line

ANSWERS FOR FILL IN THE BLANKS

Fill in the blank spaces with the correct word or phrase to complete each statement.

1. The three most basic causes of cell injury are

a. deficiency b. intoxication/poisoning c. trauma/physical injury

2. The five classic signs of infection are a. redness b. heat c. pain d. swelling e. loss of function

3. The two major components of the inflammatory response are a. vascular b. cellular

24. A client having a Swan – Ganz catheter inserted asks how the MD will know when it is in the right place.

What is the most accurate reply to the client ’ s question? a. A chest X-ray shows the position. b. It is inserted under fluoroscopy so it can be seen on a television screen. c. The pressure in the artery changes depending on where the catheter is located. d. The distance from the point of entry to the heart is measured and the catheter is marked off in centimeters.

25. When preparing a client for insertion of a pulmonary artery catheter, the nurse ’ s explanation of the procedure could include information based on which fact?

a. Procedure is usually done in an operating room or treatment room. b. EKG is monitored continuously during insertion. c. Insertion is basically a risk-free procedure. d. Light, general anesthesia is used for client comfort.

ANSWERS & RATIONALES


4. The three types of exudates are a. serous b. purulent/suppurative c. hemorrhagic

5. The four components of the healing process are a. regeneration b. repair c. revascularization d. reepithelialization

6. Collagen fibers in scar tissue are very weak for 6 – 8 days.

7. The four most common sites of nosocomial infection are a. urinary tract b. respiratory tract c. bloodstream d. wounds

8. Cancers arising in tissues derived from mesoderm such as muscles, bones, or connective tissue are called sarcomas.

9. The two distinct processes involved in carcinogenesis are a. initiation

b. promotion

10. Another name for the contractile force of the heart is inotropy.

TRUE & FALSE ANSWERS

Mark each of the following statements True or False. Correct all false statements in the space provided.

1. Calcification occurs only in necrotic tissue. False

Deposits of calcium can occur in normal tissues as a result of marked hypercalcemia.

2. Chronic inflammation progressively destroys tissue and results in loss of function and scarring.

True

3. Once regeneration occurs, function is restored to damaged organs. False

Function is restored if the stroma is undamaged; if stroma is damaged then regeneration may be disorganized and some degree of functional loss results.

4. If a child cuts his hand on a piece of broken glass and has eight sutures to close the wound, healing will occur by second intention. False

Healing is by first intention when the edges of the wound are approximated; it is second intention when the wound is not closed but is left to granulate in.

5. To facilitate healing of a wound across the middle knuckle of the index finger, the joint needs to be immobilized.

True

6. Signs of systemic infection include swollen lymph nodes, fever, and elevated ESR. True

(continued)


MATCHING ANSWERS

Match the following:

1. Adhesions a. Type of nosocomial infection, which is the direct result of a diagnostic or

therapeutic procedure

2. Hypertrophy b. Angioneogenesis

3. Serous exudates c. Ability of a microorganism to produce infection

4. Dehiscence d. Enlargement of cells and organs as a result of increased demand

5. Apoptosis e. Number of cells increased through cell division in response to demand

6. Contracture f. Fluid in blisters of a mild sunburn

7. Exudate g. Microorganism that causes infection only in a susceptible person

8. Necrosis h. Tissue death e p b t r h

9. Granuloma i. Process by which strains of microorganisms become resident flora in an area of the body

10. Keloid j. Tissue is disordered and cells vary in size and shape

11. Hyperplasia k. Shrinking of cells and organs as a result of decreased demand

12. Phagocytosis l. Lack of organ development

13. Revascularization m. Exaggerated contraction of maturing collagen, mostly affecting large wounds which results in distortion and limited mobility

14. Colonization n. Joining of serous membranes which normally move freely against each other due to organization of inflammatory exudates. Risk is greatest with trauma to abdominal organs, heart, and lungs i

u s f d q o n

7. Total length of the cell cycle is the same for all cells; what differs is the length of time spent in each phase. False

Total length of cell cycle varies with the type of cell ranging from 1 hour to 100 hours with the difference a result of time spent

in G0 and G1.

8. A characteristic of a benign tumor is that it is composed of cells that resemble the tissue of origin. True

9. Malignant tumors cause systemic symptoms such as altered taste and weight loss. True

10. The initial effect of an increase in heart rate is a decrease in cardiac output. False

The initial effect is an increase in heart rate because cardiac output equals heart rate x stroke volume. When the heart rate reaches 180 bpm and is sustained there is less time for the ventricle to fill with blood so the stroke volume starts to decrease and ultimately the cardiac output decreases even though the rate is high.


15. Atrophy o. Breaking open of a healing wound usually a result of pressure on the wound

16. Opportunistic p. Irregular masses of scar tissue protruding from the skin that result from pathogen overproduction of collagen

17. Iatrogenic infection q. Decreased number of cells as a result of self-destruction

18. Virulence r. Round masses of transformed macrophages surrounded by lymphocytes and

fibroblasts

19. Aplastic s. Shortening of a muscle or scar tissue causing distortion or deformity c a j l

20. Dysplasia t. Ingestion of particles by cells u. Material that passes through vessels into adjacent tissues in inflammation g k

APPLICATION ANSWERS

1. Of which process is gangrene an example? a. Coagulation necrosis b. Liquefaction necrosis c. Autolysis d. Phagocytosis

Rationale

Correct answer: a.

Gangrene is an example of coagulation necrosis and is characterized by initial appearance of a firm area with the structure of normal tissue even though cells are dead; subsequently, the area is broken down and cleared by phagocytes. Gangrene is common when cells die due to anoxia or toxic injury except in the brain.

Liquefaction necrosis is characterized by an initial liquid

area of dead cells. It is seen in death of nervous-system cells due to anoxia and in death of cells associated with bacterial infections.

2. Which is the primary factor that determines the time interval that can elapse between removal of an organ from a donor and its transplantation into a recipient? a. Time an organ can survive ischemia b. Ability of the organ to withstand temperature change c. Amount of DNA present in the organ ’ s cells d. Number of organelles in the organ ’ s cells

Rationale

Correct answer: a.

Oxygen, which is essential to cell survival, is brought to the tissues by the blood. Once an organ is removed from the donor its cells no longer have a source of oxygenated blood until it is implanted in the recipient. Different types of cells/tissues can withstand ischemia for different lengths of time. Hence, how long the organ can survive until implanted depends on this ability of the cells to withstand ischemia.

3. Which factors can initiate an inflammatory response?

(Select all that apply.) a. Heat or cold b. Trauma

c. Infection d. Antigen – antibody-complex deposition e. Complement activation

Rationale

Correct answers: a, b, c, and d.

Inflammation is a nonspecific response that occurs when there is damage to skin or mucous membranes, which serve as the body ’ s first line of defense against infection. Anything that can damage these tissues can cause inflammation.

Thus, factors such as prolonged exposure to the sun, surgery, exposure to irritating chemicals, and accidental cuts and scrapes are all initiators of the inflammatory response.

The inflammatory response is nonspecific because it occurs as a result of many different kinds of damage and is the same regardless of the specific initiating factor.

(continued)


4. What type of diet should be encouraged for a client having radiation through an abdominal port who complains of nausea and vomiting? (Select all that apply.) a. High-protein b. High-carbohydrate c. High-fat d. High-residue e. High-calorie

f. Low-protein g. Low-calorie h. Low-carbohydrate i. Low-residue j. Low-fat

Rationale

Correct answers: a, b, and e.

Clients having radiation therapy need a high-protein, high-carbohydrate, and high-calorie diet. Radiation causes tissue damage so extra protein is needed for tissue repair. Carbohydrates and calories are needed to provide the energy for tissue repair and to combat the fatigue associated with radiation therapy. Fat is high in calories but is harder to digest; neither a low-fat nor a high-fat diet is recommended. Amount of residue is unrelated.

5. When caring for a client having radiation therapy the nurse receives a report that the client ’ s laboratory values are normal and there are no signs of anemia, infection, or bleeding. Which conclusion should the nurse draw from this information? a. Radiation has not yet reached a therapeutic level. b. The client is free of side effects of radiation. c. Nutritional status is normal. d. Bone-marrow suppression is not a problem.

Rationale

Correct answer: d.

Some effect on bone marrow occurs with almost all radiation therapy regardless of port. Bone-marrow suppression becomes a significant problem when RBC and WBC counts and platelet count drop below critical levels. This drop is seen in laboratory values and can result in the development of anemia, infection, or bleeding. Therefore, normal laboratory values and the absence of signs/symptoms of anemia, infection, and bleeding indicate that bone-marrow suppression is not a problem at this time.

6. The father of a 9-month-old boy just diagnosed with a primary immune deficiency says to the nurse “ I don ’ t understand it. Why did my son seem healthy until he was 6-months old and then start getting all these infections?

” On which fact should the nurse ’ s response be based? a. Under 6 months of age, most babies do not show signs of active infection. b. It takes about 6 months for babies to be exposed to enough pathogens for infection to readily occur. c. Until about 6 months, babies are protected from infection by immunity from their mothers. d. Before 6 months, babies are only susceptible to bacterial infections.

Rationale

Correct answer: c.

In utero, fetuses are protected against infection by passive immunity received from the mother via the placenta. This passive protection against pathogens that the mother has immunity to lasts for approximately 6 months at which time the infant becomes dependent on his or her own immune system for protection against infection. Therefore, it is not until the passive immunity has “ worn off ” that immunodeficiency in the infant manifests itself in chronic or recurrent infections. Infants develop signs of infection.

Infection can occur at any time; it can even be present at birth. The cause of infection can be any type of microorganism.

7. When assessing skin of a client having external radiation therapy, which fact should the nurse keep in mind? a. Skin damage is preceded by changes in oral mucous membranes. b. Most skin changes occur 4 – 8 weeks after the start of radiation. c. Skin areas with poor blood flow are at greatest risk for injury. d. Intertriginous areas are at particular risk for skin reactions.

Rationale

Correct answer: d.

Skin fold areas are at particular risk for developing a reaction to radiation therapy.

It is important to keep these areas clean, dry, and free of irritation to help decrease the risk. Changes in oral mucous membranes do not always occur with radiation therapy; it depends on the port. This is different from chemotherapy, which is administered systemically. Acute skin reactions consist of erythema which increases over

2 – 3 weeks and then either fades or progresses to dry or moist desquamation.

Areas of poor bloodflow are less well-oxygenated and hypoxic tissues are resistant to radiation not at greater risk for injury.


8. How should the care of a client undergoing brachytherapy be assigned? a. To male nurses whenever possible b. On a rotating basis among nonpregnant nursing staff c. Consistently to the same nurses d. Never to a nurse with a history of cancer

Rationale

Correct answer: b.

To limit exposure to specific individuals, care of clients

undergoing brachytherapy should be rotated among staff members with the exception of those who are pregnant because of the risk of damage to the developing fetus.

Male gender or cancer history are not considered influencing factors. Assigning the same nurses would support consistency and efficiency of care but these benefits do not outweigh the risk of exposure.

9. A client having radiation therapy asks the nurse if his blood cells are going to be affected. Which fact should form the basis of the nurse ’ s answer? a. Bone marrow and therefore blood cells are affected with almost all ports of radiation. b. If radiation is delivered to the hip or leg, no effect should occur. c. It depends on whether or not medications are being taken that sensitize blood cells to radiation. d. Speed and volume of blood to tissues of the port will determine the effect.

Rationale

Correct answer: a.

Radiation therapy exerts its greatest effect on well-oxygenated, actively dividing cells. As a result, bone-marrow cells are almost always affected. The hip and long bones of the leg contain large amounts of bone marrow so effects on the blood from radiation to these areas do occur. The effect

on the blood occurs because the active cells in the bone marrow are affected, not because of any sensitizing drug.

10. Which direction should be given to a client with a platelet count of 45,000 mm3, a WBC count of

1250/mm3, and an RBC count of 4.8 million/mm3? a. Cook vegetables well. b. Use an electric razor. c. Rest at regular intervals. d. Increase vitamin B12 intake.

Rationale

Correct answer: b.

A platelet count of 45,000 mm3 is significantly below the normal of 150,000 – 400,000/mm3 and so the client is at risk for bleeding. A basic bleeding precaution is to use an electric razor to avoid cutting the skin. The WBC and RBC counts are within normal range so do not require precautions.

Cooking vegetables well is a direction given to neutropenic clients. Rest at regular intervals is needed by clients with anemia and other sources of fatigue. Increased vitamin

B12 intake is needed by clients with pernicious anemia.

11. A client having chemotherapy for breast cancer reports a temperature of 101.4 F. How should the nurse interpret this fact? a. Sign of infection, which needs to be reported right away

b. Side effect of chemotherapy, not requiring intervention c. Sign of infection, which needs monitoring and reporting if it persists for 48 hours d. Indicator of dehydration requiring client teaching regarding fluid intake

Rationale

Correct answer: a.

Any temperature over 101 F is considered a sign of infection and needs to be reported right away. Clients having radiation therapy are immunosuppressed because of the effect of the radiation on the bone marrow and so infection poses a particular risk for this population.

12. A client who had a dose of chemotherapy at 8 a.m. calls the clinic at 2:30 p.m. complaining of nausea and vomiting despite having taken the prescribed medication. She asks how much worse the nausea and vomiting is going to get. On which fact should the nurse ’ s answer be based? a. Nausea and vomiting is totally unpredictable. b. Nausea and vomiting typically peak in the first 12 hours. c. Nausea and vomiting will ease on going to bed. d. Vomiting should cease in about 36 hours but nausea may persist for 7 – 10 days.

Rationale

Correct answer: b.

Nausea and vomiting typically peak in the first 12 hours so in this case the nausea and vomiting should begin to subside after 8 p.m. The degree of nausea and vomiting can vary from person to person and with different types of chemotherapy but broad patterns are evident; it is not totally unpredictable. Going to bed does not ease nausea and vomiting and its absolute duration is not known.

13. For which type of toxicity would the nurse plan to monitor a client who is being treated with cisplatin? a. Neurotoxicity b. Cardiotoxicity c. Nephrotoxicity d. Hepatotoxicity

(continued)


Rationale

Correct answer: c.

Cisplatin is associated with nephrotoxicity and as a result, the nurse must monitor for signs of renal tubule damage.

Intake and output must be monitored. The client must be well-hydrated before administration of cisplatin and encouraged to maintain a fluid intake of 2 – 3 l daily for the duration of therapy. Cisplatin can also cause ototoxicity

(deafness) and should be monitored for tinnitus.

14. Which class of chemotherapy drugs is most likely to affect fertility? a. Alkylating agents b. Antimetabolytes c. Cytotoxic antibiotics d. Mitotic inhibitors

Rationale

Correct answer: a.

Alkylating agents are the type of chemotherapeutic agents that most commonly affect the ovaries and testes resulting in changes in fertility. Amenorrhea is common in young females and induced menopause common in older females. Decreased sperm production as well as sperm and semen abnormalities occur in men. In some cases, fertility returns after treatment but this varies with the age of the client and the specific drug and dose of drug received.

15. Which information could be correctly included in the teaching plan for a client receiving chemotherapy? a. Scalp hair may be lost but body hair is unaffected. b. Hair loss usually occurs 6 – 8 weeks after chemotherapy starts. c. Regrowth usually starts 1 – 2 months after chemotherapy is completed. d. Hair regrowth can be expected to take 24 – 36 months.

Rationale

Correct answer: c.

Regrowth of hair usually starts 1 – 2 months after chemotherapy is completed. Both scalp and body hair may be lost and loss usually starts 2 – 3 weeks after treatment starts. Regrowth takes about a year.

16. Which comment about measuring pulmonary artery wedge pressure indicates a correct understanding of at least one aspect of the procedure? a. The pressure-monitoring system must be calibrated at least every 12 hours. b. Normal mean pressure is 15 mmHg. c. The balloon must be completely deflated after each pressure measurement is obtained. d. The catheter is passed through the right heart and into the right pulmonary artery.

Rationale

Correct answer: c.

The balloon must be completely deflated after each pressure measurement is obtained. This is correct. The other statements are incorrect because calibration should be checked before each reading; normal mean pressure is 10 mmHg not 15; and the catheter passes through the left ventricle into the left pulmonary artery because it provides a measure of left ventricle end diastolic

pressure, which is increased in left ventricular failure and pericardial tamponade and decreased in hypovolemia.

17. Which statement is an appropriate practice guideline when CVP is being monitored? a. A pressure greater than 6 mmHg must be reported immediately. b. A CVP of greater than 10 mmHg indicates the need for immediate fluid. c. Overall trend is more important than any individual measure. d. A CVP of 1 – 3 mmHg requires immediate intervention to prevent pulmonary edema.

Rationale

Correct answer: c.

Trend in CVP change is more significant than any individual measurement. Normal range of CVP is 0 – 8 mmHg or 5 – 10 cm H2O depending on equipment used; so, a pressure of 6 mmHg is within normal range and would not need to be reported immediately. A CVP 10 mmHg is the upper limit of normal and does not indicate need for immediate fluid; elevated CVP is associated with hypervolemia not hypovolemia. Risk of pulmonary edema is indicated by an elevated CVP.

Think Smart/Test Smart

This question is looking for a correct statement

because it asks which statement shows that the person making it correctly understands some aspect of the procedure. Thus, three distractors are going to be incorrect statements about the procedure and one is going to be correct and will be the answer.


18. Which statement made by a client receiving radiation therapy indicates a need for further teaching? a. “ Today is my last treatment so by next week I will know if I am going to have any side effects from the radiation.

” b. “ I ’ m tired of having blood drawn but I know I need it to check my bone marrow.

” c. “ I need to check my skin for redness, especially in the skin folds.

” d. “ I ’ m awfully fatigued all the time but I understand it is expected.

”

Rationale

Correct answer: a.

There are late as well as immediate effects of radiation therapy. Late effects are due to blood vessel or connective tissue damage and occur months or years after therapy.

Examples of late effects include skin atrophy, fibrosis or ulceration, pulmonary fibrosis, and cataracts.

19. When caring for a client with a Swan – Ganz catheter, for which complications would the nurse monitor?

(Select all that apply.) a. Heart failure b. Thromboembolism c. Hypervolemia d. Cardiac dysrhythmia e. Infection

Rationale

Correct answers: b, d, and e.

Thromboembolism, cardiac dysrhythmia, and infection are risks associated with a Swan – Ganz catheter.

Thromboembolism is a risk because the catheter is a foreign object in the circulatory system that interferes with bloodflow. Cardiac dysrhythmia is a risk because the catheter is threaded through the heart. Infection is a risk because the catheter enters through the skin and thus provides a potential source of entry for bacteria into normally sterile areas of the body.

20. A client who has received a biopsy report indicating dysplasia asks the nurse if this means she has cancer.

Which is the most appropriate response? a. “ Yes, it is cancer but an early form that is usually treatable.

” b. “ It may be cancer. More tests have to be done and

you will know in about 5 days.

” c. “ No, it is not cancer but the tissue is abnormal and sometimes it becomes cancerous.

” d. “ No, it is not cancer and it doesn ’ t turn into cancer.

”

Rationale

Correct answer: c.

Dysplastic tissue is characterized by disorder and cells that vary in size and shape. It results from severe and prolonged irritation and often precedes neoplasia. Some forms are known as precancerous lesions.

21. Which complication must the nurse be alert for when caring for a client on intra-arterial blood pressure monitoring? a. Ventricular tachycardia b. Myocardial infarct c. Pulmonary artery rupture d. Hemorrhage

Rationale

Correct answer: d.

Hemorrhage is a potential complication because the catheter is inserted directly into a pulsating artery. Other complications are infection, air embolism, and throboembolism.

The arterial line called an art line or A line does not pass through the heart so dysrhythmias are not a major risk nor do they enter or affect the pulmonary

artery so pulmonary artery rupture is not a concern.

Occurrence of MI is unrelated.

22. The spouse of a client who is to have intra-arterial blood pressure monitoring initiated, tells the nurse he heard someone say that an Allen test would be done and asks what it is for. Which fact should form the basis of the nurse ’ s response? a. To make sure there is collateral circulation sufficient to keep tissue supplied with oxygenated blood. b. To check for abnormal clotting because of the risk of thromboembolism. c. To check if the volume of bloodflow is sufficient to provide an accurate measurement. d. To determine if the artery has a diameter great enough to allow passage of the catheter.

Rationale

Correct answer: a.

An Allen test is done to ascertain that inserting a catheter into one of the large arteries of an extremity will not result in a decrease in oxygenated blood to the part such that tissue damage occurs. When performing the Allen test on an upper extremity, both the radial and ulna arteries are compressed until the pulses are obliterated while the client is making a fist. The client is then asked to open the

fist and pressure is released on one of the arteries and the palm is observed for flushing. This procedure is then repeated for the other artery.

(continued)


23. When measuring CVP, which is the reference point or the zero point of the manometer or the transducer? a. Fourth intercostal space at the left midclavicular line b. Fourth intercostal space at the left sternal border c. Sixth intercostal space at the right sternal border d. Sixth intercostal space at the left midclavicular line

Rationale

Correct answer: a.

The reference level for the transducer is the right atrium, whose filling pressure is measured by CVP. The right atrium is located below the fourth intercostal space at the left midclavicular line.

24. A client having a Swan – Ganz catheter inserted asks how the MD will know when it is in the right place.

What is the most accurate reply to the client ’ s question? a. A chest X-ray shows the position. b. It is inserted under fluoroscopy so it can be seen on a television screen.

c. The pressure in the artery changes depending on where the catheter is located. d. The distance from the point of entry to the heart is measured and the catheter is marked off in centimeters.

Rationale

Correct answer: a.

A chest X-ray is done to confirm the position of a Swan –

Ganz catheter once it is inserted. It is inserted usually as a bedside procedure; it is not done under fluoroscopy.

Pressure in the arterial system does change in different locations but this is not how placement is confirmed nor is it confirmed by the length of catheter inserted. No IV fluid is run into a central line until placement is confirmed by X-ray.

25. When preparing a client for insertion of a pulmonary artery catheter, the nurse ’ s explanation of the procedure could include information based on which fact? a. Procedure is usually done in an operating room or treatment room. b. EKG is monitored continuously during insertion. c. Insertion is basically a risk-free procedure. d. Light, general anesthesia is used for client comfort.

Rationale

Correct answer: b.

EKG is monitored continuously due to the risk of the

catheter triggering a dysrhythmia as it passes through the right ventricle. The procedure is typically done at the bedside and general anesthesia is not needed. However, the procedure is not without risk. Air embolism, thromboembolism, pulmonary artery rupture or infarct, dysrhythmia, and infection can all occur.

Part III

TAKING

THE TEST

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1073

Practice Test for

NCLEX-RN®

CHAPTER 34

HEALTH PROMOTION AND

MAINTENANCE

Human Sexuality

Counsel client/family/significant others on sexuality issues

1. A client who has experienced a myocardial infarction is being discharged from the hospital. The client questions when he can resume sexual activity with his spouse. The nurse ’ s best response is:

A. sex is no longer possible after your surgery.

B. you must avoid foreplay but sex is acceptable as

long as it is of a short duration.

C. sex can be resumed when you can climb stairs without becoming short of breath.

D. masturbation is the only allowable form of sexual expression after the surgery.

The answer is C. Sex can be resumed when the client can climb two flights of stairs without becoming short of breath or the client can walk more than 2 miles without shortness of breath.

A is incorrect — Sex is possible after a myocardial infarction.

B is incorrect — Foreplay is encouraged to slowly prepare the body for the changes in heart rate and respiratory rate that accompany sex. D is incorrect — Masturbation is acceptable after a myocardial infarction but it is not the only form of sexual expression allowed.

SAFE AND EFFECTIVE CARE

ENVIRONMENT

Safety and Infection Control

Disaster Planning

Identify nursing roles in disaster planning

2. What is the most important nursing role in disaster planning?

A. Knowing the policy for disasters in the facility.

B. Maintaining contact with community resources.

C. Making a list of the most frequent contacts in the hospital.

D. Attending meetings that discuss the potential for disasters in the community.

The answer is A. Knowing the policy for disasters in the facility is the most important role for the nurse. This allows the nurse to function within the policies of the hospital, which aids in maintaining patient and staff safety.

B is incorrect — Maintaining contact with community resources will benefit the nurse in a disaster situation, but is not the most important role. C is incorrect — Making a list of frequent contacts is helpful but not the most important nursing role. D is incorrect — Attending meetings on the disasters that can occur in the community will not prepare the nurse for how to handle the disaster in the facility.


ENVIRONMENT


Medical and Surgical Asepsis

Evaluate whether aseptic technique is performed correctly

3. A nurse is working with a physician on the insertion of a central line. What action performed by the physician requires the nurse to stop the procedure due to a breach in asepsis?

A. The kit is opened toward the physician last.

B. The physician drops his or her gloved hands below the level of the chest.

C. The physician touches two sterile hands together.

D. The physician turns his or her back to the sterile field.

The answer is D. A person who is working in a sterile field should not turn his or her back to the sterile field or it is considered contaminated.

A is incorrect — A sterile kit is opened toward the outside first and toward the individual last to avoid contamination

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1074 PART III: Taking the Test of the sterile contents. B is incorrect — The sterile field is from the chest to below the level of the sterile field. C is incorrect — A person wearing sterile gloves is allowed to touch two sterile gloved hands together without causing contamination to the field.


MAINTENANCE

Developmental Stages and Transitions

Identify expected physical, cognitive, psychosocial, and moral stages of development

4. Which verbal complaint during the assessment of a

55-year-old female client is considered abnormal and requires further investigation?

A. Absence of menstrual cycle

B. Thinning of hair

C. Periods of sweating and feeling warm

D. Lumps in axilla area

The answer is D. Lumps in the axilla area could be lymph nodes, which could be a sign of cancer and needs further attention.

A is incorrect — The loss of menses is normal at the age of 55. B is incorrect — The thinning of hair is secondary to a drop in estrogen levels and is considered normal in the 55- year-old woman. C is incorrect — Periods of sweating and feeling warm are a response to the body ’ s hormonal changes.

PSYCHOSOCIAL INTEGRITY

Coping Mechanisms

Assess client response to illness (rationalization, hopefulness, anger)

5. A client receives a diagnosis of cancer after a biopsy of a suspicious lymph node. The client states, “ You must have made a mistake, I want a second opinion.

” Which stage of grief is the client experiencing?

A. Denial

B. Anger

C. Bargaining

D. Despair

The answer is A. The client is denying that the diagnosis is correct and desires a second opinion. This is a normal response and the client should be allowed to work through it with support from staff.

B is incorrect — The client is not yet angry but may encounter this response as time progresses. The client who is angry will blame others or himself as to why the health crisis occurred. C is incorrect — The client will begin to bargain with

God or others whom he or she feels holds the key to healing.

D is incorrect — The client will exhibit signs of depression in despair and will become disorganized with daily activities.

PHYSIOLOGICAL INTEGRITY

Basic Care and Comfort

Elimination

Perform irrigations

6. A nurse is performing continuous bladder irrigation at

1 L/h. Which assessment is the priority?

A. The amount of fluid being returned.

B. The size of the indwelling catheter.

C. The client ’ s knowledge level of the procedure.

D. The percentage of formalin ordered for irrigation.

The answer is A. The amount of fluid being returned is priority since a decrease in output without a decrease in the input may indicate clot formation or catheter malfunction and needs to be addressed immediately.

B is incorrect — The size of the catheter is important but not priority in bladder irrigation. C is incorrect — The client should have his knowledge level assessed prior to the beginning of the procedure. D is incorrect — Formalin is used in

the operating room under anesthesia due to the pain it causes and the need to prevent ureteral reflux.


ENVIRONMENT


Standard/Transmission-Based/Other Precautions

Educate client/family/staff on infection control measures

7. A nurse is discharging a client who has been undergoing chemotherapy. When discussing at home care, the priority instruction should be to:

A. avoid public places.

B. include fresh fruits and vegetables in your diet.

C. limit visitors in the home.

D. wash your hands often.

The answer is D. Hand washing is the number one method of preventing infection and should be taught to all clients who are immunosuppressed.

A is incorrect — While avoiding public places is important and should be taught, it is not the priority teaching. B is incorrect — While fresh fruits and vegetables will aid in including vitamin C and other essential nutrients in the diet, this is not the priority. C is incorrect — Limiting visitors is important but not the priority.

CHAPTER 34 Practice Test for NCLEX-RN® 1075


MAINTENANCE

Self-Care

Assess and intervene in client performance of instrumental activities of daily living

8. When planning the care of a client with rheumatoid arthritis, which plan would be best to assist with activities of daily living?

A. Teach the client methods of energy conservation.

B. Provide the client with a shower chair.

C. Encourage family members to take over challenging activities.

D. Provide the client with large handled instruments for eating.

The answer is A. The client should learn which activities are the most tiresome and limit the activities to conserve energy.

The client with rheumatoid arthritis needs rest to limit increased inflammation in joints.

B is incorrect — The client can benefit with a shower chair but it is not the best plan to assist with activities of daily living. C is incorrect — The client needs to be able to perform the activities of daily living and delegate the activities that he or she is unable to perform. The nurse should not encourage family members to take over these activities. D is incorrect —

The client does need instruments for eating but it is not the best plan to assist with activities of daily living.


Sensory/Perceptual Alterations

Evaluate client with altered ability to communicate effectively and intervene to promote successful adaptation

9. A client has undergone a total laryngectomy due to cancer. The nurse should plan on assisting the client with communicating by:

A. providing an interpreter.

B. providing a sheet explaining sign language.

C. providing a tablet and pencil.

D. talking to the client ’ s face, accentuating words through lip movement.

The answer is C. The client should be given a tablet and pencil for communication postop.

A is incorrect — An interpreter is not needed unless the client does not speak English. B is incorrect — The client should be allowed to communicate through the written word unless he requests a sheet about sign language. D is incorrect — The client should not be expected to read lips to communicate with the nurse due to the possibility of miscommunication.



Potential for Complications of Diagnostic

Tests/Treatments/Procedures

Apply knowledge of nursing procedures and psychomotor

skills when caring for a client with potential for complications

10. A client is 24 hours postop from gastric bypass surgery.

Which of the following nursing actions is best in preventing thrombus formation?

A. The application of sequential compression devices.

B. Ambulating the client.

C. Administering salicylate (Aspirin).

D. Massaging of lower extremities.

The answer is B. The best method of preventing thrombus formation is ambulation. This will prevent a deep vein thrombosis as well as a pulmonary embolism.

A is incorrect — Sequential compression devices are beneficial in preventing thrombus formation but the best method is ambulation. C is incorrect — Aspirin is known for decreasing platelet aggregation and reduction in inflammation.

It is not the best method of prevention of thrombus formation.

D is incorrect — Massaging extremities is not appropriate in the postop client. Massaging of extremities may dislodge clots that have formed.


Reduction of Risk Potential

Monitoring Conscious Sedation

Assist with preparing client for conscious sedation

11. Prior to administering conscious sedation the nurse must first:

A. verify informed consent.

B. perform ABGs.

C. assess vital signs.

D. place high-flow oxygen on the client.

The answer is A. Prior to initiating conscious sedation, the nurse must ensure informed consent has been obtained and is on the chart.

B is incorrect — ABGs are not performed on a client before conscious sedation. C is incorrect — Vital signs are taken prior to medication administration but the first action is to verify consent has been obtained. D is incorrect — The client is not routinely placed on high-flow oxygen prior to conscious sedation. The client has a loss of protective reflexes but will breathe and the assessment of the client ’ s oxygen saturation should occur.

1076 PART III: Taking the Test



System-Specific Assessment

Perform focused assessment or reassessment

12. A client presents to the ED complaining of acute low back pain, which is unrelieved with over the counter pain medications. The client is pacing the room, diaphoretic and grimacing. Which assessment data is most indicative of renal calculi?

A. Hematuria

B. Hypertension

C. Vomiting

D. Groin pain

The answer is A. A client with renal calculi will have hematuria or numerous red blood cells in the urine upon examination.

B is incorrect — Hypertension is not an indicative sign of renal calculi. Hypertension is common in a client who is experiencing severe pain. C is incorrect — While the client with renal calculi may experience vomiting, this is a side effect of the pain and not an indicative sign. D is incorrect — Some clients experience pain in the groin with renal calculi while some only experience unilateral flank pain making this not an indicative sign.



Vital Signs

Apply knowledge needed to perform related nursing procedures and psychomotor skills when assessing vital signs

13. The nurse will plan to avoid performing which nursing actions on the left arm of a client with an arteriovenous fistula?

A. Blood pressure monitoring

B. Oxygen saturation monitoring

C. Blood glucose monitoring

D. Assessment of capillary refill

The answer is A. A client with a arteriovenous fistula for hemodialysis should not have a blood pressure taken in that area to prevent damage and thrombosis formation inside the fistula.

B is incorrect — Oxygen saturation monitoring is acceptable in the site where a fistula is placed. C is incorrect —

Blood glucose monitoring is appropriate in the affected arm as long as dialysis is not in progress. D is incorrect —

Assessment of capillary refill is possible and safe for the client with an arteriovenous fistula.


Physiological Adaptation

Hemodynamics

Identify cardiac rhythm strip abnormalities

14. What is the most appropriate action for a rapidly occurring wide QRS complex with no discernable p-waves?

A. Shock the client with 200 J

B. Perform chest compressions

C. Administer oxygen

D. Take a manual blood pressure

The answer is C. The client has a rhythm known as ventricular tachycardia and needs to have oxygen applied to meet the standards of ABC.

A is incorrect — The client will not require a shock of the rhythm. B is incorrect — Chest compressions should not be initiated until it is determined if a pulse is present. D is incorrect —

A blood pressure is measured after a pulse is obtained.



Hemodynamics


15. The nurse is assessing his or her patients at the beginning of the shift. One of the client ’ s exhibits a rhythm that displays p waves occurring regularly, a p – r interval of 0.20 and a QRS complex for every p wave measuring

0.12 with a rate of 70 and the t wave is upright. The nurse would document this rhythm as:

A. normal sinus rhythm

B. sinus bradycardia

C. first-degree AV block

D. second-degree AV block type I

The answer is A. The rhythm is regular since the rate is regular with a p – r interval and QRS complex measures within normal limits and the rate is above 60 and below 100.

B is incorrect — The rhythm is not below 60 beats per minute. . C is incorrect — The p – r interval is not elongated making this a normal sinus rhythm. D is incorrect — The relationship between the p wave and the QRS is consistently occurring.



Medical Emergencies

Perform emergency care procedures

16. When responding to a code in the hospital, the nurse finds a client who is being bagged with high flow oxygen by a fellow nurse. The client is pulseless and


CPR was begun less than 1 minute ago; there is no doctor on scene. Which action is next?

A. Reassess for a pulse

B. Attach the echocardiogram electrodes to the client

C. Begin a fluid bolus of normal saline

D. Ask another nurse for a history of the client

The answer is B. If CPR is in progress, the staff that arrives on scene should attach the electrodes to the client to prevent interruption of CPR.

A is incorrect — Reassessment for a pulse occurs after two full minutes of CPR. C is incorrect — Normal saline boluses must be ordered by the physician in the event the client has a history of heart failure. D is incorrect — A history regarding the client can occur after the electrodes are attached and the physician takes over the code.



Alterations in Body Systems

Provide postoperative care

17. A client is in the recovery room following a carotid endarterectomy. Place the following assessments in priority order

___ neurological status

___ signs of hemorrhage

___ intracranial pressure

___ blood pressure

The nurse ’ s first priority is to assess the area for signs of hemorrhaging.

This is most important since hemorrhage indicates that the brain is not receiving much needed oxygen and a stroke could occur as a result. Blood loss will affect the blood pressure and could cause the client to rapidly deteriorate.

The second priority is the client ’ s blood pressure. This is important since fluctuations are common during the first 24 hours postprocedure. The blood pressure should be monitored for hypertensive emergencies and hypotension, which will lead to poor perfusion of vital organs. The client ’ s neurological status is the third assessment to monitor for changes consistent with a stroke. The last assessment is the intracranial pressure. The first three assessments will help identify if there is an increase in the intracranial pressure.


ENVIRONMENT


Error Prevention

Ensure proper identification of client when providing care

18. Which of the following is the best method of identifying an infant before providing care?

A. Verify the information on the armband with the chart.

B. Ask the mom if the armband information is correct.

C. Ask the client if the information on the armband is correct.

D. Ask the previous nurse the client ’ s name and date of birth.

The answer is B. Verifying the information on the armband with the mom will ensure that the correct armband was placed on the correct client before treatment is rendered.

A is incorrect — While verifying the chart against the band does demonstrate that the order for the client matches the client ’ s armband, it does not ensure that the correct client is wearing the correct armband. Not verifying the information with a family member could still lead to a treatment error. C is incorrect — An infant will not be able to speak and so this is not an appropriate method. D is incorrect — Each nurse providing care should verify the correct client each time that care is provided during a shift.


ENVIRONMENT

Management of Care

Ethical Practices

Intervene to promote ethical practice

19. A client returns from surgery with a diagnosis of cancer.

The physician informs the staff to avoid telling the client the diagnosis. Upon awakening the client asks if he has cancer. Which response by the nurse is best?

A. I will call the physician and have him speak with you.

B. I do not know the results of the test.

C. You need to ask your family if they know the results.

D. The surgeon found what he feels is cancer; he will speak with you later.

The answer is A. Calling the physician is the best answer to this ethical dilemma. The physician is responsible for informing the client of the diagnosis; questions will be asked that the nurse may not be able to answer. By calling the physician, the nurse is not compromising fidelity and/or veracity.

B is incorrect — This is a violation of veracity, which is the principle that a nurse will not knowingly lie to a client.

C is incorrect — The family is not responsible for informing a client of the results of a surgery performed. Informing a family member may fall into a HIPPA violation if the client does not want the family to know the results. D is incorrect —

Informing the client of the diagnosis is a violation of fidelity.

Fidelity is when a health care provider must maintain a professional loyalty to those in the profession, which in this case is the physician.



ENVIRONMENT


Advocacy

Act as a client advocate

20. A client presents to the emergency department complaining of pain. The physician refuses to prescribe narcotic pain medication after stating the client is drug seeking.

Which action by the nurse would be most appropriate?

A. Report the physician to nursing administration for unethical behavior.

B. Ask the physician why he or she believes the client is drug seeking.

C. Discuss with the physician the client ’ s chief complaint and ask if another type of pain reliever can be ordered.

D. Go to the charge nurse, tell her of the physician ’ s actions and ask if another physician can assess the client.

The answer is C. The nurse is responsible for acting as a client

advocate. If the nurse feels that the physician is not addressing the client ’ s pain due to a fear of narcotic addiction, the nurse is responsible for discussing alternative methods of pain relief with the physician.

A is incorrect — It does not address the needs of the client. B is incorrect — It only questions the physician and does not allow for a solution to the client ’ s needs. D is incorrect — It does not address the issue that is with the physician and is not cost-effective to have another physician see the client.


ENVIRONMENT


Confidentiality/Information Security

Maintain client confidentiality/privacy

21. You are working in an intensive care unit when an individual approaches you to ask about the unresponsive client in the bed you are assigned to. Before giving out information regarding the client you should first:

A. verify that the individual is a family member by asking for the name of the client.

B. ask the individual about his or her relationship to the client.

C. ask the individual what is the personal identification

number for the client.

D. ask to see a driver ’ s license and compare it to the information listed on the chart as the next of kin.

The answer is C. According to HIPPA laws, a person requesting information on a client must present the personal identification number before information can be distributed. In this case, the client is unresponsive; therefore, the nurse must ensure that a HIPPA violation does not occur.

A is incorrect — Knowing the name of the individual does not authorize information to be distributed. B is incorrect —

Regardless of the relationship of the individual to the client, information cannot be distributed without the PIN. D is incorrect — It does not follow the policy for identification and distribution of medical information.


ENVIRONMENT


Referrals

Assess the need to refer clients for assistance with actual or potential problems

22. While developing the clinical pathway of four clients, which client will need a referral to speech therapy based on the nurse ’ s assessment?

A. A client who experienced a fractured hip.

B. A client who underwent a laryngectomy.

C. A client who underwent a cholecystectomy.

D. A client who was admitted for congestive heart failure.

The answer is B. A client who underwent a laryngectomy may require therapy to regain voice function or consume food.

A is incorrect — A client with a fractured hip will not require speech therapy. C is incorrect — A client who underwent a cholecystectomy will not require speech therapy. D is incorrect — A client with congestive heart failure will not require speech therapy.


ENVIRONMENT


Safe Use of Equipment

Remove malfunctioning equipment from client care area and report the problem to appropriate personnel

23. While performing a morning check on the crash cart and defibrillator, the nurse notices the defibrillator does not charge and discharge as expected. Which action by the nurse is most appropriate?

A. Place a repair tag on the equipment for biomedical services to pick up.

B. Notify the charge nurse and page biomedical services to check the equipment.


C. Notify the house supervisor and request a temporary cart and defibrillator.

D. Ask the nursing assistant to take the cart to the biomedical department and ask for an immediate repair.

The answer is C. If a defibrillator is found to be nonfunctioning, then the nursing supervisor needs to replace the equipment immediately to cover the area in the event a code occurs.

A is incorrect — Placing a tag on the equipment does not resolve the problem, which leaves the clients on the floor vulnerable if cardiac arrest occurs. B is incorrect — Paging biomedical services is not a resolution to the need for a new defibrillator. D is incorrect — Although asking for an immediate repair is possible, it may not be repaired. The need to replace the defibrillator is immediate and a replacement is needed while repairs are being completed.


MAINTENANCE

Health Screening

Perform targeted screening exams

24. A school nurse should schedule which type of screening exam for all 12-year-olds enrolled in the school?

A. Scoliosis

B. Diabetes

C. Hypertension

D. Hearing

The answer is A. Scoliosis screening occurs when a child reaches the age of puberty and should be conducted in the school setting with referrals made as needed.

B is incorrect — Diabetes is not a screening exam that needs to be performed in the school setting. C is incorrect —

Hypertension screenings are not needed in the school setting.

D is incorrect — Hearing exams are performed before school and if a child complains of difficulty hearing in class.


End-of-Life Care

Assist client/family/significant others in resolution of end-of-life issues

25. During the initial meeting with a client who has been referred for palliative care for a terminal illness, what is the primary nursing goal?

A. To determine the client ’ s religious preference.

B. To determine the client ’ s goals for the care to be provided.

C. To form a trusting relationship with the client.

D. To form a list of support systems that the client can use.

The answer is C. The primary goal of the nurse during the first encounter with a client who is in need of palliative care is to form a trusting relationship. The trusting relationship is the bridge to begin planning care that will focus on the level

of care he or she desires and to ensure that the end of life is met with the client having a sense of control.

A is incorrect — The client ’ s religious preference is important but is not the goal of the initial meeting. B is incorrect — The nurse will determine the client ’ s goals for care after a trusting relationship has been formed with the client. D is incorrect — A list of support systems for the client will be formed after an analysis is performed of the client ’ s goals, current financial situation, family members, physical abilities, religious preferences, and psychosocial status.


Unexpected Body Image Changes

Assess client/family/significant other’s reactions to a change in body image

26. Which statement made by a client indicates that acceptance of a new colostomy has not occurred?

A. “ My husband will never want to be intimate with me again.

”

B. “ I will experiment with various pouches to see which one controls odor the best.

”

C. “ I plan on beginning elimination training for my colostomy as soon as the doctor says it is okay.

”

D. “ I will teach my spouse how to work with the colostomy in the event I ever need assistance.

”

The answer is A. The client is feeling despair that her spouse

will not accept the changes she has undergone and will not desire her in a way he once did. She has not accepted the colostomy and assumes her spouse has not either.

B is incorrect — The client has accepted the colostomy and is ready to work with it so that it fits into her life. C is incorrect — The client has accepted the colostomy and is open to working with it to fit her needs. D is incorrect — The client has accepted the colostomy and is ready to teach others how to work with it as she does.



Nutrition and Oral Hydration

Monitor client’s hydration status

27. Which of the following is the best indicator of a negative hydration status in a client who weighed 200 pounds on admission and has been vomiting for 3 days after being diagnosed with diabetic ketoacidosis?

A. Daily weight of 170 pounds on day 3.

B. Serum glucose 100 mg/dL.


C. Ketones negative in urine.

D. Potassium level 4.0 mEq/L.

The answer is A. The client who is dehydrated will have a decrease in daily weights. This is a reflection of a negative fluid volume status.

B is incorrect — The serum glucose will rise in a client who is dehydrated due to insulin deficiency and glycogen breakdown to glucose of which cannot be eliminated by the body. C is incorrect — Ketones are positive due to free-floating fatty acids. The ketones are not eliminated due to low urine output and fluid volume deficit leading to ketones being in the urine. D is incorrect — As the client vomits and the potassium leaves the cell and goes to circulation, the level will rise; 4.0 mEq/L is considered a normal potassium level and therefore is an incorrect response.


Pharmacological and Parenteral Therapies

Central Venous Access Devices

Access implanted venous access devices

28. A client has a medi-port for chemotherapy administration.

The nurse has an order to access the medi-port for a blood draw and the administration of normal saline at 125mL/hr. The nurse will plan on obtaining which of the following to access the device?

A. A 20-gauge 1.5-inch Huber needle

B. A 20-gauge 1.5-inch jelco

C. A butterfly needle

D. A needleless syringe system

The answer is A. A Huber needle is required to access a mediport system so that damage will not occur to the structure of

the system.

B is incorrect — A jelco is not the correct needle to access a medi-port. The use of a jelco would damage the implanted device and possibly the client. C is incorrect — A butterfly needle is small and used for lab collection only. It does not contain a catheter for fluid administration. D is incorrect — A needle is required to access the medi-port. A needleless system can be used after the medi-port is accessed by the appropriate needle.



Total Parenteral Nutrition

Administer/maintain/discontinue total parenteral nutrition

29. Which site is the best for administering total parenteral nutrition to a client whose feeding contains greater than 10% glucose?

A. PEG tube

B. NG tube

C. Peripheral site

D. Central catheter site

The answer is D. The preferred site for the administration of parenteral nutrition is to use a central catheter site to prevent damage to the peripheral areas.

A is incorrect — Parenteral nutrition is administered intravenously not in a PEG tube site; tube feedings are

reserved for PEG tube sites. B is incorrect — TPN is an intravenous form of feeding a client and an NG tube goes directly to the stomach, which requires tube feeding solutions. D is incorrect — Placing a high concentration of glucose in a peripheral site will irritate the vein and can cause damage to the client ’ s surrounding tissues. TPN with greater than 10% glucose should use a central site.



Potential for Alterations in Body Systems

Monitor client output for changes from baseline

30. The client ’ s output trend from a chest tube drainage system is as follows:

0700 1500 2200

Day 1 600 mL 750 mL 648 mL

Day 2 500 mL 425 mL 400 mL

Day 3 400 mL 380 mL 400 mL

Day 4 500 mL 600 mL 700 mL

Based on the data trended, which initial action by the nurse would be best?

A. Report the trend to the physician.

B. Continue to monitor the client ’ s drainage.

C. Review the chart to see what the acceptable parameters are.

D. Increase the suction on the chest tube.

The answer is C. On day 4 the output is similar to day 1, the nurse should verify with the chart what parameters are acceptable before consulting the physician.

A is incorrect — Before calling the physician, the nurse should verify the parameters with the chart to see what the physician considers acceptable. B is incorrect — Continuing to monitor the client comes after ensuring that the output is within expected limits. D is incorrect — The suction should never be increased unless a physician writes an order.




Fluid and Electrolyte Imbalances

Identify signs and symptoms of client fluid and/or electrolyte imbalance

31. A client ’ s serum calcium level is 7 mg/dL. What would be the clinical manifestations of for this laboratory result?

A. Abdominal cramps

B. Depressed DTRs and dysrhythmias

C. Lethargy and weakness

D. Numbness and tingling in the extremities

The answer is D. Normal serum calcium range is 8.5

– 10.5 mg/dL and so the client has hypocalcemia. Symptoms of

hypocalcemia include numbness and tingling in the extremities, carpopedal spasm, and ultimately tetany.

A, B, and C are incorrect — Lethargy and weakness as well as depressed deep tendon reflexes, anorexia, nausea, vomiting, constipation and dysrhythmias are symptoms of hypercalcemia. Abdominal cramping occurs with hyponatremia.



Adverse Effects/Contraindications and Side Effects

Implement procedures to counteract adverse effects of medications and parental therapy

32. A client who takes digoxin (Lanoxin) at home has presented with a digoxin level of 4 ng/mL and a heart rate of 38. What is the priority nursing action?

A. Set up the client for external pacing.

B. Administer Atropine 1 mg IV.

C. Administer Digibind 228 mg IV.

D. Assess the client for visual changes and nausea/ vomiting.

The answer is C. The therapeutic digoxin level is 0.5

– 2 ng/mL. The client who has digitalis toxicity will require a dose of Digibind, which binds to the digoxin in the serum and removes it from the circulating system.

A is incorrect — The client does not need external pacing for digoxin toxicity. B is incorrect — While Atropine will raise

the heart rate, it will not remove digoxin from the serum, which is the cause of the bradycardia. D is incorrect — The client may have visual changes and nausea/vomiting but the priority nursing action is to remove the digoxin from the system.

The nurse understands the client is has digoxin toxicity by the level in the serum and the client ’ s heart rate.



Radiation Therapy

Implement interventions to address side/adverse effects of radiation therapy

33. What is the priority of care in a client that is undergoing external radiation therapy?

A. Washing the markings off of the face.

B. Maintaining a 6-ft distance.

C. Grouping client care to minimize exposure to the radiation.

D. Assessing the skin for burned areas.

The answer is D. The client should be assessed for areas that are burned so that treatment can occur to prevent further damage to the skin and underlying tissues. Fluid volume status should also be addressed due to the body ’ s response to the burn.

A is incorrect — The markings placed on the body for radiation therapy should not be removed to ensure that alignment

of the radiation can occur with preciseness. B is incorrect —

Only with internal radiation should a distance be kept from the patient. C is incorrect — Grouping client care to minimize exposure to radiation is not necessary with external radiation.




Apply knowledge of nursing procedures and psychomotor skills when caring for a client experiencing a medical emergency

34. A client presents to the emergency department after being involved in a vehicular accident. The client has obvious facial fractures and a head injury. The nurse should refrain from:

A. placing a nasogastric tube.

B. inserting a urinary catheter.

C. cleaning the blood from the face.

D. bagging the client with a bag valve mask and high flow oxygen.

The answer is A. With obvious facial fractures, the client should not receive a nasogastric tube through the nose.

B is incorrect — A urinary catheter is safe as long as there is not any blood at the meatus. C is incorrect — The nurse should clean blood from the face to see what injuries are present. D is incorrect — The client can be bagged with

BVM until an artificial airway is placed by the physician.



ENVIRONMENT



Understand communicable disease and the modes of organism transmission

35. A client is admitted with active tuberculosis. Which form of isolation should the client be placed on?

A. Contact

B. Droplet

C. Airborne

D. Standard

The answer is C. Airborne isolation includes particles transmitted by droplet or airborne particles. By placing the client on airborne isolation, the client receives a room with negative airflow; mask are worn by staff while in the patient room and by the patient if out of the room for test.

A is incorrect — Contact isolation is for pathogens that are transmitted through direct or indirect contact with the client or items the client may have touched. B is incorrect —

Droplet transmission is when the client coughs or the mucous membranes of the client are touched. Droplet transmission does not mean the client will need negative air pressure

in his or her room since the particles are not suspended in the air as they are with airborne. D is incorrect — Standard is used for blood or body fluid pathogen transmission.


MAINTENANCE

Family Systems

Assess impact of change on family system

36. Which statement made by a parent would indicate a need for immediate evaluation and counseling after the birth of the fifth child?

A. “ I just don ’ t know how I will pay for college for all of the children.

”

B. “ I have thoughts of throwing the baby in a dumpster.

”

C. “ The four oldest siblings argue constantly over the remote.

”

D. “ I wish I made more money so my family would be happier.

”

The answer is B. The parent making the statement of the desire to throw the baby in the dumpster is indicative of a need for counseling. The parent could be experiencing depression or psychosis that needs intervention.

A is incorrect — Wondering how a parent will pay for college is a normal concern and does not pose an immediate threat to the parent or children. C is incorrect — A sibling arguing with another is normal and does not pose a threat to

the children or parent. D is incorrect — A parent wishing he or she made more money is normal and does not pose an immediate threat.


MAINTENANCE

Lifestyle Choices

Assess client lifestyle choices

37. Which statement made by a parent indicates that a child may need to be evaluated every year by a health care provider?

A. “ My children are home schooled to avoid societal influences.

”

B. “ I allow my children to attend private schools only.

”

C. “ We encourage our children to take a multivitamin at bedtime every night.

”

D. “ We don ’ t allow our children to go outside alone.

”

The answer is A. The parents in this situation have chosen to teach the children at home to avoid societal influences. The children need a yearly screening to note for developmental delays and issues associated with a lack of social interaction with other children. The children are also at risk for being victims of abuse by not having outside observers to notice signs or symptoms of abuse leading for the need of the parents to participate in a yearly evaluation of the children by a health care professional.

B is incorrect — The parents have chosen to place their children in private schools, which still allows for health screenings by the school nurse and evaluations for signs of abuse. C is incorrect — Taking a multivitamin is not a reason for yearly visits to the physician. D is incorrect — By not allowing children to go outside alone, the children are being protected from external dangers; furthermore, this is not a reason for yearly visits by a health care provider.


Chemical and Other Dependencies

Assess client for drug-/alcohol-related dependencies, withdrawal, or toxicities

38. A client presents with a history of illegal use of prescription narcotics. Which assessment data is the earliest sign of withdrawal?

A. BP 90/60, HR 100

B. Anxiety, irritability

C. Insomnia, diarrhea

D. Nausea, vomiting


The answer is B. Anxiety and irritability is one of the first signs of opioid withdrawal with salivation, diaphoresis, and other symptoms following.

A is incorrect — The client presents with hypertension and tachycardia with an opioid withdrawal. C is incorrect —

Insomnia does occur with opioid withdrawal but later in the cycle. Diarrhea is usually not seen as the client has a decrease in motility due to the opioid. D is incorrect — Nausea and vomiting occur late in the withdrawal process.


Grief and Loss

Assist client/family/significant others in coping with suffering grief, loss, dying, and bereavement

39. A client is nearing the end of his life. To assist the family to cope, the nurse should suggest that the family:

A. tell the client good-bye.

B. leave the client to die in peace.

C. become visibly upset to expel all emotions.

D. contact a local psychiatrist to discuss what has occurred.

The answer is A. The family will gain closure through telling the client good-bye. Gaining closure will help the family through the grieving and bereavement process.

B is incorrect — When the family leaves the client, they carry the fact that their family member died alone and this can harm the grieving process. C is incorrect — A family should respond to death in their own way; therefore, encouraging the family to become visibly upset is inappropriate. D is incorrect — The family should be provided with a list of support services to assist with grieving but a family should not be

instructed to contact a psychiatrist by the nurse.


Stress Management

Implement measures to reduce environmental stressors

40. A client is being weaned from a patient controlled analgesic pump (PCA pump). Which nursing intervention would be best to assist in the control of pain?

A. Provide small chatter in the background.

B. Play classical music in the background.

C. Darken the room and close the door.

D. Teach the client to only call for pain meds when pain is a 10/10.

The answer is C. Dimming the lights and closing the client ’ s door will lessen environmental stressors, which can precipitate pain.

A is incorrect — Chatter can be perceived as an added stress to the client. B is incorrect — While music in the background can assist in pain control, the client may find classical music annoying and not helpful. The client should be allowed his or her favorite music, if desired, during the period weaning. D is incorrect — The client should learn to call for pain medication before the pain is a 10/10 or pain management becomes more difficult.




Monitor client hydration status

41. Based on the postsurgical client ’ s 24-hour intake and output documentation, which data should be reported to the physician?

Day 1 Day 2 Day 3 Day 4

Intake Output Intake Output Intake Output Intake Output

A 2000 1000 1500 1250 1325 1300 1250 1300

B 2000 900 1800 1100 1750 1000 1500 1000

C 2000 1700 1700 1625 1575 1400 1300 1275

D 2000 1500 1500 1300 1400 1300 1425 1400

The answer is B. The client is not maintaining an appropriate fluid balance after surgery as expected and the chances of electrolyte imbalances and pulmonary edema are high. The physician should be notified so that pharmacological interventions can occur and a fluid restriction can be ordered.

A, C, and D represent a normal ratio of fluid intake to fluid lost and does not require notification of the physician.



Blood and Blood Products

Check the client for appropriate venous access for red blood cell/blood product administration

42. Prior to administering a blood product, the nurse must ensure which of the following is present?

A. A patent intravenous line

B. Y-Site tubing

C. An intravenous pump

D. A 20 gauge or large intravenous line

The answer is D. A client must have a 20 gauge or larger intravenous line before blood products can be administered. If this is not present, a new IV must be initiated.

A is incorrect — While a patent line is important, the size of the line is the most important item a nurse must ensure is present before blood is administered. A 22-gauge line may be patent, but it is not sufficient for blood administration and a

1084 PART III: Taking the Test new site IV must be initiated. B is incorrect — Y-site tubing is important but not as important as the correct size intravenous line. C is incorrect — Blood should be administered on a pump, but it is not as important to ensure a pump is present as it is to ensure the proper size intravenous line is present.



Medication Administration

Review pertinent data prior to medication administration

43. Prior to administration, a client starting an increased dose of clonidine (Catapress) should be assessed for which of the following

A. Orthostatic hypotension

B. Tachycardia

C. Hyperglycemia

D. Oliguria

The answer is A. A client who starts an increased dose of

Catapress will experience orthostatic hypotension and so assessment for preexisting orthostatic hypotension is important and the physician can be notified for further orders.

B is incorrect — An adverse effect of Catapress is bradycardia not tachycardia and is not a contraindication to administering the medication. C is incorrect — Hyperglycemia is not a side effect of Catapress and is not a contraindication to administering the drug. D is incorrect — There is no contraindication to administering Catapress if oliguria is present.




Monitor client for side/adverse effects of TPN

44. For a client that is receiving total parenteral nutrition

(TPN), which assessment data would be most indicative of infection within 48 hours of initiation of therapy?

A. Confusion

B. Diaphoresis

C. Heart rate 120

D. Temperature of 101_Fahrenheit.

The answer is D. Fever in an afebrile patient is indicative of sepsis in a client that is receiving TPN.

A is incorrect — Confusion is common in the first 24 – 48 hours of initiation of TPN. This is due to the shift of electrolytes from the plasma to the cell. B is incorrect —

Diaphoresis is common with hypoglycemia associated with

TPN. C is incorrect — While tachycardia accompanies a fever, it is not the most indicative sign of infection in the client.





Intervene to manage potential circulatory complications

45. Which finding in a client who has undergone repair of a radial fracture 12 hours ago would require immediate notification of the orthopedic surgeon?

A. Pain at the incision site

B. Edema of the affected arm

C. Pain with passive movement of the fingers

D. Fever

The answer is C. The client has compartment syndrome and one of the indicative signs is pain with passive movement of the fingers. This requires the physician to be notified immediately so that intervention can occur.

A is incorrect — Pain is common after a surgical repair of a fractured arm. B is incorrect — Edema is common after surgical repair due to the body ’ s response to the injury and the

beginning of repair. D is incorrect — Fever is a sign of infection and should be reported but it does not require the nurse to notify the orthopedic surgeon immediately.




Perform a risk assessment

46. A home health nurse is performing an admission assessment on a client who has been discharged from the hospital.

Which finding on the risk for falls assessment must be resolved prior to the nurse leaving the home?

A. Carpet in the home

B. Throw rugs over hardwood floors

C. Shower/tub combo with shower curtain

D. Steps leading into the home

The answer is B. Throw rugs over hardwood floors are a common problem in homes of older clients and is an area where clients may fall. The nurse should remove the throw rugs prior to leaving the home and explain to the client her rationale.

A is incorrect — Carpet is not a falls risk. C is incorrect —

While a tub/shower combo is not ideal and the client can fall getting into or out of the tub, the nurse cannot fix this before leaving and should request items that would assist the client to continue using the shower. D is incorrect — Although

steps leading into the home present a fall risk, the nurse cannot modify these.





Evaluate achievement of client treatment goals

47. A client with a history of COPD complains of increased shortness of breath and has wheezing noted upon auscultation. The client is administered a nebulizer treatment of Albuterol and Atrovent. Which evaluation would indicate a therapeutic response to this treatment?

A. Increase in wheezing upon auscultation

B. Pink frothy sputum

C. Decrease in shortness of breath

D. Decrease in heart rate

The answer is C. The client is complaining of shortness of breath, and therefore, a decrease would be considered a therapeutic response to the treatment.

A is incorrect — An increase in wheezing upon auscultation is not considered a therapeutic response to the breathing treatment. B is incorrect — Pink frothy sputum is indicative of pulmonary edema and is not a therapeutic response to the treatment. D is incorrect — A decrease in the heart rate

is not a therapeutic response and indicates a complication since Albuterol and Atrovent are known to increase the client ’ s heart rate.




Apply knowledge of pathophysiology when caring for a client experiencing a medical emergency

48. A client presents to the emergency department after being ejected from an all terrain vehicle. The client received an opioid analgesic in route for control of pain associated with a lower leg injury. Which assessment data is most indicative of early increased intracranial pressure?

A. Irritability

B. Hypotension

C. Pupils 2 mm

D. Decreased respiratory rate

The answer is A. Irritability is the most indicative sign of increased intracranial pressure due to the changes the oxygen the brain receives due to compressed vessels. The absence of oxygen places the brain in a state of hypoxia, which causes irritability to occur.

B is incorrect — Hypertension is a sign of increased intracranial pressure due to the excited fibers, which control vasoconstriction. C is incorrect — Pupil dilation occurs due

to increased intracranial pressure but in this case the pupils are constricted due to the administration of an opioid analgesic in the field. D is incorrect — Initially, the respiratory rate will be increased due to the body ’ s response to hypoxia, as a late sign it will decrease.




Apply knowledge of pathophysiology when discussing radiation therapy with client/family/significant others

49. A nurse is teaching a client about care of a wound after surgery, which will also be the site of radiation treatments.

Discharge instructions should include:

___ How to care for the surgical site.

___ Signs and symptoms of delayed wound healing.

___ How often to report to outpatient for a treatment.

___ Signs and symptoms of anaphylactic reaction to radiation.

___ Signs of radiation toxicity.

___ Foods to avoid during therapy.

The discharge instructions should include how to care for the surgical site and the signs and symptoms of delayed wound healing since difficulties in wound healing are common in the client undergoing radiation therapy. Reporting to outpatient is important so that treatments stay on the

scheduled path for the greatest benefits. Radiation toxicity is common and the signs and symptoms should be discussed with the client so that the individual can seek medical attention as needed. Foods to avoid are taught about due to the possibility of oral ulcerations and sores associated with radiation therapy.

Anaphylactic reactions are not a risk with radiation therapy.




Administer blood products and evaluate the client response

50. A nurse has an order to administer packed red blood cells to a client. Prior to administration, the nurse should (check all that apply):

___ obtain consent

___ gather IV tubing with a filter

___ gather D5 1 ⁄ 2 NS

___ prime the line with fluid

___ check the blood with either an RN or LPN


___ warm the blood to 100_F

___ assess the site for patency

Before administering blood, the nurse should obtain consent for blood administration, gather IV tubing ensuring a filter for blood administration is present, prime the line with

fluid, and assess the site for patency.

The nurse should not use D5 1 ⁄ 2 NS for blood administration.

Only NS can be used for blood administration and only an RN can check blood with another RN. The blood should not be warmed unless orders are present to warm the blood to a specific temperature for rapid infusion. Warming of the blood will cause it to clot and can promote bacterial growth.


ENVIRONMENT


Reporting of Incident/Event/Irregular

Occurrence/Variance

Report error/event/occurrence per protocol

51. A nurse walks into a room after the bathroom call light is sounded and finds a client lying on the floor. The client states that he became dizzy and lost his balance after using the bathroom. Which documentation of the fall is most appropriate?

A. “ Client fell after standing-up from the toilet.

”

B. “ Client fell due to lowering in blood pressure upon standing.

”

C. “ Client found lying in floor, states ‘ I became dizzy and lost my balance after using the bathroom ’ .

”

D. “ Client experienced a vagal response and fell after using the bathroom.

”

The answer is C. The nurse should only document what she saw and what the client told her. Documentation other than what was stated and visualized is falsifying a document.

A is incorrect — This is a nursing assumption and is not legal. B is incorrect — This is not reporting what was seen or what the client told the nurse; therefore, it is inappropriate charting. D is incorrect — This is assuming the client experienced a vagal response and is not appropriate charting.


MAINTENANCE

Ante-/Intra-/Postpartum and Newborn Care

Calculate expected delivery date

52. A client has her pregnancy confirmed by the nurse in a physician ’ s office. The client wishes to know her expected date of delivery and the first day of her last menstrual period was July 4th. The nurse calculates the delivery date as:

A. April 10th

B. April 11th

C. April 1st

D. April 4th

The answer is B. The client ’ s expected date of delivery is

April 11th. This is calculated by subtracting 3 months from the month the client had her last menstrual period and adding 7 days to the date of the last menstrual period.

A, C, and D are incorrect using this method.





53. List in order from first to fourth the assessment technique used for a client who is complaining of abdominal pain.

A. Inspection

B. Palpation

C. Auscultation

D. Percussion

Inspection is the first step for an assessment of the gastrointestinal system. The second step is auscultation so that sounds can be heard since manipulation of the abdominal wall may alter sounds. The third step is to percuss for tympani or dullness and the last step is to palpate the abdomen for pain, tenderness, or other abnormalities.



Laboratory Values

Obtain specimens other than blood for diagnostic testing

54. A nurse has an order for a wound culture to be taken via aspiration; prior to aspirating the wound bed, the nurse should:

A. massage the wound bed.

B. irrigate the wound bed with normal saline.

C. clean the wound bed edges with normal saline.

D. dry exudate from the wound bed with sterile gauze.

The answer is B. The wound bed should be irrigated first with normal saline to remove exudate, which allows for fresh exudate from the wound bed to surface.

A is incorrect — The wound is massaged after the old exudate and saline irrigant is removed from the wound bed.


C is incorrect — Wound edges are not required to be cleaned when aspirating for a culture. D is incorrect — Exudate is removed from the wound bed with sterile gauze after saline irrigant is placed in the wound.


ENVIRONMENT


Continuity of Care

Perform procedures necessary for admitting, transferring, or discharging a client

55. Prior to transferring a client from the medical surgical floor to the intensive care unit, the nurse should first:

A. obtain a signed consent from the client for transfer.

B. notify the nurse manager.

C. obtain an accepting physician.

D. phone a report to the nurse in the ICU who will receive the client.

The answer is D. The nurse must transfer care of the client to another nurse and this is performed in a patient report.

A is incorrect — A client does not need to sign consent if a transfer is within the same facility. B is incorrect — A nurse manager is not needed in a transfer as long as there is a physician order and a bed is available in the receiving unit.

C is incorrect — The client ’ s primary physician is responsible for following the client within the facility, and if a transfer of care to another physician is required, it is the responsibility of the physician to obtain an accepting physician.


ENVIRONMENT


Staff Education

Assess purpose of staff education activities

56. A nurse understands that the primary rationale behind attending an in-service for newly acquired unit specific equipment is to:

A. aid in medicaid reimbursement for the hospital.

B. gain continuing education credits for licensure.

C. meet JCAHO requirements for staff education of hospital equipment.

D. maintain patient safety by understanding the proper

use of hospital equipment.

The answer is D. The nurse possesses the responsibility to remain current on all equipment that is used in a specific area of employment so he or she can assist in maintaining patient safety. Being unfamiliar with equipment can lead to litigation if he or she is negligent and causes client harm.

A is incorrect — Medicaid does not require nurses to attend in-services before reimbursement for client care is awarded. B is incorrect — While gaining continuing education credits are possible with some in-services, those that deal specifically with equipment use are not governed by the licensure board therefore are not applicable for continuing education credits. C is incorrect — JCAHO requires that staff is educated regarding equipment used in the facility but the primary purpose of attending an in-service on equipment use is to maintain patient safety.


MAINTENANCE

Aging Process

Provide care that meets the special needs of the preschool client ages 1 month to 4 years

57. When performing a routine assessment on a 1-year-old client, which data should be collected first?

A. Rectal temperature

B. Heart rate

C. Respirations

D. Blood pressure

The answer is C. Respirations should be counted first before the client becomes upset with the assessment process.

Changes in respiratory rate will often occur before other signs and symptoms are present in a child.

A is incorrect — The rectal temperature should be performed last since it will upset the child. B is incorrect — The heart rate should be assessed after the respiratory rate since it requires a stethoscope and will alter the respiratory rate if the client becomes upset. D is incorrect — The blood pressure is not performed on the 1-year-old client unless there is a cause of concern such as altered level of consciousness, depressed or bulging fontanels, or signs and symptoms of dehydration. In this scenario, the assessment is routine.


MAINTENANCE

Health and Wellness

Evaluate client/family/significant other understanding of health promotion behaviors/activities

58. A client in the doctor ’ s office for a routine check-up demonstrates an understanding of health promotion behaviors and activities when he says that he will:

(check all that apply)

___ walk at least twice a week.

___ avoid excessive caffeine.


___ cut down to one pack of cigarettes a day.

___ eat a vegetable at every meal.

___ take medication exactly as prescribed.

___ have blood pressure checked regularly.

The client voicing that he will walk at least twice a week, avoid excessive caffeine, eat a vegetable at every meal, take medication as prescribed and have blood pressure monitored frequently demonstrates an understanding of health promotion behaviors and activities.

The client stating he will cut down to one pack of cigarettes a day shows he does not realize the necessity of quitting smoking to improve health and further education is needed.


Abuse/Neglect

Identify risk factors for domestic, child and/or elder abuse/neglect, and sexual abuse

59. Which clients are at a high risk for sexual abuse?

(Select all that apply.)

___ An 8-year-old boy who lives with both parents.

___ A 6-year-old girl living in foster care.

___ A 21-year-old female living in a college dorm.

___ An 88-year-old client living in a nursing home.

___ An 18-year-old male living in an apartment in a

new town.

The answers are the 6-year-old girl living in foster care and the

21-year-old female living in a college dorm. Females are at a higher risk for sexual abuse than any other group. Sexual abuse for this group can consist of molestation of the 6-yearold girl or rape of either the 6- or 21-year-old.

Incorrect — The 8-year-old is at a low risk because he is male and lives with both parents making it a stable environment.

The 88-year-old client living in a nursing home is at a low risk of being sexually abused due to age and facility. An

18-year-old male is at a low risk of being sexually abused even though he lives in a new town.


Psychopathology

Identify signs and symptoms of impaired cognition

60. A client ’ s family is concerned about recent changes in their family member ’ s behavior and is afraid that he is developing Alzheimer ’ s disease. Which signs and symptoms reported by the family is associated with

Alzheimer ’ s disease? (Check all that apply.)

___ Memory loss

___ Seizures

___ Syncope

___ Personality changes

___ Anorexia

___ Poor judgment

The answers are memory loss, personality changes, anorexia, and

poor judgment. All of these are signs and/or symptoms of

Alzheimer ’ s disease and require reporting to the physician for follow up.

Seizures is incorrect — they are not associated with the disease. Syncope is not associated with Alzheimer ’ s unless a pre- or coexisting cardiac problem exists.



Complementary and Alternative Therapies

Evaluate client/family/significant other outcomes of alternative and/or complementary therapy practices

61. A cancer client has been attending yoga to aid in relaxation and mind healing. Which evaluation would indicate a therapeutic response to this alternative therapy?

A. The client claims to be “ cancer free.

”

B. The client has decided death will occur and is ready to “ pass on.

”

C. The client states she has found inner strength and has accepted the diagnosis.

D. The client has decided to stop treatment and allow the body to heal itself.

The answer is C. The cancer patient will often turn to alternative therapies to assist in the treatment process. Yoga has

proven to be a method of relaxation and allows for reflection and finding peace within one ’ s self. The client who has a successful response to yoga will find the peace within and learn how to relax and channel thoughts until peace is achieved.

A is incorrect — The client has a false sense of being cancer free and this has proven to be a negative result of an alternative therapy. B is incorrect — The client has made the decision that the end will occur and this can leave the client with a negative outlook on the future and impede healing. D is incorrect — The client has a false assurance of the reality of yoga and the expectations of ones self. The client needs counseling on the benefits of yoga and the expected outcomes.




Assess client for actual or potential side effects and adverse effects of medications

62. A client is being discharged home with a prescription for warfarin (Coumadin). Discharge instructions include:

A. avoid Tylenol while taking Coumadin.

B. avoid ginseng while taking Coumadin.


C. avoid clopidogrel (Plavix) while taking Coumadin.

D. avoid clonidine (Catapress) while taking Coumadin.

The answer is B. A client who takes Coumadin should avoid

taking herbal supplements that contain ginseng due to the risk of increased risk of blood thinning beyond desired effects.

A is incorrect — Tylenol is acceptable to take while on

Coumadin therapy unless hepatic function is impaired. C is incorrect — Plavix is a common drug used to prevent platelet aggregation and is compatible for use with Coumadin therapy.

D is incorrect — Catapress is commonly used for hypertension and is compatible with Coumadin therapy.



Pharmacological Interactions

Provide client/family/significant others with information on known pharmacological interactions of medication prescriptions

63. A client is prescribed theophylline (Theo-24) for

COPD. Discharge instructions should include the interaction of which of the following:

A. Nicotine transdermal patches

B. fosinopril (Monopril)

C. Advair Diskus 250/50

D. clopidogrel (Plavix)

The answer is A. Nicotine is contraindicated with the use of theophylline because of the stimulant effects and may cause tachycardia.

B is incorrect — Monopril is an ACE inhibitor and does

not carry any interactions with theophylline. C is incorrect —

Advair is a nonsteroidal bronchodilator and is safe to be used concurrently with theophylline. D is incorrect — Plavix is a platelet aggregate and is safe to be used with theophylline.



Vital Signs

Intervene when client vital signs are abnormal

64. The vital signs on a client are as follows:

• B/P 178/120

• P 112

• R 28

• O2Sat 98%

• T 99.0

The client is complaining of a headache and blurred vision. Which medication from the client ’ s MAR should the nurse administer?

A. Metoprolol (Toprol XL) 100 mg p.o.

B. Clonidine (Catapress) 0.3 mg p.o.

C. Metoprolol (Lopressor) 5 mg IV

D. Tylenol 650 mg p.o.

The answer is C. The client meets criteria for a hypertensive crisis. Lopressor is to be given intravenously. This is the best drug to give from the client ’ s MAR. Lopressor will lower the blood pressure and heart rate.

A is incorrect — The Toprol XL will also lower blood pressure and heart rate, but it is taken by mouth and will take

30 minutes to act. In hypertensive emergency, intravenous antihypertensives are given followed by oral dosing. B is incorrect — The client has an increased heart rate as well as increased blood pressure, the drug of choice would be an antihypertensive agent that will work on both areas. The

Catapress is used for hypertensive emergencies but it does not have a labeled use for lowering the heart rate and the oral dose will take longer to show results. D is incorrect — The client does have a low-grade fever and a headache, but the headache will resolve with a resolution in the blood pressure.


Abuse/Neglect

Assess client risk for abuse/neglect

65. Which client is at the highest risk for neglect?

A. Infant of a 30-year-old woman who is single.

B. Infant of a 14-year-old girl who lives with her parents.

C. 95-year-old client living in an assisted living facility.

D. 79-year-old client living at home with her 41-yearold daughter.

The answer is B. Statistically, a child of a teenager is at the highest risk for neglect. The mother and father live with the teenager but in most situations, the teenager is still responsible for the care of the infant. A teenager generally does not

have the coping skills and knowledge to care for an infant.

A is incorrect — The mother is an adult and the infant is less likely to be neglected. C is incorrect — A client in an assisted living facility is able to provide care with some assistance by other personnel lessening the chances of neglect. D is incorrect — The client living with her daughter is at a low risk with the daughter still young enough to provide adequate care.




Perform peritoneal dialysis

66. A nurse is performing peritoneal dialysis and instills 2 L of dialysate into the peritoneal cavity. After 30 minutes has elapsed, the client returns only 1 L of solution. The nurse should:


A. have the client roll from side to side.

B. gather a syringe and pull fluid from the peritoneal cavity.

C. apply warm compresses to the abdomen.

D. stop the process and call the physician.

The answer is A. The client should move from side to side in the bed so that drainage can occur.

B is incorrect — A syringe should not be used to pull

dialysate from the cavity. C is incorrect — Warm compresses on the abdomen will not help removing the solution from the peritoneal cavity. D is incorrect — The physician should not be notified unless moving the client is unsuccessful in removing the fluid.





67. A client has vancomycin (Vancocin) ordered every 12 hours. The client has one IV access and it currently has dopamine (Intropin) infusing to maintain blood pressure.

Prior to the administration of the vancomycin

(Vancocin) the nurse should:

A. obtain another IV access.

B. check for patency of the existing IV site.

C. discontinue the Dopamine.

D. check for compatibility ofDopamineandVancomycin.

The answer is D. Before obtaining another IV site, the nurse should check for compatibility of the Dopamine and the

Vancomycin. If compatibility is not assured, then another IV site should be obtained.

A is incorrect — The nurse should check for compatibility first. B is incorrect — The patency of the IV line should be unquestionable if a medication is infusing in it currently. C is

incorrect — Dopamine cannot be discontinued for the length of time it will take for Vancomycin to infuse.



Illness Management

Teach client about managing illness

68. A client is being discharged after receiving the diagnosis of human immunodeficiency virus (HIV). Priority teaching at the time of discharge is:

A. how to prevent the spread of infection to others.

B. when to take medications.

C. what foods to avoid.

D. when to follow up with physician.

The answer is A. Preventing the spread of the disease is the most important fact to teach the client prior to discharge from the hospital. This is most important with a new diagnosis of HIV.

B is incorrect — Although when to take medications is important, the nurse should first ensure that the client knows how to prevent the spread. C is incorrect — With a new diagnosis there are not any food restrictions. D is incorrect —

When to follow up with the physician is important but not the most important fact to teach to the client before discharge.


ENVIRONMENT


Client Rights

Recognize the client’s right to refuse treatment/procedures

69. A client who is scheduled to undergo chemotherapy today states, “ I do not wish to undergo my treatment today.

” Which action by the nurse is most appropriate?

A. Discuss with the client the need to follow the prescribed treatment regime.

B. Ask the client as to what has occurred to make him or her not want today ’ s treatment.

C. Notify the physician that the client has refused a treatment.

D. Notify the chemotherapy nurse that the client has refused today ’ s treatment.

The answer is B. The nurse needs to recognize that the client has the right to refuse treatment but he or she should also determine what has occurred to make the client refuse treatment so that an intervention can occur if needed.

A is incorrect — It discounts the client ’ s feelings. C and D are incorrect — Although they recognize the client has refused treatment neither choice addresses the client and his or her current state of mind.


ENVIRONMENT


Information Technology

Use information technology to enhance the care provided to a client

70. A 14-year-old client has been diagnosed with diabetes and needs diabetes education at the time of discharge. Which method of instruction would be best for this client?

A. A book that discusses diabetes, including how to administer medications.

B. Interactive computer software that discusses diabetes management.


C. A diabetes educator discussing diabetes management in a group environment.

D. A pamphlet that contains pictures on diabetes management.

The answer is B. A teenage would benefit most from computer software since teenagers are accustomed to a computer and learn best when they can interact with the information being given.

A is incorrect — A teenager is less likely to read a book discussing diabetes and thus leading to incomplete information. C is incorrect — Because of the nature of the illness and the psychological changes that a teenager goes through, a teenager often will not participate in a group discussion about diabetes management and therefore will not learn. D is incorrect — A pamphlet is not best for a teenager since they are active learners.


ENVIRONMENT


Home Safety

Educate client/family on home safety issues

71. Which of the following should be included in the discharge teaching for a family who is in the pediatrician ’ s office for a 2-year-old well baby check-up?

A. Cover all outlets in the home.

B. Place pots and pans on the front of the stove while cooking.

C. Avoid leaving the child for more than 1 minute while in the tub.

D. Remove all pets while the child is in the home.

The answer is A. A 2-year-old child is ambulatory and possess the motor skills to place objects in the electrical outlets which could potentially cause an electrical shock. The parents need to cover all outlets to prevent this from occurring.

B is incorrect — The parents should not place pots and pans on the front of the stove. They should be placed on the back. C is incorrect — A child should never be left alone in the tub. D is incorrect — Pets are not required to be removed from the home unless the child has an allergy to pets or other risks are associated.


ENVIRONMENT


Emergency Response Plan

Implement emergency response plans

72. A nurse would expect the internal disaster plan to be enacted if which event occurs?

A. Plane crash

B. Infant abduction

C. Fire in a client ’ s room

D. Explosion at a local plant

The answer is C. A fire in a client ’ s room is an internal disaster and the plan should be enacted by administrative staff.

A is incorrect — A plane crash is an external disaster and requires an external disaster plan to be enacted. B is incorrect —

An infant abduction carries a separate plan of action by the hospital and is not considered an internal disaster. D is incorrect — An explosion at a local plant is an external disaster and requires the external disaster plan to be enacted.


MAINTENANCE

Expected Body Image Changes

Assess occurrence of expected body image changes

73. A client is in the hospital after experiencing a burn to the face. Which statement made by the client demonstrates an acceptance of the change in her appearance?

A. “ I will make sure to avoid going outside during the day.

”

B. “ I am ready to look into the mirror.

”

C. “ I can put a scarf over my face so no one will notice.

”

D. “ Going to a salon is worthless; a new hairstyle won ’ t fix my deformity.

”

The answer is B. This statement made by the client demonstrates an acceptance of the changes that occurred as a result of the burn. The client is ready to see her face after the event, which is the first step to healing.

A is incorrect — This demonstrates that the client continues to have a disturbed body image. C is incorrect —

Wearing a scarf is a sign that the client has not accepted the changes that have occurred. D is incorrect — The client continues with a disturbed body image and has yet to accept the changes that have occurred. The client needs continued support and counseling.


ENVIRONMENT


Reporting of Incident/Event/Irregular

Occurrence/Variance

Identify need/situation where reporting of incident/ event/irregular occurrence/variance is appropriate

74. The nurse should fill out an incident report for which occurrence?


A. A client is found lying on the floor of his room.

B. An “ as needed ” medication is given for a complaint of pain.

C. Calling a physician for an illegible order.

D. A medication is held due to a decreased blood pressure.

The answer is A. A client found lying in the floor is considered an unexpected event and requires an incident report to be completed.

B is incorrect — A medication given for the complaint of pain is an expected occurrence and an incident report is not needed. C is incorrect — Calling a physician for an illegible order is preventing an error and does not require an incident report. D is incorrect — Holding a medication due to a low blood pressure is a valid nursing judgment and does not require an incident report.


Crisis Intervention

Assess the need for, initiate, and maintain suicide precautions

75. A client presents to the emergency department and states that he wants to kill himself. Which action by the nurse is the priority?

A. Removal of client ’ s clothing.

B. Placement of client in room with camera.

C. Search of client for weapons.

D. Pad the side rails of the bed.

The answer is B. The first action by the nurse is to place the client in a room with a camera. The client will need to be monitored at all times and this is the best method.

A is incorrect — The client will need to remove clothing that could be used to assist with a suicide but this needs to be done in a room with a camera so that the staff can make sure the client is not harming self while alone. C is incorrect — The client ’ s clothing will be searched for a weapon upon removal and the search of clothing is performed by security staff. D is incorrect — The side rails do not need to be padded for a suicidal client. The padding of side rails is reserved for the client experiencing seizures.


Therapeutic Communications

Use therapeutic communication techniques to provide support to client and/or family

76. A pediatric client is scheduled for a bone marrow biopsy. The mother begins to sob stating, “ I am a horrible mother for letting this happen to my little girl.

”

The nurse ’ s best response is:

A. to leave the mother alone to cry.

B. to ask “ Is there anyone I can call for you?

”

C. to call the physician and request a sedative for the mother.

D. to state “ You are not responsible for your child being ill; you have placed your child in the best environment for what she needs.

”

The answer is D. The mother needs hope for the situation at hand and needs to be reminded that this is not her fault and that she is doing what is best for her child.

A is incorrect — Leaving the mom will only worsen the situation. B is incorrect — The mother needs support at the moment. Calling other family is helpful but does not address the current situation. C is incorrect — The physician will not be able to prescribe a sedative for the mother. The mother must be of sound mind to make decisions for her child if needed and a sedative would impair her mental state.



Personal Hygiene

Assist the client in the performance of activities of daily living

77. Which of the following should a nurse perform every day to ensure the client ’ s activities of daily living have been met?

A. Set the client in a chair with the supplies needed to bathe.

B. Administer medications on time.

C. Place a consult for occupational therapy.

D. Perform wound care.

The answer is A. The client needs to bathe every day, and to assist the client the nurse should set him or her in a chair and allow time for bathing.

B is incorrect — Administering meds is not ensuring that activities of daily living have been met. C is incorrect —

Placing the consult does not ensure that activities of daily living have been met. D is incorrect — Wound care is not part of the client ’ s activities of daily living.



Expected Effects/Outcomes

Evaluate and document client response to medication

78. Which of the following is a sign that IV ondansetron

(Zofran) was therapeutic?

A. The client has a bowel movement within 6 hours.

B. The client no longer complains of a headache.


C. The client ’ s abdominal pain is relieved.

D. The client no longer complains of nausea.

The answer is D. Zofran is an antiemetic and is used for nausea and vomiting associated with chemotherapy and surgery.

A is incorrect — Zofran, as with all antiemetics, has the

tendency to cause constipation. B is incorrect — Zofran does not contain any pain-relieving properties. C is incorrect —

Zofran does not contain any pain-relieving properties.



Diagnostic Tests

Evaluate the results of diagnostic testing and intervene as needed

79. The technician reports to the nurse that the client has

2 mm ST segment elevation in lead II and III on a 12- lead electrocardiogram. What is the priority nursing intervention?

A. Assess the client

B. Repeat the test

C. Administer Oxygen 2L NC

D. Phone the physician

The answer is A. When a nurse is presented with a suspicious test result, the nurse must first assess the patient for signs and symptoms of distress, as in this case, a suspected myocardial infarction. This allows the nurse to intervene as needed.

B is incorrect — The test may be repeated after an assessment of the client. C is incorrect — The nurse must first assess the client before performing any nursing action. D is incorrect —

The physician is phoned after the nurse assesses the client and any actions are taken that are deemed necessary.




Identify factors that result in delayed wound healing

80. A nurse is assessing four of her assigned clients. Which client is at the highest risk for delayed wound healing?

A. 18-year-old admitted after right knee arthroscopy.

B. 34-year-old diabetic admitted for hernia repair.

C. 64-year-old with peripheral vascular disease that underwent a toe amputation.

D. 78-year-old with congestive heart failure admitted for a thoracentesis.

The answer is C. The 64-year-old client with peripheral vascular disease is at the highest risk for delayed wound healing.

The client has vascular deficiency already as evidenced by the toe amputation. The body ’ s ability to transport oxygenrich blood and nutrients to the area is compromised and the client is likely to have difficulty healing from the procedure due to the already compromised state.

A is incorrect — The 18-year-old is not likely to have difficulty healing from the procedure. B is incorrect — While

34-year-old diabetic client will have difficulty with wound healing, the 64-year-old client with peripheral vascular disease is at the highest risk due to evidence of an already compromised system. D is incorrect — The 78-year-old client with

congestive heart failure has a cardiac pump problem and will have decreased blood supply; although, for this question, C is the best answer.



Therapeutic Procedures

Educate client and family about home management of care

81. A client is being discharged with a CPAP machine for a diagnosis of sleep apnea. Which of the following should be included in the discharge instructions?

A. Clean the face mask with bleach solution.

B. Stop using the machine if noise precipitates insomnia.

C. Place the mask securely on the face.

D. Redness to the face where the mask is placed is normal.

The answer is C. The mask should fit securely on the face to prevent air leaking around the mask and causing eye irritation and maintain desired outcome.

A is incorrect — The bleach solution will harm the client ’ s skin; the mask should be cleaned with vinegar and water solution. B is incorrect — The CPAP should be worn as directed by the physician and if the noise is causing insomnia, the physician should be notified. D is incorrect —

Redness to the face may indicate an allergic reaction to the mask and should be reported to the physician.




Perform or assist with dressing change

82. A nurse has an order to perform central line care.

Which action by the nurse will be best in removing bacteria from the catheter insertion site?

A. Allowing the chlora-prep to dry on the site.

B. Scrubbing the insertion site for 2 minutes with chlora-prep.


C. Wearing a mask during the procedure.

D. Placing a medicated disk (bio-patch) around the insertion site.

The answer is B. Scrubbing the site with chlora-prep will be best nursing action in removing bacteria from the site of the catheter and prevent infection.

A is incorrect — The chlora-prep can dry on the site after it is scrubbed. C is incorrect — Wearing a mask is beneficial in preventing the introduction of new bacteria, but is not the best action when removing bacteria from the catheter insertion site. D is incorrect — Placing a bio-patch on the site will prevent growth of bacteria but it is not the best action in removing bacteria from the site.



Fluid and Electrolytes

Implement interventions to restore client fluid and/or electrolyte balance

83. A client has a magnesium level of 1.4 mg/dL. The nurse administers magnesium oxide at 1300 and will plan on ordering a redraw of the magnesium level at:

A. 1500

B. 1600

C. 1700

D. 2100

The answer is C. Magnesium has an onset of action in 3 hours of administration. The blood redraw is performed in

4 hours from administration to see if a desired response occurred.

A and B are incorrect — These time frames are not long enough from administration to onset for levels to increase. D is incorrect — This time frame is too long from the time of administration to know if desired outcomes occurred.



Hemodynamics

Apply knowledge of pathophysiology to interventions in response to the client’s abnormal hemodynamics

84. Which client will not exhibit the expected assessment

findings in response to septic shock?

A. A client with a previous myocardial infarction.

B. A client who is taking a beta blocker for hypertension.

C. A client who performs peritoneal dialysis.

D. A client with diabetes.

The answer is B. A client taking a beta blocker will not exhibit the heart rate change associated with septic shock and the blood pressures will remain at a lower level.

A is incorrect — A client with a myocardial infarction will exhibit the anticipated response. C is incorrect — A client who performs peritoneal dialysis will have the findings expected with septic shock. D is incorrect — While the client with diabetes will have an alteration such as an increase in blood pressure, the individual will exhibit the findings associated with septic shock.




Provide emergency care for wound disruption

85. List in order the steps the nurse will take if faced with a wound dehiscence

___ Notify the physician

___ Cover the wound with sterile saline soaked gauze

___ Lay the client in low Fowlers and bend the client ’ s knees

___ Instruct the client to splint the abdomen if needing to cough

The client should first lie down initially to prevent further strain on the incision site. Next, the nurse applies saline soaked sterile gauze to the area to keep the area moist. The nurse should then instruct the client on splinting during coughing in the event he or she needs to cough while the physician is being notified.



Unexpected Response to Therapies

Assess client for unexpected adverse response to therapy

86. A client is on the ventilator due to a diagnosis of acute respiratory distress syndrome (ARDS). Which assessment finding is most indicative of a complication?

A. Diminished breath sounds on auscultation

B. Deviation of the trachea

C. Weight gain

D. Decreased urine output

The answer is B. A deviated trachea is indicative of a tension pneumothorax associated with noncompliant lungs (as with

ARDS) being ventilated at a higher pressure than the lung can tolerate. This requires immediate intervention by the physician.

A is incorrect — Diminished breath sounds are common in the client with ARDS due to decrease lung compliance

CHAPTER 34 Practice Test for NCLEX-RN® 1095 and collapsed alveoli. C is incorrect — While weight gain may occur in ARDS, it is not the most indicative sign of a complication. D is incorrect — Although decreased urinary output is a problem and needs to be addressed, it is not the most indicative sign of a complication.





Implement measures to manage/prevent/lessen possible complications of the client condition and/or procedure

87. A client with a history of congestive heart failure who has gained 3 pounds in 1 day should be placed on:

A. 1800 calorie ADA diet

B. calorie count

C. fluid restriction

D. potassium restriction

The answer is C. The client who has gained more than 2 pounds in 1 day and has a history of congestive heart failure should be placed on a fluid restriction to keep the client from exacerbating his or her condition.

A is incorrect — The 1800 calorie ADA diet is for a diabetic and will not be beneficial in this situation of volume

overload. B is incorrect — The client should not count calories but count liquid intake in volume. D is incorrect — A potassium restriction is not needed unless lab values indicate a high potassium level.




Administer oxygen therapy and evaluate response

88. A nurse is assessing the vital signs of a client and notices that the oxygen level is 91% on room air. The client complains of a headache and wheezing is noted upon auscultation.

Which nursing intervention would be best?

A. Ask the client to sit in high Fowlers.

B. Ask the client to cough and reassess.

C. Apply 2 L of oxygen per nasal cannula.

D. Offer a pain medication for the headache.

The answer is C. The client has a low oxygen saturation level, is wheezing, and has a headache. The headache could be attributed to the low oxygen saturation level and so the nurse should place oxygen on the client to see if symptoms improve.

The wheezing should be addressed with a bronchodilator.

A is incorrect — Making the client sit in high Fowlers will not resolve the situation of a low oxygen level. B is incorrect —

Asking the client to cough is used when rhonchi is auscultated; wheezing is due to a narrowing of the airway. D is incorrect —

Pain medication will worsen the oxygen saturation level.


ENVIRONMENT


Medical Surgical Asepsis

Assess client environment area for sources of infection

89. In the room of a client who has sustained a burn, which of the following would be the greatest potential source of infection?

A. Fresh flowers

B. Fresh fruit

C. Helium filled latex balloons

D. Staff

The answer is D. Staff is the greatest source of infection for clients with a burn. For this reason, isolation is ordered for most clients who have sustained a burn.

A is incorrect — Fresh flowers produce toxins as they die; they are also a source of infection and should be limited in the rooms of client ’ s with a burn. B is incorrect — Fresh fruit that is to be eaten is safe in the room of a client as long as it has not begun to rot. C is incorrect — Helium filled latex balloons are safe as long as the client does not have a latex allergy.


ENVIRONMENT


Informed Consent

Ensure that client has given informed consent for treatment

90. A client is scheduled for a colonoscopy to be performed this morning. Prior to preparing the client for the procedure, the nurse must first:

A. ensure that the client has an advance directive in the chart.

B. assess the client ’ s level of understanding about the procedure.

C. verify that consent for the procedure has been signed by the client.

D. verify that the client has not eaten since midnight.

The answer is C. Prior to preparing the client for the procedure, the nurse must ensure a signed consent is on the chart.

The signing of the consent is the responsibility of the physician who will be performing the surgical procedure.


A is incorrect — An advanced directive is desired but not essential in the chart of a client who is going for a colonoscopy. B is incorrect — The client ’ s level of understanding regarding the procedure is required prior to consent being signed. The signed consent establishes that the client understands the procedure that the physician will perform. D is incorrect — Verification that the client has remained NPO is less of a priority than verification that consent is on the chart

prior to prepping the client for the procedure.


MAINTENANCE

Ante/Intra/Postpartum and Newborn Care

Assess client for symptoms of postpartum complications

91. Which assessment data would be most indicative of a uterine infection in the postpartum client who underwent a vaginal delivery?

A. Dark brown discharge from the vagina.

B. Pain at the site of the episiotomy.

C. Cramping in the lower abdomen.

D. Foul smelling vaginal discharge.

The answer is D. Foul smelling discharge is indicative of an infection in the postpartum client and requires intervention.

A is incorrect — Dark brown discharge is old blood that is being expelled through the vagina and is normal. B is incorrect — Pain at the site of the episiotomy is normal until healed. C is incorrect — Cramping in the lower abdomen occurs as the uterus returns to its pre-pregnancy state.


MAINTENANCE

Principles of Teaching/Learning

Assess readiness to learn, learning preferences, and barriers to learning

92. Which evaluation would be most indicative of readiness

to begin self-wound care?

A. The client does not wish to see the wound.

B. The client no longer needs pain medication before wound care.

C. The client watches the nurse perform care of the wound.

D. The client begins to ask questions about the care of the wound.

The answer is D. When the client begins to ask questions about the care of the wound he or she has taken an interest in the procedure, which demonstrates a readiness to learn.

A is incorrect — If the client is unwilling to visualize the wound then he or she is not ready to care for the wound. B is incorrect — The client may no longer require pain medication before wound care but that does not show a readiness to learn how to care for the wound. C is incorrect — The client may begin to watch the care of the wound prior to being ready to take over the care. Watching the wound care is the first step but is not most indicative of a readiness to begin self-care.



Mobility/Immobility

Maintain client skin integrity

93. Which of the following is the best method for preventing skin breakdown in an immobile client?

A. Use of an alternating mattress.

B. Turning every 2 hours.

C. Keeping wrinkles out of sheets.

D. Elevating heels off of the bed.

The answer is B. The best method of preventing skin breakdown is to turn the client every 2 hours.

A is incorrect — Even though a client uses an alternating mattress, a staff member must still turn the client every 2 hours. C is incorrect — The client will benefit from removal of wrinkles that may be in the sheets but it is not the best method of preventing skin breakdown. D is incorrect — While elevating the feet will prevent shearing, it is not the best method of preventing skin breakdown for an immobile client.




Identify the client according to facility/agency policy prior to administration of red blood cells/blood products

94. Which of the following is the first action a nurse must take prior to initiating blood administration?

A. Check the chart for the physician ’ s order.

B. Ask the client to sign consent for blood.

C. Order a type and cross from the lab.

D. Check the chart for the hematocrit and hemoglobin level.

The answer is C. Prior to blood administration, the nurse must be sure an order is on the chart signed by the physician.

Without an order, the nurse cannot proceed with the process.

B is incorrect — The client should not sign consent unless an order is present on the chart. For the options given, ensuring an order is on the chart is the best answer. C is incorrect —

The physician must write an order for a type and cross to be performed on the client. D is incorrect — After a physician ’ s order is received, the nurse is responsible for checking the client ’ s level before having a consent signed by the client.




Pharmacological Pain Management

Evaluate and document client use and response to pain medications

95. The assessment of a client complaining of pain is documented as:

• RR 24

• BP 140/90

• HR 100

• grimacing, guarding

Demerol 50 mg IM was administered 30 minutes prior to the pain reassessment. Which findings would best indicate a therapeutic response to the medication?

A. RR 20

B. HR 95

C. BP 138/88

D. Patient resting with eyes closed

The answer is D. The client is resting now, which shows a resolution from the grimacing and guarding the client was demonstrating before pharmacological intervention.

A is incorrect — The respiratory rate is not the best indicator of pain resolution. B is incorrect — The heart rate has only decreased by 5 bpm, which is not a significant indicator of pain relief. C is incorrect — The blood pressure has not decreased enough to demonstrate pain relief and is not the best indicator of pain relief.



Hemodynamics


96. The nurse attaches an unresponsive client to the monitor.

What is the rhythm the nurse sees on the monitor?

A. Asystole

B. Ventricular fibrillation

C. Ventricular tachycardia

D. Torsades De Pointes

The answer is B. The rhythm is ventricular fibrillation. There are irregular ventricular contractions due to the absence of

depolarization in the heart.

A is incorrect — With asystole, there is an absence of impulses to cause ventricular contractions. C is incorrect —

Ventricular tachycardia exist with an increased and irregular ventricular rate. D is incorrect — Torsades De Pointes is due to prolonged repolarization and will progress to VF if left untreated.




Apply knowledge of pathophysiology when caring for a client experiencing a medical emergency

97. A client is brought to the emergency department after working outdoors. The temperature is 99_F with a heat index of 102. The nurses assess for which of the following knowing it is the most indicative sign of a heat stroke?

A. Agitation, confusion

B. Nausea, headache

C. Shedding of clothes, unable to move

D. Syncope, neck stiffness

The answer is A. Agitation and confusion are the first signs of a heat stroke due to the body ’ s response to the vasoconstriction and subsequent cerebral hypoxia associated with the body attempting to conserve fluid loss from sweating.

B is incorrect — Nausea and headache are common with heat exhaustion. C is incorrect — The shedding of clothes

and inability to move is found with hypothermia. D is incorrect —

Syncope and neck stiffness are not associated with heat stroke, but are associated with meningitis.





Implement measures to manage/prevent/lessen possible complications of client condition and/or procedure

98. A client is being admitted to the floor from the emergency department with possible seizures. Before the client arrives to the floor, the nurse should plan on:


A. padding the rails of the bed.

B. placing a bed alarm on the bed.

C. placing restraints at the bed side.

D. placing the crash cart at the bedside.

The answer is A. The rails of the bed should be padded to prevent injury if the client has a seizure while in the bed.

B is incorrect — Placing a bed alarm on the bed will not be beneficial in protecting the client if he or she has a seizure. C is incorrect — Restraints are not used on a client who might have a seizure. D is incorrect — There is no need for the crash cart to be at the bedside for a client with possible seizures.




Counsel/teach client, family, or significant others about managing client health problems

99. The nurse is teaching the client and the family regarding peritoneal dialysis, which will be performed at home. The priority discharge instruction is:

A. signs and symptoms of peritoneal infection.

B. how to care for and clean the catheter.

C. how to take a blood pressure and heart rate.

D. how long the procedure should take.

The answer is B. How to care for and clean the catheter is priority teaching for the client. Prevention of infection is a high priority for clients who are performing peritoneal dialysis at home.

A is incorrect — Signs and symptoms of peritoneal infection are important and the client should be taught to report these to the physician. C is incorrect — How to take a blood pressure and heart rate is important but not necessary before every at-home treatment unless the client has complaints. D is incorrect — How long a procedure should take is important but it is better to teach the client about how to measure input to output to know that the treatment was successful.


Family Dynamics

Assist client/family/significant others to integrate new

members into family structure

100. A mother states that her 3-year-old potty trained child has begun to urinate in his pants after the new baby was brought home from the hospital. Which response by the nurse is best?

A. “ Children often regress when new members are introduced; continue to remind him to go to the rest room every hour.

”

B. “ Punish him before this becomes a pattern.

”

C. “ Children often regress at this age; it is normal and will improve with time.

”

D. “ Talk to your child about what is occurring and then show him he is still important by spending an hour of one-on-one time with him every day while someone watches the baby.

”

The answer is D. The most important thing is to let the parents know it is okay to talk about what is occurring with their child and assist the family with a plan to help the child feel loved and still an important member of the family.

A is incorrect — This does explain to the family what is occurring but reminding the child to go to the restroom does not show the child that he or she is still a valuable member of the family. B is incorrect — Regression is a normal response to a new family member and punishment does not validate normalcy.

C is incorrect — This will not resolve without intervention

by the parents. Waiting for change to occur without action by the parents will only lead to more problems.




Provide client with information about the purpose and procedure of prescribed laboratory tests

101. A client presents to the ED with chest pain. The nurse draws blood during the initiation of an intravenous line for a triponin and CPK. The client asks what this test is for. The best response by the nurse is:

A. “ the triponin looks for a heart attack.

”

B. “ the triponin will verify what the EKG shows.

”

C. “ the triponin is the cardiac marker test that shows cardiac injury.

”

D. “ the triponin shows muscle damage.

”

The answer is C. The triponin is the only test that is explicitly for cardiac muscle ischemia making this the correct option.

A is incorrect — Although the client can have muscle ischemia from lack of blood supply, it is not the only indicator of a heart attack. B is incorrect — While the EKG and the triponin are used as indicators of muscle ischemia, this test is not used to verify another test. D is incorrect — The triponin is specifically a cardiac marker test. The CPK is the test that shows muscle damage.



Dosage Calculation

Perform calculations needed for medication administration

102. A client has ordered Cardizem 250 mg in 250 mL to run at 10 mg/h. To deliver the ordered dose, the infusion pump should be set at:

A. 8 mL/h

B. 10 mL/h


C. 5 mL/h

D. 1 mL/h

The answer is B. The concentration of drug is a 1:1 ratio. The infusion pump should be set to 10 mL/h.

A, C, and D are incorrect — These choices would be under dosing the client.



Assistive Devices

Assess client for actual/potential difficulty with communication and speech/vision/hearing problems

103. Which of the following drugs requires regular hearing exams with prolonged use?

A. Streptomycin

B. Ciprofloxacin (Cipro)

C. Hydromorphone (Dilaudid)

D. Isoniazid (INH)

The answer is A. The client who receives an aminoglycoside such as streptomycin requires auditory exams routinely to assess for hearing loss due to the drugs ototoxic affects.

B is incorrect — Cipro does not require routine exams of any sensory functions. C is incorrect — Dilaudid causes CNS depression, which leads to changes in respiratory rate and blood pressure and does not require routine auditory exams.

D is incorrect — INH requires routine liver enzyme studies due to the possibility of liver toxicity with use.


ENVIRONMENT


Resource Management

Plan safe, cost-effective care for the client

104. Which action by the nurse would be the safest and most cost-effective when administering daily medications?

A. Administer all morning meds at the same time regardless of time scheduled.

B. Date and time all IV tubing on piggybacks and continuous infusions.

C. Use only one medicine cup per client when administering meds in a 24-hour period.

D. Use Betadine versus alcohol swabs when cleaning

sites for injections.

The answer is B. Dating and timing all tubing for intravenous medications and fluids eliminates the need to change tubing each shift. Tubing is acceptable for continuous use 24 hours after being attached to a bag and the client.

A is incorrect — Medications are scheduled by the pharmacy and should be followed. Administering medications as scheduled can prevent poor absorption and alterations in the client ’ s physiologic status. C is incorrect — Using one medicine cup per day is unsanitary and should be avoided.

D is incorrect — Betadine can damage the cells of the skin; using Betadine is not recommended for routine injections.


ENVIRONMENT


Advance Directives

Provide client or family with information about advance directives

105. While admitting a client to the unit, the nurse asks the client if he or she has a living will. The client questions the nurse as to what a living will is. The nurse ’ s best response is:

A. “ A living will lets the family know your wishes if you go into cardiac arrest.

”

B. “ A living will is a legal document that explains your

wishes for health care depending on the severity of your illness.

”

C. “ A living will is a written order by the physician.

”

D. “ A living will allows you to name someone to make decisions for you.

”

The answer is B. A living will is an advance directive that states the wishes of a client in the event he or she is critically or terminally ill.

A is incorrect — A living will states more than the wishes of a client if he or she is in cardiac arrest. A living will not only informs the family of the client ’ s wishes but also the health care team. C is incorrect —“ Do not resuscitate ” is the order written by the physician and placed in the chart after the wishes are made known by the client in an advance directive.

D is incorrect — A living will does not allow the client to name an individual to make decisions for him or her, a durable power of attorney allows an appointed individual to make decisions for the client anytime he or she is unable to do so.


ENVIRONMENT


Collaborate with Interdisciplinary Team

Identify significant information to report to other disciplines

106. A nurse enters a client ’ s room to administer ferrous sulfate

324 mg. When the nurse checks the MAR against

the medication, he or she notices that the dosage on

1100 PART III: Taking the Test the package indicates ferrous sulfate 300 mg. Which action would be the most appropriate?

A. Notify the pharmacist of the dosage error and request the correct dosage.

B. Administer the medication since milligrams to be administered is lower than the ordered dose making it safe.

C. Hold the medication until the physician can be notified.

D. Ask the nurse who cared for the client yesterday what he or she administered to the client.

The answer is A. The nurse should phone the pharmacist first to request the correct dosage for the client before it is administered.

B is incorrect — Administering a medication that is under or over the ordered dose is a medication error unless an order is written for the dose being administered. C is incorrect —

The pharmacy is responsible for dispensing medication and needs to be notified of the error. D is incorrect — The nurse should take responsibility for today and clarify the dosage with the pharmacy.


ENVIRONMENT


Legal Rights and Responsibilities

Report unsafe practice of health care personnel to internal/ external entities

107. A nurse walks by the room of a client and sees a licensed practical nurse beginning the administration of blood. Which action by the nurse would be most appropriate?

A. Confront the licensed practical nurse as to what is occurring.

B. Check the chart of the client to see if blood was ordered.

C. Report what was seen to the charge nurse.

D. Phone the board of nursing to report unsafe practice.

The answer is C. If a nurse suspects unsafe practice, it is imperative he or she follows the chain of command and report the nurse to the charge nurse. The charge nurse is responsible for confronting the nurse and continuing to report the nurse through the chain of command to the appropriate individuals.

A is incorrect — It is policy of most institutions to report unsafe practice to the nurse in charge of the unit. B is incorrect —

Regardless of the order, it is not in the scope of practice of an LPN to administer blood. D is incorrect — The nursing administration is responsible for reporting a nurse for unsafe practice.


ENVIRONMENT


Supervision

Evaluate effectiveness of staff member’s time management skills

108. Which assessment by the charge nurse is most indicative that a staff member is demonstrating difficulty with time management of daily assignments?

A. Performing 3 minute assessments on all clients.

B. Being unable to leave the unit by the end of shift.

C. Administering medications as scheduled.

D. Not meeting the standards of client care during the shift.

The answer is D. Not meeting the standards of care is a sign that a nurse has difficulty with time management. Nurses are required to multitask to complete all assignments but meeting the standards of care is essential and should never be compromised.

A is incorrect — A 3-minute assessment is acceptable on a client that is not a new admission. It addresses the systemspecific assessment and an overview of all other systems. B is incorrect — Being unable to leave the unit when the day is complete is not the highest indicator that a nurse has poor time management skills. Not meeting the standards of care ranks higher. C is incorrect — Administering medications on

time demonstrates that a nurse does have the correct priorities for time management.


ENVIRONMENT


Security Plan

Participate in maintaining the institution’s security plan

109. The hospitals policy regarding infant abductions is below:

Hospital Policy Regarding Infant Abductions: Code Pink

1. If an infant is found to be missing or is reported missing by staff, phone the hospital operator immediately and a code pink will be called over the intercom system.

2. All staff should stand by elevators, doors leading to the outside, and stairwells in their department.

3. Anyone carrying a large bag, backpack, wearing a heavy coat or appears to be pregnant should be followed and a description of the person should be noted.

4. Phone security and follow the person.

5. Avoid confronting the individual, wait on security.


A nurse is working in a hospital and as she is exiting the elevator on the main floor a code pink is called over the intercom. Which action by the nurse is most appropriate?

A. Stand outside the elevator until an all clear is called.

B. Return to the assigned floor to stand outside the stairwell.

C. Leave the elevator and go to a stairwell and stand.

D. Begin stopping all staff and visitors and ask them to open bags and coats.

The answer is A. If a code pink is called, according to the policy the staff is to stand by any port of exit. In this case, the nurse should stand outside of the elevator so that it is attended during a possible abduction.

B is incorrect — Returning to the assigned floor does not follow the policy and leaves the elevator as a possible exit site for the abductor. C is incorrect — The elevator is a portal of exit as is the stairwell and so the one the staff member is at should be manned. D is incorrect — According to the policy, staff should not confront anyone suspected of being the abductor, but follow the possible abductor and phone security.


MAINTENANCE

Health Promotion Programs

Instruct client on ways to promote health

110. A male should be instructed on using which method when performing a routine testicular self-examination?

A. Perform before taking a shower.

B. Perform every 3 months.

C. Roll the testicle between the thumb and fingers.

D. Pinch the epididymis until sensation is loss in the penis and release.

The answer is C. The client should be instructed to roll the testicle between the thumb and fingers to monitor for abnormalities.

A is incorrect — The test should be performed after taking a shower so that the scrotum is relaxed. B is incorrect — Self-exams should be performed every month to monitor for changes so they can be caught early. D is incorrect — The epididymis should not be pinched due to the potential for damage to the structure.


ENVIRONMENT


Handling Hazardous and Infectious Materials

Identify biohazardous, flammable, and infectious materials

111. Which of the following should be placed in a biohazardous bag?

A. Foley urine bag of a client with CHF.

B. Used intravenous medication bag of a client suffering from dehydration.

C. Soiled diaper of a client with Clostridium difficile.

D. Syringe used to flush a central line.

The answer is C. Clostridium difficile is highly contagious and the stool of this client should be placed in a biohazardous bag for proper disposal.

A is incorrect — A client ’ s Foley bag should be emptied

in the toilet prior to throwing the bag in the trash can which removes waste into the appropriate facility. B is incorrect — A used intravenous bag can be thrown into the trash can in a client ’ s room as long as a name is not on the bag. If a name is on the bag, the label should be removed and the bag can be placed in the trash receptacle. D is incorrect — A syringe used to flush a central line should be placed in a sharps receptacle and not into a biohazardous bag.


Mental Health Concepts

Explore why the client is refusing/not following the treatment plan (e.g., nonadherence)

112. A client with end stage renal disease (ESRD) tells the transporter that he is not going down for his dialysis treatment today. The nurse should

A. tell the client that it is okay and he can go tomorrow.

B. notify the physician.

C. ask the client if he is frustrated with the process of dialysis.

D. tell the client he will need to sign an “ Against

Medical Advice ” form.

The answer is C. The most common reason for nonadherence to treatment regimens is a frustration with the procedure and the aspects of the disease process. Acknowledging that the client may be unhappy with the demands of the disease and the loss

of control over life will help the nurse and client devise a plan to meet the treatment regimen that benefits both parties.

A is incorrect — The client needs to go to dialysis every scheduled day, telling him it is okay to miss a treatment will enable him to refuse every treatment and does not determine why he refused. B is incorrect — Notifying the physician does not explore why the client refused today ’ s treatment. D is incorrect — Having the client to sign an AMA form does not explore why the client refused today ’ s treatment.


Support Systems

Promote independence of client/family/significant others

113. Which of the following would promote independence in the client who recently underwent a below-the-knee amputation?


A. Teach range of motion exercises.

B. Provide the client with a wheelchair.

C. Instruct the client on proper wound care.

D. Provide analgesics for pain relief.

The answer is B. The client has the disability of limited mobility after an amputation. Providing the client with a wheelchair will enable him or her to move around in the environment and continue with independent activities.

A is incorrect — While a range of motion exercises prevent

contractures and prepare the stump for prosthesis, it is not the best method of promoting independence initially. C is incorrect — Instructing the client on wound care promotes readiness to care for self, but does not promote independence overall. D is incorrect — Analgesics do not promote independence for the client.



Palliative/Comfort Care

Assess client’s symptoms related to end of life

114. Which of the following would a nurse find in her assessment of a client that is nearing the end of life?

(Check all that apply.)

___ Decrease in time spent sleeping

___ Loss of appetite

___ Alteration in mental status

___ Generalized weakness

___ Periods of apnea

___ Seizures

The answers are loss of appetite, alteration in mental status, generalized

weakness, and periods of apnea. These are consistent with the findings a nurse might see in his or her assessment of someone nearing the end of life. The loss of appetite is due to the decrease in metabolism that the body undergoes at death. Generalized weakness and an alteration in mental status is due to the

changes in metabolism as well. Periods of apnea occur and are called Cheyne-Stokes; panting respirations will accompany the periods of apnea in some cases.

Incorrect answers are decrease in time spent sleeping and seizures. The client will often have an increase in time sleeping and seizures are uncommon.





115. The morning assessment of a client reveals this data:

• BP 90/60

• HR 110

• RR 20

• Temp 98.9

The nurse should hold which of the following drugs:

A. levothyroxine (Synthroid)

B. carvedilol (Coreg)

C. gabapentin (Neurontin)

D. pioglitazone (Actos)

The answer is A. The nurse should hold the dose of

Levothroid if the client has a resting pulse of greater than

100 bpm. This is a sign of hyperthyroidism and a dose will only compound the problem.

B is incorrect — While the blood pressure is borderline,

it is within normal limits. Coreg is a beta blocker and is needed to lower the heart rate. C is incorrect — Neurontin is a drug used for nerve pain and there are no contraindications to administration based on vital signs. D is incorrect —

Actos is used to serum glucose levels and does not carry a contraindication based on vital signs.




Provide client/family/significant others with information on TPN

116. A family is taking a client home that will be receiving total parenteral nutrition (TPN). The family should be instructed on:

A. how to perform glucose monitoring.

B. how to change the intravenous dressing every

24 hours.

C. how to dilute the TPN solution.

D. how to turn off the infusion pump.

The answer is A. The client receiving total parenteral nutrition requires frequent monitoring of glucose levels. The client ’ s family will need to learn how to assess the client ’ s glucose level and what action to take depending on the outcome.

B is incorrect — The dressing is changed every 48 – 72 hours unless contamination is suspected. Changing more

often than needed is not cost-effective and opens the site to the possibility of contamination. C is incorrect — The TPN solution should not be diluted. The solution should be administered in its prepared form. D is incorrect — The infusion should never be stopped or changed abruptly to allow time for the body to change its metabolic needs.



Potential for Alterations in Body Systems

Identify client potential for aspiration

117. Which client is at the highest risk for aspiration pneumonia?


A. A client who has a nasogastric tube to low suction and an endotracheal tube in place.

B. A client who has a PEG tube feeding and is lying at

20 degrees

C. A client who has recently undergone surgery and is eating clear liquid diet.

D. A client who has returned from esophageal dilatation and is ready for discharge.

The answer is B. A client who has a PEG tube should not lie below 30 degrees to prevent aspiration of gastric contents.

A is incorrect — A client with an endotracheal tube has a protected airway and aspiration is not a worry. C is incorrect —

A client on a clear liquid diet has an intact gag reflex

and aspiration is a low risk. D is incorrect — A client who has undergone an esophageal dilatation and is ready for discharge is at a low risk for aspiration.



Potential for Complications from Surgical

Procedures and Health Alterations

Apply knowledge of pathophysiology to monitoring for complications

118. A client has returned to the floor following a transverse loop colostomy. Which assessment finding would be indicative of a complication?

A. Hypoactive bowel sounds

B. A dusky color to the stoma

C. Liquid stool measuring 900 mL

D. Scant bleeding at the stoma site

The answer is B. A dusky colored stoma reveals that necrosis is occurring to the bowel that has been brought to the surface.

The physician needs to be notified of this finding.

A is incorrect — Hypoactive bowel sounds are expected following a colostomy and are no cause for concern postoperatively.

C is incorrect — Liquid stool is a normal finding following a colostomy. The bowel will need time to begin reabsorbing water from the GI track before stool will be more formed. D is incorrect — Scant bleeding is normal following a

colostomy and is due to a rich blood supply from the GI track.




Assess client for signs of hypoglycemia or hyperglycemia

119. A nurse is performing the morning assessment on a client that has a diagnosis of diabetes mellitus controlled by diet. Which assessment finding requires notification of the physician?

A. Urine output of 1000 cc in 2 hours

B. BP 140/90

C. Heart rate 100

D. Temp 99.9_F

The answer is A. Polyuria is indicative of hyperglycemia and requires the physician to be notified so that orders can be written for fluid replacement and insulin administration if needed.

B is incorrect — This is borderline hypertension, but does not require notification of the physician. A reassessment of the blood pressure should occur. C is incorrect —

Mild tachycardia is not a reason to consult the physician.

The tachycardia may be secondary to the polyuria and may resolve when the condition improves. D is incorrect — This is a mildly elevated temperature and does not require notification of the physician.




Provide pre- and/or postoperative education

120. Prior to a client undergoing a pinning of the right hip, the client should be instructed on:

A. how to use the client controlled analgesic pump.

B. when he can expect to eat a meal.

C. how soon after surgery discharge is possible.

D. how to care for the surgical wound.

The answer is A. The client should be instructed on how to use the client controlled analgesic pump prior to surgery to ensure understanding has occurred.

B is incorrect — When the client can eat is not something the nurse must prepare the client for prior to a surgical procedure. C is incorrect — Discharge is based on the individual ’ s progress and the physician is responsible for writing the order and discussing a time frame for discharge with the client. D is incorrect —

How to care for the wound occurs after the surgery when the client feels he or she is ready to take over the care.



Assess parental techniques related to discipline

121. A school nurse is evaluating families during an open house at a school. Which assessment indicates

1104 PART III: Taking the Test abnormal discipline techniques and requires intervention?

A. A mother telling her child she will place her in

“ time out ” once they are at home.

B. A mother yelling at her child to “ behave ” during a walk down the hall.

C. A mother stating “ When we get home, I will beat you with a belt.

”

D. A mother stating “ You need to learn to control your behavior or you will go straight to bed when we are home.

”

The answer is C. The mother is threatening the child with physical harm, which is a sign of abuse and should be acted on by the school nurse. Not reporting abuse or suspected abuse places the child in danger.

A is incorrect. Placing a child in “ time out ” is an appropriate method of discipline. B is incorrect — Asking a child to

“ behave ” is a normal form of parental discipline. D is incorrect —

Threatening a child with going to bed does not place the child in physical harm and is an appropriate form of parental discipline.




Implement interventions to address side/adverse effects of radiation therapy

122. A client has experienced mucositis while undergoing radiation therapy. Which nursing action will be best to assist the client ’ s nutritional intake?

A. Offer the client foods with enhanced taste.

B. Offering a commercially prepared mouth rinse.

C. Offer the client bland, soft foods such as puddings, shake.

D. Administer oral antibiotics to the client to swish daily.

The answer is C. The client should avoid spicy or hard foods if mucositis occurs. By offering the client foods that are bland and soft, he or she will be more likely to continue eating and maintain a nutritional intake sufficient for the body ’ s needs.

A is incorrect — Offering foods with enhanced taste is equivalent to offering foods with spices. These foods may irritate or worsen the condition. B is incorrect — Most mouthwashes contain alcohol, which can worsen the mucositis. The client should rinse with water and hydrogen peroxide. D is incorrect — Oral antibiotics will not be beneficial in assisting the client with his or her nutritional intake when mucositis is present.



Hemodynamics

Connect and maintain pacing devices

123. Place an X where the nurse will place the pads for pacing on a client who is in a third-degree heart block with a rate of 38.

The pads should be placed on the anterior chest wall and the back for external, noninvasive transcutaneous pacing.





124. A client is admitted for pneumonia. Which assessment finding is most indicative of a potential complication?

A. Skin that appears dry

B. Clear sputum

C. Asymmetric fremitus

D. Bronchiovesicular breath sounds

The answer is C. Asymmetric fremitus is a significant finding.

Fremitus is the vibration felt upon palpation in pneumonia.

If this is asymmetrical, it means that the side with fremitus may have a tumor or the side without fremitus may be indicative of a pneumothorax. Decreased fremitus occurs when there is excess air in the lung space.

A is incorrect — Skin can appear dry and still be considered normal. B is incorrect — Clear sputum is a normal finding.

D is incorrect — Bronchiovesicular breath sounds are the normal sounds heard upon auscultation of the lung fields.


MAINTENANCE

Immunizations

Identify precautions and contraindications to immunizations

125. The MMR (measles, mumps, rubella) vaccine should be held if the client has a history of


A. anaphylactic reaction to eggs.

B. HIV.

C. rotavirus.

D. tuberculosis.

The answer is A. A client with a history of an anaphylactic reaction to eggs should not receive the MMR vaccine.

B is incorrect — A history of HIV is not a contraindication to the MMR vaccine. C is incorrect — The rotavirus is not a contraindication to receiving the MMR vaccine. D is incorrect — A client with tuberculosis or a positive PPD skin test can still receive the MMR vaccine.


MAINTENANCE

Disease Prevention

Inform client/family/significant others of actions to maintain health and prevent disease

126. While preparing a client for discharge, which of the following should be included in the discharge instructions for a client who received stents during a heart catheterization?

A. Eat foods high in fat

B. Exercise daily

C. Limit fruits and vegetables

D. Increase intake of garlic

The answer is B. A client with new stents should exercise daily to maintain proper blood flow and improve overall health.

A is incorrect — Eating foods high in fat should be avoided after stent placement to prevent occlusion due to plague accumulation. C is incorrect — A client who has undergone stents needs a diet of fruits and vegetables for heart health. D is incorrect — Garlic should be avoided and may interact with postprocedure prescription medications administered at home.


ENVIRONMENT


Case Management

Plan individualized care for client based on need

127. A client is being discharged from the hospital after experiencing a myocardial infarction. The client desires to have home health care scheduled to make biweekly visits. Which finding in the discharge needs assessment indicates that home health care will not be beneficial?

A. The client does not have a home telephone.

B. The client does not have a wheelchair ramp to get into the home.

C. The client is unable to drive.

D. The client does not have family in town to check on him daily.

The answer is A. If the client does not have a home telephone, he or she will not have the ability to call 911 for an emergency or a method for the home health care agency to contact the client, which is a requirement for admission into home health care services.

B is incorrect — The question does not state that there is a need for a wheelchair ramp. C is incorrect — In order for a client to receive home health care, he or she is considered homebound and the inability to drive is irrelevant. D is incorrect — Not having family in town does not indicate that home health care will not be beneficial.


ENVIRONMENT


Consultation

Initiate consultations

128. Which of the following clients would benefit from the social services department consultation for help with prescription medications? (Check all that apply.)

___ A disabled veteran who uses the veterans ’ hospital facilities.

___ A homeless client with HIV.

___ A elderly client who has Medicare.

___ A child who does not have health insurance.

___ A client who is employed but is without health insurance.

___ A teenager who is currently enrolled on his parents ’ health insurance.

The homeless client, the child, and the client who is employed all are without health insurance and would benefit from social services for assistance with payment for prescription medications. These clients are the best choice for the answer since they are without any governmental or private assistance.

The veterans ’ hospital will assist the client who is a veteran, Medicare has prescription cards that are dependent upon the need of the client, and the teenager who is on his parent ’ s health insurance will have coverage for medications.



ENVIRONMENT


Ergonomic Principles

Review necessary modifications with client to reduce stress on specific muscle or skeletal groups

129. An elderly client is going home after hip replacement surgery. Which discharge instructions are most appropriate for this client?

A. Turn kneecap toward body while standing still to maintain balance.

B. Avoid crossing legs while sitting in a chair.

C. Keep the operative leg behind you when bending.

D. Use a long handled grabber to reach.

E. Avoid using an elevated toilet seat.

F. Keep a pillow between legs while sleeping.

The answers are B, C, D, and F. These activities will allow the client to avoid flexion greater than 90 degrees, adduction of the hip and internal rotation of the hip, which can cause the prosthesis to become dislocated.

A and E are incorrect answers — The client should not cause adduction by placing the kneecap inward toward the operative side to maintain balance. If balance is in question, an alternative assistive device should be used. Avoiding an

elevated toilet seat is incorrect since it is recommended that clients use an elevated toilet seat to ease with standing and help to avoid dislocation of the prosthesis while standing and sitting.



Nonpharmacological Comfort Interventions

Provide therapies for comfort and treatment of inflammation and swelling

130. A client has undergone repair of a fractured femur. Which nonpharmacological therapy is best for reducing swelling?

A. Application of heat.

B. Application of compression bandages.

C. Elevation of affected leg.

D. Acupuncture therapy.

The answer is C. Elevation of the leg will decrease swelling and subsequent pain in the leg.

A is incorrect — Heat is used to reduce muscle spasms and not for the reduction of swelling. Ice is used for the reduction of swelling. B is incorrect — Compression bandages are used to prevent deep vein thrombosis and do not provide relief from swelling. D is incorrect — Acupuncture therapy is an alternative therapy for pain relief but does not aid in the reduction of swelling.




Identify symptoms/evidence of an allergic reaction

131. A client has an order for an intravenous injection of sodium ferric gluconate complex (Ferrlecit). Which nursing action would be best in monitoring for allergic reaction to the medication?

A. Administer the dose in twice the recommended time frame.

B. Perform an iron reaction scan prior to administration.

C. Administer 10 gtts/min for a 10 minute test dose.

D. Assess the client for allergy to eggs and wheat.

The answer is C. A test dose of 10 drops/minute for 10 minutes is best to monitor for allergic reaction to the iron-containing product.

A is incorrect — Administering a dose faster than the recommended time frame is not safe nursing practice and can lead to undesired effects. B is incorrect — There is no such scan as an iron reaction scan. D is incorrect — While a client taking iron supplements should avoid using eggs or whole grain breads an hour after the administration of iron-containing medications, there is no evidence of a correlation between these items and reactions to iron medications.


ENVIRONMENT


Establishing Priorities

Assess/triage client(s) to prioritize the order of care delivery

132. Which client should be assessed first upon receiving report?

A. A 70-year-old postop client with hip replacement who has a new onset of A-fib.

B. A 54-year-old client admitted 2 hours ago with chest pain, which is relieved by ketorlac (Toradol) while in the ED.

C. A 69-year-old client scheduled for discharge today after being treated for a pulmonary embolism.

D. A 75-year-old client admitted 2 days ago for a myocardial infarction who has been transferred from CCU during the night shift.

The answer is A. The client who has a rhythm change is a priority to assess for symptoms associated with atrial fibrillation,

CHAPTER 34 Practice Test for NCLEX-RN® 1107 such as shortness of breath and/or chest pain. This client is already at a high risk for thrombosis due to the nature of the surgical procedure.

B is incorrect — A client whose pain was relieved by an antiinflammatory is lower priority than option A. C is incorrect —

A client who is scheduled to be discharged receives the last assessment of all four. This client is considered stable

if discharge was ordered by the physician. D is incorrect — A client who is transferred from CCU is considered stable and requires assessment after the client described in option A.


MAINTENANCE

Growth and Development

Compare client psychosocial/behavioral/physical development to norm for age/developmental stage of client

133. Which of the following is an abnormal finding in the growth and development assessment of a 6-month-old client?

A. Imitates sounds

B. Bears weight on hands while prone

C. Holds bottle

D. Pulls self to standing position

The answer is D. A child does not pull self to standing position until the ninth month. A 6-month-old child will bear most of weight if held in standing position by an adult.

A is incorrect — A 6-month-old child will babble sounds such as ma and hi. B is incorrect — A child of this age can bear weight on hands while prone and will lift chest and upper abdomen. C is incorrect — A child of this age can hold a bottle without assistance.


Behavioral Interventions

Orient client to reality

134. A client presents to the emergency department stating that he is an FBI agent and is there to secure the building.

Which technique will be best in caring for this client?

A. Following with the story and allow the client to continue with the delusion.

B. Medicate the client till sedation occurs.

C. Tell the client that he is in a hospital and he does not work for the FBI.

D. Ask the client if he has used drugs in the last 24 hours.

The answer is C. The client needs to be oriented to reality to begin the process of treating the delusion.

A is incorrect — The nurse should not follow with the story, this only feeds the delusion and does not allow for interventions to begin. B is incorrect — The client does not need sedation until an assessment can be performed to see if the client is a danger to self or others and what other manifestations are associated with the current delusion. D is incorrect — The client is delusional and will not be able to tell the nurse what occurred in the last 24 hours.

Psychosocial Integrity

Situational Role Changes

Evaluate whether client/family/significant others have successfully adapted to situational role changes

135. Which statement made by a client ’ s wife indicates that

she has not accepted her husband ’ s acute condition?

A. “ I will call a gardener to take over the yard until my husband recovers.

”

B. “ I know my husband will recover faster than expected and be ready to go back to work.

”

C. “ I will look into how we can modify our schedule so someone can always be by his side in the hospital.

”

D. “ I have planned on having someone at home to help me when we are discharged.

”

The answer is B. The wife has not accepted her husband ’ s illness and the change in her role in the family as the support person and the caregiver.

A is incorrect — The wife realizes her husband is ill and will not be able to continue strenuous labor at the home. C is incorrect — The wife understands her role change as the caregiver and is ready to change as needed. D is incorrect —

The wife understands her husband ’ s illness and the need to gather support personnel to assist where needed.


Therapeutic Environment

Make client room assignments that promote the therapeutic milieu

136. When planning to provide a therapeutic environment for a client, the appropriate room assignment for a client who has recently been diagnosed with breast

cancer is

A. a room with a client who has renal cell carcinoma.

B. a room with a client who has bone cancer.

C. a room with a client who recently underwent a mastectomy.

D. a room with a client who is scheduled for a lobectomy.

The answer is C. The client who has been diagnosed with breast cancer will be able to relate to the client who has undergone a mastectomy providing for a therapeutic environment.

A is incorrect — The client who has renal cell carcinoma is not a therapeutic choice for the client since the cancers

1108 PART III: Taking the Test differ and the treatments will differ as well. B is incorrect —

The client with bone cancer is in chronic pain; therefore, sharing a room with a client is not a therapeutic environment for either. D is incorrect — A client who is undergoing a lobectomy is not a therapeutic choice for the client who has breast cancer due to the difference in the type of cancer and the treatments.




Administer and document medications given by common routes

137. Which of the following forms of insulin can be given intravenously?

A. Novolin 70/30

B. Novalog

C. Lantus

D. Novolin-R

The answer is D. Regular insulin is a short-acting insulin and is the only insulin approved to be given intravenously.

A is incorrect — Novolin 70/30 is a combination of 70%

NPH and 30% regular insulin and therefore contains a short and intermediate acting form of insulin and is only approved to be administered subcutaneously. B is incorrect —

Novalog is a rapid-acting insulin and is only administered subcutaneously. C is incorrect — Lantus is a long-acting insulin and is not approved to be given intravenously, only subcutaneously.




Know laboratory values for ABGs, BUN, cholesterol, glucose, hematocrit, hemoglobin, hemoglobin A1C, platelets, potassium, RBC, sodium, urine-specific gravity, and WBC

138. The respiratory therapist draws ABGs and shows them to the nurse. Which state is the client currently in based on the values:

• pH: 7.39

• CO2: 40

• HCO3: 23

• PaO2: 90

A. Metabolic acidosis

B. Respiratory acidosis

C. Respiratory alkalosis

D. Homeostasis

The answer is D. The client ’ s values are within normal limits and the client has compensated and is a state of homeostasis.

A is incorrect — For a client to be in a state of metabolic acidosis the pH less than 7.35 and the HCO3 less than 22. B is incorrect — The client would need a pH less than 7.34 and a CO2 greater than 45 to be in a state of respiratory acidosis.

C is incorrect — The client would need a pH greater than

7.45 and CO2 less than 45.





Intervene to manage potential circulatory complications

139. A client is found lying on the floor after a fall out of the bed. On assessment, the left foot appears shorter than the right and externally rotated. Palpation of the affected leg reveals a cold extremity with no palpable pulse at the doralis pedis or the posterior tibial. What is the priority nursing action?

A. Palpate for a popiteal pulse

B. Call the physician

C. Try to realign the injured leg

D. Elevate the injured leg and reassess

The answer is B. When an injury has caused disruption of the neurovascular system to the point that pulses are lost, the physician must be notified immediately so that action can be taken to prevent the tissue in the affected extremity from becoming necrotic.

A is incorrect — Palpating for a popiteal pulse would show whether the injury was severe enough to cause vascular compromise.

Regardless if a pulse is present or not at the popiteal site, the area distal is without adequate blood supply and the physician needs to be notified immediately. C is incorrect —

An injured leg should not be realigned by the nurse to prevent further injury. D is incorrect — The leg should not be elevated to prevent further injury to the vascular system.




Monitor and maintain the client on a ventilator

140. A client is placed on the ventilator and has positive end-expiratory pressure (PEEP) added. Which assessment data will be most indicative of a potential complication?

A. Tachycardia

B. Wheezes


C. Hypotension

D. Hypertension

The answer is C. Hypotension is a sign of a complication.

Hypotension can be related to a decreased venous return or a pneumothorax. Assessments should follow that determine the cause of hypotension.

A is incorrect — Tachycardia is due to the body ’ s response to the illness and is not necessarily indicative of a complication. B is incorrect — Wheezing is due to bronchial constriction and is common with intubation. D is incorrect —

Hypertension is due to the physiological response to the stress the client is under.




Implement interventions to restore client fluid and/or electrolyte balance

141. A client has a sodium level of 153. The nurse consults the physician and is given orders for dietary restrictions. The nurse should instruct the client to avoid which foods?

A. Cheese

B. Squash

C. Tomatoes

D. Apples

The answer is A. Cheese is considered to be high in sodium and should be restricted for the client who has a high sodium level.

B, C, and D are incorrect — These items are fresh foods and are not considered to be high in sodium.



Hemodynamics

Assess the client for decreased cardiac output

142. A client with congestive heart failure has been coughing up pink frothy sputum and exhibiting shortness of breath. The client ’ s assessment 1 hour ago revealed:

• BP 80/40

• HR 90

• rhonchi upon auscultation

• oxygen saturation 90%

• normal sinus rhythm

Which assessment finding shows a worsening in the client ’ s condition and a decrease in the client ’ s cardiac output?

A. Premature ventricular contractions

B. HR 99

C. Wheezing upon auscultation

D. Oxygen saturation of 89%

The answer is A. Premature ventricular contractions are a direct result of cardiac muscle hypoxia, which is secondary to the pulmonary edema. PVCs do not allow for the diffusion of gasses to occur across the alveolar capillary membrane. All of this is directly proportional to the decrease in the cardiac output, which has caused blood to back up into the lungs.

B is incorrect — The heart rate change is due to the body trying to compensate for the state of hypoxia that exist by pumping faster in an attempt to supply dying cells with oxygen.

C is incorrect — Wheezing does not indicate a worsening in the cardiac output. D is incorrect — The hypoxia is still present and is not the best indicator of a worsening in the client ’ s condition.




Monitor and maintain a client on the ventilator

143. A client on the ventilator becomes agitated and restless.

Which action by the nurse is best?

A. Check the cuff pressure on the tube.

B. Remove the ventilator and bag the patient.

C. Assess for breath sounds.

D. Restrain the client to prevent tube dislodgement.

The answer is C. The client should be assessed for breath sounds to see if ventilation is occurring. Agitation is often due to hypoxia and lack of adequate ventilation would be

seen with absent breath sounds.

A is incorrect — Checking the cuff pressure will not assist in determining the source of agitation. B is incorrect —

Bagging the client will not be beneficial if the tube is not in the lungs. D is incorrect — Restraining the client will prevent tube dislodgement but it is not the best method to determine the cause of the agitation.




Assess the client for unexpected adverse response to therapy

144. Which of the following are preventable adverse outcomes to the placement of a urinary catheter?

___ Infection

___ Urethral damage


___ Ureter damage

___ necrosis of the meatus

___ Vaginal tearing

A client who has an indwelling urinary catheter may develop infection from nonmaintenance of sterile technique, urethral damage if the balloon is placed in the urethra, and necrosis of the meatus due to shearing of the catheter on the meatus.

All these are preventable by appropriate nursing actions

such as maintenance of sterile technique and meticulous perineal care, ensuring the balloon is in the bladder before inflation, and applying a lubricant to the meatus to lessen shearing.

Ureter damage should not occur since the tube does go above the structure of the bladder. Vaginal tearing should not occur since the catheter is placed in the bladder and not the vaginal area.



Identify signs and symptoms of impaired cognition

145. An elderly client is brought to the emergency department after being found trying to enter a home. The paramedics state that the client says she is 25 years old and lives in the home. The client is barefoot and has feces- and urine-stained clothes. The first nursing action is to:

A. provide the client with a change of clothes.

B. assess the client for bruising/injuries.

C. reassure the client that she is safe and in a hospital.

D. ask the client her name and date of birth.

The answer is C. The client should be assured that she is safe and of her location. Then the physical assessment can continue.

A is incorrect — The client can undergo a change of clothes after trust is formed. B is incorrect — The client ’ s physical

exam will show any bruising or injuries after the client is assured of her safety. D is incorrect — The client will not give the correct date of birth due to her current confused state.



Vital Signs

Evaluate invasive monitoring data

146. A client has a ventriculostomy after suffering a traumatic brain injury. The monitor is measuring the intracranial pressure at 30 mm Hg. Which nursing action is best for this client?

A. Raise the head of bed to 30 degrees.

B. Assess the client for peripheral edema.

C. Dim the lights and place the bed at 15 degrees.

D. Suction the client.

The answer is C. The client should have minimal stimuli and the bed should not be at a height that will cause increased pressure. This will help to lower the intracranial pressure and prevent it from rising.

A is incorrect — Raising the bed to semi Fowlers will cause the pressure to rise. B is incorrect — The client has increased pressure in the cranial vault. Assessment for peripheral is not a priority action for this situation. D is incorrect — Suctioning the client will increase the pressure, which can lead to ischemia of the brain.


ENVIRONMENT



Identify appropriate person to provide informed consent for client

147. An unidentified client is brought to the emergency department after being found on the side of the road with multiple stab wounds and an obvious head injury. After a series of radiological test, it is found that the client has a lacerated liver, brain injury, and needs immediate surgery. Which of the following would be best in obtaining consent for the surgical procedure?

A. The client should be placed in state custody and consent obtained from the appropriate personnel.

B. The physician should consider this implied consent and should follow the hospital policy for the situation.

C. The nurse should sign consent for the client as the client advocate.

D. The facility should wait to see if the client wakes up to give consent.

The answer is B. The hospital policy should be followed in this situation. In implied consent, the law recognizes that

client in need of life saving measures will be provided with those measures unless documents can be provided that states otherwise. In this situation, the client is unidentified and needs surgery to save his life.

A is incorrect — To place a client in state custody, the state must go through a judge. In this case, there is not enough time for that to occur and this action would place the client ’ s life in jeopardy. C is incorrect — The nurse cannot sign consent for a client. D is incorrect — The client may not

CHAPTER 34 Practice Test for NCLEX-RN® 1111 wake up to give consent and while waiting on this to occur, the client ’ s condition could decline.


MAINTENANCE


Perform health history/health and risk assessment

148. When performing the health history of a pediatric client in for a well baby visit, the nurse should determine if which of the following is present?

___ Immunizations are up to date

___ Smoking in the home

___ History of cardiac disorders

___ History of Asthma

___ Eating habits

___ Toileting concerns

The nurse should assess for immunizations, smoking in the home, eating habits, and any toileting concerns to understand if the client is receiving the care needed and if there are concerns that may not be verbalized by the mom without a direct question.

A history of cardiac disorders or asthma should be questioned on a routine visit only if assessment findings indicate a concern.





149. A client is found in the room holding his hands to his throat and his lips are turning blue. Which action by the nurse is most appropriate?

A. Lying the client on the floor and administering abdominal thrust.

B. Ask the client to cough.

C. Placing both fists around the abdomen above the umbilicus and administering abdominal thrust.

D. Attempting a blind finger sweep.

The answer is C. The nurse should perform the Heimlich maneuver. The client is demonstrating the universal sign for choking and is obviously lacking oxygen.

A is incorrect — The client should not be lowered to the

floor unless he or she is unconscious. B is incorrect — The client will not be able to cough at this point. D is incorrect —

A blind finger sweep is not recommended since it can push the food further into the throat.




Notify primary health care provider of side effects, adverse effects, and contraindications of medications and parenteral therapy

150. A client is taking digoxin (Lanoxin) for atrial fibrillation and cardiomegally. Which assessment finding requires the nurse to notify the physician of a potential adverse effect?

A. Abdominal pain and nausea

B. Rhythm change to normal sinus rhythm

C. Heart rate of 62

D. Weight gain of 1 ⁄ 2 pound

The answer is A. Abdominal pain and nausea are the first signs of digoxin toxicity in the elderly and should be reported so that the physician can order a digoxin level desired.

B is incorrect — A rhythm change is not an adverse effect. The client continues to need the digoxin to treat the cardiomegally. C is incorrect — The heart rate is within normal

limits for the drug to be administered. D is incorrect — A

1/2 pound weight gain is not an adverse effect. Monitoring of

I&O should continue.




Interpret client data that needs to be reported immediately

151. Which of the following should be reported to the physician immediately?

A. Monitor showing a sinus rhythm with a premature ventricular contractions (PVC) occurring every 10th beat.

B. Sodium level 130 mEq/L.

C. Potassium level of 5.9 mEq/L.

D. Oxygen saturation level of 90% on room air.

The answer is C. The nurse should phone the physician to receive orders for treatment of the high potassium level, which can cause cardiac arrhythmias if untreated.

A is incorrect — This is considered sinus rhythm with occasional PVCs and is considered a normal finding. B is incorrect — This sodium level is lower than the normal range of 135 – 145 mEq/L, but is not low enough to bear reporting to the physician immediately. Lower than 127 mEq/L is considered critical. D is incorrect — The oxygen saturation level


should not be reported unless it remains low after oxygen is applied. This finding requires a nursing intervention before phoning the physician.





Assess the client for an abnormal response following a diagnostic test/procedure

152. A client has just undergone a computerized tomography

(CT) of the abdomen with oral contrast. Which assessment finding is indicative of an abnormal response to the exam?

A. Feeling of fullness in the abdomen

B. Redness of the face, generalized itching

C. Increase in urination

D. Nausea, diarrhea

The answer is B. The client who has undergone a CT of abdomen has been exposed to oral contrast. Those who are allergic to oral contrast will experience redness to the face, generalized itching, and other signs of a systemic reaction.

This requires intervention by a physician order.

A is incorrect — Feeling of fullness is common after a CT where oral contrast was used. C is incorrect — The client will have an increase in urination following the ingestion of oral

contrast for a CT. D is incorrect — The oral contrast contains a laxative and it is common for the client to become nauseated and experience diarrhea until the contrast has been passed through the system.




Assess the client for unexpected adverse response to therapy

153. After placing a nasogastric tube into the right nare of a client, which assessment finding is indicative of an adverse response to this therapy?

A. Epistaxis

B. Vomiting

C. Feeling of fullness in the throat

D. Sore throat

The answer is A. Epistaxis is an adverse response to the placement of a nasogastric tube and measures should be implemented to stop the bleeding.

B is incorrect — The nasogastric tube will cause the client to vomit due to the irritation of the gag reflex. C is incorrect — The client will feel fullness in the throat until the body becomes accustomed to the tube. D is incorrect — A sore throat is common after a nasogastric tube is placed due to the irritation during insertion.




Assess the client for signs and symptoms of adverse effects of radiation therapy

154. Which assessment finding requires immediate nursing intervention in a client who is receiving radiation therapy for esophageal cancer?

A. Alopecia

B. Skin ulceration

C. Hearing loss

D. Difficult swallowing

The answer is D. The nurse should take action regarding the client ’ s difficulty swallowing. If there is damage to the esophagus then subsequent damage to the trachea could be occurring, which will compromise the client ’ s airway.

A is incorrect — Alopecia is the loss of hair and is inevitable for the client undergoing radiation therapy. B is incorrect — Skin ulcerations are common with radiation therapy and require wound care to prevent infection. C is incorrect — Hearing loss is common with radiation to the neck and while precautions can be taken to lessen the effects, damage will likely occur.



Infectious Disease

Evaluate client response to treatment for an infectious disease

155. Which evaluation would indicate a therapeutic response to treatment for tuberculosis?

A. A negative sputum culture after 3 months of therapy.

B. Absence of symptoms.

C. Decrease in cavities on an x-ray.

D. Completion of medication therapy.

The answer is A. If cultures convert to negative within 3 months of therapy, the treatment is considered a success.

B is incorrect — Symptoms may disappear even if the bacteria are active. C is incorrect — Cavities on the x-ray are not a

CHAPTER 34 Practice Test for NCLEX-RN® 1113 determinant for a therapeutic response to treatment. D is incorrect —

Completion of medicinal therapy is not a therapeutic response to the treatment since the bacteria can still be active.



Hemodynamics

Monitor and maintain arterial lines

156. A nurse is assessing the arterial line via an intra-arterial catheter in a client in the ICU. Which assessment finding is most indicative of a potential complication?

A. Cool extremities bilaterally

B. Low blood pressure reading

C. Capillary refill 2 seconds on affected arm

D. Low mean arterial pressure

The answer is C. The capillary refill of less than 2 seconds is a sign that a thrombus may have formed and blood flow via the ulnar artery and the microcirculation is compromised.

A is incorrect — Cool extremities bilaterally are not the most indicative finding in a potential complication. B is incorrect — A low blood pressure reading is not a sign of a complication since the arterial line is used for monitoring the client ’ s blood pressure. D is incorrect — A low mean arterial pressure is a direct reflection of the client ’ s blood pressure and does not indicate a complication with the line itself.




Provide suctioning via endotracheal or tracheostomy tube

157. Prior to suctioning a client who has an endotracheal tube, the nurse must first:

A. hyperoxygenate the client.

B. place saline in the endotracheal tube.

C. ask the client to cough.

D. deflate the cuff on the endotracheal tube.

The answer is A. Prior to suctioning a client with an artificial airway such as an endotracheal tube, the nurse must provide adequate oxygen to the client.

B is incorrect — While placing saline down the tube may loosen secretions, it is not what the nurse must first do prior to suctioning the client. C is incorrect — A client with an endotracheal tube should not cough to prevent tube dislodgement.

D is incorrect — The endotracheal tube cuff is only deflated when moving of the tube is necessary.




Monitor effective functioning of therapeutic devices

158. When performing an assessment on a client with a chest tube and an attached drainage system, which assessment finding is indicative of a complication?

A. Continuous bubbling in the suction chamber.

B. Yellow fluid accumulating in the drainage chamber.

C. Suction in the off position.

D. Vigorous bubbling in the water seal chamber.

The answer is D. Vigorous bubbling in the water seal chamber is indicative of a leak. The nurse must determine where the leak is and fix the problem before the lung is compromised.

A is incorrect — The suction chamber should have continuous bubbling if suction is connected. B is incorrect —

Yellow fluid is serous and is normal with a chest tube drainage system. C is incorrect — Suction may or may not be connected to the drainage system depending on the client needs based on the physician ’ s assessment.


ENVIRONMENT


Concepts of Management

Supervise care provided by others

159. A member of the nursing team approaches you to complain that an unlicensed assistive personnel is not performing accuchecks on patients as assigned. Which action is most appropriate?

A. Confront the unlicensed assistive personnel about the neglect in her role.

B. Ask the nurse why he or she could not perform the accucheck on the patient.

C. Ask the unlicensed assistive personnel if there is something preventing her from completing her assignment.

D. Report the unlicensed assistive personnel to the nurse manager of the unit for a verbal reprimand.

The answer is C. Asking the unlicensed assistive personnel if there is something preventing her from completing her assignment gives the individual an opportunity to verbalize what is occurring that has delayed client care and follows the

chain of conflict resolution.

A is incorrect — Confronting an individual will cause increased tension and does not resolve the conflict. B is incorrect — The licensed personnel is being asked to perform the duty of an unlicensed personnel therefore negating the

1114 PART III: Taking the Test delegation of duty. D is incorrect — This response does not follow the chain of conflict resolution and does not provide the unlicensed assistive personnel the opportunity to explain her actions.


ENVIRONMENT


Delegation

Ensure appropriate education, skills, and experience of personnel performing delegated task

160. Match the appropriate personnel to the task that is within the scope of practice. (Choices may be used more than once.)

___ Insert a Foley catheter.

___ Perform an admission assessment.

___ Perform postprocedure vital signs.

___ Administer one unit of packed red blood cells.

___ Perform a morning assessment.

A. Registered Nurse

B. Licensed Practical Nurse

C. Unlicensed Nursing Assistant

B Insert a Foley catheter: It is within the scope of practice for a LPN to insert an indwelling catheter.

A Perform an admission assessment: Only a registered nurse can perform an admission assessment.

C Perform postprocedure vital signs: It is within the scope of practice for unlicensed personnel to perform postprocedure vital signs as long as a licensed personnel is reviewing the data obtained and the unlicensed personnel has gone through the verification process in conjunction with the rules of the hospital.

A Administer one unit of packed red blood cells: Only a registered nurse can administer blood products.

B Perform a morning assessment: A LPN can perform a morning assessment on a client who has undergone an assessment by a RN upon admission to the area.


ENVIRONMENT


Performance Improvement (Quality Improvement)

Define performance improvement/assurance activities

161. Which of the following is an example of quality assurance that meets the standards of JCAHO?

A. Gathering a second opinion before administering as needed pain medications.

B. Use of clinical pathways by all health care team members.

C. Avoid admitting clients that have chronic conditions.

D. Performing tests that are covered by insurance and avoiding those that are not.

The answer is B. The use of clinical pathways has replaced nursing care plans. Clinical pathways enable the staff to monitor for a progression of prescribed client care among all health care disciplines, which is a component of quality assurance.

A is incorrect — A client should receive pain medication based on his or her rating on the pain scale. Gathering a second opinion before medication is administered delays care and is not cost-effective and does not meet the standards. C is incorrect — Clients with chronic conditions may need to be admitted making this not an effective method of quality assurance. D is incorrect — Avoiding tests that are not covered by insurance may lessen overall cost, but is not meeting the standards of care a client deserves.


ENVIRONMENT


Accident Prevention

Identify deficits that may impede client safety

162. Which finding in an admission assessment is most indicative of a potential falls risk?

A. Hearing deficit

B. Numbness in the left foot

C. Confusion

D. Unsteady gait

The answer is D. A client with an unsteady gait is at the highest risk for a fall due to an inability to correct a potential fall or brace during a fall.

A is incorrect — A loss of hearing is not the highest risk.

A client who cannot hear can still maintain a steady gait while ambulating in a room. B is incorrect — Numbness in one foot does not place the client at the highest risk for falls risk, often a client will compensate with the normal extremity.

C is incorrect — A confused client can possess a steady gait therefore not placing this client at the highest risk.


ENVIRONMENT


Injury Prevention

Question prescriptions for treatments that may contribute to an accident or injury

163. Which discharge prescription should be questioned for a client who has peripheral neuropathy due to diabetes?


A. A prescription for shoes to be purchased at a health care supply store.

B. A prescription to follow up with diabetic services for routine foot care.

C. A prescription for a heating pad to be used on the lower extremities twice a day.

D. A prescription for TED hose to be used on the lower extremities unless bathing.

The answer is C. An order for a heating pad should be questioned because a client with diabetic neuropathy should not use a heating pad since he or she will be unable to feel if burning to the skin is occurring. A is incorrect — A prescription for shoes at a health care supply store is appropriate for the diabetic client. B is incorrect — The client with peripheral neuropathy due to diabetes should follow up with diabetic services for routine foot care such as nail cutting and inspections for ulcerations. D is incorrect — TED hose are useful to prevent deep vein thrombosis and swelling that may occur with peripheral neuropathy and diabetes.


ENVIRONMENT


Use of Restraints/Safety Devices

Monitor client responses to restraints

164. Which assessment is priority for a client who is being placed in restraints due to confusion and agitation?

A. Toiletry needs

B. Hydrations needs

C. Circulation in restrained extremities

D. Client ’ s knowledge of restraint purpose

The answer is C. Monitoring the extremities for adequate circulation is most important to prevent damage to underlying structures. Assessments of the area where the restraint is placed should be performed every 2 hours or per hospital policy.

A is incorrect — Toiletry needs are important while a client is in restraints but this is not the priority assessment. B is incorrect —

Hydration needs are assessed every 2 hours but this is not the priority. D is incorrect — A client who is confused and agitated will not understand why he or she is being restrained.


MAINTENANCE

Family Planning

Assess client need/desire for contraception

165. Which statement made by a client indicates a need for counseling regarding contraceptive devices?

A. “ I plan on abstaining from sex until I am married.

”

B. “ My boyfriend and I use condoms for protection.

”

C. “ I have been having sex, but my boyfriend pulls out.

”

D. “ It is against my religion to use birth control.

”

The answer is C. The client is using the withdrawal method, which is has a high failure rate. The client needs information regarding contraceptive devices to prevent pregnancy.

A is incorrect — The client does not have a plan to participate in sexual activity. The client should be reminded to contact her health care provider if her intentions change. B is incorrect —

The client currently has a form of contraception in use. D is incorrect — The client is citing a religious restriction on the use of birth control; therefore, counseling is not needed.


MAINTENANCE

High-Risk Behaviors

Assist client/family/significant others to identify behaviors/ risks that may impact health

166. A client is being discharged after an admission for a sodium of 127 and recent weight loss. The family voices a concern that the client may be suffering from anorexia.

At the time of discharge, the family will be instructed to monitor the client for which sign of the disorder?

A. Increase in menstrual cycles per month.

B. Pushing food around plate without taking bites.

C. Lack of desire to exercise.

D. Heat intolerance.

The answer is B. The client with anorexia nervosa will push food around on the plate and put bites of food to the face without eating the bite.

A is incorrect — A client with anorexia nervosa will experience amenorrhea due to loss of weight. C is incorrect — In

anorexia nervosa, a client will exercise excessively and may not attend events/school to exercise. D is incorrect — With anorexia nervosa the client is intolerant of cold.


MAINTENANCE

Techniques of Physical Assessment

Choose physical assessment equipment and technique appropriate for the client

167. Which equipment will be most important when performing the physical assessment of a client with a deep vein thrombosis (DVT) of the left leg?

A. Tape measure

B. Doppler


C. Tongue depressor

D. Penlight

The answer is B. When a client has a DVT, a Doppler is needed to assess for pulses in the affected extremity to ensure blood flow is occurring in the extremity at one of two pedal pulse areas.

A is incorrect — A tape measure is used to document the size of the leg compared to the unaffected leg, but it is not as important as the Doppler, which will assess for adequate blood flow to the affected foot. C is incorrect — A tongue depressor is not needed when assessing the client who has a

DVT. D is incorrect — A penlight is needed to assess papillary

response when performing a physical assessment, but is not the most important piece of equipment for this client.


Cultural Diversity

Incorporate client cultural practice and beliefs when planning and providing care

168. A client of Asian descent has been admitted to the surgical floor. Which of the following should the nurse consider when building the client care map for pain management?

A. Consult an acupuncturist.

B. Offer a narcotic every 4 hours.

C. Offer daily medications only in the morning.

D. Have a rabbi visit the client daily for prayer.

The answer is A. The Asian American culture uses acupuncture as a form of oriental medicine, which is based on an energy system that when used balances the yin and yang and promotes balance in the life and thus pain relief.

B is incorrect — This Asian American culture uses narcotics as a last form of pain relief, and the primary form of pain relief is acupuncture and herbs. C is incorrect — The

Asian American culture does not have a preference on when medications are offered making this a nonjustified choice. D is incorrect — The Asian American culture uses a temple healer for religious needs and this is not a significant choice

for care mapping of pain management.


Religious and Spiritual Influences on Health

Assess and plan interventions that meet client emotional and spiritual needs

169. A client who practises Catholicism will be undergoing a hip repair. Which nursing plan will be best to prevent tension between the patient and nurse and meet hospital policies and procedures?

A. Allow the client to wear his medicine bundle into the operating room.

B. Remove the client ’ s traditional headpiece before leaving for the operating room.

C. Inform the client that you will take his rosary and give it to his wife.

D. Inform the client that all spiritual pieces need to be surrendered to security until after surgery.

The answer is C. The nurse should take the client ’ s rosary and allow a trusted family member to hold it while he is in surgery.

A rosary is sacred to the catholic religion and the nurse must treat is respectfully.

A is incorrect — Medicine bundles are worn by Native

Americans. B is incorrect — Traditional headpieces are worn by Islamic Muslim women and they are not to be removed in public leaving the patient to remove it once in the holding room

and giving it to a family member. D is incorrect — Spiritual pieces are not surrendered to security unless the client requests.



Elimination

Insert/remove nasogastric, urethral catheter, or other tubes

170. A nurse is inserting a nasogastric tube when resistance is met. The nurse should:

A. continue to push the tube into the nose.

B. ask the client to swallow.

C. pull out the tube and try the other side.

D. check for correct placement with 30 cc of air.

The answer is C. If resistance is met during the insertion of a nasogastric tube, the nurse should remove the tube and try the other nostril to prevent damage to the nasal mucosa and internal structures.

A is incorrect — The nurse should avoid continuing to push the tube into the nose to prevent injury. B is incorrect —

Asking the client to swallow will not prevent injury to the client. D is incorrect — The tube has met resistance and when it is inserted in the stomach, this does not occur; therefore, checking for placement is invalid.




Assess client’s ability to eat

171. A client has returned from having a procedure that required conscious sedation. Prior to offering food the nurse should:

A. assess for the return of the gag reflex.

B. administer morning medications missed due to

NPO status.

C. order a warm tray for the client.


D. view the chart to see the time the last dose of a medication was given for sedation.

The answer is A. Prior to offering food, the client should be evaluated to see if the gag reflex has returned.Without a gag reflex, the client should not eat due to the potential for aspiration.

B is incorrect — The client may need to eat before being offered meds. The client must also have an intact gag reflex before meds can be offered. C is incorrect — The client will need a warm tray but only after the client has been assessed to see if eating can occur without the risk of aspiration. D is incorrect —

Regardless of the last dose of medication, the nurse is responsible for assessing to see if the gag reflex is intact before offering food.



Rest and Sleep

Schedule client care activities to promote adequate rest

172. A burn client is recovering and needs periods of rest to aid in healing. Which plan would be best to promote rest periods for the client?

A. Group activities such as physical assessment, bath, linen change, and morning meds together.

B. Administer a sleeping aid every night from the “ as needed ” medication list.

C. Schedule the client to go to occupational therapy and physical therapy consecutively.

D. Place a sign on the door to limit visitors.

The answer is A. The best method for promoting rest is to group client care so that there are periods of time for the client to rest without interruption.

B is incorrect — The client may not need a sleeping aid at night when activities can be altered to assist with rest during the day. C is incorrect — Sending the client to both areas for therapy consecutively will place the client at a disadvantage.

A client who has experienced a burn will need to rest between sessions due to an increased use of energy for healing.

The client will not benefit from therapy sessions if he or she is too tired to participate. D is incorrect — Placing a sign on the door will help to warn visitors that the client is resting but it is not the best method of promoting rest.




Administer blood products and evaluate client responses

173. A client who is experiencing an acute hemolytic transfusion reaction will exhibit what symptom?

A. Hypertension

B. Back pain

C. Bradycardia

D. Hyperglycemia

The answer is B. The symptoms of an acute hemolytic transfusion reaction are due to the breakdown of the red cell antibodies and cell destruction, which manifest as pain and an increase in body temperature.

A is incorrect — Hypotension occurs with an acute hemolytic transfusion reaction. C is incorrect — Tachycardia is common with an acute hemolytic transfusion reaction due to the body ’ s response to the stress, increase in temperature, and hypotension. D is incorrect — Hyperglycemia does not occur in a hemolytic reaction.



Pharmacological Agents/Actions

Identify a contraindication to the administration of a prescribed or over-the-counter medication to a client

174. During an admission assessment a client states an allergy to Motrin. Which drug order should be questioned?

A. ketorlac (Toradol) 60 mg IM every 8 hours _2 doses for pain.

B. Tylenol 650 mg p.o. every 4 hours as need for pain.

C. Morphine 2 – 4 mg IV every 4 hours as needed for pain.

D. orphenadrine (Norflex) 100 mg p.o. BID prn pain.

The answer is A. Toradol is an antiinflammatory and is in the same classification as Motrin. A cross sensitivity may exist so it is best to avoid using Toradol for client ’ s with an allergy.

B is incorrect — Tylenol is a non-opioid analgesic and

Motrin is a nonsteroidal antiinflammatory. There is no evidence of cross sensitivity leaving this to be a safe drug for mild pain relief. C is incorrect — Morpine is an opioid analgesic and does not fall into the same category as Motrin. D is incorrect — Norflex is a muscle relaxant and is not contraindicated in the client with an allergy to Motrin.




Provide wound care

175. A nurse caring for a client with a burn has an order to apply a silver sulfadiazine (Silvadene) dressing to the area. Which plan would be best to prevent infection of the wound during cleaning?

A. Avoid applying Silvadene to areas that are not burned.

B. Cleaning the area with Betadine.

C. Using an irrigation system for cleaning.

D. Wearing a mask, gown, and sterile gloves during care.


The answer is D. The nurse ’ s goal for wound care is to prevent infection and promote revitalization of the tissue. The nurse should place a barrier between her and the client to prevent infection.

A is incorrect — Applying Silvadene to areas that are not burned will cause redness to the surrounding skin. B is incorrect — Betadine is avoided in burns since it can cause damage to the cells and will dry out the tissue. C is incorrect —

While an irrigation system is best for removal of debris found in the wound bed, it is not the best plan for preventing infection.




Use clinical decision making/critical thinking when addressing expected effects/outcomes of medications

176. A client is complaining of tightness in her throat and arm pain. The nurse assesses the client and administers nitroglycerine 0.4 mg sublingual. After 4 minutes, the client claims no relief was felt. The nurse should:

A. administer another dose and reassess in 5 minutes.

B. check the client ’ s blood pressure.

C. administer Maalox from the “ as needed ” order list.

D. notify the physician.

The answer is B. The client has no relief from the initial dose of nitroglycerine but with its potent vasodilatation, the nurse should assess the client ’ s blood pressure before administering the second dose. If hypotension exist, the next dose should be held and other actions taken.

A is incorrect — The client ’ s blood pressure should be assessed after every dose of nitroglycerine to assess for hypotension. C is incorrect — The nurse could attempt the use of Maalox to see if relief occurs but the blood pressure should be assessed prior to the administration of any other medications. D is incorrect — The physician should be notified after the nurse exhausts the protocol.




Evaluate and document client response to emergency interventions

177. A client in respiratory distress is intubated by the physician. Which evaluation by the nurse best indicates the intubation was successful?

A. Decrease in anxiety

B. Lowering of blood pressure

C. Increase in heart rate

D. Bilateral breath sounds

The answer is D. Bilateral breath sounds are the best indicator of a successful intubation.

A is incorrect — While anxiety is an indicator of hypoxia, the resolution of anxiety is not the best indicator of a successful intubation. B is incorrect — Lowering of a client ’ s blood pressure is not an indicator of a successful intubation.

C is incorrect — An increase in the heart rate is not an indicator of a successful intubation.




Perform an electrocardiogram test

178. Place a client in lead II using a 5-lead monitor.

An “ X ” should be placed at:

RA (white lead) is placed below the right clavicle where the arm and torso meet. The LA is placed below the left clavicle where the arm and torso meet. The LL is red and is placed on lower abdomen where the leg and torso meet. The RL is placed at the lower right abdomen and the C lead is placed at the fourth intercostal space, right sternal border.





Monitor client for signs of bleeding

179. A client has recently undergone a cardiac catheterization.

Which assessment is the best to monitor for postprocedure bleeding?

A. Assessing the insertion site.

B. Assessing the area directly posterior to the insertion site.

C. Assessment of vital signs.

D. Assessment of neurological status.

The answer is A. Assessment of the insertion site is best when monitoring for postoperative bleeding. This site will be the first source of clot dislodgement and hemorrhage.


B is incorrect — The area posterior to the insertion site is secondary on the areas to assess for bleeding. This is usually noted if vital signs change. C is incorrect — Although vital signs are an appropriate assessment for the procedure that was performed, the first area to be assessed is the insertion site. D is incorrect — The neurological status will not be the best assessment for postprocedure bleeding.



Vital Signs


180. A nurse takes the blood pressure with an electronic blood pressure machine and receives a reading of

80/54. A review of the chart indicates this is uncharacteristic of the client ’ s usual reading. The nurse should perform which action next?

A. Retake the blood pressure using the electronic machine.

B. Auscultate the blood pressure using a manual cuff.

C. Phone the physician for orders.

D. Leave the client and reassess in 30 minutes.

The answer is B. The nurse should assess the blood pressure using a manual cuff and stethoscope prior to taking any further action.

A is incorrect — The machine could be reading inappropriately.

The nurse should perform option B. C is incorrect —

The physician should not be notified until a manual pressure is taken. D is incorrect — The client should not be left for 30 minutes.




Apply knowledge of pathophysiology when caring for client with fluid and electrolyte imbalances

181. A nurse is assigned to four clients. Which client is at an increased risk for developing fluid volume deficit?

A. A client who is in renal failure.

B. A client receiving normal saline at 125 mL/h.

C. A client who has an NG tube to low continuous suction.

D. A client who has diarrhea related to Clostridium difficile.

The answer is D. The client with Clostridium difficile is at an increased risk for fluid volume deficit due to the loss of fluid via the GI tract.

A is incorrect — The client in renal failure is at an increased risk of fluid volume excess. B is incorrect — The client receiving normal saline is at a risk for fluid volume excess. C is incorrect — A client with an NG tube to low suction is not at as high a risk as the client with diarrhea.




Perform gastric lavage

182. A nurse has an order to perform a gastric lavage on a client who has overdosed on Tylenol. After the lavage tube is inserted in the nose, the nurse should:

A. place tap water in the stomach and begin pulling out gastric contents.

B. verify placement of the tube in the stomach using

60 cc of air.

C. tape to tube in place.

D. verify placement of the tube in the stomach using

30 cc of normal saline.

The answer is B. Prior to instilling anything in the stomach of a client who is undergoing gastric lavage, the nurse must make sure the tube is in the correct place by auscultation for air.

A is incorrect — While tap water can be used for lavage where the tap water will be pulled from the stomach, the nurse must assure the tube is in the stomach prior to performing the lavage. C is incorrect — The tube should not be taped in place until placement is verified. D is incorrect —

Verification of the placement should be performed using air and not normal saline.




Apply knowledge of pathophysiology when caring for client with fluid and electrolyte imbalances

183. A client is in a state of respiratory acidosis. The nurse understands that which of the following is a potential cause of the current acidotic state?

A. Morphine (M.S. Contin)

B. Vomiting

C. Diarrhea

D. Over the counter antacids

The answer is A. Morphine will place a client in a state of respiratory acidosis by lowering the respiratory drive, which causes the client to retain carbon dioxide.


B is incorrect — Vomiting will place a client in a state of metabolic alkalosis due to the loss of acid through the GI track. C is incorrect — Diarrhea will place the client in a state of metabolic acidosis by removing the bicarbonate from the

GI track. D is incorrect — Antacids cause a build up on bicarbonate and will place the client in a state of alkalosis.


MAINTENANCE

Ante/Intra/Postpartum and Newborn Care

Provide newborn care

184. An 8-pound infant is delivered via vaginal delivery.

After the cord is cut and handed to the nurse, the nurse should first assess the baby ’ s:

A. respiratory effort

B. Apgar score

C. vital signs

D. blood sugar

The answer is A. The respiratory effort should be assessed and assisted as needed.

B is incorrect — The Apgar score is second in the assessment.

C is incorrect — Vital signs are assessed after the respiratory

effort and Apgar score. D is incorrect — Unless mom was a diabetic, the baby does not require a blood sugar check.


ENVIRONMENT


Concepts of Management

Apply principles of conflict resolution as needed when working with health care staff

185. Two staff nurses on the nursing unit disagree on how to involve a client ’ s family in the client ’ s care. Nurse A feels that only the husband needs to be included in the planning of the client ’ s care as he will be the primary care giver when she is discharged home. Nurse B feels that both her husband and her son need to be involved as they are both very close to the client and both will have a role in her care once she is discharged. As the nurse leader you must decide how you will manage the conflict.

A. Ignore the situation: if it isn ’ t acknowledged it will go away.

B. Do nothing and allow the two staff nurses to work out a mutually agreed upon decision.

C. Make a decision for the staff nurses, as it is not appropriate for the client to be in the middle of the conflict.

D. Sit down with the two staff nurses and allow them to express their points of view, encouraging both to consider the positive and negative aspects of their views.

The answer is D. By sitting with both nurses, each has a chance to consider the other ’ s opinion. This will help the nurses to settle conflicts in the future.

Ignoring the situation and doing nothing will not resolve the problem. Decisions made by the authority will not resolve future problems and may lead to resentment on the nurses ’ part.





186. A client has been brought to the floor by the PACU nurse after having a cholecystectomy. When performing the postop assessment, which finding would be most indicative of a complication?

A. Nausea, vomiting

B. Abdominal pain

C. Shoulder pain

D. Rigid abdomen

The answer is D. A rigid abdomen is a sign of internal bleeding and requires immediate intervention.

A is incorrect — Nausea and vomiting are common

after abdominal surgery and are not a complication. B is incorrect — Pain is common after surgery and is not a complication unless other symptoms of hemorrhage are present.

C is incorrect — Shoulder pain is due to the gas that is placed in the abdomen for the surgeon to see the organs inside the abdominal cavity.





Position client to prevent complication following tests/ treatments/procedures

187. A client who has undergone a spinal tap should be placed in what position after the procedure?

A. Prone

B. Supine

C. Semi-Fowlers

D. Side lying

The answer is B. A client who has undergone a spinal tap should be placed in the supine position for 2 hours after the procedure.


A is incorrect — The client should not be placed prone after the procedure to prevent airway compromise. C is incorrect — The client should remain supine. Semi-Fowlers would likely place pressure on the insertion site and cause

bleeding. D is incorrect — While the client may be placed in the side-lying position during the procedure, after the procedure the client should be supine. Side-lying carries the possibility of placing pressure onto the insertion site.





188. A nurse will expect which assessment findings when caring for a client with a potassium level of 2.9?

A. Irregular pulse

B. Orthostatic hypertension

C. Seizures

D. Deep tendon hyperreflexia

The answer is A. An irregular pulse is found in the client with a low potassium level due to the effects on cardiac muscle activity.

B is incorrect — Hypokalemia will cause orthostatic hypotension not hypertension. C is incorrect — There are alterations in neuromuscular excitability leading to muscle weakness and flaccidness. D is incorrect — Hyporeflexia is common in hypokalemia due to alterations in neuromuscular excitability.




Monitor wounds for signs and symptoms of infection

189. A nurse is caring for a surgical wound which is 3 days old. Which assessment data is most indicative of a wound infection?

A. Increased white blood cell count

B. Separated wound edges

C. Purulent drainage

D. Edema at the site

The answer is C. Purulent drainage is an indication of a wound infection due to the body ’ s response to the bacteria that has invaded the wound.

A is incorrect — While an elevated white blood cell count is indicative of the activation of the body ’ s immune response system, it does not mean the source of infection is the wound itself. B is incorrect — Wound edges may separate without infection being present. A client can strain and dislodge sutures or sutures can be dislodged if enough stress is placed on the operative area. D is incorrect — Edema is expected initially due to the body ’ s response to invasion of skin integrity.


Abuse/Neglect

Provide a safe environment for an abused/neglected client

190. A client presents to the emergency department after

her husband physically assaulted her during a fight.

She states she feels as though he will come to the hospital to find her and she does not want to see him.

Which nursing intervention will be best to protect this client from her husband?

A. Notify security

B. Place the client as “ confidential ”

C. Notify the police department of the assault

D. Place the client in a room separate from the emergency department

The answer is B. Placing the client as confidential places a restriction on employees of the hospital so they cannot tell any visitors that the client is at the hospital. This is best since the husband may try to search for his spouse and/or lie to security about who he is.

A is incorrect — Notifying security is not the best intervention for this client as evidenced by the rationale provided for answer A. C is incorrect — While the police should be notified on all assaults, it is not the best choice for protecting the client at the hospital. D is incorrect — Placing the client away from the emergency department is not an appropriate choice.

If the client is away from the department, she is too far for the nurse to monitor and the husband may be able to find her.




Remove sutures or staples

191. An order has been written to remove the staples, which were placed in a client ’ s left hip during surgery.

Prior to removing the staples, the nurse should first:

A. assess the site for infection.

B. determine the number of staples from the operative note.

C. soak the site with normal saline.

D. clean the site with hydrogen peroxide.

The answer is B. Prior to removing sutures from a wound, the nurse needs to determine how many staples were placed

1122 PART III: Taking the Test during surgery to make sure the same number of staples is removed as were placed.

A is incorrect — Assessing the site is part of the process but not the first step. C is incorrect — The site is soaked if excess dry blood is around the area or the staples are embedded into the wound bed but this is not the first step. D is incorrect — Hydrogen peroxide can be used as needed if the wound has dried exudate or the staples are embedded in the skin, but this is not the first step.




Recognize signs and symptoms of infectious diseases

192. A client presents to the emergency department complaining of cough, fever, and night sweats. Which nursing intervention would have the highest priority?

A. Provide the client with a sputum cup.

B. Place a mask on the client.

C. Move the client to a private room in the treatment bay.

D. Provide the client with a tissue to cover the mouth when he or she coughs.

The answer is B. The client exhibits signs of tuberculosis and should be placed on isolation via a mask until he or she can be placed in a room in the treatment bay to prevent spread to those in the surrounding area.

A is incorrect — The client can be given a sputum cup after isolation measures are taken to protect those in the area. C is incorrect — The client does need to be moved after begin given a mask to wear. D is incorrect — The client should wear a mask or airway coverage at all times versus only when coughing.





193. A nurse is assisting a physician with the intubation of a client. Which assessment is the priority after the

intubation is complete?

A. Oxygen saturation level

B. Heart rate

C. Breath sounds bilaterally

D. Rise and fall of the chest

The answer is C. The breath sounds are the priority for a client who has just been intubated. If breath sounds are present, then the intubation was successful and the lungs are being ventilated.

A is incorrect — The oxygen saturation level is not the best indicator of successful intubation immediately after the procedure is complete. The oxygen level will improve as the lungs are ventilated and diffusion of gases occurs. B is incorrect —

While the heart rate is important, the first assessment after intubation should be breath sounds in both lungs. The heart rate will respond to the physiological status of the body. Initially, the heart rate will be high while the heart is trying to pump blood to meet the oxygen needs of the body.

It will return to a more normal state as oxygen rich blood is available. D is incorrect — The rise and fall of the chest is important, but the nurse must hear breath sounds bilaterally to ensure the intubation was successful and the lungs are being ventilated.



Hemodynamics


194. A client on the unit was complaining of chest pain when he became unresponsive. The nurse attaches the monitor and sees the following rhythm. Which action by the nurse is most important?

A. Begin chest compressions

B. Palpate for a pulse

C. Check to see if the leads are attached properly

D. Assess for breathing

The answer is D. The first step in CPR is to assess for breathlessness and begin rescue breathing for the client. If breathing is present, assess for lead placement; if the client is not breathing, begin CPR.

A is incorrect — Chest compressions begin after airway, breathing, and pulses are assessed. B is incorrect — Palpation

CHAPTER 34 Practice Test for NCLEX-RN® 1123 for pulses occurs after airway and breathing are assessed. C is incorrect — Lead placement is assessed after airway and breathing is assessed.





195. A client with a diagnosis of chronic obstructive pulmonary

disease (COPD) is being discharged from the hospital. Which of the following is appropriate patient teaching before discharge?

A. “ Make sure to use a humidifier in your room while you sleep.

”

B. “ Apply powder to all crevices to prevent yeast while taking oral steroids.

”

C. “ Turn the oxygen up to no more than 6 L if you are short of breath.

”

D. “ Use your inhalers every day as directed even if symptoms are not present.

”

The answer is D. The client needs to use the inhalers every day regardless of symptoms to keep condition controlled and lessen the frequency of exacerbations.

A is incorrect — A humidifier is not necessary in the room of a client with COPD and can be a source of infection.

B is incorrect — Powder can be an irritant to the client with

COPD and cause an exacerbation of the disease. C is incorrect —

The client with COPD should not use oxygen at greater than 2 L per nasal cannula.



Hemodynamics

Monitor and maintain arterial lines

196. A nurse is working with a client who has an arterial

line for direct blood pressure monitoring. What is the first action the nurse should take when performing an assessment of the system?

A. Ensure the transducer is at the phlebostatic axis.

B. Zero out the system.

C. Flush the system with normal saline.

D. Administer a bolus of normal saline into the line.

The answer is A. The transducer should be placed at the phlebostatic axis, which is at the junction of the fourth intercostal space and the midchest area. If the transducer is placed above the axis, the monitor will give a low reading; if it is too low, the reading will be high.

B is incorrect — The transducer must be at the phlebostatic axis before zeroing occurs. C is incorrect — The system allows for blood draws but does not allow for fluid infusion.

D is incorrect — The system has a Heparin solution which is used to keep the area from clotting; with that known other fluids such as normal saline are not to be instilled into the line as a flush or bolus.





197. A nurse is reviewing a client ’ s chart and notices the

potassium level is 6.0; the nurse plans on administering which drug from protocol?

A. Sodium polystyrene sulfonate (Kayexalate) 30 grams retention enema _ 1 dose.

B. 1 L normal saline with 20 mEq potassium chloride

IV over 2 hours.

C. Normal saline 1 L IV over 10 hours.

D. phosphate/biphosphate (Phospho-Soda) 48 grams by mouth _ 1 dose.

The answer is A. Kayexalate binds with the potassium and removes it from the body via the GI track. This drug carries less of a risk of hypovolemia than other preparations.

B is incorrect — This is adding potassium to the client, which will potentiate the problem. C is incorrect — Normal saline will not remove the potassium. Attempting to flush the system with normal saline places the client at risk for fluid overload. D is incorrect — Phospho-Soda inhibits absorption of fluids and electrolytes in the small intestine through an increase in peristalsis. This drug can potentially place a client in a state of hypovolemia and is not preferred for potassium reduction.



Vital Signs

Evaluate invasive monitoring data

198. A nurse is caring for a client who has a pulmonary artery catheter. Which assessment finding should be reported to the physician immediately?


A. Increase in capillary wedge pressure to 15 mm Hg.

B. Central venous pressure of 2 mm Hg.

C. Right ventricular pressure of 20 mm Hg systolic.

D. Cardiac output of 4 L/min.

The answer is A. The normal wedge pressure is from 8 to 12 mmHg and anything above that indicates increased pressures in the left side of the heart, which are indicative of left sided heart failure and should be reported to the physician immediately.

B is incorrect — The normal central venous pressure is

2 – 6 mm Hg and indicates the volume status of the client.

This reading will rise with volume overload. C is incorrect —

The normal right ventricular pressure is 20 – 30 mm Hg and indicates the right ventricular function and volume. D is incorrect — The normal cardiac output is 4 – 8 L/min and is found by multiplying the stroke volume by the heart rate.

This value is a direct reflection of the adequacy of cardiac function.



Pathophysiology

Identify client status based on pathophysiology

199. The nurse has received report on a client who has just been admitted for an acute myocardial infarction. The nurse ’ s assessment findings are:

• BP 90/66

• HR 100

• RR 16

• skin cool to touch

• A&O _ 3 with mild anxiety

• Urine output 40 mL/h

The nurse understands that this assessment data is indicative of:

A. class I cardiogenic shock

B. class I hypovolemic shock

C. class II septic shock

D. class II neurogenic shock

The answer is A. In mild cardiogenic shock, the body responds to hypoperfusion by the heart through the activation of the Renin-Angiotensin system, which causes vasoconstriction.

The heart rate increases to meet the demand of the body and the blood pressure is within normal limits during compensation. The antidiuretic hormone is secreted in response and urine output is decreased due to an increased resistance in the vascular system. Respirations will increase to provide oxygen to the critical organs. The cool skin is the

response of the body shunting blood to the critical organs and the anxiety is due to the body ’ s response to the shock and developing metabolic acidosis.


Elimination

Insert/remove nasogastric, urethral catheter, or other tubes

200. List in order the steps a nurse would follow prior to inserting a nasogastric tube:

___ Idenfy the client

___ Explain the procedure to the client

___ Wash hands

___ Gather supplies

___ Measure for tube placement

___ Assess the client

___ Turn suction to desired level

___ Sit client in high Fowlers

The nurse should first identify the client and then explain the procedure to gather a verbal acceptance. At that point, a system-specific assessment should be performed to ensure the client has no underlying complications that need immediate attention. Next the nurse gathers his or her supplies, washes hands, and then measures for tube placement. The suction is then set for the ordered level and finally the client is placed in high Fowlers.

MANAGEMENT OF CARE



Verify appropriateness and/or accuracy of a treatment order

201. A client who has been in a car wreck resulting in head trauma and chest contusion is complaining of headache, chest pain radiating down his left arm, and difficulty breathing. The nurse receives the following orders from the physician. Which of the orders would the nurse question?

A. Start an IV at a keep open rate.

B. Raise the head of the bed 45 degrees.

C. Start oxygen at 4 L per minute as ordered.

D. Medicate with Nitrostat (Nitroglycerine) sublingual every 5 minutes _ 3 for chest pain

The answer is D. Nitroglycerine is a vasodilator and may increase intracranial pressure.

The other actions would all be inappropriate.



MAINTENANCE


Perform comprehensive health assessment

202. Which cranial nerve is being tested when the nurse asks the client to shrug his/her shoulders and resist

pressure to put them down?

A. One (olfactory)

B. Eleven (spinal accessory)

C. Five (trigeminal)

D. Seven (facial)

The answer is B. Cranial nerve eleven (spinal accessory) is tested by asking the client to shrug the shoulders and resist pressure to put them down because this cranial nerve controls muscular strength of the trapezius and sternocleidomastoid muscles.

A is incorrect — Cranial nerve one (olfactory nerve) is responsible for the sense of smell. It is tested by occluding each of the client ’ s nostrils one at a time, holding a substance such as coffee or vanilla with a familiar aroma under the other nostril, and asking the client to identify the smell. The test is repeated with a different aromatic substance to determine if the client can differentiate smells.

C is incorrect — Cranial nerve five (trigeminal nerve) has both motor and sensory components. It is responsible for sensation in the face, scalp, oral and nasal mucous membranes, and the cornea and allows chewing movements of the jaw. Its three-part sensory division is tested by touching the forehead, cheek, and chin on each side with a wisp of cotton and asking the client whose eyes are closed to identify

the type of touch and its location. Next the cornea of each eye is lightly touched with a wisp of cotton brought in from the side and the eye observed for the normal blink response. The motor function of cranial nerve five is tested by asking the client to clench the teeth and keep them clenched while the examiner pushes down on the chin to try and separate the jaws.

D is incorrect — Cranial nerve seven (facial nerve) is responsible for taste on the front two thirds of the tongue and for movement of the face including the ability to close the eyes and move the lips for speech. To test taste, an applicator dipped in a sugar, salt, or lemon solution is placed on the tongue and the client is asked what is tasted.

Motor function of cranial nerve seven is tested by asking the client to smile, frown, grimace, show the upper and lower teeth, keep the eyes closed while the examiner tries to open them and puff out the cheeks. The examiner observes for symmetry and movement and presses the puffed out cheeks in to check if air is expelled equally from both sides.




Evaluate appropriateness/accuracy of medication order for client

203. A client is admitted with a diagnosis of cholecystitis.

One of the admitting orders is for morphine PRN for pain. Why would the nurse question this order?

A. Morphine is constipating.

B. Morphine can cause nausea and vomiting.

C. Morphine promotes biliary stone formation.

D. Morphine causes spasm of the bile ducts.

The answer is D. Morphine is contraindicated for clients with cholecystitis because of the risk of precipitating duct spasm.

A, B, and C are incorrect — Morphine, which is an opioid, does cause constipation and also can cause nausea and vomiting but these are not the reason it is not used for clients with cholecystitis. Morphine is not documented as a factor in the formation of biliary stones.


MAINTENANCE



204. Which would be a normal finding when percussing the left 10th intercostal space at the anterior axillary line?

A. Tympany over the gastric air bubble

B. Dullness over the spleen

C. Resonance over the lungs

D. Flatness over bone

The answer is B. Dullness over the spleen.

A, C, and D are incorrect. At the tenth intercostal space one is percussing over the spleen not over the gastric air bubble, lungs, or bone.




Obtain specimens other than blood for diagnostic testing

205. A diabetic client is admitted with a foul smelling, draining leg wound and a wound culture is ordered.

When should the nurse plan to obtain the culture?

A. Before any antiinfectives are administered.


B. When the blood sugar is within normal range.

C. Within 12 hours of a dose of a broad spectrum antibiotic.

D. After 48 hours of antimicrobial therapy

The answer is A. The culture needs to be obtained before any antiinfectives are given because antiinfectives will alter the microbial population. Blood sugar is unrelated to the timing of the culture.


Basic Care and Comfort

Elimination

206. The nurse is planning care for a client who requires

a Sarita lift or the assistance of two people for transfer or ambulation. Which likely would be the best time to schedule having the client taken to the bathroom?

A. On awakening in the morning.

B. After breakfast.

C. Following mid-morning medications.

D. At bedtime after a warm drink.

The answer is B. The gastrocolic reflex is most active after breakfast so this is the time that the client is most likely to have a bowel movement. It is important to utilize the reflex because the client is somewhat immobilized and therefore prone to constipation. Warm fluids can stimulate the reflex but it is still most active in the morning.



Assess client appearance, mood, and psychomotor behavior and identify/respond to inappropriate/abnormal behavior

207. Which is an appropriate nursing intervention for a newly admitted client diagnosed with schizophrenia?

A. Avoid offering choices to the client.

B. Use touch to calm and reassure the client.

C. Keep explanations of care and activities to a minimum.

D. Spend time with the client even if there is no response.

The answer is D. The nurse should spend time with the client

even if the client cannot respond. Being with the client is an indication of caring and is a form of human interaction.

Initially, the client should not be offered choices; with treatment the client is gradually assisted in making decisions.

Maintenance of ego boundaries is important when caring for the schizophrenic client and touching the client should be avoided. Explanations are an important part of the care of the schizophrenic client and everything that is being done should be explained to help create trust.





208. Which instruction would the nurse give when teaching a client pursed lip breathing?

A. Take a slow breath in through your mouth.

B. Breathe out through your mouth puffing out your cheeks.

C. Use your abdominal muscles to help exhale as deeply as possible.

D. Use this breathing technique before any strenuous activity.

The answer is C. Abdominal muscles should be used to help force as much air out as possible during each exhalation.

All other instructions are incorrect. When teaching

pursed lip breathing the client is instructed to breathe in through the nose with the mouth closed and then to purse the lips as if to whistle and exhale slowly

(exhalation should be double the time of inspiration) through the mouth without puffing the cheeks using the abdominal muscles to maximize exhalation of air. Pursed lip breathing should be used during not before physical activity.


Physiological Adaptation

Illness management

209. Which statement made by a client with cirrhosis indicates the need for further clarification on self-care?

A. “ I will not get any injections unless my doctor specifically approves.

”

B. “ I will use an electric razor.

”

C. “ I will take two acetaminophen tabs every 4 hours if

I have pain.

”

D. “ I will avoid exposure to people with colds or other infections.

”

The answer is C. Acetaminophen is hepatotoxic and contraindicated in cirrhosis so if the client says that he or she is going to take acetaminophen then further instruction is selfcare is required.

A, B, and D are incorrect — Avoiding unnecessary injections

and using an electric razor are appropriate because of the

CHAPTER 34 Practice Test for NCLEX-RN® 1127 risk of bleeding due to impaired clotting. Avoiding exposure to infection is appropriate because of decreased immune function.


MAINTENANCE



210. When assessing the heart, the nurse palpates for heaves over the tricuspid area which would be an abnormal finding. Which lettered block on the accompanying diagram marks the location where the nurse would place the ball of the hand to palpate over the tricuspid area. Write the letter of the block on the line provided.

The answer is D.




Use the six “rights” when administering client medications

211. A client ’ s order for pain medication reads “ Codeine 15 sc q4h PRN for pain.

” Which aspect of this order should the nurse question?

A. Frequency

B. Route

C. Dose

D. None

The answer is C. The dose is incomplete and therefore needs to be questioned. No unit of dosage is specified and the nurse cannot assume mg or any other unit was intended.

Route and frequency are specified. This is an as needed order and the reason for the need is also specified as required. a b c d e

First thoracic

First lumbar


MAINTENANCE



212. When assessing the knee, which types of motion must be present to a normal degree for the nurse to document full range of motion? (Mark all that apply.)

___ A. Supination

___ B. Flexion

___ C. Pronation

___ D. Hyperextension

___ E. Internal rotation

___ F. External rotation

___ G. Abduction

___ H. Adduction

The answers are B, D, E, and F. Normal range of motion in the knee is flexion, hyperextension, and internal and external rotation. Normal flexion is the ability to fully bend the knee so the calf touches the thigh. Hyperextension is the ability to extend the knee beyond the normal point of extension.

Internal rotation is the ability to rotate the knee and lower leg toward the midline. External rotation is the ability to rotate the knee and lower leg laterally.




Evaluate the client response to interventions to correct fluid and electrolyte imbalance

213. Which assessment finding indicates that a young adult client admitted with dehydration has been successfully rehydrated?

A. Urine output of 40 Ml/h.

B. Skin “ tents ” when pinched.

C. Urine-specific gravity of 1.031.

D. Apical pulse of 120 and blood pressure of 90/40.

The answer is A. Urinary output of 40 mL/h or more indicates

adequate hydration and glomerular filtration rate.

B is incorrect — Tenting of the skin is indicative of dehydration, although care must be taken particularly with the elderly to check for tenting in areas such as around the top of the sternum because tenting can occur when the skin of the forearm or hand is pinched due to normal age changes and therefore does not always indicate dehydration. C is incorrect — Urine-specific gravity of

1.031 is indicative of concentrated urine, which would be seen when hydration is inadequate. D is incorrect — An

1128 PART III: Taking the Test apical pulse of 120 is abnormally rapid and a blood pressure of 90/40 is low. These findings are consistent with dehydration.


MAINTENANCE



214. When assessing the heart, the nurse auscultates for abnormal heart sounds over the mitral area. Which lettered block on the accompanying diagram marks the location where the nurse would place the diaphragm of the stethoscope to auscultate the mitral area? Write the Letter of the block on the line provided.

The answer is E.




Apply knowledge of client pathophysiology to illness management

215. When assessing a client with cholecystitis, a report of which type of pain would the nurse interpret as consistent with the diagnosis?

A. Dull, aching upper right abdominal pain.

B. Sharp, crampy periumbilical pain.

C. Sharp pain in the back under the shoulder blade.

D. Dull upper abdominal and right shoulder pain.

The answer is C. Cholecystitis causes right upper quadrant pain referred to the back under the shoulder blade.

A is incorrect — Liver cancer causes dull, aching pain in the right abdomen. B is incorrect — Crampy, sharp periuma d e b c

First thoracic

First lumbar bilical pain is characteristic of a variety of intestinal disorders including food poisoning. D is incorrect — An enlarged

spleen can press on the diaphragm and stimulate the phrenic nerve resulting in referred shoulder pain but this is pain on the left side not the right.


MAINTENANCE



216. When assessing a client ’ s hands, the nurse notes clubbing of the fingers. The nurse recognizes that clubbing is a sign of:

A. respiratory disease

B. cardiomegaly

C. diabetes

D. rheumatoid arthritis

The answer is A. Clubbing of the fingers occurs secondary to low oxygen tension leading to an increased hemoglobin and hematocrit. The other answers are incorrect.





217. Which is the priority assessment when caring for a client taking a calcium channel blocker medication?

A. Weight

B. Breathing

C. Blood pressure

D. Urinary output

The answer is C. Calcium channel blockers cause coronary and peripheral vasodilation, which can lead to drop in blood pressure. There are no effects on weight, breathing, or urinary output requiring priority assessment.


MAINTENANCE



218. Which lung sound if auscultated over point E in the diagram would be evaluated by the nurse as a normal assessment finding?


A. Bronchovesicular

B. Crackle

C. Gurgle

D. Sibilant

E. Tracheal

F. Vesicular

G. Wheeze

The answer is A. Bronchovesicular sounds are normally heard over the areas where the right and left bronchi branch.

Anteriorly this is at the first and second intercostal spaces

and posteriorly between the scapulae so this includes point

B. Bronchovesicular sounds are of medium intensity and pitch with the inspiratory and expiratory phases equal.




Implement interventions to manage the client recovering from an illness

219. Which intervention would be inappropriate in the emergent care of a client with a dislocation?

A. Putting joint through passive range of motion

B. Splinting the joint in the dislocated position

C. Applying ice to the joint

D. Providing tactile stimulation distal to the affected joint

Option A is the inappropriate intervention. The joint is not moved through a ROM; so this option is incorrect.

Other interventions are correct actions — The joint would be splinted in the dislocated position until controlled reduction is possible. Cold is applied initially to reduce swelling. Tactile stimulation distal to the affected joint serves no purpose. a b c d e f g

First thoracic

First lumbar


ENVIRONMENT



Assess/triage the client to prioritize the order of care delivery

220. The nurse is planning care for a client newly admitted for rectal bleeding. What is the priority order in which the nurse should plan to carry out the following nursing care activities? (Arrange the options in priority order. All options must be used.)

A. Start an intravenous.

B. Observe the client ’ s level of anxiety.

C. Continue to monitor the client for rectal bleeding.

D. Teach the client self-care in preparation for the discharge.

E. Assess the client ’ s skin, blood pressure, heart rate, and urine output.

F. Teach the client about the upcoming diagnostic tests that the doctor has ordered over the next couple of days.

Correct order of priorities: E, A, B, C, F, and D. Physical needs precede psychological needs. Client teaching would be the

last priority in this situation.



Potential for Complications of Diagnostic Tests/

Treatments/Procedures


221. When caring for a client with a long intestinal tube attached to suction, the nurse would ensure that the suction does not exceed how many mmHg? (Record your answer using a whole number.)

The answer is 25. Suction higher than 25 mmHg can damage the intestinal mucosa.


MAINTENANCE



222. The nurse asks a client what the client would do if she/he found a stamped and addressed envelope on the street.


The client says she/he would put it in a mailbox.

What conclusion should the nurse draw from this exchange?

A. Judgment is intact

B. Short-term memory is intact

C. Mathematical abilities are intact

D. Abstract thinking is intact

The answer is A. Judgment is intact. This scenario requires the patient to exercise judgment before reacting.

B, C, and D are incorrect — The question and answer exchange does not address short-term memory, mathematical ability, or abstract thinking.




Educate the client/family about medications

223. A 19-year-old college student is diagnosed with a strep throat and penicillin is prescribed. Which question should the nurse ask the girl when giving her the prescription?

A. Do you drink milk?

B. Are you allergic to shellfish?

C. Do you take birth control pills?

D. Have you ever had vaginitis?

The answer is C. Penicillin can interfere with the action of oral contraceptives so if they are being used for birth control, the client needs to be advised to use an additional method while taking the medication. The other questions are not relevant to taking penicillin.





224. When monitoring abdominal girth, which guideline should the nurse follow?

A. Measure at the same time each day.

B. Measure before breakfast each morning.

C. Have the client empty the bladder before measuring.

D. Measure at the same location each time.

The answer is D. In order for the measurements to be comparable and therefore provide accurate information on the development of ascites, the girth of the abdomen must be measured at the same location each time. Usually the umbilicus is the location of choice but records of the measurements need to specify the location.

A, B, and C are incorrect — Time of day, breakfast, or a full bladder do not have the same potential for affecting the measurement as does location of the measurement on the abdomen.




Assess the client for actual or potential side effects and adverse effects of medications

225. A client comes to the clinic complaining of unexplained black and blue areas and red tinged urine.

Which type of medication is it most important to find out if the client is taking?

A. Urinary antiseptic

B. Systemic glucocorticoid

C. Antianemic

D. Anticoagulant

The answer is D. Unexplained black and blue areas and hematuria are signs of bleeding associated with excessive doses of anticoagulants. Because of the potential harmful effects of abnormal bleeding, checking for use of anticoagulants is the most important.


MAINTENANCE



226. When assessing the hip, which types of motion must be present to a normal degree for the nurse to document full range of motion? (Mark all that apply.)

___ A. Supination

___ B. Flexion

___ C. Pronation

___ D. Extension

___ E. Internal rotation

___ F. External rotation

___ G. Abduction

___ H. Adduction

The answers are B, D, E, F, G, and H. The hip is a ball and socket joint as is the shoulder and this type of joint provides for the most movement. Types of movement possible are flexion, extension, adduction (movement toward the midCHAPTER

34 Practice Test for NCLEX-RN® 1131 line of the body), abduction (movement away from the midline of the body), and internal and external rotation.



Pathophysiology

227. Which are risk factors for cancer of the liver? Mark all that apply.

A. ___ Hepatitis A

B. ___ Cirrhosis

C. ___ History of gastric cancer

D. ___ Alcohol abuse

E. ___ Portal hypertension

F. ___ Exposure to environmental toxins

G. ___ Smoking

H. ___ Hepatitis C

The answers are B, D, F, G and H. Cirrhosis, alcohol abuse, exposure to chemicals and toxins, smoking, and hepatitis C are identified as risk factors for liver cancer. Liver cancer occurs more often among males and heredity seems to play

a role in its occurrence.

A, C, and E are incorrect — Hepatitis A and a history of gastric cancer are unrelated to the development of liver cancer.

Portal hypertension occurs with cirrhosis and can accompany liver cancer and other diseases. It is a result of rather than a cause of liver cancer.





228. Which results of a CBC (complete blood count) with differential should the nurse interpret as indicating the client has a viral infection?

A. WBC 8,500; lymphocytes 45%

B. WBC 25,000; band neutrophils 20%

C. WBC 15,000; segmented neutrophils 50%

D. WBC 20,000; segmented neutrophils 58%

The answer is A. With a viral infection the WBC is normal with elevated lymphocytes.

B is incorrect — This indicates a severe bacterial infection because the total white blood cell count is above normal and the band neutrophils are elevated because the body is trying to fight the infection so quickly that the neutrophils are being released into the circulation before they

are mature cells. C is incorrect — This indicates a bacterial infection, but not a severe one because the WBC count is above normal but the segs are normal. D is incorrect — This again indicates a bacterial infection, but not a severe one because although the WBC count is elevated, the segs are still within normal limits.


MAINTENANCE

Immunizations

Assess the client/family/significant other knowledge of immunization schedules

229. Which statement made by a client at an immunization clinic indicates an understanding about the hepatitis B vaccine?

A. “ I have to come back in six months to a year for the booster dose.

”

B. “ I won ’ t have maximum protection until after the third dose of the vaccine.

”

C. “ I ’ ll be able to eat shellfish without worry once I get all these injections.

”

D. “ I regret I won ’ t be able to give blood anymore after

I get these injections.

”

The answer is B. Three doses of vaccine are needed for maximum protection.

A is incorrect — It is hepatitis A vaccine that requires a

booster dose in 6 – 12 months after the initial dose is given.

C is incorrect — Hepatitis A, not hepatitis B, can be contracted from eating contaminated shellfish. D is incorrect —

Receiving hepatitis B vaccine does not prevent blood donation.




Apply knowledge of pathophysiology to illness management

230. Which would be an expected finding when assessing a client with gout?

A. Rash over the nose and cheeks.

B. Joint stiffness for 1 – 2 hours on arising.

C. Reddened edematous joints.

D. Intolerance of vegetable protein.

The answer is C. Reddened erythematous joints are signs of gout.

A is incorrect — Rash over the nose and cheeks is a symptom of SLE. B is incorrect — Joint stiffness for more than 1 hour on arising in the morning is characteristic of rheumatoid

1132 PART III: Taking the Test arthritis. D is incorrect — Intolerance to vegetable program is unrelated to a musculoskeletal disorder.





231. Because of the risk of a toxic drug reaction, monitoring laboratory reports for hypokalemia would be a part of the plan of care for a client receiving which medication?

A. Hydrodiuril

B. Motrin

C. Lovastatin

D. Digoxin

The answer is D. Hypokalemia can precipitate a toxic reaction to digoxin.

A, B, and C are incorrect — Hypokalemia does not precipitate a toxic reaction to Hydrodiuril, Motrin, or Lovastatin.


MAINTENANCE



232. In which group of clients would the nurse expect to find a positive plantar reflex with an up going first toe and the others fanning out?

A. The elderly

B. Adolescents

C. Infants

D. School aged children

The answer is C. Infants. The plantar or Babinski reflex in

infants is positive, i.e., first toe goes up and toes fan.

A, B, and D are incorrect — In all other age groups, the first toe curls and the rest of the toes move downward.




Educate the client/families about medication

233. Which instruction should the nurse give to an elderly patient about the proper storage of medications?

A. Keep medications in their original containers.

B. Store in a bathroom cabinet out of the reach of children

C. Keep in a brightly lit area to better read labels.

D. Avoid storing in dry, cool locations.

The answer is A. Medications should always be kept in their original, properly labeled containers to decrease the risk of taking the wrong drug, or of taking the right drug but in the wrong amount, by the wrong route, or at the wrong time.

B is incorrect — Medications should be stored out of the reach of children but not in the bathroom cabinet where exposure to moisture can occur. C is incorrect — Drugs should be stored out of the light and away from heat and so a dark, cool location is needed. D is incorrect — It is important to pour pills from their containers in good lighting so that labels can be read accurately but bottles of medication should not be stored in bright light.




234. Which is a priority goal for a client with borderline personality disorder?

A. Acceptance of group therapy.

B. Elimination of bizarre fantasies.

C. Development of social relationships

D. Decrease of actual and intended self-destructive behavior

The answer is D. Clients with borderline personality disorder make recurrent threats or gestures of self mutilation or suicide or actually attempt to mutilate or kill themselves. As a result a priority nursing intervention is to support efforts to decrease the actual behaviors as well as the client ’ s intent to perform them. Group therapy can assist the client with borderline personality disorder in developing awareness of how one ’ s behavior affects others.

PHYSIOLOGIC INTEGRITY





235. When caring for a client with pancreatitis, the nurse monitors the nasogastric tube attached to suction for proper functioning. It is important that proper functioning be maintained:


A. To prevent backup of secretions to the liver.

B. To protect the intestine from gastric secretions.

C. To allow for monitoring of gastric pH.

D. To protect the gastric lining from pancreatic enzymes.

The answer is B. The N/G tube serves to remove acidic gastric contents so these do not enter and damage the intestine.

This is a risk because alkaline pancreatic secretions are not available to neutralize them.

A, C, and D are incorrect — Gastric secretions do not back up to the liver, gastric pH is not measured as part of the management of pancreatitis, and pancreatic enzymes back flowing to the stomach is not a problem.


MAINTENANCE



236. When assessing the elbow, which types of motion must be present to a normal degree for the nurse to

document full range of motion? (Mark all that apply.)

___ A. Supination

___ B. Flexion

___ C. Pronation

___ D. Extension

___ E. Rotation

___ F. Tilting

The answers are A, B, C, and D. As a hinge joint the basic movement possible in the elbow is flexion and extension. In addition checking ROM of the elbow joint includes pronation and supination. To assess pronation the nurse asks the client to hold each arm straight out and turn the palm upward toward the ceiling. To assess supination, the arms are held out straight and the palms turned downward toward the floor.





237. What instruction would be most effective in helping a client relax the rectal sphincter in preparation for administration of a rectal suppository?

A. “ Turn on your left side and flex your knees.

”

B. “ Bear down as though for a bowel movement.

”

C. “ Take a deep breath exhaling through the mouth.

”

D. “ Think of something that you find soothing.

”

The answer is C. Taking a deep breath and exhaling through the mouth helps relax the rectal sphincter. Turning on the left side and flexing the knees is a desirable position for inserting the suppository. Bearing down as though for a bowel movement would act to eject the suppository. Thinking of something soothing may help the client relax but is not specific to the rectal sphincter.





238. A nurse is reading a PPD test that he or she administered to a healthy 50-year-old grade school teacher. Which of the following measurements would the nurse interpret as a “ positive ” reading for this individual?

A. 10 mm of erythema

B. 5 mm of induration

C. 10 mm of induration

D. 15 mm of induration

The answer is C. With the exception of the immunocompromised, clients with risk factors such as teachers, health care workers, and people living in crowded areas, 10 mm and above of induration is considered positive.

A is incorrect — Erythema is not considered as positive.

B is incorrect — 5 mm of induration is positive if the person is immunocompromised. D is incorrect — 15 mm of induration is positive for persons with no known risk factors.





239. Which would be an expected finding when assessing a client with lupus erythematosis?

A. Rash over the nose and cheeks.

B. Joint stiffness for 1 – 2 hours on arising.

C. Reddened edematous joints.

D. Intolerance to milk sugar.

The answer is A. Rash over the nose and cheeks is a symptom of SLE, which is an autoimmune disease.

B is incorrect — Joint stiffness for more than 1 hour on arising in the morning is characteristic of rheumatoid arthritis.

C is incorrect — Reddened erythematous joints are a sign of gout. Intolerance to milk sugar or lactose intolerance is unrelated to lupus erythematosis.



MAINTENANCE



240. When assessing the ankle, which types of motion must be present to a normal degree for the nurse to document full range of motion? (Mark all that apply.)

___ A. Supination

___ B. Dorsiflexion

___ C. Pronation

___ D. Hyperextension

___ E. Eversion

___ F. Plantar flexion

___ G. Abduction

___ H. Adduction

___ I. Inversion

The answers are B, E, F, G, H, and I. Movements that are part of the normal range of motion for the ankles are dorsiflexion

(foot bent upward with toes pointing at head), plantar flexion

(foot pointed downward, abduction, adduction, and eversion

(movement of the sole of the foot outward), and inversion

(movement of the sole of the foot inward. Supination and pronation are movements of the elbow. Hyperextension is a movement of the shoulder, elbow, and knee.


Reduction in Risk Potential

Vital Signs

Apply knowledge needed to perform related nursing procedures

and psychomotor skills when assessing vital signs

241. When delegating blood pressure measurement to an unlicensed assistant, the nurse cautions that correct technique must be used to avoid obtaining false low pressures. Which is one of the directions the nurse would give to prevent a false low pressure reading?

A. Take the blood pressure on an extremity positioned below heart level.

B. Use a cuff whose width is 40% of the diameter of the extremity.

C. Wrap the cuff loosely around the extremity.

D. Apply the cuff unevenly to the extremity.

The answer is B. The width of the cuff should be 40% of the diameter of the arm; use of a cuff that is too wide can cause false low blood pressure readings and use of a cuff that is too narrow can result in false high readings.

A is incorrect — Taking the blood pressure on an extremity positioned below heart level can result in a false low reading; it does not prevent it. The extremity needs to be supported and at heart level. C is incorrect — Wrapping the cuff too loosely on the extremity results in a false high reading not a false low reading. D is incorrect — If the cuff is wrapped unevenly around the extremity, the result can be a false high, not a false low, pressure reading.


MAINTENANCE



242. When assessing the heart, the nurse auscultates for both aortic and pulmonic murmurs over Erb ’ s point. Which lettered block on the accompanying diagram marks the location where the nurse would place the diaphragm of the stethoscope to auscultate over Erb ’ s point? Write the letter of the block on the line provided.

The answer is C.




Perform diagnostic testing

243. When instructing a client on obtaining a stool specimen for an FOBT, the nurse tells the client not to take aspirin or NSAIDs for how many days prior to collecting the specimen?

Record your answer using a whole number.

The answer is 2 days. FOBT is a screening test for colon cancer, a sign of which is occult blood in the stool. Aspirin and

NSAIDS can cause GI irritation and bleeding and thus can result in a positive FOBT. a b c

d e

First thoracic

First lumbar





Administer and document medications given by parenteral routes

244. In which situation would the nurse need to administer an injection using Z-track technique?

A. The client is malnourished with muscle wasting.

B. The medication is thick and requires a large gauge needle.

C. The medication is very irritating.

D. The client ’ s platelet count is 200,000 or more.

The answer is C. The Z-track method is designed to prevent backflow of medication through the needle track and into the surrounding tissues. It is used when medications are very irritating and can cause tissue damage.

A, B, and D are incorrect — Administration using a Z-track technique is not determined by the size of the client, the thickness of the medication, or the client ’ s platelet count.


MAINTENANCE



245. Which lung sound if auscultated over point F in the diagram would be evaluated by the nurse as a normal assessment finding?

A. Bronchovesicular

B. Crackle

C. Gurgle

D. Sibilant a b c d e f g

First thoracic

First lumbar

E. Tracheal

F. Vesicular

G. Wheeze

The answer is F. Vesicular sounds are normally heard over alveolar lung tissue, which is the majority of both lungs including point B. Vesicular sounds are soft in intensity and low in pitch.

The inspiratory phase is longer than the expiratory phase.




Provide the client with information about the purpose and procedure of prescribed laboratory tests

246. A client receives a report that his PSA level is 9 ng/mL and asks the nurse what this means. The nurse will base the response on the knowledge that:

A. This result is within normal range and no follow up is required.

B. This result is below the normal range and repeat testing is needed.

C. This result is slightly elevated and may reflect problems such as urinary tract infection and benign prostatic hypertrophy as well as prostate cancer; follow up is needed.

D. This result is above normal and indicative of prostate cancer; treatment is needed.

The answer is C. The normal PSA is less than 4 ng/mL but can be elevated into the hundreds with metastatic prostate cancer. Elevations can occur as a result of BPH, cirrhosis, prostatitis, urinary tract infection, and urinary retention.

False elevated levels can occur after urinary catheterization, cystoscopy, transrectal ultrasound, or prostate biopsy.




Recognizes deviations from normal

247. A pregnant woman is seen in the prenatal clinic. The following lab values are received during this visit.

Which lab value requires further investigation?

A. Positive HCG

B. High alpha fetoprotein

C. Low hemoglobin and hematocrit

D. Urine negative for protein and glucose

The answer is B. High alpha fetoprotein is seen in conjunction with fetal abnormalities, such as spina bifida and Down ’ s syndrome and should be investigated further.


A is incorrect — Positive HCG means she is pregnant. C is incorrect — During pregnancy, the volume portion of blood increases at a faster rate than the cellular portion producing a pseudoanemia. D is incorrect — Negative urine protein and glucose is normal.





248. Because of the risk of spontaneous bleeding, the

nurse would institute bleeding precautions for a client whose laboratory report documents a platelet count below ___ /mm3. Record your answer using a whole number.

The answer is 20,000. Spontaneous bleeding can occur with a platelet count of less than 20,000/mm3. Therefore bleeding precautions are required:

• Test all urine and stool for blood.

• No rectal treatments (temperatures, suppositories, enemas, etc.).

• No IM injections.

• Put firm pressure on all venipuncture sites for 5 minutes and on arterial puncture sites for 10 minutes.




Teach the client about managing illness

249. Which topic would be included in the teaching plan for a client with gout?

A. Need to decrease dietary intake of foods high in purine.

B. Importance of restricting caffeine in the daily diet.

C. Necessity of limiting fluid intake.

D. Benefits of decreasing intake of dairy products.

The answer is A. Clients with gout need to limit intake of high purine foods such as scallops, sadines, gravies, and cream sauces.

B is incorrect — Caffeine does not need to be restricted.

C is incorrect — Fluid intake should be increased to aid renal filtration of uric acid from the blood; it should not be restricted. D is incorrect — Dairy products do not have to be decreased.


MAINTENANCE



250. Which lung sound if auscultated over point D in the diagram would be evaluated by the nurse as a normal assessment finding?

A. Bronchovesicular

B. Crackle

C. Gurgle

D. Sibilant

E. Tracheal

F. Vesicular

G. Wheeze

The answer is A. Bronchovesicular sounds are normally heard over the areas where the right and left bronchi branch.

Anteriorly this is at the first and second intercostal spaces

and posteriorly between the scapulae so this includes point

B. Bronchovesicular sounds are of medium intensity and pitch with the inspiratory and expiratory phases equal.




Assess the client for actual or potential side effects and adverse effects of medications

251. When caring for a client on antibiotic therapy, monitoring for which type of common complication is an important component of the plan of care?

A. Electrolyte imbalance

B. Suprainfection a b c d e f g

First thoracic

First lumbar


C. Liver failure

D. Abnormal bleeding

The answer is B. Suprainfection is a common complication of antibiotic therapy because as organisms susceptible to the prescribed

antibiotic are eliminated, other nonsusceptible organisms can overgrow. This results in a second infection caused by an organism different from the one causing the infection for which the antibiotic was prescribed. Common examples of suprainfection are monilial vaginal infections and diarrhea.


ENVIRONMENT


Delegation

Utilize five “rights” of delegations (right task, right circumstances, right person, right direction or communication, and right supervision or feedback)

252. When delegating blood pressure measurement to an unlicensed assistant, the nurse cautions that correct technique must be used to avoid obtaining false high blood pressures. Which errors in technique should be identified as the potential causes of false high blood pressures? Mark all that apply.

A. ___ Use of an unsupported limb to take the blood pressure

B. ___ Use of a cuff that is too wide.

C. ___ Immediate reinflation of the cuff

D. ___ Too rapid deflation of the cuff

E. ___ Uneven application of the cuff

The answers are A, C, and E. Taking the blood pressure on

an unsupported extremity, reinflation of the cuff without waiting 1 – 2 minutes, and applying the cuff unevenly to the arm all can cause a false high blood pressure.

B and D are incorrect — Use of a cuff that is too wide or deflating the cuff too rapidly can cause false low blood pressures.




Educate client/family about medications

253. Which statement made by a client who has been given instructions on taking NSAIDs for joint pain indicates the need for further teaching?

A. “ I have to take these pills with food and a full glass of liquid.

”

B. “ I can ’ t have beer or other alcoholic drinks while taking these pills.

”

C. “ I need to be on the alert for any signs of abnormal bleeding.

”

D. “ I can take other over the counter drugs with these as long as I don ’ t take more than the prescribed dose.

”

The answer is D. NSAIDS cannot be mixed with any over the counter drugs; safe use of other drugs varies with what they are and how they work. NSAIDS should not be mixed with any other NSAIDS. This statement indicates that the client has not understood all the information necessary for safe use of

the prescribed NSAID. Therefore the client is in need of further teaching. Other responses are correct. NSAIDS should be taken with food and a full glass of fluid because of their irritating effects on the gastric mucosa; alcoholic beverages also should be avoided. Because aspirin and ibuprofen, which are classic examples of the two types of NSAIDS (a salicylate and a prostaglandin synthetase inhibitor respectively) affect platelet function and can cause GI bleeding, a client needs to observe for and report any signs of bleeding.




Recognizes deviations from normal

254. A child is admitted to the hospital with a diagnosis of

“ rule out meningitis.

” A spinal tap is performed in the emergency room. It will take 24 – 48 hours before a culture is grown. Which finding in the spinal fluid indicates a probable bacterial meningitis?

A. Elevated protein

B. Decreased glucose

C. Elevated WBC count

D. Cloudy in appearance

The answer is B. The bacteria feed on the glucose lowering that level.

A, C, and D are incorrect — Elevated protein is usually

indicative of a slowing or obstruction of the CSF, and elevated

WBCs and cloudy appearance are seen in both types of meningitis.


MAINTENANCE



255. When assessing deep tendon reflexes, when does the nurse use the pointed end of the reflex hammer? Mark all that apply. The nurse uses the pointed end of the reflex hammer to check


A. ___ brachioradialis reflex

B. ___ biceps reflex

C. ___ triceps reflex

D. ___ patellar reflex

E. ___ Achilles reflex

F. ___ cremasteric reflex

The answers are A, B, and C. The brachioradialis reflex located in the forearm above the radial styloid process of the wrist, the biceps reflex located in front of the elbow, and the triceps reflex located just above the elbow on the back of the arm are all checked using the pointed end of the reflex hammer.

D, E, and F are incorrect — The patellar and Achilles

reflexes located at the front of the knee and the back of the heel respectively are tested using the broad end of the reflex hammer. The cremasteric reflex is a superficial reflex, which causes elevation of one side of the testicle in response to stroking the thigh on that side. The handle of the reflex hammer is used to stroke the thigh.




Provide the client with information about the purpose and procedure of prescribed laboratory tests

256. Which instruction should the nurse give to a client who is to be scheduled for blood work, which includes measures of cholesterol?

A. Do not drink alcohol for at least 24 hours before the test.

B. Fast for 8 hours before the test.

C. Drink at least 4 large glasses of water the evening before the test.

D. Avoid fatty foods for 2 days before the test.

The answer is A. Alcohol should be avoided before the test.

B, C, and D are incorrect — Fasting is necessary for 9 – 12 hours before the test. There is no requirement regarding fluid intake or avoidance of fatty foods.





Apply knowledge of nursing procedures and psychomotor skills when caring for a client with potential for complications

257. A 72-year-old client is scheduled for a CT scan with contrast media. Prior to the test, the nurse checks to ascertain that which laboratory tests have been done?

Mark all that apply.

A. ___ Urinalysis

B. ___ Fasting blood sugar

C. ___ BUN

D. ___ Aspartate aminotransferase (AST)

E. ___ Alanine aminotransferase (ALT)

F. ___ Creatinine

The answers are C and F. BUN and creatinine are tests of kidney function. Because contrast media is excreted through the kidneys, clients undergoing CT scans using contrast media need adequate kidney function. Because older clients are at risk for decreased renal function, those over age 60 have BUN and creatinine assessed prior to a test using contrast media.

Abnormal urinalysis, blood sugar (FBS), or liver function tests (AST, ALT) do not typically prevent a patient from

having a CT scan.





258. Which instructions should be given to the client with gout?

(Mark all that apply.)

A. “ Do not drink red wine or other alcohol.

”

B. “ Drink a lot of nonalcoholic fluids.

”

C. “ Decrease intake of foods high in purine.

”

D. “ Increase intake of foods high in calcium.

”

E. “ Reduce intake of salt.

”

The answers are A, B, and C. Clients with gout need to limit intake of high purine foods such as scallops, sadines, gravies, and cream sauces. Alcohol especially red wine should be avoided. Fluid intake should be increased to aid renal filtration of uric acid from the blood.

D and E are incorrect — Calcium does not need to be increased and salt does not need to be restricted.



Provide client and family with information about acute and chronic mental illness

259. The nurse is speaking to a group of family members of

clients with Alzheimer ’ s disease. Which behaviors would the nurse identify as characteristic of Stage 2

Alzheimer ’ s disease?


A. Progressive impairment primarily of short term memory

B. Difficulties with house keeping and cooking

C. Agitated movements and speech

D. Confabulation

E. Expressions of concern over loss of mental capacity

The answers are A, B, and D. Stage 2 of Alzheimer ’ s disease is the stage of confusion. In this stage there is a progressive loss of memory with short term memory being most impaired. There is difficulty with the Instrumental Activities of Daily Living including house cleaning and cooking. Confabulation and stereotyped speech word usage occurs to cover up for memory loss. Agitation is a characteristic of stage 3 Alzheimer ’ s disease which is ambulatory dementia. Expressions or awareness of the problem and concerns over mental abilities occur in Stage

1 which is the Stage of forgetfulness.





Implement measures to manage/prevent/lessen possible

complications of client condition and/or procedure

260. When preparing to care for a client returning from surgery after a left lower extremity amputation, which piece of equipment is most critical to obtain for the bedside?

A. Traction set up

B. Alternating pressure mattress

C. Tourniquet

D. Wire cutters

The answer is C. If hemorrhage occurs, a tourniquet must be immediately applied and therefore is kept at the bedside.

A is incorrect — Traction is used for a variety of orthopedic conditions including fractures and low back pain. B is incorrect — An alternating pressure mattress is used to prevent or manage skin breakdown. D is incorrect — Wire cutters are needed at the bedside of clients who have wired jaws.


MAINTENANCE


Provide newborn care

261. A newborn is admitted to the newborn nursery. Initial assessment findings are axillary, temperature 97_F, pulse

128, and respirations 33. Based on these findings, the nurse would delay which normal admission activity?

A. Bath newborn and shampoo hair.

B. Complete a head to toe assessment.

C. Feed the infant 1 ounce or less of glucose water.

D. Place in an overbed warmer for easy observation.

The answer is A. Bathing a newborn with a low temperature will further lower the infant ’ s temperature and put the infant in cold stress. All other responses are correct.




Evaluate and monitor client height and weight

262. A 2-month-old infant was admitted for poor weight gain and frequent vomiting. The child is diagnosed with gastroesophageal reflux. Nursing interventions are implemented to reduce the vomiting. The nurse will know the interventions have been successful when:

A. urine output increases.

B. the infant is discharged home.

C. the child shows daily weight gain.

D. the mother says she is comfortable feeding her infant.

The answer is C. Weight gain is the best indication that sufficient food is being retained.

A is incorrect — Urine output may or may not increase.

B is incorrect — Discharge home does not indicate the problem is totally solved. D is incorrect — This is a physical problem

for the child, not the mother.




Promote client wound healing

263. A client has been admitted to the hospital unit for stasis venous ulcers. Nursing care for this client would include:

A. doing Burger-Allen exercises.

B. providing bedrest with legs in a dependent position.

C. placing a foot board on the bed.

D. placing the client in a high fowlers position.

The answer is C. This keeps pressure off of the ulcer.

A is incorrect — Burger-Allen Exercises are done for

Buerger ’ s disease. B is incorrect — Keeping legs in a dependent position increases edema. D is incorrect — High Fowlers position increases pressure and kinking on the vascular system.



MAINTENANCE



264. Which lung sound if auscultated over point G in the diagram would be evaluated by the nurse as a normal assessment finding?

A. Bronchovesicular

B. Crackle

C. Gurgle

D. Sibilant

E. Tracheal

F. Vesicular

G. Wheeze




Pharmacological and Parenteral Therapies

Expected effects/outcomes

265. Which class of drug is given to prevent heart failure in the first 24 hours after a myocardial infarction (MI)?

A. Calcium channel blocker

B. ACE inhibitor

C. Beta blocker

D. Digitalis derivative

The answer is B. Ace inhibitors prevent conversion of angiotensin I to angiotensin II. a b c d e

f g

First thoracic

First lumbar

A is incorrect — Calcium channel blockers cause coronary and peripheral vasoconstriction. C is incorrect — Beta blockers reduce heart rate and contractility. D is incorrect — Digitalis slows the heart and increases the force of contraction.




Implement procedures to counteract adverse effects of medications and parenteral therapy

266. A client who is in the cardiac care unit complains of mediastinal chest pain, dyspnea, and anxiety. The nurse gives the client a nitroglycerine tablet sublingual. The client now complains of being dizzy. Which of the following nursing interventions should the nurse do first?

A. Get a 12 lead ECG.

B. Raise the side rails on the bed.

C. Open the D5W IV to 100 cc per hour.

D. Take the client ’ s vital sign including pulse oximetry.

The answer is B. Safety is the priority.

Option C would not be correct because it is not an isotonic solution and would not help to maintain circulating

volume. Option A would be done but would not be the priority.

Option D is not indicated as a priority.




Use clinical decision making/critical thinking when addressing actions of prescribed pharmacological agents on clients

267. A client with atrial fibrillation is receiving warfarin

(Coumadin) 5 mg each day. His INR today is 1.8.

What is the expected decision regarding change in medication dosage?

A. His INR is too low. His warfarin dose needs to be increased.

B. His INR is too high. His warfarin dose needs to be decreased.

C. His INR is too high. His warfarin dose needs to be increased.

D. His INR is within desired range. No change is warfarin dose is needed.

The answer is A. Target INR for clients with afib is 2.0

– 3.0.

This client ’ s INR is below this range so it would be expected that the dose of warfarin would be increased.


B and C are incorrect — The client ’ s INR is not too low or

high. D is incorrect — The INR is not within desired range.


ENVIRONMENTS



Use ergonomic principles when providing care

268. While assisting a client to perform activities of daily living, how can the nurse best enhance his/her balance?

A. By spreading his/her feet a comfortable distance.

B. By stretching the thoracic cavity by taking deep breaths.

C. By performing the activity(ies) to the level the client can tolerate without experiencing adverse effects.

D. By exerting pressure against a solid object.

The answer is A. By spreading his/her feet a comfortable distance.

Balance is achieved when there is a low center of gravity over a wide stable base of support.

B, C, and D are incorrect — Stretching the thorax will have no effect on balance; maintaining equilibrium responds to various head movements. Activity tolerance is performed to the level the individual can tolerate the activity, but this does not impact the nurse ’ s balance. Isometric exercises involves exerting pressure against a solid object.




Plan nursing care based on assessment findings

269. A 4-year-old child was diagnosed with hydrocephaly shortly after birth and had a ventricular-peritoneal shunt inserted. The child has started vomiting and complaining of headaches in the morning but is well the rest of the day. Which problem would the nurse suspect?

A. Meningitis

B. Gastroenteritis

C. Malfunctioning shunt

D. The development of a brain tumor

The answer is C. The symptoms are those of increased intracranial pressure. Early morning vomiting and headaches are common. While the child is asleep at night, blood increases the intracranial contents causing symptoms.

The other responses would not be early morning only symptoms.






270. Your patient is an 80-year-old female who is 4 hours

postoperative from a right total hip replacement and is experiencing urinary retention. What is the most likely cause of this problem?

A. Decreased renal blood flow

B. Decreased bladder muscle tone

C. Urethral edema

D. Benign prostatic hypertrophy.

The answer is B. Decreased bladder tone will result in urinary retention.

A is incorrect — Decreased renal blood flow is incorrect because this would result in decreased production of urine

(anuria or oliguria) not urinary retention, which refers to the inability to empty urine from the bladder. C is incorrect —

Urethral edema is unlikely because the surgery does not involve manipulation of the urethra or any adjacent tissues.

D is incorrect — Benign prostatic hypertrophy is incorrect because the patient is female.


MAINTENANCE



271. Which lung sound if auscultated over point C in the diagram would be evaluated by the nurse as a normal assessment finding? a b

c d e f g

First thoracic

First lumbar


A. Bronchovesicular

B. Crackle

C. Gurgle

D. Sibilant

E. Tracheal

F. Vesicular

G. Wheeze

The answer is E. Tracheal sounds are normally heard over the trachea, which lies below point B. Tracheal sounds are very loud and high pitched rather like the sound made by blowing through the cardboard tube found at the center of a roll of paper towels. The expiratory phase is longer than the inspiratory phase.





272. Which interventions would appropriately be included in the care plan of a client experiencing an acute episode of rheumatoid arthritis? (Mark all that apply.)

A. ___ Keep affected joints splinted for rest.

B. ___ Apply ice packs to affected joints.

C. ___ Maintain affected joints in a neutral, functional position.

D. ___ Assist the client to weight bear on affected joints for at least 15 minutes tid.

E. ___ Use heat to relieve pain.

The answers are A, B, and C. Ice helps reduce inflammation and relieve pain during acute episodes; heat is used to relax muscles and relieve pain at other times. During acute episodes affected joints are splinted for rest, are not exercised, are used to bear weight nor placed in a hyperextended position.



273. A client is receiving vancomycin intravenously when the nurse notices the client ’ s neck and face becoming red. The immediate response by the nurse should be to:

A. notify the physician

B. stop the infusion

C. administer benadryl

D. do nothing since this is a common reaction to

vancomycin

The answer is B. The nurse would stop the infusion, then notify the physician who would order Benadryl. Once Benadryl has been administered and the flushing disappears, the antibiotic can be restarted, but at a slower rate. This reaction is called Red Man ’ s syndrome and can be fatal if appropriate interventions do not occur.



Indentify Pharmacological interactions


274. Instructions given to a client taking which medication would include the need to keep the amount of green leafy vegetables eaten steady from day to day?

A. Heparin

B. Warfarin sodium

C. Lovastatin

D. Digoxin

The answer is B.Warfarin sodium exerts its anticoagulant effect through interference with the use of vitamin K for clotting.

Green leafy vegetables are a major dietary source of vitamin K.

If a person varies the amounts of green leafy vegetables in the diet significantly, the dosage of warfarin will be incorrect — either too much or too little depending on whether the client has increased or decreased intake of the green leafy vegetables.

For correct dosage of warfarin amounts of vitamin K need to be stable and so dietary intake needs to be stable.

A, C, and D are incorrect — Green leafy vegetables do not impact the effect of heparin, lovastatin, or digoxin.



Assess client appearance, mood, and psychomotor behavior and identify/respond to inappropriate/abnormal behavior.

275. Which is a priority nursing intervention for a client with borderline personality disorder?

A. Encourage acceptance of intensive therapy.

B. Eliminate bizarre fantasies.

C. Facilitate social relationships

D. Promote verbalization of feelings about self.

The answer is D. Promoting verbalization of feelings about self is important in an attempt to gain insight for clients with borderline personality disorder. These clients have a poor and unstable self image and sense of self. They have overwhelming feelings of aloneness, emptiness and rage which is often manifested as self abusive behavior such as head banging, skin scratching, substance abuse, and suiCHAPTER

34 Practice Test for NCLEX-RN® 1143 cide gestures and attempts. Relationships are typically unstable.

Clients with borderline personality disorder are dependent and needy and tend to seek help readily. Bizarre fantasies are not a prominent component of this disorder and facilitation of social relationships is not a priority need.




Identify a contradiction to the administration of a prescribed or over-the-counter preparation to the client

276. You are reviewing the medications taken by a client who is going to be scheduled for surgery. You note that one baby aspirin is taken each day. When asked if the medications listed are all that he takes, the client says “ Oh, I also take two garlic pills because I heard garlic was good for me.

”

What should the nurse instruct the patient to do?

A. Continue to take all of your medication including the garlic pill.

B. Discontinue taking the garlic pill and continue all other medication.

C. Discontinue taking the baby aspirin and continue all other medication.

D. Discontinue taking both the baby aspirin and garlic pill now

The answer is D. Both the garlic pill and aspirin inhibit platelet aggregation and prolong bleeding.

A, B, and C are incorrect because the client is only told to stop either taking the garlic or aspirin.


MAINTENANCE


Assist client/family to identify/participate in activities fitting his/her age, preference, physical capacity, and psychosocial/behavior/physical development

277. The parents bring their 2-month-old to the clinic for a well baby check-up. The mother asks how they should start the baby on solid foods. Which information should be included in the nurse ’ s response?

A. It is too early to start solid foods.

B. Rice cereal will be the first food added to the diet.

C. Start with baby desserts as the baby will not spit that out.

D. The solids can be put in the bottle with the milk in the beginning.

The answer is B.

A is incorrect — The parents did not ask when to start solids but how to start solids. C is incorrect — Desserts are not necessary and promote a “ sweet tooth.

” D is incorrect — If the infant should need to take medication, it will be from a spoon and this new skill will not be learned if the solids are put in the bottle.




Instruct the client on medication self-administration procedures

278. Which client statement indicates understanding of the correct use of nitroglycerine paste?

A. “ I will decide on a convenient site for the medicine and use it consistently.

”

B. “ I will make sure I have medicine on 24 hours per day.

”

C. “ I will wipe the skin with alcohol before I put the paste on.

”

D. “ I will make sure to keep enough paste on hand because it is dangerous to just stop it.

”

The answer is D. Use of nitroglycerine paste is tapered off at the direction of the prescriber; it is not abruptly stopped.

A is incorrect — Sites need to be rotated to avoid skin irritation. B is incorrect — The medication is not used 24 hours per day; there needs to be a period each day when the medication is not used. This is typically 8 hours out of every

24. C is incorrect — Skin should not be shaved nor should alcohol be applied prior to application of the paste because of irritation and possible breaks in the skin, which allows for increased absorption of medication.


MAINTENANCE



279. Which cranial nerve is being tested when the nurse asks the client to smile, frown, grimace, show the upper and lower teeth, keep the eyes closed while the examiner tries to open them and puff out the cheeks?

A. One (olfactory)

B. Five (trigeminal)

C. Seven (facial)

D. Eleven (spinal accessory)

The answer is C. Cranial nerve seven (facial nerve) is responsible for taste on the front two thirds of the tongue and for movement of the face including the ability to close the eyes and move the lips for speech. Motor function of cranial

1144 PART III: Taking the Test nerve seven is tested by asking the client to smile, frown, grimace, show the upper and lower teeth, keep the eyes closed, while the examiner tries to open them and puff out the cheeks. The examiner observes for symmetry and movement and presses the puffed out cheeks in to check if air is expelled equally from both sides. To test taste, an applicator dipped in a sugar, salt, or lemon solution is placed on the tongue and the client is asked what is tasted.

A is incorrect — Cranial nerve one (olfactory nerve) is

responsible for the sense of smell. It is tested by occluding each of the client ’ s nostrils one at a time, holding a substance such as coffee or vanilla with a familiar aroma under the other nostril, and asking the client to identify the smell. The test is repeated with a different aromatic substance to determine if the client can differentiate smells.

B is incorrect — Cranial nerve five (trigeminal nerve) has both motor and sensory components. It is responsible for sensation in the face, scalp, oral and nasal mucous membranes, and the cornea and allows chewing movements of the jaw. Its three-part sensory division is tested by touching the forehead, cheek, and chin on each side with a wisp of cotton and asking the client whose eyes are closed to identify the type of touch and its location. Next the cornea of each is lightly touched with a wisp of cotton brought in from the side and the eye observed for the normal blink response. The motor function of cranial nerve five is tested by asking the client to clench the teeth and keep them clenched while the examiner pushes down on the chin to try and separate the jaws.

D is incorrect — Cranial nerve eleven (spinal accessory) is tested by asking the client to shrug the shoulders and resist pressure to put them down because this cranial nerve controls muscular strength of the trapezius and sternocleidomastoid muscles.




Recognize signs and symptoms of infectious diseases

280. The nurse is assessing an infant in the newborn nursery.

Which finding requires intervention?

A. Milia on the nose

B. Breasts are heavily engorged.

C. Erythema toxicum on the trunk

D. White adherent patches on the tongue

The answer is D. White patches are a sign of a candida infection called thrush. This must be reported to the physician so that a fungicide can be ordered.

A, B, and C are normal findings. Milia are white epidermal cysts that disappear on their own. Breast engorgement is normal and due to maternal hormones. Erythema toxicum or newborn rash is common and requires no intervention.




Recognize deviations from normal for values of WBC

281. How should the nurse interpret a laboratory report of

“ WBC 15,000; segmented neutrophils 50% ” ?

A. Severe bacterial infection

B. Low- to moderate-grade bacterial infection

C. Viral infection

D. No infection

The answer is B. WBC count is elevated but segs are normal.

This indicates nonsevere bacterial infection. Severe infection is indicated by an elevated WBC with elevated band neutrophils.

Viral infection is indicated by a normal WBC and elevated lymphocytes. No infection is indicated by a normal

WBC with normal segs.


MAINTENANCE



282. The nurse checks radial deviation as a part of the range of motion assessment of which joint (s) ?

A. Cervical spine

B. Elbow

C. Wrist

D. Ankle

The answer is C. Radial deviation occurs at the wrist and allows the hand to be pointed toward the side with the thumb and the radial artery. Other movements of the wrist are ulnar deviation in which the hand is pointed toward the side with the fifth or little finger and the ulnar artery.



Infectious Diseases

Apply knowledge of client pathophysiology when managing infectious disease

283. Which assessment findings would the nurse expect when caring for a client in the preicteric phase of hepatitis?


A. ___ Anorexia

B. ___ Scleral jaundice


C. ___ Fatigue

D. ___ Liver tenderness

E. ___ Headache

F. ___ Weight loss

G. ___ Vomiting

The answers are A, C, and E. Anorexia, headache, and fatigue are symptoms of the preicteric phase of hepatitis. Any jaundice, liver tenderness and weight loss are characteristic of the icteric phase. In the posticteric phase, the client begins to improve and anorexia lessens and jaundice begins to disappear.





284. The nurse would interpret a PaO2 value of less than

how many mmHg as indicating hypoxemia? Record your answer using a whole number.

The answer is 70.





285. Which statement made by a client who has a fractured hip indicates the need for additional teaching about required activity restrictions?

A. “ I can ’ t fully extend my leg at the hip for one month.

”

B. “ I won ’ t be able to cross my knees for up to 8 weeks.

”

C. “ I can ’ t put weight on the affected leg until my doctor says to.

”

D. “ I can flex my hip but not more than 90 degrees for up to 2 months.

The answer is A. There is no restriction on extending the leg so if the client says she is not allowed to fully extend her leg for a month it means that she has misunderstood her selfcare instructions.

B is incorrect — Adduction past the midline must be avoided for up to 2 months so the knees cannot be crossed for 2 months. C is incorrect — Weight bearing is restricted and doctor ’ s orders regarding extent of restriction need to be followed. D is incorrect — Hip flexion of more than 90

degrees must be avoided for up to 2 months.


MAINTENANCE


Identify and report deviations from expected growth and development

286. When assessing the anterior fontanel, the nurse would interpret it as an abnormal finding requiring follow up if it was not closed in a child of which age?

A. Six months

B. Nine months

C. One year

D. Two years

The answer is D. It would be an abnormal finding if the anterior fontanel was not closed by age 2 years. The posterior fontanel is smaller and closes earlier.





287. A 0.7-mL oral dose of liquid medication is ordered for an infant. In which device should the nurse measure the dose for administration?

A. 2 mL syringe

B. Tuberculin syringe

C. Infant teaspoon

D. Medicine cup

The answer is B. A tuberculin syringe allows accurate measurement of tenths of millimeters and so a dose of seven tenths of a milliliter can be obtained.

A, C, and D are incorrect — A 2-mL syringe is marked off in two tenths of a milliliter increments and so seven tenths cannot be accurately measured and for an infant very small extra amounts of drug have the potential to cause serious effects. Neither an infant teaspoon nor a medicine cup allow accurate measurement of tenths of millimeters.






288. Which postoperative exercise is best used to prevent deep vein thrombosis in postoperative clients?


A. Deep knee bends

B. Straight leg lifts

C. Side leg lifts

D. Forward lunges

The answer is B. Straight leg lifts exercise the muscle similar

to walking to maintain normal blood flow to and from the lower extremity.

A, C, and D are incorrect. These exercises cannot normally be performed immediately following surgical procedures and require movement that may not be appropriate for all clients.

SAFE AND EFFECTIVE ENVIRONMENT



Assess/triage the client to prioritize the order of care delivery

289. The nurse obtains the following vital signs on a client who has just been admitted to the unit. BP 162/84, pulse 100 and irregular, respirations 16, and pulse oximetry 88%. Which would be the immediate nursing intervention?

A. Place the client on cardiac telemetry.

B. Call the physician to report the vital signs.

C. Start a saline lock for IV medication access.

D. Start oxygen at 2 – 4 L per minute per nasal cannula per protocol.

The answer is D. The client ’ s oxygen level is very low. All other interventions would be done later.





290. Which statement made by the mother of a child with muscular dystrophy indicates a need for further teaching about the disease?

A. “ I cannot believe that my son inherited this terrible disease.

”

B. “ I ’ m going to try to see that my son has the best life possible even though it will be short.

”

C. “ If intellectual impairment was not always a part of the disease, it would be easier to deal with.

”

D. “ It will be very hard watching as the muscle wasting and loss of function occur.

”

Option C indicates a misunderstanding. Intellectual impairment occurs with a few forms of MD but not with all so the mother believing that intellectual impairment is always a part of the disease indicates a misunderstanding and therefore further teaching is needed.

The other statements are correct — Muscular dystrophy is an inherited disorder, with a shortened life expectancy.

Muscle wasting, weakness, and loss of function are characteristic of muscular dystrophy.


MAINTENANCE



291. When assessing the temporomandibular joint, where does the nurse palpate as the client is asked to clench the teeth and move the jaw?

A. In front of the ear

B. Behind the mastoid process

C. Just beneath the occipital lymph nodes

D. Over the insertion of the sternocleidomastoid muscle

The answer is A. The nurse palpates in front of the ear as the client clenches his/her teeth and moves the jaw. The temporomandibular joint is the junction of the temporal and mandibular bones in front of each ear and allows movement of the jaw.





292. Which symptom reported in the health history of a 45- year-old man should be interpreted by the nurse as requiring immediate follow-up evaluation for possible upper GI bleeding?

A. Black, tarry stools

B. Loose, frothy stool

C. Flat, ribbon-shaped stool

D. Mahogany colored, formed stool

The answer is A. Black, tarry stools are indicative of blood from the upper GI tract, which has been in the GI tract long

enough to be completely digested.

B is incorrect — Loose, frothy stool is indicative of high fat content and is associated with malabsorptive disorders. C is incorrect — Flat, ribbon shaped stool is consistent with a tumor, which alters the shape of the left colon and prevents formation and passage of normally formed stool. D is incorrect —

Mahogany colored stool is a symptom of right-sided cancer of the colon. It results from the mixing of blood from the tumor with the stool and its exposure to digestive tract secretions as it progresses through the remaining colon.




Vital Signs

Assess vital signs

293. A client is assessed for orthostatic hypotension with blood pressure and pulse taken lying and standing after

3 minutes in the supine position and then after standing for 1 minute. Which sets of blood pressure measurements is indicative of orthostatic hypotension? Mark all that apply.

A. Supine 188/92; standing 164/78

B. Supine 148/84; standing 116/52

C. Supine 132/84; standing 102/50

D. Supine 114/72; standing 90/56

The answers are B and C. A drop of 30 mm Hg or more is indicative of orthostatic hypotension.






294. Which direction given to a postoperative client will best promote comfort during coughing and deep breathing?

A. Listen to music

B. Practice imagery

C. Watch TV during the exercise

D. Splint the incision with a pillow

The answer is D. Splinting the incisional area prevents stress on the injured area and thereby reduces pain associated with coughing and deep breathing.

A, B, and C are incorrect — Listening to music, practising imagery, and watching TV are good distractors but do not address the actual prevention/limitation of pain that occurs with deep breathing and a forceful cough.


MAINTENANCE



295. What is being assessed when the client is approached from the back and the nurse puts his or her hands on either side of the trachea pushing one side medially while asking the patient to swallow?

A. Patency of the trachea

B. Size and regularity of the thyroid gland

C. Size and movement of the pineal body

D. Elasticity of the cricoid cartilage

The answer is B. The size and regularity of the thyroid gland.





296. When using an oral syringe to administer medications, where should the tip of the syringe be placed?

A. Between the cheek and the gums half way back in the mouth.

B. In the hollow of the mouth under the tongue.

C. One third of the way back on top of the tongue.

D. In the lower back corner of the mouth.

The answer is A. Placing the medication between the cheek and the gums half way back in the mouth helps prevent choking, medication running out of the mouth, or medication being

spit out of the mouth. In the other locations these problems are more likely.





297. Which statement made by a client indicates a need for further teaching about systemic lupus erythematosis?

A. Exposure to sunlight can exacerbate the disease.

B. Exacerbations are most likely to occur in the spring and summer.

C. Pulmonary function tests are needed annually because of frequent lung involvement.

D. Blood pressure needs monitoring because of the risk of hypertension.

Option C indicates a need for further teaching. Pleuritis can be a symptom of the disease, but monitoring with annual pulmonary function tests is not part of the medical routine.

The client stating that pulmonary function tests are needed annually is incorrect and therefore indicates that self-care instructions have been misunderstood and more teaching is needed.

The other statements regarding the disease are correct —

Sunlight can exacerbate the disease and exacerbations occur


most often in the spring or summer. Clients with systemic lupus erythematosis are at risk for hypertension and therefore blood pressure monitoring is needed.






298. The charge nurse is observing another nurse who is inserting a nasogastric tube in a preterm infant. The charge nurse observes the following activities. Which action would the charge nurse correct?

The nurse

A. checks placement by aspirating stomach contents.

B. lubricates the tip of the tube with a water-soluble lubricant.

C. measures the length to be inserted from the tip of the nose to the ear to the sternum.

D. checks placement by inserting 5 mL air while listening over the stomach for the gurgle.

The answer is D. 5 mL of air would be an extremely large amount for the size of the infant. This volume is not necessary to check placement; 1 mL or less will provide adequate air for testing. All other activities are correct.




Recognize deviations from normal for values of WBC

299. Which results of a CBC (complete blood count) with differential should the nurse interpret as indicating the client has a severe bacterial infection?

A. WBC 8,500; lymphocytes 45%

B. WBC 15,000; segmented neutrophils 50%

C. WBC 25,000; band neutrophils 20%

D. WBC 20,000; segmented neutrophils 58%

The answer is C. With a severe bacterial infection, the total white blood cell count would be above normal. Band neutrophils would be elevated because the body is trying to quickly fight the infection; in fact, so quickly that the neutrophils are being released into the circulation before they are mature cells.

A is incorrect — The WBC count is normal with elevated lymphocytes, indicating viral infection. B is incorrect — WBC count is above normal but segs are normal, thus indicating the infection is not severe. D is incorrect — Although the

WBC count is elevated, the segs are still within normal limits, again indicating the infection is not severe.


MAINTENANCE



300. The nurse checks inversion as a part of the range of motion assessment of which joint(s)?

A. Lumbar spine

B. Knee

C. wrist

D. ankle

The answer is D. Movements that are part of the normal range of motion for the ankles are dorsiflexion (foot bent upward with toes pointing at head), plantar flexion (foot pointed downward, abduction, adduction, and eversion (movement of the sole of the foot outward) and inversion (movement of the sole of the foot inward)). Flexion, hyperextension, abduction, and adduction are movements of the knee.

Movements at the wrist are flexion, extension, radial deviation, and ulnar deviation.




Evaluate impact of disease/illness on nutritional status of the client

301. What symptom reported in the health history of a underweight teenager indicates the need for careful assessment of nutritional status?





The answer is B. Loose, frothy stool is indicative of steatorrhea or fat in the stool. Large amounts of fat are expelled in the stool as a result of a variety of malabsorption syndromes.

Therefore a report of this symptom would cause the nurse to carefully assess for other signs of malnutrition.

A is incorrect — Black, tarry stools are indicative of blood from the upper GI tract, which has been in the GI tract long enough to be completely digested. C is incorrect — Flat, ribbon shaped stool is consistent with a tumor, which alters the shape of the left colon and prevents formation and pasCHAPTER

34 Practice Test for NCLEX-RN® 1149 sage of normally formed stool. D is incorrect — Mahogany colored stool is a symptom of right-sided cancer of the colon. It results from the mixing of blood from the tumor with the stool and its exposure to digestive tract secretions as it progresses through the remaining colon.



Assess parental techniques related to discipline

302. The mother of a preschool child tells the child, “ If you don ’ t behave, I ’ ll have the nurse give you a shot.

” The

best nurse ’ s response would be to:

A. ignore the comment as it is obviously not true.

B. reply, “ Oh yes, you better be good while you are here.

”

C. wait until the mother leaves the room and then tell the child that this was incorrect.

D. reply, “ Oh, no, I only give shots when the doctor thinks it will make you better.

”

The answer is D. This response provides the child with information about the nursing function and will reduce fear of the nurses.

A is incorrect — Ignoring the comment does not resolve any problem. B is incorrect — provides incorrect information.

C is incorrect — would not help the mother to understand that her comment will make the child afraid of nurses.





303. Which instruction should the nurse give a client for whom a vaginal cream has been prescribed?

A. Lie on your left side for about 5 minutes.

B. Remain supine with hips elevated for 5 – 10 minutes.

C. Remove excess medication with soap and water in

15 minutes.

D. Urinate and wipe front to back in 15 – 30 minutes.

The answer is B. Remaining supine with hips elevated for 5 – 10 minutes keeps the medication in place in the vagina where it is needed to exert its effect. If the client stands up immediately, the medication can slide down and out of the vagina.

A, C, and D are incorrect — Clients should lie on the left side following a rectal treatment such as an enema.

Instructions regarding washing or urinating are not critical to the self-administration of the medication.




304. Which medication is given preoperatively to decrease gastric and pharyngeal secretions?

A. Glycopyrrolate (Robinul)

B. Pentobarbitol sodium

C. Hydroxyzine hydrochloride (Vistaril)

D. Lorazepam (Ativan)

The answer is A.

B, C, and D are incorrect — Pentobarbitol sodium is used as an induction agent for anesthesia, hydroxyzine hydrochloride is used to decrease anxiety, and lorazepam is used to provide sedation and impair memory of the perioperative events.


MAINTENANCE


Provide education on age-specific growth and development to clients and family

305. An 11-year-old girl is upset. She states her friends are buying bras and their breasts are much larger than hers. She is worried because only one of her breasts is developing and asks the school nurse what is wrong with her. How should the nurse respond? (Mark all that apply.)

___ A. Suggest an appointment with an endocrinologist

___ B. Explain that development is unique to each individual

___ C. Suggest she watch her progress by looking at the Tanner stages of development

___ D. Reassure that asymmetrical development is not unusual

___ E. Ask her to return weekly so her progress can be monitored

The answers are B, C, and D. Explaining that development is unique to each individual, suggesting she use the Tanner stages of development to watch her progress, and reassuring that asymmetrical development is not unusual are all appropriate responses.

A and E are incorrect — There is no information given to suggest an endocrine consult is needed and asking her to return for weekly monitoring is unnecessary and communicates the idea of a problem.






306. For which of the following medications should a patient undergo therapeutic drug monitoring?

A. Penicillin (antibiotic)

B. Propranolol (beta-blocker)

C. Furosemide (diuretic)

D. Lithium (mood stabilizer)

The answer is D. There is a narrow margin of safety between therapeutic drug effect and drug toxicity with lithium.

A, B, and C are incorrect — There is a wide margin of safety with penicillin, propranolol, and furosemide and so therapeutic drug monitoring is not needed.





307. Which intervention is inappropriate as part of the emergent treatment of a simple long bone fracture?

A. Application of cold

B. Elevating the limb

C. Splinting above and below the fracture

D. Application of a pressure bandage

Option D is the inappropriate intervention. A pressure bandage would not be used for a simple fracture.

Other interventions are correct actions — Cold is applied immediately and the limb is elevated not lowered to limit edema. Above and below the fracture is stabilized to prevent movement of the bone segments and further damage.


MAINTENANCE



308. The nurse checks adduction as a part of the range of motion assessment of which joints? Mark all that apply.

A. ___ Lumbar spine

B. ___ Knee

C. ___ Wrist

D. ___ Ankle

E. ___ Finger

F. ___ Toe

G. ___ Shoulder

H. ___ Elbow

The answers are D, E, F, and G. The ankle, fingers, toes, and shoulders can all be adducted and abducted. Adduction is movement toward the midline of the body and abduction is away from the midline. When the ankle is adducted, the foot is turned inward toward the other foot; when the ankle is abducted, the foot is turned out to the side away from the other foot. When fingers and toes are adducted they are brought close together; when they are abducted, they are spread apart.

When the shoulder is adducted the arm is brought across the body to the opposite side; when abducted the arm is extended out to the side away from the body. Remember ad means to or toward: you send a letter to an address. Ab means away from as when a student is absent or away from class.





309. Which client statement indicates understanding of the procedure for using a steroid inhaler?

A. “ I will rinse my mouth out with water after using the inhaler.

”

B. “ I will take 5 to 6 slow deep breaths after each puff on the inhaler.

”

C. “ I will use my bronchodilator immediately after my steroid inhaler.

”

D. “ I will blow my nose forcefully after I finish with the inhaler.

”

The answer is A. Steroid residual in the mouth can lead to

Candida overgrowth and infection. Rinsing the mouth out with water after using the inhaler removes residual steroid and can prevent this problem.

B is incorrect — Deep breaths do not have to be taken after using the inhaler. C is incorrect — Bronchodilator inhalers are always used first to open the lung passages so that other medications such as the steroids can get deep into the lung for maximum effect. D is incorrect — Blowing the nose forcefully has no role in the use of a steroid inhaler.


ENVIRONMENTS


Medical and Surgical Asepsis

Use appropriate supplies to maintain asepsis

310. When getting a drainage set for an indwelling catheter, the nurse notices that the bag containing the set is not

CHAPTER 34 Practice Test for NCLEX-RN® 1151 entirely sealed at one end. Which is the appropriate action for the nurse to take?

A. Use it but notify purchasing about the condition of

the bag.

B. Dispose of it and get another.

C. Use it only if the drainage system appears untouched.

D. Check with the nurse manager on agency policy.

The answer is B. If the protective packaging is not sealed then the equipment is not sterile and it cannot be used.

This applies regardless of its appearance. Notifying purchasing or whomever is responsible for equipment can help with quality control. It is not necessary to check on agency policy regarding its use because use of contaminated sterile items places the client at risk for infection and so the decision to not use falls within the scope of ethical, professional decision making of the individual nurse.




311. Which is an appropriate nursing intervention for a client diagnosed with schizophrenia?

A. Maintain a slightly higher level of environmental stimuli than usual.

B. Prevent the client from lapsing into periods of silence of longer than 5 minutes.

C. Tell the client if you do not understand what is being communicated.

D. Be warm with a show of positive emotion when interacting with the client.

The answer is C. The nurse should tell the client in a simple, direct manner that he or she is not being understood.

Excessive environmental stimuli should be avoided; stimuli should not be increased. Clients may be silent and the nurse should accept this and sit with the client even during periods of silence if necessary. The client should be approached in a neutral manner as it is less threatening to the client than an overly warm approach.





312. What symptom reported in the health history of a 64- year-old man should be interpreted by the nurse as requiring immediate follow-up evaluation for possible left colon cancer?





The answer is C. Flat, ribbon shaped stool is consistent with a tumor, which alters the shape of the left colon and prevents formation and passage of normally formed stool.

A is incorrect — Black, tarry stools are indicative of blood from the upper GI tract, which has been in the GI tract long enough to be completely digested. B is incorrect —

Loose, frothy stool is indicative of steatorrhea or fat in the stool. Large amounts of fat are expelled in the stool as a result of a variety of malabsorption syndromes. D is incorrect —

Mahogany colored stool is a symptom of right-sided cancer of the colon. It results from the mixing of blood from the tumor with the stool and its exposure to digestive tract secretions as it progresses through the remaining colon.


MAINTENANCE



313. When assessing the heart, the nurse palpates for pulsation over the aortic area which would be an abnormal finding. Which lettered block on the accompanying diagram marks the location where the nurse would place his or her finger tips to palpate over the aortic area. Write the letter of the block on the line provided.

The answer is A.




Assess client response to recovery from local, regional,

or general anesthesia

314. An elderly postoperative client has a history of chronic c d obstructive pulmonary disease. Based on this history, a b e

First thoracic

First lumbar

1152 PART III: Taking the Test the nurse is especially concerned with monitoring the client for which problem?

A. Aspiration

B. Delirium

C. Decreased gas exchange

D. Positioning difficulty

The answer is C. Decreased gas exchange is a particular risk with a history of COPD.

A is incorrect — Aspiration would be associated with the age related changes of the gastrointestinal system. B is incorrect —

Delirium is associated with the age-related changes of the neurological system. D is incorrect — Positioning difficulty is associated with age related changes of the musculoskseletal system.


MAINTENANCE



315. Which criterion should the nurse use when selecting the proper size cuff to use when assessing the blood pressure of an 8-month-old infant?

The cuff will

A. say infant on the cuff

B. wrap around the arm twice

C. cover 1 ⁄ 4 of the upper extremity.

D. cover 80% of the length of the extremity section

The answer is D. The cuff should cover 80% of the extremity section, if the upper arm is the site, the cuff should cover 80% of the distance from the elbow to the acromian process. Another way to determine size is the bladder should cover 40% of the circumference of the extremity. All other responses are incorrect.





316. When assessing a client in the emergency room, which finding should be interpreted as a major indicator of acute pancreatitis?

A. Positive Cullen ’ s sign.

B. Postprandial elevated serum amylase.

C. Decreased pancreatic secretion with secretin stimulation.

D. Midepigastric pain worsened by fasting.

The answer is A. A positive Cullen ’ s sign (cyanosis of the periumbilical skin due to subcutaneous intraperitoneal hemorrhage) is symptomatic of acute disease. Reduced volume of pancreatic secretions on a secretin stimulation test is the most diagnostic measure of chronic disease. Elevated serum amylase is found with both acute and chronic disease. LUQ pain radiating to the back, not mid epigastric pain, is characteristic of acute disease.




Provide/maintain special diets based on the client diagnosis/ nutritional needs and cultural considerations

317. Which is the basic type of diet that the nurse would obtain for a client with celiac disease?

A. Fat free

B. Gluten free

C. Lactose free

D. Low sodium

The answer is B. Clients with celiac disease are unable to break down gluten, which is a protein. These clients are

treated with a gluten-free diet. This diet excludes products containing wheat, rye, oats and barley since these grains contain gluten.


MAINTENANCE



318. When assessing the heart, the nurse palpates for thrills over the pulmonic area which would be an abnormal finding. Which lettered block on the accompanying diagram marks the location where the nurse would place the ball of the hand to palpate over the pulmonic area. Write the Letter of the block on the line provided.

The answer is B. d e a b c

First thoracic

First lumbar




Pharmacological Agents and Actions

Apply knowledge of pathophysiology when addressing the pharmacological agents/actions of client prescriptions

319. During discharge teaching, a client asks the nurse how the prescribed antacids relieve heart burn. The nurse ’ s response should be based on the knowledge that antacids work by

A. decreasing the secretion of gastric acid.

B. coating the stomach lining.

C. thickening the mucus secreted by the stomach wall.

D. neutralizing the acid present in the stomach.

The answer is D. Antacids are alkaline and they relieve heartburn by neutralizing the acid in the stomach.




Identify a contraindication to the administration of a prescribed or over-the-counter medication to the client

320. On admission to the emergency room, a client with a traumatic lower extremity amputation is given an opioid for pain. Which herbal medication if taken by the client prior to the accident will prolong the sedative effects of the opioid?

A. Echinacea augustifolia

B. Hypericum perforatum (St. John ’ s Wort)

C. Piper methysticum (Kava-kava)

D. Valeriana officinalis (Valerian)

The answer is B. Hypericum perforatum (St. John ’ s Wort) prolongs the sedative effects of opioids. It also prolongs the sedative effects of anesthesia.

A, C, and D are incorrect — Echinacea augustifolia increases the effectiveness of corticosteroids. Piper methysticum

(Kava-kava) potentiates central nervous system depressants, anesthetics, and corticosteroids. Valerian only prolongs the sedative effects of anesthesia.




Assess client for abnormal neurological status

321. The nurse is assessing for diminished deep tendon reflexes in a client with increasing intracranial pressure.

Which location on the accompanying diagram would the nurse strike with the reflex hammer to check the biceps reflex?

___ A _______

___ B _______

___ C _______

___ D _______

The answer is A. To check the biceps reflex, the examiner ’ s thumb is placed over the biceps tendon located in the antecubital space. The thumb is struck with the pointed

end of the reflex hammer. The forearm should flex in response.

Location B denotes the triceps reflex; location C denotes the patellar or knee jerk reflex; location D denotes the

Achilles reflex.


MAINTENANCE



322. Which cranial nerve is the nurse assessing when the client ’ s gag reflex is checked?

A. Five (trigeminal)

B. Six (abducens)

C. Nine (glossopharyngeal)

D. Twelve (hypoglossal)

The answer is C. The glossopharyngeal nerve is responsible for the pharyngeal gag reflex as well as for movement of the phonation muscles of the pharynx. It is also responsible for taste on the posterior third of the tongue and sensation from the ear drum and ear canal. The gag reflex is tested by touching the posterior pharyngeal wall with a tongue blade and observing for gagging.

A is incorrect — Cranial nerve five (trigeminal nerve) has both motor and sensory components. It is responsible for sensation in the face, scalp, oral and nasal mucous membranes,

and the cornea and allows chewing movements of the jaw. Its three-part sensory division is tested by touching the forehead, c c b a cheek, and chin on each side with a wisp of cotton and asking the client whose eyes are closed to identify the type of touch d

1154 PART III: Taking the Test and its location. Next the cornea of each is lightly touched with a wisp of cotton brought in from the side and the eye observed for the normal blink response. The motor function of cranial nerve five is tested by asking the client to clench the teeth and keep them clenched while the examiner pushes down on the chin to try and separate the jaws.

B is incorrect — Cranial nerve six (abducens nerve) is responsible for lateral eye movement.

D is incorrect — Cranial nerve twelve (hypoglossal nerve) is responsible for tongue movement. It is tested by asking the client to stick out the tongue and later having the client say “ late date night.

”






323. After a difficult delivery, a newborn develops a large cephalohematoma. The nurse will monitor this infant for:

A. infection

B. brain damage

C. hyperbilirubinemia

D. congestive heart failure

The answer is C. Cephalohematoma is bleeding into the periosteum of the bone. When blood escapes the vascular system, it is broken down. When red blood cells are broken down, bilirubin is released. The immature liver is unable to handle large amounts of bilirubin and jaundice is the result. The nurse will need to monitor the child so early interventions can be instituted to prevent complications from high levels of bilirubin in the blood.

A, B, and D are incorrect — The hematoma is on the outside of the skull and will cause no brain damage. There is no risk of infection or congestive heart failure from this condition.


Reduction of Risk Potential

System-specific assessments

324. Which assessment finding should the nurse interpret

as abnormal when admitting an infant to the newborn nursery?

A. Pulse 142

B. Respirations 38

C. Head circumference: 29 cm

D. Chest circumference: 34 cm

The answer is C. Head circumference should exceed the chest circumference and could indicate microcephaly. The other assessment findings are normal.


MAINTENANCE

Techniques of Physical Assessment

325. When assessing the scrotum of a 64-year-old client, what would be a normal difference as compared to the scrotum of a 24-year-old client?

The scrotum of the 64-year-old would be

A. longer

B. more pendulous

C. less flexible

D. more firm

The answer is B. The scrotum becomes more pendulous with age. It does not become longer, less flexible, or more firm.





326. The nurse is assessing for diminished deep tendon reflexes in a client with hypothyroidism. Which location on the accompanying diagram would the nurse strike with the reflex hammer to check the triceps reflex?

___ A _______

___ B _______

___ C _______

___ D _______

The answer is B. To check the triceps reflex, the client ’ s arm is positioned with the elbow bent and the arm and the forearm and hand relaxed and down. The triceps tendon located just above the elbow on the back of the arm is struck with the b a c c d

CHAPTER 34 Practice Test for NCLEX-RN® 1155 pointed end of the reflex hammer. The forearm should extend in response.

Location A denotes the biceps reflex; location C denotes the patellar or knee jerk reflex; location D denotes the

Achilles reflex.




Assess client response to recovery from local, regional, or general anesthesia

327. Which of the following is a common postoperative cause of airway obstruction?

A. Difficult intubation

B. Facial edema

C. PO2 greater than 60 mmHg

D. Tongue blocking the airway

The answer is D. The tongue blocking the airway is a risk in the postoperative client who has had general anesthesia.

A is incorrect — Difficult intubation is not a common cause of airway obstruction in postoperative clients; it is most often associated with age-related respiratory system changes in the elderly. B is incorrect — Facial edema does not necessarily cause a blocked airway. C is incorrect — A PO2 greater than

60 mmHg is not associated with respiratory difficulty.




Educate the client and family about treatments and procedures

328. A client having surgery for glaucoma asks the nurse how

the doctor will know if the surgery is successful. Which would be an appropriate response for the nurse to make?

A. IOP will decrease.

B. Ability to read small print will improve.

C Pupil will remain permanently dilated.

D. Peripheral vision will increase.

The answer is A. The reason surgery is done for glaucoma is to lower intraocular pressure because increased IOP causes progressive loss of vision. Surgery is done when medication is ineffective.

B is incorrect — Damage done by increased IOP is permanent therefore ability to read will not improve. C is incorrect —

The pupil is not affected by the surgery so contraction and dilation occur normally. D is incorrect — Glaucoma causes loss of peripheral vision before loss of central vision and this loss is irreversible.


MAINTENANCE



329. Which lung sound is auscultated over point A in the diagram would be evaluated by the nurse as a normal assessment finding?

A. Bronchovesicular

B. Crackle

C. Gurgle

D. Sibilant

E. Tracheal

F. Vesicular

G. Wheeze

The answer is F. Vesicular sounds are normally heard over alveolar lung tissue, which is the majority of both lungs including point A. Vesicular sounds are soft in intensity and low in pitch. The inspiratory phase is longer than the expiratory phase.



Alterations in body systems

330. Six hours after birth, an infant is found to have an axillary temperature of 97_F. The child is placed in an overbed warmer. When the nurse tells the mother that the infant will not be able to leave the nursery at the next feeding, the mother asks why this low temperature is a concern. The nurse explains that low body temperature in the newborn can cause which effects?

(Select all that apply.) a b c d e f g

First thoracic

First lumbar


A. Hypoglycemia

B. Metabolic acidosis

C. Respiratory distress

D. Hyperbilirubinemia

E. Caput Succedaneum

The answers are A, B, C, and D. Heat loss causes the body to try to produce heat which causes the respiratory rate to rise and can lead to respiratory distress. Metabolic acidosis occurs from the anaerobic burning of fats for energy. Hypoglycemia occurs because the body has burned the glucose to produce heat. All of the stress taxes the liver which is unable to convert the indirect bilirubin to direct bilirubin causing hyperbilirubinemia.

Caput is a swelling of the presenting part and not related to cold stress.



Assess client appearance, mood and psychomotor behavior and identify/respond to inappropriate/abnormal behavior

331. Which is a priority nursing intervention for a client with narcissistic personality disorder?



C. Minimize potential for self harm.

D. Promote verbalization of feelings about self.

The answer is D. Clients with narcissistic personality disorder are self-centered, independent, not easily intimidated, quite aggressive individuals who lack the ability to be empathetic and hence have difficulties with establishing and maintaining interpersonal relationships. They put forth a sense of grandiosity but underneath have low self esteem, and feel insecure and inadequate. These clients need to be helped to view themselves differently and verbalization of feelings about self is a first step toward this goal. Other responses do not apply to the client with a narcissistic personality disorder.



Potential for complications from surgical procedures and health alterations

332. A child is being discharged 18 hours after a tonsillectomy and adenoidectomy. Discharge instructions for the parents would include:

A. Give the child aspirin for pain

B. Use a straw to encourage drinking

C. Offer a soft diet without spicy or acidic foods.

D. Encourage the child to clear throat and cough frequently to remove secretions

The answer is C. A soft diet is maintained to prevent injury to the surgical area.

A, B, and D are incorrect — Aspirin would increase bleeding and would not be desirable. Drinking through a straw and throat clearing increases pressure and could dislodge a forming clot and cause hemorrhage.


MAINTENANCE



333. Which direction would the nurse give to a client when assessing function of cranial nerve twelve (hypoglossal)?

A. “ Holding your head straight, move only your eyes to look first to the right and then to the left.

”

B. “ Clench your jaw as tightly shut as you can.

”

C. “ Stick out your tongue.

”

D. “ Raise your eyebrows.

”

The answer is C. Cranial nerve twelve (hypoglossal nerve) is responsible for tongue movement. It is tested by asking the client to stick out the tongue and later having the client say

“ late date night.

”

A, B, and D are incorrect — Cranial nerve six (abducens) is responsible for lateral eye movement. Clenching the teeth and keeping the jaw shut while the examiner pushes down on the chin to try and separate the jaws is a test of cranial

nerve five (trigeminal nerve). Raising eyebrows along with smiling, frowning, and showing the upper and lower teeth are tests of the motor division of cranial nerve seven (facial nerve).


MAINTENANCE



334. The nurse would assess a client ’ s short-term memory by asking the client:

A. his/her birth date

B. to count backwards from 100 to 7

C. to repeat the phrase “ no ifs ands or buts ”

D. about current events

The answer is D. Asking about current events assesses shortterm memory.


A is incorrect — Asking about birth date assesses longterm memory. B is incorrect — asking the client to count backwards from 100 by 7s assesses mathematical calculation.

C is incorrect — Asking the client to repeat the phrase

“ no ifs ands or buts ” assesses speech.




335. When teaching a type II diabetic client about preventing hypoglycemic episodes, which information is appropriate for the nurse to include?

A. Delaying a meal for as little as 15 minutes can significantly increase the risk of hypoglycemia.

B. With the onset of menses, insulin requirement may decrease.

C. Prolonged exercise can precipitate a hypoglycemic episode.

D. Five grams of CHO raise blood sugar about

30 mg/dL.

The answer is B.With the onset of menses progesterone drops and this may cause a decrease in the need for insulin and so the risk of hypoglycemia is increased.

A, C, and D are incorrect — Delaying a meal for more than a half hour increases the risk of hypoglycemia. Exercise is associated with a drop in blood glucose levels in clients with type I diabetes. Prolonged exercise in these clients can cause increased rate of glucose uptake and use by cells for several hours after the exercise is complete. Thus blood glucose needs to be monitored and CHO supplements taken during exercise. Five grams of CHO raise blood sugar about

20 mg/dL not 30 mg/dL.


ENVIRONMENTS




336. The nurse considers which of the following aspects when performing a client ’ s activity and exercise assessment.

Select all that apply:

A. ___ body alignment and posture

B. ___ routine exercised patterns

C. ___ the body ’ s response to activity and exercise

D. ___ impact of activity and exercise on overall health

The answers are A, B, C, and D. All four aspects are components that necessary to consider to determine a correct nursing diagnosis.

Assessment of activity tolerance, physical fitness, body alignment, and mobility are defining characteristics necessary to make a nursing diagnosis.



Dosage Calculations

Perform calculations needed for medication administration

337. The drug book states that a therapeutic dose for a medication is 50 – 75 mg per kg of body weight per day.

The child weighs 33 pounds and is to receive the medication

4 times a day. What would be the maximum amount of drug the child should receive per dose?

Record your answer is a whole number carried out to

two decimal places. _____ mg per dose

Answer: 281.25 mg per dose; 33 pounds divided by 2.2 pounds per kilogram _ 15 (the child ’ s weight in kilograms);

15 times 75 _ 1125 mg per day divided by 4 doses equals

281.25 mg.





338. The nurse is assessing for hyperreflexia in a client with preeclampsia. Which location on the accompanying diagram would the nurse strike with the reflex hammer to check the patellar reflex?

___ A _______

___ B _______

___ C _______

___ D _______ c d a c

The answer is C. To check the patellar reflex, the client sits with legs dangling. The patellar tendon located just below the patella on the front of the knee is struck b

1158 PART III: Taking the Test with the wide end of the reflex hammer. The lower leg should extend in response. If the client cannot dangle, the knee may be supported by the examiner ’ s nondominant hand in a flexed position while the reflex is checked.

Location A denotes the biceps reflex; location B denotes the triceps reflex; location D denotes the Achilles reflex.


MAINTENANCE

Health Promotion Programs

Plan and/or, Participate in the Education of Individuals in the Community

Provide the client information about health screening tests

339. A 24-year-old unmarried woman has never had a mammogram. The client states that she has heard that the exam is painful and she is afraid to have one. The nurse ’ s response should be:

A. “ Why don ’ t you have the test once and if it is too painful don ’ t do it again?

”

B. “ No, the mammogram is not painful. Whoever told you this was lying to you.

”

C. “ Yes, it is uncomfortable but it only lasts a few seconds.

And the test is so important.

”

D. “ Since you are not married, it is okay to delay the test until you become sexually active.

”

The answer is C. Honesty is important when responding to the client. This response will assist the client in seeking health promotion activities.

A is incorrect as if she decides it was too uncomfortable, the nurse has given permission to not follow national guidelines.

B and D are incorrect information.

MANAGEMENT OF CARE



Apply knowledge of the client pathophysiology to interventions related to standard/transmission based/other precautions

340. A child is being treated for bacterial meningitis. Nursing interventions would include:

A. forcing fluids.

B. positioning in Trendelenburg position.

C. maintaining a brightly lit room to observe for seizures.

D. maintaining respiratory isolation for 24 – 48 hours after antibiotics are started.

The answer is D. Although the organism may be a common one (H. influenzae or pneumococci), other children on the unit must be protected from the infection. Isolation is maintained for at least 24 hours after antibiotics are started.

A is incorrect — Forcing fluids would not be advisable as

cerebral edema is a concern. B is incorrect — The child should be positioned in semi-Fowler ’ s position for comfort.

C is incorrect — The child has photophobia; so a brightly lit room would not be appropriate.





341. Which is a step in the assessment of jugular venous pressure?

A. Assist the client to a right side lying position.

B. Raise the head of the bed 10 – 15 degrees.

C. Shine a light across the client ’ s neck.

D. Measure the horizontal distance from the sternal angle to the meniscus of the internal jugular vein.

The answer is C. A light is shone tangentally across the client ’ s neck to highlight the pulsations of the jugular vein. All other steps listed are incorrect. The client is placed in a supine position. The head of the bed is raised 30 – 45 degrees. The meniscus which is the highest point at which the pulsation of the internal jugular vein can be seen is identified. The sternal angle is located and a centimeter ruler is used to measure the vertical distance from the sternal angle to the meniscus. The number of centimeters, normally not more than 4, equals the jugular venous pressure.



Parenteral/intravenous therapies

342. A client ’ s parenteral antibiotic therapy has been completed.

The physician writes orders to discontinue to

IV line and discharge the client home. Which is a step the nurse will take when discontinuing the intravenous line?

A. Leave the IV site open to the air.

B. Use sterile gloves for catheter removal.

C. Remove the catheter and apply an occlusive dressing.

D. Use alcohol to prevent infection of the site during removal.

The answer is C. An occlusive dressing is recommended following catheter removal. The site should not be left open to the air. Clean gloves, not sterile gloves, are necessary for

CHAPTER 34 Practice Test for NCLEX-RN® 1159 nurse protection. Alcohol will increase the bleeding at the site. A dry sterile dressing will be applied to the site.



Vital Signs

Assess vital signs

343. A client is assessed for orthostatic hypotension with blood pressure and pulse taken lying and standing after

3 minutes in the supine position and then after standing for 1 minute. Which sets of pulse rates is indicative of orthostatic hypotension? Mark all that apply.

A. Supine 96 beats per minute; standing 54 beats per minute

B. Supine 88 beats per minute; standing 62 beats per minute

C. Supine 84 beats per minute; standing 70 beats per minute

D. Supine 80 beats per minute; standing 50 beats per minute

The answer is A. A drop of 40 beats per minute or more in pulse rate is indicative of orthostatic hypotension.


MAINTENANCE

Health Promotion Programs

Instruct the client on ways to promote health

344. A female client is being taught self-breast exam. Which information should the nurse include in the instructions?

A. The nipple area should be avoided in palpating the breast.

B. Breast exams are best performed immediately prior to menses.

C. Self-breast exams are performed in the upright and supine positions.

D. Should a lump be found, make an appointment for a professional examination if it hasn ’ t disappeared in a month.

The answer is C. Supine and upright positions are used while palpating the breast.

A is incorrect — The entire breast including the nipple region should be palpated. B is incorrect — The best time for self-breast exam is immediately after their menstrual period as the hormonal influence will be at the minimal. D is incorrect —

If a lump is found, a medical appointment should be made immediately.



Applies knowledge of intravenous therapy to the care of client

345. A child is admitted to the hospital with gastroenteritis.

The physician orders D51/4 NS with 20 mEq KCL per 1000 ml to be administered at a rate of 50 ml per hour. The appropriate nursing action for this order would be to

A. delay adding the KCL until the child has voided.

B. ask why the physician didn ’ t include other electrolytes.

C. question the physician why a hypertonic solution was ordered.

D. monitor the child for fluid volume overload because

of the fast rate.

The answer is A. Potassium would not be added until the child has voided. Hyperkalemia would occur if kidney function was impaired resulting in cardiac dysfunction.

The other responses are incorrect. Fluid replacement is the main concern in gastroenteritis, the fluid is hypotonic and the rate is not excessive.



Mobility/Immobility

Apply knowledge of nursing procedures and psychomotor skills when providing care to clients with immobility

346. Mr. Clark, a 77-year-old, was admitted with a CVA 3 days ago. This is the first time you have been assigned to care for the gentleman. You carry out an assessment of Mr. Clark ’ s mobility level and ability to participate in activities of daily living. You identify a nursing diagnosis of Impaired Mobility related to Hemiplegia and

Weakness. Select all the nursing interventions that would be appropriate for the nursing diagnosis.

A. ___ Change Mr. Clark ’ s position every 2 hours, maintaining sound body alignment.

B. ___ Use appropriate supportive devices to assist in maintaining correct positioning.

C. ___ Teach client and his family correct positioning.

D. ___ Prepare Mr. Clark for bed based on his usual bedtime patterns prior to the stroke.

The answers are A, B, and C. Correct positioning prevents contractures and maintains proper body alignment; support devices aid in maintaining correct body alignment; teaching involves the family in Mr. Clark ’ s care from the beginning.


D is incorrect — Bedtime patterns are not related to nursing diagnosis of impaired mobility.


ENVIRONMENTS




347. Identify the position depicted in the picture.

A. Sims ’ position

B. Supine position

C. Prone position

D. Fowlers position

The answer is C. In the prone position, the client has her/his head turned to the side when lying on the abdomen. The shoulders, head, and neck are in an erect position, the arms are in alignment with the shoulder girdle, the hips are extended.

A is incorrect — Sims ’ position is a position halfway

between the lateral and prone positions where the lower arm is placed behind the client and the upper arm is flexed; both legs are flexed in front of the client. B is incorrect — Supine position is a position in which the client lies on his/her back with head and shoulders slightly elevated on a pillow. D is incorrect — Fowlers position is a semisitting position with the head of the bed elevated 45 – 60_.




348. When teaching a client with type I diabetes, which factors would the nurse identify as increasing the risk of hypoglycemic episodes? Mark all that apply.

A. ___ End of menses

B. ___ Change in injection site

C. ___ Use of a new bottle of insulin

D. ___ Delaying a meal for 30 minutes

The answers are B, C, and D. Some individuals experience hypoglycemia as a result of an increased rate of absorption of insulin when the site of injection is changed. Hypoglycemia can occur when a new bottle of insulin is used if the old bottle had lost some of its potency. Delaying a meal for more than 30 minutes can also result in hypoglycemia because of deficient food intake.

Onset of menses with the associated drop in progesterone

can increase the risk of hypoglycemia; the end of menses does not.




Uses assessment findings to plan nursing care

349. A nurse is working in the labor and delivery unit. The nurse assesses all the laboring clients and notes that one has a small baby in breech position, one has a large baby who is engaged, one has an average sized infant in a transverse lie, and the last has an average sized infant with a floating head. Which client will the nurse definitely have to prepare for a cesarean delivery?

The client with the

A. small baby in breech position

B. large baby who is engaged

C. average sized infant in transverse lie

D. average sized infant with a floating head

The answer is C. A transverse lie is a shoulder presentation and cannot be delivered in this position. All of the other infants could be delivered vaginally.


MAINTENANCE



350. Which parameters would the nurse assess as part of a complete neurological assessment? (Mark all that apply.)

___ A. Deep tendon reflexes

___ B. Shape of the head

___ C. Cranial nerves

___ D. Sensory perception

___ E. Coordination

___ F. Skin

___ G. Heart

The answers are A, C, D, and E. The other areas are not part of the neurological examination.



Reduction risk potential

Provide Pre- or Postoperative Education

351. A 4-year-old child has just returned from surgery for a tonsillectomy. Instructions that the nurse should give the parents would include:

A. encourage the child to cough frequently.

B. have the child drink through a straw to promote hydration.

C. aviod red liquids in the postoperative period.

D. aspirin is available for pain relief.

The answer is C. Red liquids are avoided to prevent confusion

over bleeding in vomitus or stool.

A is incorrect — Coughing can cause the loss of a clot, leading to hemorrhage. B is incorrect — Drinking through a straw may cause the loss of the clot and lead to hemorrhage.

D is incorrect — Aspirin inhibits clotting.



Nutrition and oral hydration

352. A postpartum woman comes to the lactation clinic

2 weeks after birth. The woman states that she doesn ’ t seem to produce enough milk for her infant. Which statement by the woman indicates a possible source of the lactation problem?

A. “ My breasts are not the least bit sore.

”

B. “ I am always hungry and just eat and eat.

”

C. “ I make sure I drink 500 ml of fluid every day.

”

D. “ The baby latches on and nurses for 20 minutes on each breast every 2 to 3 hours.

”

The answer is C. A minimal fluid intake is 1000 ml a day.

Most breast feeding moms exceed this fluid intake as thirst is common.

A, B, and D are incorrect — The fact that the breasts are not sore is a positive finding. A breast feeding mother needs to increase her caloric intake by about 500 calories per day, which this woman seems to be doing. The infant is nursing

for sufficient time.



Hemodynamics

353. A woman has delivered an infant by cesarean section.

Which factors place this woman at risk for thromboembolic disease? (Select all that apply.)

A. Due to the surgical procedure, the client will be less active.

B. The platelet count is elevated as the body prepared for delivery.

C. The pregnant woman ’ s blood volume decreases in later pregnancy.

D. Venous stasis in the lower extremities is common in late pregnancy.

E. The fetus produces platelets which cross the placenta into the maternal circulation.

The answers are A, B, and D. Stasis of blood due to pressure of the term uterus and elevated platelet count in late pregnancy places all postpartum women at risk for thrombus.

The cesarean client has the added burden of decreased mobility. The pregnant woman ’ s blood volume increases not decreases. The fetal blood components do not readily cross the placenta.


MAINTENANCE



354. Which lung sound if auscultated over point B in the diagram would be evaluated by the nurse as a normal assessment finding?

A. Bronchovesicular

B. Crackle

C. Gurgle

D. Sibilant

E. Tracheal

F. Vesicular

G. Wheeze a b c d e f g

First thoracic

First lumbar






Medical emergencies

355. While being fed, a newly admitted infant with tetralogy of Fallot suddenly becomes very cyanotic and shows severe cardiac distress. Physician orders have not been written. Which action should the nurse take?

A. Administer oxygen

B. Administer morphine sulfate

C. Place the child in knee chest position

D. Place the child in high fowler ’ s position

The answer is C. The child is displaying a “ Tet ” or hypercyanotic spell. Placing the child in knee chest reduces the blood return from the lower extremities and allows better recovery of the heart. High Fowler ’ s position does not as effectively trap blood in the lower extremities and decrease venous return to the heart. The other responses are not appropriate as independent nursing actions.


MAINTENANCE



356. When assessing deep tendon reflexes, when does the nurse use the wide end of the reflex hammer? Mark all

that apply.

The nurse uses the wide end of the reflex hammer to check

A. ___ brachioradialis reflex

B. ___ biceps reflex

C. ___ triceps reflex

D. ___ patellar reflex

E. ___ Achilles reflex

F. ___ cremasteric reflex

The answers are D and E. The patellar and Achilles reflexes located at the front of the knee and the back of the heel respectively are tested using the broad end of the reflex hammer.

A, B, C, and F are incorrect — The brachioradialis reflex located in the forearm above the radial styloid process of the wrist, the biceps reflex located in front of the elbow, and the triceps reflex located just above the elbow on the back of the arm are all checked using the pointed end of the reflex hammer.

The cremasteric reflex is a superficial reflex, which causes elevation of one side of the testicle in response to stroking the thigh on that side. The handle of the reflex hammer is used to stroke the thigh.


ENVIRONMENTS



Apply principles of infection control

357. Which type of precautions would be used when caring for a client with hepatitis A?

A. Standard precautions

B. Airborne precautions

C. Droplet precautions

D. Contact precautions

The answer is A. Standard precautions are used to decrease the risk of transmission from bloodborne pathogens and moist body substances. Moist body substances include blood, urine, feces, sputum, saliva, wound drainage, and all aspirated fluids. Because hepatitis A is spread by the fecal oral route, standard precautions are appropriate.

B is incorrect — Airborne precautions are used when the mode of spread of an organism is by small particle droplets borne on air currents. Airborne precautions require a private room with negative airflow and adequate filtration; those entering the room wear a mask and if the client leaves the room, a mask is worn. C is incorrect — Droplet precautions are used when the mechanism of transmission is by large droplets spread by coughing, sneezing, or talking. Droplet precautions require a private room or a room shared with someone infected with the same organism. Those entering the room and coming within 3 feet of the client need to wear a mask and the client wears a

mask if taken out of the room. D is incorrect — Contact precautions are used when organisms causing serious disease are easily transmitted through direct contact. Contact precautions require a private room or a room shared with someone infected with the same organism. Gloves are worn at all times and gowns and protective barriers are used if direct contact is required.




358. A young female adult client is admitted for anorexia nervosa. The client ’ s weight has reached a precarious level and hospitalization was deemed necessary for the

CHAPTER 34 Practice Test for NCLEX-RN® 1163 client ’ s physical well being. Which is the priority nursing intervention?

A. Obtaining daily weights

B. Referring for psychological counseling

C. Administering total parenteral nutrition

D. Reinforcing a positive body image

The answer is C. Because the client ’ s weight loss has reached a critical level, it is important that nutritional support be begun immediately. The other interventions are not the priority interventions.



Provide client and family with information about acute and chronic mental illness

359. The daughter of a woman who has just been admitted to an Alzheimer ’ s care unit because of stage 3 symptoms of ambulatory dementia, asks the nurse what changes she should expect in her mother as the disease continues to progress. The nurse explains that stage 4 is endstage disease and identifies which symptoms that the client will likely manifest?

A. Does not recognize family members

B. Does not walk

C. Engages in minimal purposeful activity

D. May yell or scream spontaneously

E. Is incontinent

F. Does not recognize self in the mirror

The answers are A, B, C, D, E, and F. Endstage Alzheimer ’ s

Disease is characterized by inability to recognize family members, inability to recognize self in a mirror, incontinence and possibly seizures, inability to walk, little purposeful activity, spontaneous yelling or screaming often interspersed in periods of muteness, forgetting how to eat, swallow or chew, weight loss, and problems associated with immobility such as pressure ulcers, contractures, UTIs, and pneumonia.



Laboratory values

360. A child is admitted to the pediatric unit with acute glomerulonephritis. The unit secretary receives a phoned lab report from the laboratory. Which result should the nurse question?

A. Urine protein 3_

B. Urine RBCs 4_

C. Urine color: Smokey gray

D. Urine-specific gravity 1.003

The answer is D. Protein and RBCs are expected findings in the urine. The urine will be very concentrated. All of these facts will cause the urine-specific gravity to be high, not low.

The color is smoky gray or “ cola ” colored.





361. A pregnant woman has been found to be very anemic.

Because she can ’ t take pills, liquid iron supplements have been ordered. Which direction would the nurse give the client about taking the liquid iron preparation?

A. Take the iron with milk

B. Drink the iron through a straw

C. Take the iron on an empty stomach

D. Take the iron at the same time every day

The answer is B. Iron stains the teeth so should be taken in a manner to bypass the teeth.

A is incorrect — Milk will prevent iron absorption — iron should be taken with juice for the best absorption. C is incorrect — Iron can be irritating to the stomach. D is incorrect —

It doesn ’ t matter what time of day the iron is taken.


MAINTENANCE


Perform a comprehensive health assessment

362. What is the nurse assessing when, with the client ’ s eyes closed, the nurse traces the number 3 on the palm of the client ’ s hand with a capped pen and asks the client to identify what was traced?

A. Two-point discrimination

B. Stereognosis

C. Graphesthesia

D. Light touch

The answer is C. This is the procedure for assessing graphesthesia.

Two-point discrimination involves touching the skin simultaneously with two sterile needles at closer and closer distances to each other until the client perceives only one touch. Stereognosis is asking the client to identify a familiar object such as a key when it is placed in the client ’ s hand with the client ’ s eyes closed. Light touch is

tested by stroking an area of the client ’ s skin with a wisp of cotton.




Pathophysiology

363. An infant ’ s crib is placed next to the window allowing the infant to lose heat to a cooler solid surface not in contact with the infant ’ s skin. This type of heat loss is termed

A. radiation

B. convection

C. conduction

D. evaporation

The answer is A. This type of heat loss occurs by radiation.

Convection is the loss of heat into the cooler room temperature.

Conduction is the loss of body heat to a solid surface in direct contact with the body. Evaporation is the loss of heat when moisture on the skin is converted to a vapor.


ENVIRONMENTS




364. Which activity requires an individual carrying out the activity to use the most energy:

A. Rolling

B. Pivoting

C. Lifting

D. Turning

The answer is C. Lifting a person or object requires going against the force of gravity.

A, B, and D are incorrect — Rolling, pivoting, and turning a client use a limited amount of energy compared to lifting a client. Moving an object along a level surface requires less energy than moving an object against the force of gravity.



Potential for alterations in body systems

365. The client has pulse oximetry ordered to monitor oxygen saturation. The nurse applies the monitoring probe to the right index finger and receives a reading of 91%. The nurse should

A. notify the physician.

B. encourage the client to take a deep breath.

C. check the oxygen level on each of the other fingers.

D. check the monitor site for skin breakdown from the probe.

The answer is A. The test is used to titrate levels of oxygen.

This value is low. Taking a single deep breath will not resolve the problem. There is no reason to check the oxygen level of

the other fingers, this is not a test of circulation to the hands.

Although the probe uses heat to read the oxygen level, skin breakdown is not common in adults.


MAINTENANCE



366. Which equipment does the nurse need to perform a

Rinne test on a client?

A. Reflex hammer

B. Pneumatic otoscope

C. Tuning fork

D. Snellen chart

The answer is C. The Rinne test utilizes a tuning fork to compare bone conduction and air conduction of sound. The base of a lightly vibrating tuning fork is placed on the mastoid process and the client is directed to state when the tone is no longer heard. When the client reports no longer hearing the tone the tuning fork is moved so the tines are in front of the opening to the suditory canal. The client is asked if sound is heard and if so to report when it stops. Normally, the client hears the sound for as long as the sound was heard with the base of the tuning fork on the mastoid bone. This means that air conduction is normally twice as long as bone

conduction. If air conduction is found to be equal to or shorter than bone conduction, the client has a conductive hearing loss. If air conduction is longer, but not twice as long as bone conduction, sensorineural hearing loss is indicated.

A is incorrect — A reflex hammer is used to check reflexes. B is incorrect — A pneumatic otoscope is used to check for motion of the tympanic membrane. D is incorrect —

A Snellen chart is used to test distance vision.




Assess the client for abnormal neurological status

367. The nurse is assessing for diminished deep tendon reflexes in a client with increasing intracranial pressure.

Which location on the accompanying diagram

CHAPTER 34 Practice Test for NCLEX-RN® 1165 would the nurse strike with the reflex hammer to check the achilles reflex?

___ A _______

___ B _______

___ C _______

___ D _______

The answer is D. To check the Achilles reflex, the knee is flexed, the foot is dorsiflexed and held by the examiner, and the leg is externally rotated to allow easy access to the back

of the heel. The Achilles tendon is struck with the wide end of the reflex hammer. The examiner should feel plantar flexion in the foot in response.

Location A denotes the biceps reflex; location B denotes the triceps reflex; location C denotes the patellar reflex.



Pharmacological interactions

368. A client with known heart disease is being treated with digoxin and lasix. The client is admitted to the hospital for lethargy and shortness of breath. The admission labs show a potassium level of 2.9. The nurse would suspect

A. renal failure

B. digoxin toxicity

C. a respiratory infection.

D. decreased chloride levels

The answer is B. Low potassium levels can result from Lasix administration but would increase the action of the digoxin causing digoxin toxicity. The other responses are incorrect.


MAINTENANCE



369. When assessing a 5-month-old child, which finding

would the nurse interpret as representing normal growth and development? c c b a d

A. Presence of the tonic neck reflex

B. Presence of the crawling reflex

C. Presence of the dance reflex

D. Presence of the rooting reflex

The answer is A. The tonic neck reflex disappears between

4 and 6 months of age and so if it was still present at 5 months it would not be interpreted as an abnormal finding.

B, C, and D are incorrect — The crawling and dance reflexes disappear between 1 and 2 months of age. The rooting and sucking reflexes disappear at 3 – 4 months of age.




370. An adult client with SIADH is on restricted fluids to return serum sodium to normal. A serum sodium level within which range would indicate that this client management goal was achieved?

A. 105 – 115 mEq/L

B. 118 – 125 mEq/L

C. 135 – 145 mEq/L

D. 148 – 158 mEq/L

The answer is C. The normal range of serum sodium is

135 – 145 mEq/L. Below 135 mEq/L is hyponatremia and above 145 mEq/L is hypernatremia. With SIADH serum sodium level is low as a result of dilution by retained fluid because of the inappropriate secretion of antidiuretic hormone which prevents diuresis.


ENVIRONMENTS




371. When moving a client from the bed to a stretcher the nurse needs to consider utilizing a:

A. draw or pull sheet

B. pillow

C. footboard

D. trapeze bar

The answer is A. A draw or pull sheet will provide friction which will lead to less force needed to move the client.

Pillows are used in positioning clients. Footboards are used to prevent foot drop. Trapeze bar is used when the client can assist in pulling him/herself up in bed.




Pathophysiology

372. A newborn is being admitted to the newborn nursery.

The father has accompanied the infant to the nursery.

During the admission process, the nurse prepares to administer vitamin K intramuscularly. The father asks why his baby needs the vitamin K. Which response by the nurse would be most appropriate?

A. “ We give this to all babies born by cesarean section.

”

B. “ Babies can ’ t take fruits and juices which are the main source of vitamin K in the diet.

”

C. “ Your baby will not have anything by mouth for the next 12 hours so he will be unable to get any vitamin

K from his diet.

”

D. “ Newborns have sterile intestines. You and I get vitamin K from bacteria that live in our intestines.

”

The answer is D. The main source of vitamin K is from the intestinal flora and from the ingestion of fats.

A is incorrect because it is also given to infants born by vaginal delivery. Vitamin K is found in fats, not fruits. The infant will not be NPO.



Pathophysiology

373. A premature male infant is admitted to the high risk nursery. On the admission assessment, the nurse notes there are no testes in the scrotum. In relation to this finding, the nurse would

A. document the finding.

B. monitor urine output.

C. prepare the parents for immediate orchiopexy.

D. evaluate the child for low set ears.

The answer is A. Undescended testes are a common finding in the preterm infant and do not warrant further investigation at this time. Orchiopexy may be scheduled prior to the child starting school, but the testes may descend on their own. Low set ears are associated with renal abnormalities. Undescended testes are a sign of immaturity not renal abnormalities.



Develop and maintain therapeutic relationships with client/ family/significant others

374. Upon return from a group meeting a client is visibly upset.

When the nurse notes this fact and asks if the client would like to talk about it, the client replies “ I ’ ll tell you what happened but you can ’ t tell anyone I told you.

” Which is the most appropriate response for the nurse to make?

A. “ I will respect your confidentiality.

”

B. “ I cannot make that promise.

”

C. “ As long as it doesn ’ t involve another client, I won ’ t say anything.

”

D. “ I won ’ t write it in your record but I may need to tell someone.

”

The answer is B. “ I cannot make that promise.

” This is the appropriate response because promising to keep information secret may be appropriate in a social relationship but is inappropriate in a therapeutic relationship. It is also an honest, direct answer to the client.





Applies knowledge of pathophysiology to selected assessment findings

375. A client is known to have hyperthyroidism with symptoms including recent weight loss, diarrhea and mild exophthalmos. The client is seen in the emergency room with a high temperature, tachycardia and hypertension.

Tremors are noted in the hands. Which problem should the nurse suspect based on these assessment findings?

A. Goiter

B. Urinary tract infection

C. Thyrotoxic Crisis (thyroid storm)

D. Overdose of Synthroid (Levothyroxine sodium)

The answer is C. Thyroid storm is the sudden oversecretion of thyroid hormone and can be life threatening. Goiter is an enlargement of the thyroid gland secondary to decreased thyroid production. A urinary tract infection would cause hyperthermia but not the other symptoms. The client with hyperthyroidism would not be on medication for hypothyroidism

(Synthroid).




376. A newly diagnosed asthma client calls the clinic nurse to ask which medication is taken routinely to prevent an asthma attack. Which medication is the one that would be taken prophylactically?

A. Cromolyn sodium (Intal)

B. Inhalant glucocorticoids such as flunisolide (Aerobid)


C. Short-acting bronchodilator such as albuterol

(Preventil)

D. Long-acting bronchodilator such as salmeterol

(Serevent)

The answer is A. Cromolyn sodium is a mast cell stabilizer and is used to prevent an asthmatic attack.

Glucocorticoids are anti-inflammatories used to reduce

inflammation and airway constriction. Oral glucocorticoids may be administered for severe asthmatics as a prophylactic, the accumulated side effects are very problematic. Short-acting bronchodilators would be used prn for exercise induced asthma. Long-acting bronchodilators are used to obtain control of asthmatic attacks.


MAINTENANCE



377. What would you ask the client to do as you assess respiratory excursion?

A. “ Take two or three rapid breaths.

”

B. “ Say 99.

”

C. “ Take a deep breath.

”

D. “ Cough.

”

The answer is C. Respiratory excursion refers to the symmetry and degree of chest expansion upon taking a deep breath.

Posteriorly excursion is measured by placing the palms of the hands with fingers spread wide and thumbs facing each other on either side of the spinal column with a skinfold pushed up between them. The client is then asked to exhale and then to take a deep breath and hold it. The examiner notes the amount of increased distance between his or her thumbs when the deep breath is taken. This increase in distance represents

the amount of chest expansion or excursion. Normally the thumbs will separate by 1 1 ⁄ 4 to 2 inches.





378. A 59-year-old male was admitted to your unit following removal of a tumor on the sigmoid colon with a diverting colostomy. On the third postoperative day, the client ’ s wife asks that you look at the dressing because it is all wet. Upon removal of the dressing you observe bowel protruding out of the abdomen through a dehisced incision. What is the priority nursing action?

A. Notify the surgeon

B. Reassure the client that he will be fine

C. Apply sterile, normal saline soaked gauze to the bowel and cover with a second sterile dressing

D. Gently push the bowel back into the abdominal cavity and apply an abdominal binder

The answer is C. Sterile gauze soaked with normal saline should be applied to the bowel to prevent drying and then covered with a secondary sterile dressing to prevent contamination.

A is incorrect — The nurse ’ s priority action is to preserve the bowel; then the surgeon is notified. B is incorrect —

Although the nurse does want to assure the client that this problem will be corrected immediately, it is not the priority action. D is incorrect — Pushing loops of bowel back into the abdominal cavity could result in injury to the bowel.



Adverse effects/contraindications

379. A known drug addict arrived in the labor unit at 8 cm dilated. The client managed the contractions and the infant was delivered within 1 hour of the mother ’ s admission. For which conditions would the infant be monitored? (Select all that apply.)

A. ___ Hyperbilirubinemia

B. ___ Congenital anomalies

C. ___ Narcotic depression immediately after birth

D. ___ Narcotic withdrawal within a few hours of delivery

The answers are B, C, and D. Many drug abusers will wait to the last minute to arrive at the labor unit and will have used recreational drugs immediately before admission. Therefore, the infant could be depressed at birth but then will develop withdrawal within a short period of time. Congenital anomalies are associated with some recreational drugs. The infant will probably not have problems with hyperbilirubinemia as the narcotic exposure in utero seems to mature the liver and infants born to substance abuses seem to have fewer problems with

bilirubin than other infants.


ENVIRONMENTS




380. A client needs help in transferring from his bed to a chair.

He is 6 feet 2 inches tall, weighs approximately 250 lbs,

1168 PART III: Taking the Test has weakness on his left side, and has been on prolonged bed rest. Which factors should the nurse consider prior to implementing the transfer? Select all that apply.

A. ___ Determine the need for assistance from other personnel

B. ___ Determine the client ’ s activity tolerance

C. ___ Assess muscle strength in the client ’ s legs and upper arms

D. ___ Assess the amount of instruction the nurse will need to provide the client ’ s

The answers are A, B, C, and D. Clients require various levels of assistance; the nurse needs to recognize her/his strengths and limitations; a safe transfer is the first priority.

Determining a client ’ s activity tolerance will aid in determining the client ’ s ability to assist in the transfer. Clients that have been immobile for a period of time may have decreased

muscle strength, tone, and mass. This will effect his/her ability to bear weight and raise the body. By explaining the transfer procedure the client will be involved and maybe able to help in the transfer.


MAINTENANCE



381. When assessing a 6-month-old child, which finding should the nurse interpret as a sign of possible developmental delay?

The child

A. is not attempting to pull up to a standing position.

B. does not turn toward a person who is speaking.

C. does not imitate speech.

D. does not respond to infant games like peek-a-boo.

The answer is B. At 6 months of age an infant should turn toward a person who is speaking. If the infant does not do this, the possibility of developmental delay or other disability exists.

A, C, and D are incorrect — At 1 year a child should have begun to pull up to a standing position; begun to imitate a variety of speech sounds; and begun to respond to games like peek-a-boo and pat-a-cake.



Alterations in body system

382. A pregnant woman at 39 weeks gestation tells the nurse “ I started feeling like I can breathe better two days ago, but now I noticed I have to void a lot.

”

How should the nurse would suspect interpret this information?

A. Lightening has most likely occurred.

B. Quickening has occurred.

C. Labor has begun.

D. A urinary tract infection has developed.

The answers is A. As the uterus descends into the pelvis in preparation for labor, the client will be able to breathe easier but will now have pressure on the bladder causing urinary frequency.

Quickening is feeling fetal movement. The client gives no indication of contractions although the body is preparing for labor. A urinary tract infection would cause frequent urination but not easier breathing.



Adverse effects/contraindications and side effects

383. An 80-year-old man comes to the clinic complaining of erectile dysfunction. Which question is most important for the nurse to ask?

A. How often do you usually have intercourse?

B. What medications do you take?

C. When was the last time you had your prostate examined?

D. Do you have any problems urinating?

The answer is B. As clients age, the likelihood that they take medications increases. Many of the medications taken by the older population have erectile dysfunction as a side effect, including antihypertensives. In many cases the problem can be eliminated by changing the medication. The other questions, although they might be asked, do not most directly impact the problem.



Assist client with achieving and maintaining self-control of behavior

384. Which statement accurately describes a “ no suicide ” contract?

A. The contract provides a boundary.

B. The contract takes the responsibility for control away from the client.

C. The contract serves to reinforce to the client that life is valuable.

D. The contract must be written to be effective.


The answer is A. A “ no suicide ” contract is a way of providing boundaries. Contracts help place control in the domain of the client; they don ’ t remove control. Contracts assure the client that someone is concerned enough about them to provide boundaries but do not directly reinforce that life is valuable. Verbal “ no suicide ” contracts have been proven effective.




385. The husband of an elderly client tells the clinic nurse that the doctor has diagnosed his wife who has been increasingly confused, with anemia caused by a vitamin deficiency. The husband asks which vitamin could be causing the problem. Which vitamin deficiency would the nurse suspect is the cause of the problem?

A. A

B. B12

C. C

D. D

The answer is B. Vitamin B12 deficiency is associated with anemia and mental confusion. This vitamin deficiency is common in the elderly. The other vitamins are not associated with these symptoms.




386. A client was diagnosed with a hiatal hernia. Discharge teaching was provided and the client was discharged home. The client returns to clinic a week later to complain that the symptoms have not improved.

The nurse questions the client on activities and notes that the client eats small frequent feedings; eats at least one hour before going to bed; has switched from coffee to tea to reduce caffeine ingestion; and has begun a smoking cessation program with moderate success.

Which activity should the nurse counsel the client to change?

A. Eats small frequent feedings.

B. Eats at least one hour before going to bed.

C. Has switched from coffee to tea to reduce caffeine ingestion.

D. Has begun a smoking cessation program with moderate success.

The answer is C. Both coffee and tea are to be avoided as they increase stomach acidity. All the other activities are appropriate for a client with a hiatal hernia.


ENVIRONMENTS




387. Prior to discharge, a client still experiencing some weakness on his left side has axillary crutches ordered for him. Which is the correct crutch gait for the nurse to teach this client?

A. four-point gait

B. three-point gait

C. two-point gait

D. swing through gait

The answer is B. The three-point gait requires the weight to be borne on both crutches and then on the uninvolved leg or side. Since this client still has some left sided weakness this would be the gait of choice.

The four-point gait requires weight bearing on both legs.

The two-point gait requires at least partial weight bearing on each foot. The swing through gait is used by an individual wearing braces which assist in supporting the person ’ s weight.



Pathophysiology

388. An obese 34-year-old black man with a high stress job is seen for primary hypertension. His diet is high in fried

foods and sodium. The client asks why he developed this problem. Which are the risk factors for hypertension that this man has? (Select all that apply.)

A. ___ Age

B. ___ Race

C. ___ Obesity

D. ___ Fat Intake

E. ___ High Stress

F. ___ Sodium Intake

The answers are B, C, E, and F. Hypertension is more common in blacks. Obesity and high sodium intake have been associated with high blood pressure. Stress is associated with hypertension. This gentleman is young, the risk of hypertension increases with age. Although fat intake is related to obesity, fat intake alone has not been associated with hypertension.




Potential for Alteration in Body Systems

Compare current client data with baseline client data

389. A 63-year-old female, with a history of lymphoma treated with chemotherapy, is admitted for repair of a fractured right tibia. Postoperatively her white blood cell count is 4 mm3 and temperature is 98.6_F. She is

complaining of not feeling well and being chilled.

Which is the priority nursing action?

A. Compare the postoperative lab value and temperature to the preoperative data.

B. Ask the client what her WBC and temperature has been in the past.

C. Notify the physician of the change.

D. Do nothing, these are normal values.

The answer is A. With a known history of cancer treated with chemotherapy the client has a low white blood cell count and a value close to normal is indicative of an infection.

B is incorrect — The client may not know what their lab values or temperatures typically have been. C is incorrect —

The answer does not provide information that should be shared with the physician. D is incorrect — Doing nothing may result in a negative event for the patient.


MAINTENANCE


Identify expected physical, cognitive, psychosocial and moral stages of development

390. The nurse is observing a 9-month-old infant to see how the child is developing cognitively. Which behavior indicates object permanence has developed?

The infant

A. has found his hands

B. reaches for a toy out of his reach

C. cries when mother leaves the room

D. puts a block into his mouth while playing

The answer is C. A child who cries when mother leaves the room is aware that mother exists outside his vision so object permanence has developed. None of the other activities indicate the child is aware of objects when not in his or her vision.



Pharmacological agents/actions

391. The nurse caring for a client on digoxin checks the client ’ s electrolyte reports because of the risk of toxicity precipitated by hypokalemia. To avoid this risk, the client ’ s serum potassium level should be equal to or above how many milliequivalents per liter?

Write your answer as a whole number carried to one decimal place. __________ mEq/L.

The answer is 3.5 mEq/L. The normal range of serum potassium is 3.5-5.0 mEq/L.




392. Which is a priority goal for a client with obsessive

compulsive personality disorder?

A. Acceptance of group therapy.

B. Elimination of bizarre fantasies.

C. Development of social relationships

D. Decrease of maladaptive behaviors

The answer is D. Clients with obsessive compulsive personality disorder are rigid and preoccupied with issues of control and power. They fear losing control and utilize different maladaptive behaviors in an effort to control anxiety. Primary goals of therapy are to reduce anxiety, improve self esteem and understand and decrease maladaptive behaviors.




393. The physician instructs a client to eat a low residue diet. Which foods would the nurse instruct the client to reduce or avoid? (Select all that apply.)

A. ___ Eggs

B. ___ Bananas

C. ___ Strong cheeses

D. ___ Lean tender meats

E. ___ Whole grain cereals

F. ___ Dried beans and beans

The answers are C, E, and F. These foods contain significant residue. The other foods are considered low residue.


MAINTENANCE


Apply knowledge of pathophysiology to health screening

394. A 68-year-old client participating in a community skin screening tells the nurse about a raised “ spot ” on

CHAPTER 34 Practice Test for NCLEX-RN® 1171 his upper, outer arm, which has enlarged and changed color. Inspection discloses an irregular border and variegated color. What is the priority nursing response?

A. Caution the client to avoid sun exposure.

B. Advise the client to see a dermatologist as soon as possible.

C. Suggest use of a topical OTC antibiotic ointment to prevent infection.

D. Instruct to wash with a mild soap and avoid irritation.

The answer is B. See a dermatologist as soon as possible. A skin lesion that has an irregular border, inconsistent color, and is enlarging may be a serious condition such as melanoma. It is wise for the patient to see a specialist soon.



Medication administration

395. A 10-year-old child is diagnosed in the pediatric clinic with conjunctivitis (pink eye) and an antibiotic eye ointment is ordered. Which instruction is appropriate for the nurse to give the mother in regard to the administration of the eye ointment?

A. Place the ointment directly on the pupil

B. Have the child apply the ointment by himself

C. Ask the child to close his eyes and spread the ointment on the lids

D. Pull the lower lid down and place the ointment into this “ sack ”

The answer is D. The lower lid is pulled down to form a sack and the ointment is spread into the sack from the inner corner to the outer corner.

The ointment should not be placed directly on the pupil. The child will be unable to instill the ointment by himself. The ointment should be placed into the subconjunctival sac not on the outer lids.


MAINTENANCE



396. When assessing a 12-month-old child, observation of which behavior is indicative of normal developmental

progression?

A. Feeds self with a spoon

B. Smiles and babbles

C. Says two or three words such as mama, dada, and bye bye.

D. Arches the back and raises the head when lying on abdomen.

The answer is C. Saying two or three words is a developmental milestone that should be achieved by 1 year of age.

A is incorrect — Feeding self with a spoon is not expected until 18 months. B is incorrect — Smiling and babbling should be present by 6 months of age and so is not an indicator of normal development at the 1-year level. D is incorrect — Arching the back and raising the head when lying prone also is expected by the age of 6 months.



Blood and blood products

397. A client is to receive a transfusion of packed cells. Prior to administering the unit, which steps will the nurse take? (Select all that apply.)

A. ___ Take vital signs

B. ___ Start an IV of D5W

C. ___ Check that the blood types match

D. ___ Check the client ’ s arm band for match to the unit of blood

E. ___ Double check the client ’ s name and packed cells unit for match

The answers are A, C, D, and E. All are correct except B. The

IV should be started with normal saline. Dextrose in the line will cause the cells to clot.


ENVIRONMENTS




398. Which type of precautions would be used when caring for a client with hepatitis B?





The answer is A. Standard precautions are used to decrease the risk of transmission from bloodborne pathogens and moist body substances. Moist body substances include blood, urine, feces, sputum, saliva, wound drainage, and all aspirated fluids. Because hepatitis B is spread by blood and blood products, standard precautions are appropriate.


B is incorrect — Airborne precautions are used when the mode of spread of an organism is by small particle droplets borne on air currents. Airborne precautions require a private room with negative airflow and adequate filtration; those entering the room wear a mask and if the client leaves the room, a mask is worn. C is incorrect — Droplet precautions are used when the mechanism of transmission is by large droplets spread by coughing, sneezing, or talking. Droplet precautions require a private room or a room shared with someone infected with the same organism. Those entering the room and coming within 3 feet of the client need to wear a mask and the client wears a mask if taken out of the room. D is incorrect —

Contact precautions are used when organisms causing serious disease are easily transmitted through direct contact.

Contact precautions require a private room or a room shared with someone infected with the same organism. Gloves are worn at all times and gowns and protective barriers are used if direct contact is required.




Administers parenteral medication in a safe and effective manner

399. The physician has ordered a medication to be given by

IV push method. Which is an appropriate nursing

action?

A. Refuse to push the medication.

B. Push the medication over 1 full minute.

C. Push the medication over 5 full minutes.

D. Determine the rate of infusion for this particular medication.

The answer is D. Each medication has an individual rate of infusion allowed for IV bolusing (pushing).




400. During the third trimester of her pregnancy, a client develops mild PIH (pregnancy induced hypertension).

Which instruction would be included in the teaching planned for this client?

A. Avoid all sodium containing foods.

B. Rest in bed during the mid-afternoon.

C. When recumbent, always lay in the supine position.

D. Notify the physician at the next prenatal visit if headaches or visual disturbances occur.

The answer is B. Rest is beneficial to reduce hypertension.

Rest should be in the lateral position to prevent vena cava syndrome.

Sodium is a necessary nutrient so eliminating all sodium

would be incorrect. If headaches or visual disturbances occur, the physician should be notified immediately as they may indicate worsening of the client ’ s condition.


MAINTENANCE



401. When assessing a 3-month-old infant, which finding indicates the need for further evaluation?

A. Infant reacts to sudden noise.

B. Infant does not vocalize sounds.

C. Infant does not reach for toys.

D. Infant raises head without arching the back when in a prone position.

The answer is B. By 3 months of age, an infant should be vocalizing sounds and so the absence of this behavior indicates possible developmental delay or other disability and requires further evaluation.

A, C, and D are incorrect — It is normal for a 3-monthold infant to react to sudden noises and so no further investigation is required. Infants are not expected to reach for toys as a developmental marker until 6 months of age. It is normal for a 3-month-old to raise the head without arching the back when in a prone position; arching of the back is not

expected until 6 months of age.


System Specific Assessment

Perform Focused Assessment or Reassessment

(Respiratory)

Identify alterations

402. A client has COPD and a barrel chest. Which finding would the nurse expect when assessing the chest?

A. Paradoxical chest movement

B. Presence of a friction rub

C. Decreased respiratory excursion

D. Absent breath sounds

The answer is C. Respiratory excursion is decreased in the client with emphysema because a barrel chest develops as a result of air trapping in the alveoli and the accompanying lung hyperinflation and flattening of the diaphragm.


A, B, and D are incorrect — Paradoxical chest movement exists when an unaffected area of the chest wall rises on inspiration and the affected area falls and the reverse occurs during expiration. This is seen with flail chest not with emphysema. Friction rubs are associated with pleural inflammation secondary to problems such as pleuritis, tuberculosis, and pneumonia.




403. A client has blood drawn for an electrolyte profile. The venipuncture was difficult and the blood aspiration was slow. The findings included the following: sodium

150 mEq/L, potassium 6.1 mEq/L, chloride 101 mEq/L, and CO2 25 mEq/L. Which conclusion could the nurse draw from this information?

A. The client is doing well as all values are normal.

B. The sodium is low so the client may have heat stroke.

C. The CO2 is elevated so there may be a respiratory problem.

D. The potassium is high, the specimen may have been hemolyzed.

The answer is D. The potassium is very high but all other values are normal. Because of the problems with the blood draw, the specimen could have been hemolyzed. Hemolysis results in the release of intracellular potassium and hence can cause hyperkalemia in the specimen. All other values are within normal limits.


MAINTENANCE

Provide education on age specific growth and development to the client and families

404. A toddler is shopping with mother. The toddler grabs

a toy off the shelf. When mother replaces the toy on the shelf, the toddler cries and falls on the floor. Which is the best response by the mother?

A. Buy him the toy

B. Spank his hands and tell him no

C. Explain to the child why he can ’ t have the toy.

D. Remove the child from the area and divert attention to something else

The answer is D. The child is expressing his frustration. The goal of the parent is to allow the child to regain control without a loss of self-esteem. Removing and distracting him will allow him to regain self control.

Buying him the toy will not help him learn to deal with frustrations. Spanking his hand does not help with selfesteem.

The child doesn ’ t have the vocabulary for long explanations and frustration will continue as long as the desired object is in sight.


ENVIRONMENTS




405. The nurse is reinforcing the correct way for a client to descend stairs using crutches. In which order would the nurse instruct the client to proceed with the listed steps?

A. Places crutches on the next stair, transfers weight to the crutches, moves affected side (leg) forward

B. Moves unaffected side (leg) forward

C. Transfers body weight to the unaffected side (leg)

The answer is C, then A, and then B. The client transfers body weight to the unaffected side (leg) then places the crutches on the next stair. Next the client transfers weight to the crutches and moves the affected side (leg) forward. Finally the client moves unaffected side (leg) forward.

This order enables balance to be maintained and allows the client to more safely go down the stairs.




406. A client is receiving a chemotherapy agent that is known to be irritating to the bladder wall. Which nursing action would best reduce irritation?

A. Encourage the client to drink milk

B. Restrict fluids to decrease urine volume

C. Administer the once daily drug at bedtime

D. Have the client void every two hours while awake

The answer is D. Having the client void frequently reduces the time the medication sits in the bladder. The nurse would also force fluids to dilute the medication and on once daily meds, give it early in the morning so the client can void frequently.

Milk would have no effect on bladder irritation.



Recognize signs and symptoms of impaired cognition

407. A client with schizophrenia says “ raining turkeys ” to himself and to others as he walks around the unit and

1174 PART III: Taking the Test performs various activities. Which would be a correct label for the nurse to use when documenting this behavior?

A. word salad

B. clang association

C. neologism

D. verbigeration

The answer is D. Verbigeration is the purposeless repetition of words or phrases. Word salad refers to the meaningless connection of words and phrases. Clang association refers to repeating words and phrases which sound alike but are otherwise unconnected. A neologism is a new word coined by the client and with meaning only to the client.



Total parenteral nutrition

408. A client has an order for total parenteral nutrition to

run at 95 ml/hour. The TPN is infusing into a central line. While transferring the client to a stretcher to go to x-ray, the central line is accidentally pulled out. Which is the immediate nursing action?

A. Give the client sugar laced orange juice by mouth.

B. Start a peripheral line with D5W running at 95 ml/hour.

C. Start a peripheral line and administer the TPN at 95 ml/hour.

D. Notify the physician and wait for the central line to be restarted.

The answer is B. The client ’ s body is accustomed to receiving a strong sugar solution at that rate so sudden stopping would cause hypoglycemia. TPN cannot be given by peripheral line. Sugar laced orange juice would not meet the need for continuous glucose infusion until the central line could be replaced.



Therapeutic procedures

409. A client has been severely burned in a house fire and admitted to the burn unit. After emergency stabilization, one of the primary nursing goals is to prevent contractures. Which nursing intervention supports achievement of this goal?

A. Administration of albumin

B. Promoting the intake of protein foods.

C. Application of splints to immobilize body parts

D. Treating the burns with the open method and not wrapping the burned injury.

The answer is C. Whereas all of the interventions may be used in the treatment of burns, the one intervention associated with prevention of contractions is the application of splints.

In addition to splinting, ROM exercises are important in maintaining joint function.


MAINTENANCE

Immunizations

410. An infant received her first immunization on schedule but is now past due for both the second and third immunization of the series. The nurse should

A. give the infant the second and third immunization during this visit.

B. start the immunizations over, giving the infant the first of the series.

C. give the second immunization and schedule the infant for a return visit for the third immunization.

D. give a double dose of the second immunization and then give the third immunization one month later.

The answer is C. Although there is an abnormal space

between the first and second immunization, the nurse will give the second and schedule the third immunization for later. There is no need to restart the immunization.

Two immunizations should not be given at the same time.



Pathophysiology

411. A teenager is admitted to the hospital with a diagnosis of osteomyelitis. An IV is started for administration of parenteral antibiotics. The teenager complains about hospitalization and asks the nurse: “ Why can ’ t I just be given some pills to take like my friend that had the abscess?

” The nurse ’ s response would be based on the knowledge that osteomyelitis:

A. Lacks an effective oral antibiotic.

B. Can cause pathologic fractures so the child must be hospitalized.

C. Is caused by a different organism than the one that causes abscesses.

D. Requires parenteral antibiotics to reach bone levels of the drug high enough to be effective.


The answer is D. Blood supply to the bones is less than to the skin. Parenteral antibiotics provide the best blood levels. The

organism may or may not be the same as the other child had.

Although pathologic fractures can occur from osteomyelitis, bedrest prevents the fracture not hospitalization.




412. A child has a tonsillectomy. On return to the floor, the child is positioned prone until fully awake. Instructions given to the parents should include: (Select all that apply.)

A. Avoid red liquids

B. Use a straw to make drinking easier

C. Cold liquids like popsicles will feel good.

D. Give milk and non-acidic liquids to soothe the throat

E. As soon as the child wakes up, start the child drinking

The answers are A, C, and E. Red liquids could be confused with blood in vomitus or stool. Cold liquids will reduce pain and promote blood clotting. Pushing orals fluids will keep the throat moist and reduce discomfort. A straw requires suction which could dislodge the clot that has formed in the throat. Milk thickens secretions requiring more throat clearing which is discouraged.



Potential for complications from surgical procedures and

health alterations

413. A client with polycystic kidney disease needs a kidney transplant. Which action will the physician take prior to another family member being considered as a suitable donor?

A. Discuss with the client feelings about the donor.

B. Instruct the client to take over the counter drugs for pain

C. Screen the family member for evidence of polycystic kidney disease

D. Stop dialysis treatment so that the client ’ s kidney function can be adequately evaluated

The answer is C. Polycystic kidney disease is inherited as an autosomal dominant disorder. Any family member should be screened for kidney disease before consideration as a donor. Until a donor is found, there is no need to discus the client ’ s feelings about the donor. Medications are avoided because of the injury to the kidneys. If the client was on dialysis, the kidney function is known so stopping would be unnecessary and unhealthy.


ENVIRONMENTS


Safe Use of Equipment

Ensure appropriate and safe use of equipment in performing

client care procedures and treatments

414. Which are safety measures that the nurse needs to keep in mind when transporting a client in a wheelchair?

Select all that apply.

A. Lock the wheels before the client transfers from bed to wheelchair

B. Push the wheelchair in a forward direction when getting on an elevator

C. Be sure the footplates are in the down/lower position as the client gets into the wheelchair

D. Position the client well back in the seat

The answers are A and D. The wheelchair ’ s wheels always need to be locked before transferring a client into the wheelchair to prevent the wheelchair from moving and the client falling. Ensuring the client is sitting fully in the wheelchair will prevent the wheelchair from being off balance and possibly tipping forward.




415. Due to an allergy to cats, a client has had several allergy attacks after visiting a family member. The physician has prescribed an antihistamine to reduce the symptoms.

The client asks the nurse when would be the best time to take the antihistamine. The nurse ’ s response is

based on the knowledge that antihistamines

A. transfer the allergic response to a mast cell.

B. destroy the allergen that caused the symptoms

C. block histamine from attaching to receptor sites.

D. destroy histamine, the cause of allergic symptoms.

The answer is C. Antihistamines compete with histamine for the receptor sites. Once histamine is attached to the receptor site, an anti-histamine will not work. The best time to take the antihistamine would be before going to the house with cats.




416. Due to injuries in a car accident, a client has a tracheostomy.

Which is a step in providing tracheostomy care?


A. Put on clean gloves in preparation for the procedure.

B. Advance the suction catheter while applying suction.

C. Insert the suction catheter as deep into the airway as possible and begin suctioning.

D. Rotate the suction catheter while applying intermittent suction during withdrawal.

The answer is D. Rotating the catheter cleans all surfaces of the trach. Intermittent suction prevents the client from becoming hypoxic. The procedure is sterile so sterile gloves are worn. Suction is never applied while inserting the

catheter. The suction catheter is inserted fully and then withdrawn slightly before suctioning begins.


MAINTENANCE

Human Sexuality

417. A woman is talking to her best friend who is a nurse.

The woman knows that she does not carry the gene for sickle cell anemia. She tells the nurse she is going to marry a man who has the disease. She asks whether her future children will be affected with sickle cell anemia.

The nurse ’ s best response would be

A. no, but they will all be carriers for the disease.

B. one in four of your children will have the disease

C. none of your children will have the disease but 50% will be carriers.

D. there is no way to determine the possible outcome for your future children.

The answer is A. Sickle cell anemia is an autosomal recessive disorder, which means the child must receive an affected gene from each parent. Since she does not carry the affected gene, none of the children will be affected. However, since the both of the husband ’ s genes are affected, the children will all receive one copy of the affected gene meaning they will be carriers. The other responses are incorrect.


Reduction in Risk Potential

Potential for complications of diagnostic tests/treatments/ procedures

418. An infant was diagnosed with hydrocephalus shortly after birth and a ventriculo-peritoneal shunt was inserted. Three years later, the child is readmitted to the hospital with a malfunctioning shunt. Which assessment findings would the nurse interpret as expected based on the problem?

A. Vomiting and headache

B. Temperature and bradycardia

C. Abdominal pain and electrolyte imbalance

D. Bulging fontanels and increasing head circumference

The answer is A. Early symptoms of a malfunctioning shunt

(and of hydrocephalus) are vomiting and headache, especially in the early morning. A younger child might have bulging fontanels and increasing head circumferences but this child is over 3 and fontanels should have closed.



Potential for alteration in body systems

419. There are several clients currently in the burn unit with extensive burns. Which client would be at greatest risk for infection in the burn?

The client who:

A. has skin grafts completely covering all burn surfaces.

B. is being discharged home with follow-up physical therapy.

C. is being treated with the open method (no dressings) of burn treatment.

D. is being treated with the closed method (dressings covering) of burn treatment.

The answer is C. The client whose burns are open to the air would be most likely to develop an infection. Dressed burns and grafted burns have coverings which will reduce the likelihood of infection. The client who is being discharged for follow-up physical therapy has burns that are well on the way to healing.


MAINTENANCE



420. Which question should the nurse ask the parent of a

7-month-old infant to obtain the most meaningful information about the child ’ s development?

A. Can she sit up by herself?

B. Does she make cooing sounds?

C. Does she turn over?

D. Can she transfer a spoon hand to hand?

The answer is A. By seven months, the infant should be able

to sit without support. The other options are appropriate for younger children.





421. A 10-month-old infant needs an immunization. Which is the best site for the intramuscular injection?

A. Deltoid

B. Gluteal

C. Dorsogluteal

D. Vastus lateralis

The answer is D. This muscle is the best choice until the child is walking well.

The deltoid is never used on young children. The gluteal and dorsagluteal both refer to the same site and should not be used in children under 2.


ENVIRONMENT


Injury Prevention

Protect the client from injury

422. After admission to the hospital unit, a 5-year-old child is diagnosed with a brain tumor involving the cerebellum.

While providing care in the preoperative period,

which would be the primary nursing intervention?

A. Protect the child from falls

B. Monitor the child for seizures

C. Measure the head circumference daily

D. Maintain the child ’ s temperature within the normal range

The answer is A. Pathology in the cerebellum leads to ataxia which places the child at risk for falls.

B, C, and D are incorrect — Seizures are a late symptom in brain tumors so would not be expected here. The child ’ s sutures have closed at 5 years of age so head circumference will not change. The temperature is not likely to be affected.




423. An elderly client is going to have a feeding tube permanently placed. The physician is debating placing a

PEG gastrostomy tube or a jejunostomy tube. Which fact about the client suggests that a jejunostomy tube is the best option?

A. The client ’ s caloric needs are high.

B. The client has a tendency to vomit.

C. The client ’ s family will be caring for the feeding tube.

D. The client is mentally confused and may pull on a tube.

The answer is B. Vomiting would decrease with a jejunostomy tube as the feeding will be placed in the duodenum rather than in the stomach. The other statements would have no bearing on the decision.


MAINTENANCE

Self-Care

424. A client has recently been diagnosed with a mild case of emphysema and has been instructed in self care at home. On a return visit to the clinic, the client makes the following statements. Which statement indicates the need for further client education?

A. “ I quit the gym since I shouldn ’ t exercise.

”

B. “ I told my family they could no longer smoke in my house.

”

C. “ I have increased the water I drink by two extra glasses per day.

”

D. “ I had a room air conditioner put into my home so that I can stay indoors when the pollution level is high.

”

The answer is A. Moderate exercise can be beneficial to help keep the airways open and clean. All other statements were correct information and do not indicate need for further intervention.




425. A nurse is working with several pediatric renal clients.

The nurse notes similarities between the labs of the pediatric clients with nephrotic syndrome and those with acute glomerulonephritis. Which lab findings would be similar?

A. Urine positive for protein

B. Serum albumin decreased

C. Elevated serum triglyceride levels

D. Urine positive for red blood cells.

The answer is A. In nephrotic syndrome, albumin is lost while in acute glomerulonephritis, red blood cells are lost in the urine. Both are proteins and would give a positive proteinuria level. In nephrotic syndrome, the serum albumin is

1178 PART III: Taking the Test decreased and serum triglyceride levels are elevated. RBCs are in the urine for acute glomerulonephtirits.




426. A child is found to be allergic to milk. To ensure adequate calcium intake, which foods would the nurse recommend be included in the child ’ s diet?

A. Coffee and tea

B. Pork and ground beef

C. Fruits such as apples and pears

D. Green leafy vegetables such as collard greens and spinach

The answer is D. Greens and spinach are good sources of calcium.

The other foods are not sources of calcium.


MAINTENANCE

Growth and Development

427. Many high schools organize programs to discourage teenagers from driving drunk, e.g., a fatal car accident involving popular students is staged in a place where students will see it. On which developmental fact is the effectiveness of these programs postulated?

Teenagers

A. view death as a result of an accident.

B. view death as a temporary separation.

C. think death only occurs to the elderly and the sick.

D. recognize that death is universal but usually do not see themselves as susceptible.

The answer is D. Teenagers can conceptionally view death as an adult does, but often do not think it can happen to them or their friends. These programs help them to understand the reality that driving and drinking can be fatal to everyone.

The other views of death are those of younger children.




428. Which is a step in the procedure for applying a transdermal patch for medication administration?

A. Wear sterile gloves when handling the patch.

B. Apply the patch to clean, dry, and un-inflamed skin.

C. Wipe the skin with alcohol and Betadine before applying the patch.

D. Rub the patch firmly after application to insure solid contact with skin.

The answer is B. Applying to clean dry and un-inflamed skin provides the best medication absorption.

Clean gloves should be worn, not sterile. The alcohol and Betadine are not used because they could affect medication absorption. Always follow manufacturer recommendations for application including rubbing the patch after application.



Diagnostic tests

429. A client admitted for a workup to rule out multiple sclerosis has an evoked response test. The client asks what this test will evaluate. Which is the correct reply?

The test will evaluate:

A. radiation uptake by the brain.

B. the size of the brain for atrophy.

C. the amount of protein in the cerebrospinal fluid.

D. the length of time it takes for the nerve cell to conduct an impulse.

The answer is D. The evoked response test stimulates one nerve and evaluates how long it takes that message to travel to the brain. The stimuli can be visual, auditory or somatosensory. Radiation uptake would be a scan, a CT will evaluate atrophy of the brain. The amount of protein in the

CSF is evaluated by a lumbar puncture.


Grief and Loss

430. A terminally ill client tells the nurse “ If I can only live to see my grandchild born.

” The nurse recognizes this is an example of

A. disbelief

B. bargaining

C. depression

D. acceptance

The answer is B. Bargaining is the “ If this, then that ” response.

The disbelief response is “ No, not me ” and doctor shopping looking for a more acceptable diagnosis. In depression, the client accepts that death is inevitable and is saddened about all that they are losing. Acceptance is when the client is at peace with the terminal illness.




Potential for complications of diagnostic test/treatments/ procedures

431. A client with a history of severe allergic reactions, is to be allergy tested. Which type of allergy test requires the most careful monitoring for a severe reaction?

A. A RAST test

B. Skin patch testing

C. An eosinophil count

D. Intracutaneous skin testing

The answer is D. This test provides the risk of the greatest exposure to potential allergens. Skin patch testing also involves exposure to potential allergens, but since the allergen is not injected, there is less risk of a systemic reaction.

RAST test and eosinophil counts involve no risk of an allergic reaction.




432. A client develops Bell ’ s Palsy affecting the right side of their face. Which would be an important nursing intervention?

A. Instill artificial tears into the right eye.

B. Reinforce that appearance doesn ’ t matter.

C. Provide a clear liquid diet to prevent choking.

D. Apply skin care products to the right side of the face from scalp to jaw line.

The answer is A. Because of the palsy, the client will be unable to blink on the right side. This will cause the right eye to dry out so artificial tears will keep the eye moist and promote comfort. Telling someone appearance doesn ’ t matter doesn ’ t affect how the client feels about appearance. Chewing and swallowing are only minimally affected so clear liquids are not appropriate. The skin on the affected side remains intact so skin care products are not required.


MAINTENANCE

Self-Care

433. A diabetic client is being taught foot care. Which information will the nurse include in the teaching? (Select all that apply.)

A. ___ Do not wear sandals or open toed shoes

B. ___ Rubber/plastic shoes are best for your feet.

C. ___ Use a mirror to inspect the soles and back of the foot daily

D. ___ Buy your shoes in the late afternoon when your feet are their largest.

E. ___ Cut your toenails first thing in the morning

when they are the softest.

The answers are A, C, and D. Sandals and open toed shoes increase the risk of injury to the feet. A mirror will allow the inspection of hard to see areas. Your feet are their largest in late afternoon, so that is the best time to shop for shoes.

Natural fibers should as leather and canvas allow perspiration to escape and are better than rubber and plastic.

Toenails should be cut after a bath when they are the softest.




434. A client is seen in the emergency room for severe pain secondary to renal calculi. Following the administration of pain medication, the client is sent home and instructed to filter all urine for stones. Which other instructions will the nurse give the client? (Select all that apply.)

A. ___ Limit milk intake

B. ___ Rest in the lateral sims position

C. ___ Void every two hours while awake

D. ___ Increase intake of meat, eggs and cranberries

E. ___ Increase fluid intake to 2 to 3 liters of fluid per day.

The answers are A, D, and E. In some clients, milk intake increases the calcium levels which are a component of some renal calculi. In addition, milk increases the alkalinity of the

urine which can be a factor contributing to renal calculi.

Meat, eggs, and cranberries produce acidic urine which reduces renal calculi. Fluid intake will help to reduce calculi.

Resting in the lateral Sim ’ s position and voiding every two hours will not reduce renal calculi.




435. A client with nutritional deficiencies has a jejunostomy tube placed for enteral feedings. The physician orders the client to receive 2400 ml of feeding per day. Which is an appropriate nursing action?

A. Divide the feeding into 3 parts and feed at meal times.

B. Feed the client an equal amount every two hours around the clock.


C. Place the feeding on a pump and feed continuously around the clock.

D. Divide the feeding into 6 feedings and feed every 4 hours around the clock.

The answer is C. Jejunostomy feedings should be continuous.

Gastrostomy feedings can be bolused.


Mental Health Concepts

436. A client has been ordered by the court into a facility

which specializes in the treatment of substance abuse. Group meetings are an integral part of the program. On the third day of treatment, the client says “ I am not going to group this morning.

” In responding to the client, which fact must the nurse consider?

A. The client may be required to be in the facility but he has the right to informed consent in regard to participation in treatment.

B. The client can be physically escorted to the meeting room but cannot be made to enter.

C. The client can be coerced into attending the meeting as long as no physical force is used.

D. The client can elect not to attend 20% of treatment activities without any repercussions.

The answer is A. Because a client is involuntarily admitted to a facility does not mean that his right to informed choice is forfeited.



Adverse effects/contraindications/side effects

437. The client has been on antibiotics for 10 days. When talking to the clinic nurse, the client mentions that diarrhea has become bothersome. Which would be an appropriate action for the nurse to suggest?

A. Decrease water intake

B. Add yogurt to the diet.

C. Increase milk in the diet.

D. Inform the physician at the next clinic visit

The answer is B. Antibiotics eliminate the normal flora of the intestines. Decreasing water intake will worsen the problem with dehydration. Adding yogurt to the diet will help replace the normal flora. Milk would not benefit the client. Putting off intervening until the next clinic visit is not appropriate.




438. A client is receiving erythromycin by peripheral IV. On the third dose, the client complains of pain at the IV insertion site. The nurse checks the insertion site but the site is benign. Which action is appropriate for the nurse take to decrease the risk of phlebitis?

A. Give the infusion faster to reduce vein exposure.

B. Give the medication orally instead of intravenously.

C. Give the client the pain medication that has been ordered prn.

D. Call the pharmacist and ask for the medication to be diluted.

The answer is D. Diluting the concentration of the drug will

reduce the irritation to the vein. The other responses will not improve the developing phlebitis.


MAINTENANCE

Family Planning

439. A woman has just delivered her fourth baby in 5 years.

She states she doesn ’ t want to become pregnant again immediately. Which is the birth control option that would offer the best protection for this client in the first 6 weeks post partum?

A. Diaphragm

B. Breast feeding

C. Intrauterine device (IUD)

D. Natural family planning (Rhythm)

The answer is C. An IUD may be inserted soon after childbirth as it does not affect involution. A diaphragm needs to be fitted to the cervix. During involution, the cervical shape could change thus altering the fit of the diaphragm so it no longer provides protection. Breast feeding is not a method of contraception. Natural family planning can be used, but since many women ovulate before menstruation returns, it may not be successful in the immediate postpartal period.


Coping Mechanisms

440. A toddler has been hospitalized for several days. The

mother visits irregularly. Although the toddler cried a lot at first, the child now seems to have settled in and is happy and playful. Which type of reaction is the child displaying?


A. Despair

B. Denial

C. Protest

D. Bargaining

The answer is B. Protest, despair, and denial are the three stages of toddler hospitalization reaction. Denial is a symptom of a severe psychological reaction. In despair, the child mourns the loss of the mother. In protest, the toddler is angry, and screams and kicks. Bargaining is not a component of toddler hospitalization reaction.




441. A child is admitted with marked edema and frothy urine. Lab tests showed proteinuria and decreased serum albumin and globulin. Which is an appropriate diet for this child?

A. Low protein, high calorie

B. High protein, no added salt

C. High calorie, low sodium

D. High protein, low calorie

The answer is B. Nephrotic syndrome is the idiopathic loss of protein in the urine. With the loss of protein, there is a loss of osmotic pressure and fluid escapes from the vessels into the tissues. Replacement of protein is key to reducing edema.

Sodium promotes fluid retention, however low sodium diets are not tasty. In children, low sodium diets are avoided if possible so no added salt would be the right choice.


MAINTENANCE


442. The mother tells the nurse that her older children have been trading money with her 3-year-old. The older children offer the toddler their pennies for her dimes. The nurse recognizes that the toddler has not developed:

A. Egocentrism

B. Conservation

C. Object permanence

D. Cognitive dysfunction

The answer is B. Conservation is the ability to deal with a number of different aspects at the same time. At this time, the toddler can only see that the penny is bigger than the dime and cannot understand that the dime has more value.

This is a skill learned in the school-age period. Egocentrism is the inability to put themselves in others ’ place. Object

permanence is the realization that objects exist even when the child cannot see the object.



Laboratory Test

Calculates an absolute neutrophil count

443. A client has a white blood cell count of 6000/mm3.

The differential reports 47% of these are neutrophils

(segs) and 5% are bands. What is the absolute neutrophil count?

A. 2520

B. 2820

C. 3120

D. 3420

The answer is C. ANC _ segs _ bands _ white blood cell count. .47 _ .05 _ .52 _ 6000 _ 3120.




444. A pregnant woman at term comes to the labor unit saying her membranes have ruptured. Which characteristic of the client ’ s vaginal secretions would confirm that the membranes had ruptured? The vaginal secretions:

A. Are positive for glucose

B. Contain red blood cells

C. Turn nitrazine paper a reddish orange

D. Appear fern like under the microscope when dried on a slide.

The answer is D. Amniotic fluid present in the vagina indicates the membranes have ruptured. When dried amniotic fluid is examined under a microscope, a crystalline fern pattern may be observed.

When vaginal secretions are tested with nitrazine paper, the color change would be blue green if the membranes have ruptured as amniotic fluid is alkaline. The presence of glucose gives no indication of the status of the membranes. Red blood cells would be positive even before the membranes ruptures.



Use therapeutic communication techniques to provide support to the client and/or family

445. A client is scheduled for a surgical procedure under local anesthesia. Which is an appropriate nursing

1182 PART III: Taking the Test intervention when preparing the client for the surgery?

A. Reassure the client that a nurse will stay with him.

B. Explain to the client what will be felt, seen, and heard.

C. Tell the client not to worry as the physician has done it many times before.

D. Explain what the nurse and the surgeon will be doing during the procedure.

The answer is B. Preparations for any procedure should be in terms of what the client will feel, see and hear.

Choice A does not prepare the patient for what will happen.

C is not a reassurance. D explains the procedures in terms of what happens to the nurse and doctor, not the client.




446. A client is suspected of having renal calculi. Which is the classic assessment finding indicative of this problem?

A. Oliguria

B. RBCs in the urine

C. Frothy appearing urine

D. Acute severe flank pain on one side

The answer is D. Pain is the chief symptom although blood may be noted especially in bladder calculi. The volume of urine does not change so oliguria is not a symptom. Frothy appearing urine is seen in the individual with albumin in the urine.




447. An elderly client returned from surgery this am. Since surgery, the client has become increasingly confused. The

nurse reviews the client chart and notes the following:

• The biopsy from surgery was positive for cancer.

• The wound dressing had a small amount of serosanguineous drainage.

• An NG tube to suction was in place during the first

6 hours post surgery.

• Meperidine HCL (Demerol) has been given every 4 hours for pain.

Which of these findings could account for the increasing mental confusion?

A. The biopsy from surgery was positive for cancer.

B. The wound dressing had a small amount of serosanquinous drainage.

C. An NG tube to suction was in place during the first

6 hours postsurgery.

D. Meperidine HCL (Demerol) has been given every 4 hours for pain.

The answer is D. Meperidine is broken down in the body and releases by-products that are difficult for the elderly client to excrete. These by-products build up in the body with repeated doses causing mental confusion. None of the other findings would be associated with mental confusion.


MAINTENANCE

Ante-/Intra-/Postpartum and

Newborn Care

448. When admitted for labor, the client had been excited and talkative. Now, two hours later, the client appears serious and does not participate in “ chit-chat.

” How should the nurse interpret this behavior?

The client is:

A. worn out from laboring.

B. in the active phase of labor.

C. dissatisfied with the nursing care.

D. displaying concern for the fetus ’ well-being.

The answer is B. Clients in early (latent) labor are excited and talkative. As they proceed into active labor, their demeanor becomes serious and they are less talkative. There is no evidence that any other of the statements are true.




Instructs the client on measures to promote health

449. A client is admitted for pneumonia. The nurse instructs the client to change positions every two hours. The client asks the nurse why this is important.

The nurse explains that turning:

A. prevents Actelectasis of the lungs.

B. promotes drainage from the lung lobes by gravity.

C. changes the portion of the lung that is splinted by

the bed.

D. keeps uninvolved portions of the lungs from becoming infected.

The answer is C. The bed splints the chest and limits the ability of the lung to expand. Turning changes the portion of the lung that is splinted promoting better oxygenation. The other responses are incorrect.





450. A child has just been diagnosed with asthma. The nurse has taught the mother how to “ allergy proof ” the home. Which statement by the parent indicates a need for additional teaching?

A. “ I will remove all stuffed toys from my child ’ s bedroom.

”

B. “ Out of season clothes will be stored away from my child ’ s room.

”

C. “ I will enclose my child ’ s mattress and box springs with plastic coverings.

”

D. “ I will put wall-to-wall carpeting in my child ’ s room to reduce exposure to chemicals.

”

The answer is D. Wall to wall carpeting will hold dust and increase allergy exposure. A better option is hard wood floors which can be mopped on a daily basis. The other

options are correct.



Infectious disease

451. The client has been diagnosed with syphilis and begins treatment with intramuscular penicillin G. Within 24 hours of this first injection, the client returns to the clinic complaining of joint pain and fever. On assessment, the nurse notes tachycardia and hypotension.

How should the nurse interpret these signs and symptoms?

A. A worsening of the syphilis

B. An allergic reaction to the penicillin

C. Cellular debris from the destruction of the spirochetes.

D. Anxiety due to the diagnosis of a sexually transmitted disease

The answer is C. The symptoms describe Jarisch-Herxheimer reaction, indication that a large amount of spirochetes have been killed by the penicillin. The client would be treated symptomatically; the penicillin would not be stopped.

Symptoms will abate in another 12 hours.


MAINTENANCE


452. During a well child visit, a mother tells the nurse she

will be bringing her toddler to a play group for the first time and asks what the child ’ s reaction is likely to be.

As part of her response, which type of play does the nurse describe as characteristic of toddlers?

A. Solitary

B. Cooperatively with several toddlers

C. Interactively in groups of no more than 3

D. Beside another toddler but not with the other toddler

The answer is C. Parallel play in which a toddler plays beside but not with another toddler is the type of play characteristic of the age group. Infants play alone, called solitary play.

Cooperative play is organized and seen in older children.

Toddlers do not interact with other children well because of their egocentricity.




453. A child is admitted to the hospital for Kwashiorkor, protein malnourishment. Which physical finding would be expected on the admission assessment?

A. Eczema

B. Edematous

C. Height below normal range

D. Weight below normal range

The answer is B. Protein provides the osmotic property of the

blood and without protein, liquid escapes into the tissues.

The child may be overweight if there were adequate carbohydrates in the diet.




454. An adult client is scheduled for a tonsillectomy. Several labs are ordered pre-operatively. Which lab test is most significant prior to this surgery?

A. CBC

B. PTT

C. Urinalysis

D. WBC with differential

The answer is B. The surgery includes a significant risk for hemorrhage; so the client ’ s ability to clot should be carefully evaluated prior to the surgical procedure. CBC is important but not the most important. Urinalysis is usually not significant. WBC with differential probably would be ordered as tonsillectomies are not done when there is infection present.




Infectious diseases

455. Several members of a family have been diagnosed with

pinworms. In addition to treating the family with medications, which is an important instruction for the nurse to give the family?

A. Cook all meats well.

B. Never go barefoot outside

C. Wash all vegetables before eating

D. Wash all clothes and bed linens in hot soapy water.

The answer is D. Pinworms are spread from person to person and have no dirt cycle. The primary source of contamination is the clothing. Cooking meats reduces the risk tapeworms.

Walking barefoot can lead to hookworm. Washing all vegetables reduces the risk of roundworms.


MAINTENANCE



456. What is the nurse assessing when with the client ’ s eyes closed, the nurse moves the client ’ s toes up or down one by one and asks the client to say in which direction each was moved?


B. Stereognosis

C. Position sense

D. Light touch

The answer is C. This procedure is a test of position sense.

A, B, and D are incorrect — Two-point discrimination involves touching the skin simultaneously with two sterile needles at closer and closer distances to each other until the client perceives only one touch. Stereognosis is asking the client to identify a familiar object such as a key when it is placed in the client ’ s hand with the client ’ s eyes closed. Light touch is tested by stroking an area of the client ’ s skin with a wisp of cotton.





457. A 2-year-old client with otitis media is to receive ear drops. To properly administer the ear drops, the nurse pulls the pinna:

A. Up and back

B. Up and forward

C. Down and back

D. Down and forward

The answer is C. The pinna of the ear is pulled down and back for children under three and up and back for children over three.





458. A 1-week-old infant has surgery to repair a cleft lip.

Which is the priority concern when the child returns from the recovery room?

A. Feeding method

B. Maintaining airway

C. Preventing scarring of the lip

D. Preventing incisional infection

The answer is B. Immediately after surgery, the concern is airway.

Because of surgery to the nares and the fact that newborns are obligant nasal breathers, swelling could occlude the nares. Feeding method will be a concern because sucking will interfere with the integrity of the suture line.

Preventing scarring and infection are also concerns but not immediately on return to the floor.


ENVIRONMENT

Safety and Infection Control

Standard/transmission-based/other precautions

459. A client with cancer is being treated with chemotherapy.

The client becomes neutropenic. To prevent infection, the nurse implements the following: (select all that apply)

A. Place the client in contact isolation

B. Eliminate fresh flowers from the client ’ s room

C. Serve the client only cooked fruits and vegetables

D. Use a soft toothbrush to prevent the gums from bleeding

E. Allow only close family members (spouses and children) to visit

The answers are B and C. Fresh flowers may spread mold.

Only cooked vegetables and fruits are allowed to be sure all organisms have been destroyed.

A, D, and E are incorrect — The client will be in protective isolation, not contact. Bleeding gums is thrombocytopenia.

Visitors are acceptable as long as they are not

CHAPTER 34 Practice Test for NCLEX-RN® 1185 sick. The client will avoid crowds and children who might be infected.




460. Following an automobile accident, the client is admitted to the hospital unit with a fractured femur. The client is placed in skeletal traction. Which is an appropriate nursing action?

A. Restrict fluid

B. Turn side to side every two hours

C. Perform Range of Motion exercises on the affected hip

D. Give sterile pin care using Betadine and sterile dressing

The answer is D. Skeletal traction involves a pin being

inserted through the bone as a component of the traction.

Since there is a loss of skin integrity at the site of the bone pinning, this site is at risk for infection. Therefore, pin care is an important part of the nursing care.




461. The nurse is attempting to start a peripheral intravenous infusion line on a client with small veins. The nurse has made one attempt without success. The nurse states the veins aren ’ t palpable with gloves on.

Which action should the nurse take?

A. Start the IV line without gloves.

B. Wear a glove on the dominant hand only.

C. Wear two gloves that the pointer finger of one glove has been removed for palpation

D. Locate the vein without gloves and mark the site then put on gloves

The answer is D. For all procedures where blood exposure could occur, gloves are required. Removal of one finger has the same consequence as removing the whole glove and is not acceptable.


MAINTENANCE


462. The nurse is doing a complete physical assessment on a young child. Which is the most appropriate order of assessment for the nurse to use?

A. Heart and lungs sounds first

B. Percussion before auscultation

C. Organized in a head to toe manner

D. Invasive procedures first to get them over.

The answer is A. Listen to heart and lungs sounds first. Once an infant starts crying, it will be more difficult to hear these.

Auscultation is before percussion. Organized is appropriate but because of the child ’ s developmental stage, it is not head to toe. Invasive should be performed last as children tend to be less cooperative after invasive procedures.




463. A baby has been diagnosed with developmental dysplasia of the hips and a Pavlik harness is applied. The

Pavlik harness is a type of splint that abducts and flexes the hips while still allowing leg movement. The harness can be removed and reapplied by the parents.

Instructions to include for the family caring for an infant in this type of harness would include:

A. increase fluid intake to promote urine output.

B. keep the harness on the child at least 23 hours a day.

C. take the harness off at night if the baby is uncomfortable.

D. the baby will need a high protein diet to allow hip repair.

The answer is B. When harnesses and splints can be applied and removed by the parents, there is a tendency for parents to remove them if the child complains.

C will result in insufficient treatment. A is not appropriate as this condition is not related to urinary function. D is incorrect as this is not a protein deficiency.



Recognize signs of acute and chronic mental illness

464. A man brings his mother to the clinic and says she has been diagnosed with Alzheimer ’ s disease but her behavior has changed drastically and he is concerned about what has happened. On obtaining the history, the nurse learns the client had been disoriented in terms of time and place, had loss of memory, and had difficulty with banking, housecleaning and other activities of daily living but has now become agitated and combative; doesn ’ t bathe or groom; and rarely speaks.

Which conclusion does the nurse draw from this information?

A. The client has entered stage 2 of Alzheimer ’ s disease.

B. The client has passed from stage 2 to stage 3 of

Alzheimer ’ s disease.


C. The client has endstage disease.

D. The client has a secondary disease process going on.

The answer is B. The client ’ s past symptoms of disorientation, memory loss and difficulty with instrumental activities of daily living are all characteristic of stage 2 Alzheimer ’ s disease.

The client ’ s new symptoms of agitation, combativeness, lack of bathing and grooming, and rarely speaking are all symptoms of stage 3 Alzheimer ’ s disease.




465. During the initial assessment process, a client tells the nurse that he is lactose intolerant. When the nurse questions the client about the lactose intolerance, the nurse would expect the client to describe symptoms including (select all that apply).

A. ___ Rashes

B. ___ Flatus

C. ___ Constipation

D. ___ Black furry tongue

E. ___ Abdominal cramping

The answers are B and E. In addition to these symptoms, the other major symptom is diarrhea which can be explosive.

Rashes are associated with allergic responses, not lactose

intolerance. Black furry tongue is usually do to the overgrowth of organisms not susceptible to antibiotics and not associated with lactose intolerance.



Adverse Effects/Contraindications


466. A cancer client is receiving chemotherapy known to cause stomatitis. Which nursing action would be appropriate in an effort to reduce or prevent the development of stomatitis?

A. Ask the physician for a prophylactic antibiotic

B. Provide a firm toothbrush to enhance oral cleaning

C. Encourage the use of mouthwash containing alcohol

D. Instruct the client to rinse their mouth with water every two hours

The answer is D. Research has shown that simply rinsing the mouth with water on a frequent basis can reduce stomatitis in chemotherapy clients. A firm toothbrush could damage the oral mucous membranes. Alcohol is drying and would damage the mucous membranes. Antibiotics would be inappropriate.


ENVIRONMENTS




467. Which type of precautions would be used when caring for a client with C. difficile?





The answer is D. Contact precautions are used when organisms causing serious disease are easily transmitted through direct contact. This includes all multidrug resistant strains of organisms such as C. difficile, shigella, and impetigo. Contact precautions require a private room or a room shared with someone infected with the same organism. Gloves are worn at all times and gowns and protective barriers are used if direct contact is required.

A is incorrect — Standard precautions are used to decrease the risk of transmission from bloodborne pathogens and moist body substances. Moist body substances include blood, urine, feces, sputum, saliva, wound drainage, and all aspirated fluids. B is incorrect — Airborne precautions are used when the mode of spread of an organism is by small particle droplets borne on air currents. Airborne precautions require a private room with negative airflow and adequate filtration; those entering the room wear a mask and if the client leaves the

room, a mask is worn. C is incorrect — Droplet precautions are used when the mechanism of transmission is by large droplets spread by coughing, sneezing, or talking. Droplet precautions require a private room or a room shared with someone infected with the same organism. Those entering the room and coming within 3 feet of the client need to wear a mask and the client wears a mask if taken out of the room.





468. A client presents to the emergency room in sickle cell crisis. The priority nursing intervention for this client to break the sickling cycle would be to:

A. administer oxygen as ordered.

B. teach sources of iron and folic acid in the diet.

C. draw blood for a hemoglobin and hematocrit value.

D. explain to the client the need to seek treatment as soon as a crisis begins.


The answer is A. The crisis is caused by a decrease in oxygen in the blood. Activities designed to reduce sickling would include administration of oxygen, fluids including intravenous fluids, promoting rest and providing pain relief.

All other activities would be inappropriate to break the sickling cycle.


MAINTENANCE

Ante-/Intra-/Postpartum and Newborn Care

469. A pregnant woman is in early labor. After performing

Leopold ’ s maneuvers, the nurse determines that the infant is probably a right occiput posterior presentation.

Where would the nurse check fetal heart tones?

A. Through the mother ’ s back.

B. At the umbilicus on the left side.

C. Below the umbilicus on the right side.

D. Above the umbilicus on the right side.

The answer is C. The infant would be a vertex presentation on the right side making the fetal heart tones heard best below the umbilicus on the right. FHTs are never assessed through the maternal back. FHTs heard at the umbilicus are due to a transverse lie. Breech presentations put the FHTs above the umbilicus.


Reduction of Risk potential


470. The client ’ s history indicates several allergic diseases including eczema and asthma as a child and hay fever as an adult. Which laboratory findings support this history?

A. Moderate anemia

B. Elevated eosinophil count

C. Elevated C reactive protein

D. Alkaline Phosphatase decreased

The answer is B. Eosinophils are a type of WBC and are elevated in persons with allergies and worm infestations. The other responses are not related to allergic reactions.


Pharmacological and Parenteral Therapy



471. A client was admitted to the burn unit after suffering extensive partial and full thickness burns in a house fire. At 24 hours postadmission, the physician orders albumin for the client. The family asks why the client is receiving albumin. The nurse ’ s response would be based on the knowledge that albumin is a:

A. blood product that will help restore circulating RBCs.

B. hypertonic solution that will help restore plasma volume.

C. source of clotting factors that will control wound bleeding.

D. source of antibodies to help the client fight infection secondary to the loss of skin.

The answer is B. Following a burn injury, the blood vessels

become permeable and fluid and protein is lost into the tissues.

Administering a hypertonic solution will cause the fluid to return from the tissues and maintain circulating volume.

Although albumin is a blood product, it does not contain red blood cells. Wound bleeding is not a problem this late in the injury. Albumin is not given to fight infection.




472. Which is a priority nursing intervention for a client with paranoid personality disorder?



C. Promote social relationships

D. Minimize potential for aggression

The answer is D. Clients with a paranoid personality disorder is suspicious and hypervigilant with irritable, agitated moods.

They can interpret all behavior as threatening and react in an aggressive manner. Therefore minimizing the potential for aggressive behavior is a priority nursing intervention. Clients with paranoid personality disorders are not good candidates for intensive therapy, especially group therapy, because it can heighten their suspiciousness and escalate the risk of aggressive response. Promotion of social relationships is a priority intervention

for clients with schizoid personality disorder. Bizarre fantasies are characteristic of schizotypal personality disorder.


Reduction of Risk potential


473. A preterm infant has significant respiratory distress due to the immaturity of the lungs. When arterial blood gases results are received, the nurse would expect to see which abnormality?

A. Respiratory alkalosis


B. The pH is lower than normal

C. The oxygen saturation is 94%

D. The carbon dioxide pressure (PCO2) is normal.

The answer is B. A lower pH is acidosis and an infant breathing poorly would have respiratory acidosis. An oxygen saturation of 94% is normal. The carbon dioxide pressure would not be normal.




474. A client had polio as a child and now wears a leg brace.

A pressure sore has formed under the leg brace.

Instructions for this client should include:

A. wear the brace only 6 hours per day.

B. do not wear the brace until the skin has healed.

C. apply a dressing over the sore to protect it from the brace.

D. cover the wound with petroleum prior to putting on the brace.

The answer is B. The brace should not be worn until the sore is healed as the brace is the most likely cause of the injury.

Wearing the brace 6 hours a day will further damage the skin. A dressing under a brace that is already rubbing on the skin will only make the pressure sore worse. Petroleum will not protect this wound if the brace is worn.



Uses therapeutic communications skills in providing care to the client

475. A 36-year-old woman has had a hysterectomy for fibroid disease. Prior to surgery, the woman stated her family was complete and she would be glad to not have to deal with her periods anymore. Two days after surgery, the nurse finds the woman crying. Which would be an appropriate response by the nurse?

A. “ I know what you are going through, I was upset after my hysterectomy too.

”

B. “ You shouldn ’ t cry. Just think, no more periods, no more cramps, no more birth control.

”

C. “ I know that you thought you wouldn ’ t be sad about the hysterectomy but it still bothers you, doesn ’ t it?

”

D. “ Other clients have told me that they were surprised about their feelings of loss even though they didn ’ t want more children. Is that what you are feeling?

”

The answer is D. This statement allows the client to recognize her feelings are common and seeks verification on the cause of the sadness.

A is incorrect — Usually it is best to avoid personal experiences when talking to clients about their feelings. Option B denies the validity of the client ’ s sadness. Option C seeks clarification but does not let the client know that her feelings are common.





476. When the family notices that the Total Parenteral

Nutrition the surgical client is receiving contains insulin, they question the nurse about why insulin has been added to the bag. The nurse explains that the client:

A. is a diabetic and needs the exogenous insulin.

B. is underweight and the insulin will help with weight gain.

C. is a pseudodiabetic due to the sugar content of the solution.

D. needs the insulin because of ileus secondary to the surgical procedure.

The answer is C. TPN has a very high sugar content which stresses the client ’ s pancreas. There is no evidence the client is diabetic or is underweight. Ileus does not affect the pancreas.


MAINTENANCE



477. Which cranial nerve is the nurse assessing when the nurse the client ’ s blink reflex is checked?

A. One (olfactory)

B. Five (trigeminal)

C. Seven (facial)

D. Eleven (spinal accessory)

The answer is B. The motor component of cranial nerve five

(trigeminal nerve) controls the blink reflex, which is tested by bringing a wisp of cotton in from the side to touch the cornea of each eye.

A is incorrect — Cranial nerve one (olfactory nerve) is

responsible for the sense of smell. It is tested by occluding

CHAPTER 34 Practice Test for NCLEX-RN® 1189 each of the client ’ s nostrils one at a time, holding a substance such as coffee or vanilla with a familiar aroma under the other nostril, and asking the client to identify the smell. The test is repeated with a different aromatic substance to determine if the client can differentiate smells.

C is incorrect — Cranial nerve seven (facial nerve) is responsible for taste on the front two thirds of the tongue and for movement of the face including the ability to close the eyes and move the lips for speech. Motor function of cranial nerve seven is tested by asking the client to smile, frown, grimace, show the upper and lower teeth, keep the eyes closed, while the examiner tries to open them and puff out the cheeks. The examiner observes for symmetry and movement and presses the puffed out cheeks in to check if air is expelled equally from both sides. To test taste, an applicator dipped in a sugar, salt, or lemon solution is placed on the tongue and the client is asked what is tasted.

D is incorrect — Cranial nerve eleven (spinal accessory) is tested by asking the client to shrug the shoulders and resist pressure to put them down because this cranial nerve controls muscular strength of the trapezius and sternocleidomastoid muscles.



Pathophysiology

478. A client has been admitted with a possible bowel obstruction. The nurse completes a head to toe assessment. Which finding should the nurse interpret as inconsistent with a bowel obstruction?

A. Vital signs normal

B. Vomitus has a fecal odor

C. Complains of colicky pain

D. Loud rumbling bowel sounds

The answer is D. Bowel sounds in early obstruction are often high pitched and tinkling above the obstruction.

Bowel sounds will be absent in late obstruction. Vital signs may remain within the normal range in early obstruction and progress to shock as the obstruction continues. The pain is often colicky and the vomitus may have a fecal odor.




479. A client ’ s care giver is performing tracheostomy care.

Which action by the care giver would the nurse correct?

The care giver

A. Used half strength hydrogen peroxide to clean the inner cannula.

B. Held the tracheostomy tube in place while changing the ties.

C. Rinsed the inner cannula with sterile normal saline after cleaning.

D. Used commercial tracheostomy dressing material to eliminate the need for cutting gauze

The answer is C. To prevent accidental decannulation, the soiled ties are not removed until the new ties have been put in place. Half strength hydrogen peroxide is used to clean the inner cannula and sterile saline is used to rinse it.

Commercial tracheostomy dressings may be used for ease of application if desired.


ENVIRONMENT


Standard/transmission-based/other precautions

480. A pregnant woman at term has an outbreak of genital herpes. She asks the nurse how this will affect her labor and delivery. Which response would be correct?

A. “ You will probably have a cesarean delivery.

”

B. “ The baby will require antibiotics after delivery.

”

C. “ You will be placed on antibiotics when you go into labor.

”

D. “ You will need antibiotics in the postpartum period to prevent a uterine infection.

”

The answer is A.With an outbreak of genital herpes, the baby is usually delivered by cesarean section to decrease the infant exposure. Herpes is a virus; so antibiotics will not be effective against this organism.



Potential for alteration in body systems

481. A child has been diagnosed with Wilms Tumor. Prior to surgery, a sign is placed over the child ’ s bed that states:

“ Do Not Palpate Abdomen.

” The mother asks why that sign was placed over the bed. The nurse ’ s response will be based on the knowledge that palpating the abdomen:

A. would be painful for the child.

B. can increase the child ’ s anxiety.

C. may affect the blood supply to the kidney.

D. could release cancer cells that will migrate to other areas.


The answer is D.Wilms Tumor is encapsulated until relatively late in the disease. Palpating the abdomen may cause a seeding of tumor cells to other tissues by way of the blood and should be avoided except as absolutely necessary for diagnosis.

Palpating the abdomen is not usually painful and should not cause anxiety. The blood supply to the kidney will not be affected except through cancer cell seeding.




Identify signs and symptoms of client fluid and/or electrolyte balance

482. A child is admitted to the hospital unit for gastroenteritis and dehydration. Which laboratory values does the nurse interpret as indicative of dehydration? Select all that apply.

A. ___ Elevated WBC

B. ___ Elevated Hemoglobin

C. ___ Elevated Hematocrit

D. ___ Decreased urine-specific gravity.

E. ___ Elevated lymphocytes in the WBC differential

The answers are B and C. Both hemoglobin and hematocrit are comparisons of solids to liquids. If the amount of solids stays constant but the volume decreases, the Hgb and Hct would be elevated. Elevated WBC indicates infection, while the elevated lymphocytes indicate a viral infection. A decreased urine-specific gravity would be a more dilute urine and not associated with dehydration.


MAINTENANCE


483. A client is 12 weeks pregnant. During her regular prenatal

visit, the following findings are noted:

• Leukorrhea is present

• Complains of urinary frequency

• Uterus is lower in the pelvis than 12 weeks gestation

• Has symptoms of PIH (pregnancy induce hypertension)

Which finding is suggestive of a hydatiform mole?

A. Leukorrhea is present

B. Complains of urinary frequency

C. Uterus is lower in the pelvis than 12 weeks gestation

D. Has symptoms of PIH (pregnancy induced hypertension)

The answer is D. PIH is rare in the first trimester except in the case of a hydatiform mole. Urinary frequency and leucorrhoea are normal in pregnancy. In molar pregnancies, the uterus is larger than anticipated.



Pathophysiology

484. A client has been diagnosed with pre-invasive cervical cancer. When assessing the client, what type of symptomology would the nurse expect?

A. Pain

B. Anorexia

C. Bleeding

D. None

The answer is D. There are usually no symptoms of preinvasive

cervical cancer.



Adverse effects/contraindications and side effects implement procedures to counteract adverse effects of medications and parenteral therapy

485. A toddler is seen in the emergency room after taking a number of codeine tablets belonging to a grandparent.

Which antidote does the nurse expect the child to receive?

A. Glucagon

B. Naloxone

C. Vitamin K

D. Sodium Bicarbonate

The answer is B. Naloxone (narcan) is an antidote for narcotics such as codeine.

The other answers are incorrect.

SAFE AND EFFECTIVE

ENVIRONMENT



Apply knowledge of pathophysiology when establishing priorities for interventions with multiple clients

486. A nurse on the postpartum unit receives report on his or her assigned clients. Which client should the nurse assess first?

A. Primipara with problems breastfeeding.

B. Fresh delivery complaining of severe perineal pain.


C. Multipara, 48 hours postpartum, with elevated blood pressure.

D. Client who received spinal anesthesia for delivery and is complaining of a headache.

The answer is B. The severe perineal pain could be a labial hematoma. The other clients present no immediate concern.



Applies knowledge of bloodborne pathogens to the care of the client

487. A nurse has been diagnosed with hepatitis C. The source of the hepatitis C is not known. Which factor may have contributed to the nurse becoming infected?

A. Having a tattoo

B. Used oral street drugs during the teen years.

C. Failure to complete the Hepatitis Vaccine Series

D. Frequently eats vegetables straight from the garden

The answer is A. There is a major concern that tattoos may be a source of the hepatitis C if the tattoo artist does not use new or properly sterilized needles.

Oral drugs would not be a source of hepatitis C, injectibles would be. The hepatitis vaccine series protects

against hepatitis B. It offers no protection for hepatitis C.

Hepatitis C is a bloodborne pathogen. Hepatitis A comes from contaminated food and water.




488. A client is receiving total parenteral nutrition. In recognition of a common complication of TPN, the nurse will monitor the client for:

A. Dehydration

B. Renal failure

C. Cerebral edema

D. Pulmonary hypertension

The answer is A. TPN is a hypertonic solution which can lead to diuresis. The other complications are not associated with TPN.




489. Which behaviors exhibited by a client alert the nurse to the need to take measures to protect self and others against an aggressive outburst? Mark all that apply.

A. ___ fist clenching

B. ___ finger snapping

C. ___ foot tapping

D. ___ pacing

E. ___ shouting

F. ___ glaring

The answers are A, D, E, and F. Fist clenching, pacing, shouting, glaring along with jaw clenching are all common signs of markedly increased agitation and indicate that the risk of aggressive behavior is real and immediate. Foot tapping and finger snapping often occur unrelated to risk of aggression and if related generally indicate a lower level of agitation.



Palliative/Comfort Care

Assess, intervene, and educate client/family/significant others about pain management

490. A client had a vulvectomy yesterday. On initial assessment, the nurse notes the client is dosing while sitting up in bed in Fowler ’ s position. When she awakens, the client states she is uncomfortable. Which is the priority nursing action?

A. Call the physician

B. Change the client ’ s position to Semi-Fowler ’ s.

C. Give more pain medication

D. Explain it is normal to be uncomfortable after a surgical procedure

The answer is B. Lowering the head of the bed will reduce the

pressure and tension on the incision and reduce the client ’ s pain.


Physiological Adaptability


Apply knowledge of client pathology to illness management

491. A newborn has been transferred to the pediatric hospital from the birth hospital with a large myleomeningocele.

On admission to the pediatric hospital, in which position will the nurse place the infant?

A. Prone

B. Supine

C. In semi-Fowler ’ s

D. In trendelenburg

The answer is A. The myleomeningocele is extremely fragile prior to surgical removal. The infant is positioned prone to

1192 PART III: Taking the Test prevent pressure on the sac. The other responses are incorrect.


MAINTENANCE


492. The home economics class in a high school has a class on pregnancy as part of the family life curriculum. A nurse has been asked to present information about

pregnancy to the class. The nurse tells the students that smoking during pregnancy can have a negative effect on the fetus. The nurse explains that mothers who smoke often give birth to:

A. diabetic infants.

B. low birth weight infants.

C. large for gestational age babies.

D. infants who grow up to be smokers.

The answer is B. Miscarriages, preterm birth, and low birth rate babies are associated with smoking during pregnancy. It is not associated with diabetic infants or large for gestational age babies. Seeing a parent smoke can be a influencing factor in the children smoking but the mother smoking during pregnancy does not encourage smoking by the infant when he or she grows up.




493. An 18-month-old child has returned from cleft palate repair. The postoperative physician ’ s orders include full liquid diet. Which would be the best feeding method for this child?

A. Cup

B. Straw

C. Spoon

D. Baby bottle

The answer is C. Anything that can be made into a liquid could be fed to the child. Drinking from a cup will prevent injury to the palate. Nothing rigid should be allowed in the mouth that could damage the palate repair. Sucking on a bottle or straw would also be inappropriate.


Coping Mechanisms

494. When the new baby comes home from the hospital, the older sibling, a toddler, begins wetting himself.

The mother calls the clinic nurse to ask what is happening as the toddler was toilet trained over a year ago. Which is the most likely explanation for this problem? The client:

A. May need more oral fluids.

B. Has a urinary tract infection.

C. Has regressed due to the stress of the new baby.

D. Is mad at the mother for bringing home a new baby.

The answer is C. Regression is common when a child is psychologically stressed. There is no evidence of a need for increased fluids or a urinary tract infection. Even a toddler that is excited about a new sibling will feel stress when the family dynamics change.





495. Which statement made by a client with COPD after being taught about the use of pursed lip breathing indicates the need for additional instruction?

A. “ I will make sure to puff my cheeks out when I breathe out through my mouth.

”

B. “ I will set my lips for breathing out like I am going to whistle.

”

C. “ Breathing out should take me twice as long as breathing in.

”

D. “ I will never hold my breath when trying to lift something heavy.

”

The answer is A. Exhalation should be slow through pursed lips taking care not to let the checks puff out. All other statements accurately reflect instructions related to pursed lip breathing. Lips are set as if to whistle. Exhalation should be twice as long as inhalation. Pursed lip breathing should be used during any strenuous physical activity and the client should inhale before exerting and exhale during the activity. The breath should never be held.





496. The nurse has completed client teaching on activities to reduce the recurrence of kidney stones. Which statement by a client indicates the need for additional teaching?

A. “ I need to increase my intake of dried fruits and milk products.

”


B. “ I should increase my intake of liquids to at least

2 – 3 liters per day.

”

C. “ It is important that I drink extra water at bedtime to keep my urine dilute during the night.

”

D. “ Cranberries, eggs and meats may help acidify my urine to reduce my kidney stones.

”

The answer is A. Dried fruits and milk products are high in calcium which is often associated with renal calculi so should be avoided. This statement indicates the need for additional teaching. Fluid intake, especially at night and acidifying the urine are all associated with reduced episodes of renal calculi.



Pathophysiology

497. Four days postoperatively, a client is noted to have thick yellow drainage on the operative dressing. The nurse would document this drainage as:

A. serous

B. purulent

C. sanguineous

D. serosanguineous

The answer is B. This drainage is purulent containing dead organisms and white blood cells. Serous is clear and watery; sanguineous is bloody; serosanguineous is pale, more watery but blood streaked.


MAINTENANCE

Self-Care

498. Following a automobile accident, a client is treated for a head injury in the emergency room. After 12 hours of observation, the client is discharged. Which information should be given to the client/family in preparation for discharge?

A. Narcotic analgesics may be taken for headache

B. Memory of the car accident should return within the next 12 hours.

C. Vomiting may be a symptom of worsening neurologic status

D. The physician should be notified if the client is sleepy but easily aroused.

The answer is C. Vomiting could be a symptom of increased intracranial pressure. Narcotics would be avoided as they

may mask increasing neurologic symptoms. Amnesia is common for the events surrounding the head injury. As long as the client is easily arousal, sleepiness is not a concern.



Vital signs

499. When delegating blood pressure measurement to an unlicensed assistant, the nurse cautions that correct technique must be used to avoid obtaining falsely high pressures. Which is one of the directions the nurse would give to prevent a falsely high pressure reading?

A. Take the blood pressure on an extremity positioned below heart level.

B. Use a cuff whose width is at least 60% of the diameter of the extremity.

C. If you have to inflate the cuff a second time, be sure to wait 1 – 2 minutes.

D. Apply the cuff loosely to the extremity.

The answer is C. Reinflating the cuff without a 1 – 2 minutes interval between inflations can result in a falsely high blood pressure reading. Therefore waiting the 1 – 2 minutes between inflations helps prevent a falsely high reading.

Taking the blood pressure on an extremity positioned below heart level can result in a falsely low reading; the extremity needs to be supported and at heart level. The

width of the cuff should be 40% of the diameter of the arm so a cuff that is at least 60% the diameter is too wide. Use of a cuff that is too wide can cause a falsely low blood pressure reading not a falsely high one. If the cuff is wrapped too loosely around the extremity the result can be a falsely high pressure reading so loose wrapping does not prevent a falsely high reading.




500. A client is receiving TPN. The bag of TPN arrives on the hospital unit with an ampule of multi-vitamins for the nurse to add. A new staff nurse asks why the pharmacy didn ’ t add the vitamins before sending the bag to the floor. The experienced nurse will explain that:

A. The client may be allergic to the vitamins.

B. The vitamins are infused in the first 100 ml of the

TPN bag.

C. The physician may change the order and leave out the vitamins.

D. Vitamins must be infused within 24 hours of being added to the bag.


The answer is D. The vitamins are stable only for 24 hours after being added to the TPN bag. The other responses are

incorrect.


ENVIRONMENTS




501. Which type of precautions would be used when caring for a client with tuberculosis?





The answer is B. Airborne precautions are used when the mode of spread of an organism is by small particle droplets borne on air currents and tuberculosis is spread by this route. Airborne precautions require a private room with negative airflow and adequate filtration; those entering the room wear a mask and if the client leaves the room, a mask is worn.

A is incorrect — Standard precautions are used to decrease the risk of transmission from bloodborne pathogens and moist body substances. Moist body substances include blood, urine, feces, sputum, saliva, wound drainage, and all aspirated fluids. C is incorrect — Droplet precautions are used when the mechanism of transmission is by large

droplets spread by coughing, sneezing, or talking. Droplet precautions require a private room or a room shared with someone infected with the same organism. Those entering the room and coming within 3 feet of the client need to wear a mask and the client wears a mask if taken out of the room.

D is incorrect — Contact precautions are used when organisms causing serious disease are easily transmitted through direct contact. Contact precautions require a private room or a room shared with someone infected with the same organism.

Gloves are worn at all times and gowns and protective barriers are used if direct contact is required.



Vital signs

502. A decrease in blood pressure of ____ mm Hg or more between the pressure taken after the client has been supine for 3 minutes and the pressure taken after the client arises and stands for a minute is indicative of orthostatic hypotension.

Answer is 30 mm Hg.




503. A wet to dry dressing has been ordered for an ulcer on the leg. Which is a step in the correct procedure for

changing the dressing?

A. Remove the soiled dressing dry.

B. Apply the new dressing that has been wet with tap water.

C. Moisten the soiled dressing with sterile water prior to removal.

D. Moisten the soiled dressing with normal saline prior to removal.

The answer is A. A wet to dry dressing starts with sterile dressing wet with sterile water, sterile saline, or other prescribed liquid, placed over the wound and allowed to dry.

Once dry, the soiled dressing is removed, taking with the dressing the adherent debris.


MAINTENANCE


504. A newborn is admitted to the nursery with a history of maternal diabetes that was poorly controlled during the pregnancy. The newborn ’ s admission weight is over 9 pounds. The initial blood glucose level is within normal limits. Which is the priority nursing intervention for this infant?

A. Initiate formula feedings.

B. Encourage parental bonding.

C. Avoid blood draws which could contribute to anemia

D. Monitor the temperature because the infant is macrosomic.

The answer is A. Although the infant ’ s blood glucose is normal now, the levels are expected to drop in the next two to three hours. Feeding protein foods (formula) will maintain blood glucose better than glucose water.

B, C, and D are incorrect — Parenteral bonding is not the priority intervention. Blood draws will be necessary to monitor glucose levels. The infant ’ s temperature will need to be monitored but it is not the priority.




505. The evening nurse is assessing a client who had a modified mastectomy earlier that morning. Which is a

CHAPTER 34 Practice Test for NCLEX-RN® 1195 fact that must be considered when planning nursing care?

A. The client will be depressed and asking for medication frequently

B. Blood pressures should not be performed on the arm of the operative side

C. The client will need to hold off doing arm exercises for 10 days

D. The client should not elevate involved extremity

The answer is B. Blood pressures should not be performed on the arm on the operative side to prevent venous congestion in the affected extremity. The other responses are incorrect.




506. A client with schizophrenia says “ cat tree swim house sick jump pretty ” when the nurse asks how he is feeling this morning. Which would be a correct label for the nurse to use when documenting this communication?

A. word salad


C. neologism

D. verbigeration

The answer is A. Word salad refers to the meaningless connection of words and phrases. Clang association refers to repeating words and phrases which sound alike but are otherwise unconnected. A neologism is a new word coined by the client and with meaning only to the client.

Verbigeration is the purposeless repetition of words or phrases.





507. A client on the burn unit is receiving IV albumin.

Which parameter will the nurse monitor to determine the effectiveness of this treatment?

A. Weight

B. Pain

C. Wound healing

D. Hematocrit

The answer is A. With a burn injury, the integrity of the vessels is lost and fluid escapes into the tissues. Albumin is a hypertonic solution which draws fluids from the tissues to the plasma from where the kidneys can excrete it. Weight loss indicates fluid loss in this manner.

Albumin will not affect pain sensation. Albumin contains antibodies but does not promote wound healing directly and is not the reason for administering it. Albumin contains no red blood cells.




508. The nurse is working with the parents of a child newly diagnosed with hemophilia. Which topics should be included in teaching about home care of the child?

A. Providing extra iron in the child ’ s diet

B. Oral administration of the missing factor

C. Avoiding sports activities as the child grows

D. Avoiding the use of aspirin for temperature elevations

The answer is D. Use of aspirin would decrease the clotting ability of the child ’ s blood. The child does not need extra iron as the child is able to produce ample red blood cells.

Factor is administered intravenously. The child would not avoid all sports. The nurse would provide guidance about sporting activities that would not put the child at risk for injury.


MAINTENANCE

Immunizations

509. A child is in for a routine immunization. The child has recently received the following medications:

• insulin

• antibiotic

• antihistamine

• immunoglobulins (IVIG)

Which would interfere with the effectiveness of the vaccination?

A. insulin

B. antibiotic

C. antihistamine

D. immunoglobulins (IVIG)

The answer is D. Immunoglobulins are antibodies. An immunization is a antigen designed to stimulate immunoglobulin production. If the immunoglobulins are already present, the antigen will be destroyed before antibodies are produced. The other responses would not have a significant effect on vaccination.




Mobility/immobility

Maintain client skin integrity

510. At what inetrval should an elderly client be instructed to change position when up in her wheelchair during the day?

A. Two (2) hours

B. One (1) hour

C. Thirty (30) minutes

D. Fifteen (15) minutes

The answer is A. Frequent shifts of body weight are needed to maintain circulation and decrease the risk of a pressure ulcer. Repositioning is required every 2 hours.

A, B, and C are incorrect because more frequent body shifts while in a chair have been shown to be ineffective.




511. A client has had a cesarean section. The client complains of postoperative discomfort due to abdominal distention.

Which suggestion would reduce the client ’ s discomfort?

A. Walk to promote peristalsis

B. Chew ice to facilitate peristalsis

C. Lay flat in bed as much as possible

D. Drink through a straw instead of sipping from a cup.

The answer is A. Walking promotes peristalsis. Drinking through a straw and chewing ice increases the amount of air the client swallows increasing the abdominal distention. Laying flat is not an appropriate intervention for abdominal distention.




512. A hospitalized client receives a transfusion of whole blood. The client suddenly develops chest pain, fever and chills. The nurse suspects a hemolytic transfusion reaction. Which is the priority nursing intervention?

A. Notify the physician.

B. Flush the line with D5NS.

C. Stop the infusion and maintain the IV line with normal saline.

D. Give the client the Benadryl (diphenhydramine)

available as a prn order.

The answer is C. Hemolytic transfusion reactions are caused by a reaction from antibodies in the recipient blood reacting to the donor ’ s blood protein. This can lead to serious consequences and may be fatal. Stopping the infusion is critical to reduce the source of the reaction. It is essential that the IV line be kept open for emergency access. The physician needs to be notified but it is not the priority action. Flushing the line with dextrose will cause the blood to clot. This is not an allergic reaction so Benadryl will not resolve the problem.


MAINTENANCE


513. A pregnant woman, whom the nurse notes has lordosis, asks why she has had bad back pain. Which factor explains the development of the lordosis and back pain and should serve as the basis of the nurse ’ s response to the client ’ s question?

A. Maternal hormones

B. The shifting center of gravity

C. The loosening of the pelvic structure.

D. Stasis of blood in the lower extremities

The answer is B. With the weight of the fetus shifting the center of gravity, the pregnant woman will develop lordosis and back pain.

Maternal hormones are present but not the cause of the back pain. The loosening pelvic structures affect the pregnant woman ’ s balance and walk, not back pain. The pressure of the uterus will cause stasis of blood in the lower extremities but not back pain.


Physiologic Adaptation



514. Which actions might the nurse discuss with a client with multiple sclerosis who has recently had a number of exacerbations of the disease? (Select all that apply.)

A. Joining a support group

B. Avoiding the use of hot tubs.

C. Preventing pregnancy

D. Limiting fluid intake to 1250 ml per day

E. Requesting a job transfer to a less stressful situation

The answers are A, B, and E. Support groups help support emotional coping mechanisms. The MS client is encouraged to avoid heat and cold situations as they have been implicated in exacerbations. A job transfer may allow the client to

CHAPTER 34 Practice Test for NCLEX-RN® 1197 continue working. Pregnancy in general does not seem to affect the overall outcome of MS. Fluid intake is important to maintain body function and should not be limited.





515. A client with thrombocytopenia, secondary to leukemia, has developed epistaxis. Which instruction should the nurse give the client?

A. Lie supine with the neck extended

B. Sit upright, leaning slightly forward and apply heat.

C. Blow the nose and then put lateral pressure on the nose

D. Hold the nose while bending forward at the waist

The answer is D. This response provides pressure to halt the bleeding while preventing the blood from draining into the lungs. The other answers are incorrect. A would promote blood entering the respiratory system. Heat would increase bleeding. Blowing the nose will remove any clots which have formed and should be discouraged.



Recognize signs and symptoms of acute and chronic mental illness

516. Which type of personality disorder does the nurse suspect when the client ’ s history indicates an apparent lack of concern with others ’ opinions, a “ loner ” , unfocused

lifestyle without close friends, and a cold, aloof persona?

A. paranoid

B. schizoid

C. antisocial

D. borderline

The answer is B. Clients with schizoid personality disorder are detached from social relationships and demonstrate little emotional expression with other people. There appears to be no pleasure derived from interaction with other people.

These individuals prefer solitary activities and can perform well when left alone.

Clients with paranoid personality disorder are suspicious of others believing that others are trying to exploit, deceive or harm them. They question the loyalty and trustworthiness of others; read hidden meanings into events; and bear grudges.

Clients with antisocial personality disorder are impulsive, risk takers who do not learn from experience, exploit others and ignore their rights; and lack guilt, honesty, fidelity and loyalty.

Clients with borderline personality disorder have a poor and unstable self image; are unable to maintain stable relationships; fear abandonment; engage in impulsive activities that are damaging to self such as substance abuse,

binge eating and reckless sexual activity; repeatedly threaten or engage in self mutilating or suicidal behavior; experience a chronic sense of emptiness; and manifest inappropriate, intense, uncontrolled anger.




Monitor client for side/adverse effects of TPN

517. A client is receiving Total Parenteral Nutrition (TPN).

Which is a common complication of TPN for which the nurse must monitor?

A. Phlebitis

B. Hypoglycemia

C. Electrolyte Imbalance

D. Fluid Volume Deficiency

The answer isD. The hypertonic fluid draws water from the tissues and can lead to fluid volume deficit. Hyperglycemia may be a problem, not hypoglycemia. The physician writes TPN orders based on the client ’ s electrolyte balance TPN is always administered by central line so phlebitis would be a minimal risk.





Intervene to prevent potential neurological complications

518. A client has been casted for a fractured radius. The cast extends from the hand to above the elbow. The client complains of constant pain under the cast. The nurse completes a neurovascular check and notes swelling of the hand and loss of sensation to the little finger.

Which is the priority nursing intervention?

A. Elevate the arm

B. Notify the physician

C. Administer pain medication

D. Reassure the client that these are common findings.


The answer is B. The client is demonstrating diminished circulation secondary to the cast which can lead to compartment syndrome. The cast may need bivalving. Elevating the arm is appropriate to reduce swelling but it is not the priority action at this time. Pain management may be appropriate but not the priority. These sensations are not normal but symptoms of compartment syndrome from a cast that is too tight.


Cultural Diversity

519. An ultra-orthodox Jewish client is 1 day postpartum. It is the Sabbath for this client. The client calls to the nurse and asks help in changing her peripad. The

client asks the nurse to open the pad ’ s packaging for her as this is considered work in her culture and not allowed on the Sabbath. Which is an appropriate nursing response?

A. Ask the client if a family member couldn ’ t open the package for her.

B. Open several pads and leave them covered so that the client can use them as needed.

C. Assign a male nurse to the client as she wouldn ’ t ask him to open her peri packages.

D. Tell the client that opening a peri pad package is not work and encourage her to do it for herself.

The answer is B. By opening several packages and leaving them within her reach, she will be able to perform self care without deviating from her religious beliefs.

The client ’ s family would probably be of the same culture and therefore would not be willing to perform this task.

A male nurse would make the ultraorthodox Jewish woman uncomfortable and not be culturally sensitive. Telling the client that this is not work does not consider her beliefs and feelings at all.


MAINTENANCE

Immunizations

520. The clinic is running short of RSV Immune Globulin (the

immunization for respiratory syncytival virus). Which child should have priority in receiving the vaccine?

A. The 8-year-old with cystic fibrosis.

B. The teenager who is sexually active.

C. The 5-year-old with failure to thrive.

D. The 6-month-old premie with a history of bronchial pulmonary dysplasia.

The answer is D. RSV is primarily a disease of infancy so preference would be given to children under 2 years of age.




Implement procedures to counteract adverse effects of medications

521. A client with leukemia is scheduled to get chemotherapy which includes vincristine. Which nursing action is appropriate?

A. Insert the intravenous line in a vein in a joint area.

B. Ensure that the intravenous is administered per pump.

C. Administer the medication in a free flowing intravenous line.

D. Always use an intravenous line that has been in place for several days.

The answer is C. Because it is so irritating to tissues, it is critical that extravasation of vincristine into tissue be prevented.

A free flowing line means that the line is most likely in the vein. A pump will continue to pump IV fluids even after the line has extraversated. A fresh line is best to ensure its integrity and the joint areas should be avoided.



Rest and sleep

522. A client informs the nurse that he is “ unable to fall asleep at night and tends to walk around until he gets sleepy.

” Which suggestion can the nurse make to help the client to develop better sleep habits?

A. Have an alcoholic drink prior to bedtime

B. Exercise when unable to sleep

C. Increase fluid intake prior to bedtime to maintain hydration

D. Avoid stressful situations prior to bedtime

E. Wear loose clothing to bed

F. Avoid caffeinated beverages before bedtime

The answers are D, E, and F. Stress will deter the client from falling asleep so avoiding stressful situations prior to bedtime will promote sleep. Wearing loose clothing to bed and avoiding caffeinated beverages before bedtime will also facilitate sleep.

Alcohol, exercise, and increasing fluid intake before bed all interfere with sleep.


MAINTENANCE


523. Which comment made by a teenager who is attending a health class on pregnancy indicates the need for clarification of information?


A. “ I didn ’ t realize that smoking during pregnancy could cause a miscarriage.

”

B. “ I didn ’ t realize that smoking during pregnancy could cause the baby to have high blood pressure as an adult.

”

C. “ I didn ’ t realize that smoking during pregnancy could result in a large baby and a difficult birth.

”

D. “ I didn ’ t realize that smoking during pregnancy is associated with asthma as the child grows older.

The answer is A. Miscarriages, preterm birth and low birth weight babies are associated with smoking during pregnancy.

It is not known to be associated with adult hypertension nor with childhood asthma.





524. Following a long history of vomiting, a child is diagnosed with GERD, Gastric esophageal reflux disease.

Instructions are given to the parents for conservative management to reduce the reflux. Following the parent teaching, the nurse will recognize the need for additional information when the parent states:

A. “ I will keep my child ’ s weight at the recommended levels.

”

B. “ My child should avoid caffeine, and spicy foods to reduce reflux.

”

C. “ I will lay my child down in bed after meals to allow time for digestion.

”

D. “ I will see that my child receives the antacid that his physician prescribed for him.

”

The answer is C. The child should not be placed flat in bed following feedings but should be maintained in a semi to high fowler ’ s position to promote formula retention.

Overweight children are more prone to GERD. Caffeine, chocolate and spicy foods seems to weaken the esophageal pressure and increase the reflux. The physician may order an

H2 antagonist, a proton pump inhibitor or other drugs to promote stomach emptying.



Assistive Devices

Evaluate correct use of assistive devices by staff/client/ family

525. A client is recovering from a broken tibia and is walking on wooden crutches. Which observed client behavior requires nursing intervention?

A. The client props his foot up while sitting.

B. The cast is visibly dirty.

C. While standing, the client rests his body weight on the top of the crutches.

D. The client uses a swing through motion when walking with the crutches.

The answer is C. Resting the arm pits on the top of the crutches could damage nerves and circulation. A visibly dirty cast can be covered with adhesive tape for better appearances but this is not the priority intervention. It is appropriate to elevate the foot while sitting. A swing through motion is often used to prevent weight bearing on the casted leg.


MAINTENANCE


Provides safe nursing care to the pregnant client

526. A pregnant woman has developed diabetes during the pregnancy. After several attempts to control the diabetes with diet alone, the physician plans to place the woman on insulin. The woman asks the nurse why she can ’ t take the “ oral ” insulins like her grandpa. The nurse ’ s response

is based on the knowledge that oral hypoglycemics:

A. May cross the placenta and be teratogenic

B. Contain too little insulin and would require multiple pills.

C. Will affect the fetal pancreas leading to infantile diabetes.

D. Contain too much insulin and would be dangerous to the fetus.

The answer is A. The full effect of the oral hypoglycemics on the fetus is not yet known. The oral hypoglycemics are not insulin but stimulate insulin production.





527. A newborn is suspected of having hydrocephalus. For which symptoms would the nursery nurse monitor the child? (Select all that apply.)

A. Sunset eyes

B. Depressed fontanels

C. Thin scalp and sparse hair

D. Increasing head circumference

E. Head circumference equal to chest circumference


The answers are A, C, and D. The fontanels would be bulging, not depressed. The head circumference is larger than the

chest circumference at birth in normal children. In this child, the difference would be even greater.




528. When assessing a client newly admitted with a diagnosis of active phase schizophrenia, which are negative symptoms of schizophrenia which the nurse might find?


A. ___ disorganized speech

B. ___ flat affect

C. ___ alogia

D. ___ impaired attention

E. ___ bizarre behavior

F. ___ avolition

The answers are B, C, D, and F. Flat affect, alogia, attention impairment, avolition along with anhedonia are all negative symptoms of schizophrenia.

Disorganized speech and bizarre or disorganized behavior are positive symptoms of schizophrenia.



Adverse Effects/Contraindications and

Side Effects


529. A client is receiving Vancomycin HCL for an infection.

Shortly after the nurse starts the intravenous infusion, the client appears flushed and complains of feeling hot. The nurse should:

A. slow the infusion.

B. stop the infusion and call the physician.

C. speed up the infusion as it seems to be making the client nervous.

D. recognize the client is having a drug interaction.

The answer is B. The client is showing symptoms of red man syndrome. The flushing is caused by a release of histamine causing vasodilatation. If untreated, the problem could be fatal. The physician will usually order Benadryl and order the vancomycin to be restarted at a slower rate.




Understand general principles of pathophysiology

530. The nurse is reviewing the laboratory report of a client who underwent a bone marrow biopsy. The finding that would most strongly support a diagnosis of acute leukemia is the existence of a large number

of immature:

A. nucleated red blood cells

B. thrombocytes

C. reticulocytes

D. leukocytes

The answer is D. Leukocytes are immature WHCs.

Thrombocytes are immature platelets and reticulocytes and nucleated red blood cells are immature red blood cells.


ENVIRONMENT


Standard/Transmission Based/Other Precautions

Provides care to the child with an infectious disease

531. A child has been diagnosed with tubercule (tuberculosis) meningitis and is admitted to the hospital. The child should be placed on:

A. contact isolation.

B. droplet isolation.

C. respiratory isolation.

D. standard precautions.

The answer is D. These children are not considered contagious.

Active, untreated respiratory tuberculosis is spread by droplets. The CDC recommends these individuals be placed in a negative flow (airflow) room with caregivers wearing masks and gowns.


MAINTENANCE


532. The nurse is performing a physical examination of a client ’ s abdomen. In what order should the assessment be performed?

A. Inspection, palpation, auscultation

B. Palpation, auscultation, inspection

C. Inspection, auscultation, palpation

D. Auscultation, inspection, palpation


The answer is C. Inspection is always the first step. Palpation is always performed last because palpation of the abdomen may interfere with bowel sounds and could cause pain.





Provide nursing care that identifies potential complications

533. A client has been admitted to the hospital for a gastrointestinal procedure. The physician orders the following:

• NPO at midnight

• Clear liquids except those that are red

• Multiple tap water enemas until clear

• One dose of an oral antibiotic the morning of the

procedure.

Which order should the nurse question?

A. NPO at midnight

B. Clear liquids except those that are red

C. Multiple tap water enemas until clear

D. One dose of an oral antibiotic the morning of the procedure.

The answer is C. Multiple tap water enemas can lead to water intoxication. NPO at midnight is a common order preceding a treatment. Prophylactic antibiotics may be ordered. Clear liquids will maintain the cleanliness of the bowel — reds are avoided as it cannot be differentiated from blood in stool or vomitus.



Pathophysiology

534. Two clients are comparing symptoms while waiting in the endocrine clinic. One client has been diagnosed with diabetes insipidus while the other client has diabetes mellitus. The clients note that they have many similar symptoms. Which symptom would differentiate the two disorders?

A. Polyuria

B. Polydipsia

C. Polyphagia

D. Nocturnal voidings

The answer is C. Both clients will have excessive urination and thirst. Nighttime voiding would be common. Polyphagia, excessive hunger, would only be seen in the client with diabetes mellitus.


ENVIRONMENT


Injury prevention

535. An elderly client is admitted to the hospital unit. On admission, the family tells the nurse that the client has fallen several times recently. The nurse evaluates the client and finds the client alert and without symptoms of ataxia. Which is an appropriate nursing action?

A. Place the client on fall precautions

B. Ask physical therapy to evaluate the client.

C. Not place the client of fall precautions

D. Question the family about what they did for the falls.

The answer is A. The nurse has been warned and therefore has a heightened legal liability to protect this client. The other responses are inappropriate.





536. A client has been diagnosed with fibrocystic breast disease.

Which information should be included in the self care teaching for this client?

A. Occasional nipple discharge is normal.

B. If breast pain is not relieved after menses begins, the client should see her primary care provider.

C. Breast pain due to inflammation and root stimulation begins before the luteal phase of the menstrual cycle.

D. Diuretics are never used to relieve symptoms of fibrocystic breast disease.

The answer is B. If breast pain is not relieved after menses begins, the client should see her primary health care provider as inflammation and nerve root stimulation begin at 4 – 7 days into the luteal phase of the menstrual cycle and end with the beginning of menses.



Vital Signs


537. A nursing assistant reports to a staff nurse that the neonate assigned to her care is crying and has axillary

1202 PART III: Taking the Test temperature of 90_F. Which is the appropriate action

on the part of the staff nurse?

A. Call a code

B. Notify the physician

C. Retake the temperature

D. Place the infant in a warming unit

The answer is C. A temperature of 90 axillary is not compatible with life. When infants cry they also tend to wave their arms around which can interfere with obtaining an accurate axillary temperature. The temperature should be retaken.



Assess client for drug/alcohol related dependencies, withdrawal, or toxicities

538. A client comes to the clinic saying he is withdrawing from heroin and needs help. Which assessment findings would support the client ’ s statement?

A. Vomiting and decreased respirations

B. confusion and ataxia

C. muscle twitching and dilated pupils

D. impaired memory and seizure activity

The answer is C. Symptoms of withdrawal from heroin include muscle twitching and dilated pupils along with yawning, rhinorrhea, lacrimation, abdominal cramps, diaphoresis, irritability, restlessness, anxiety, agitation, sleep disturbance, body aches, muscle cramps, “ goose flesh ” sensations of hot or cold,

nausea, diarrhea, anorexia, fever, hypertension, tachycardia, tachypnea, dysphoria, and craving.

Confusion, impaired memory and seizure activity occurs with withdrawal from alcohol, sedatives/hypnotics, and anxiolytic drugs. Vomiting and ataxia are associated with withdrawal from alcohol, sedatives/hypnotics, and anxiolytic drugs. Respirations are increased with withdrawal from alcohol, opiates, and sedatives/hypnotics, and anxiolytics.




Administer blood products and evaluate client response

539. A client is to receive a blood transfusion. When will the nurse plan to take vital signs? (Select all that apply.)

A. Prior to starting the transfusion.

B. Every 15 minutes during the first hour of the transfusion.

C. Fifteen minutes after the transfusion is completed

D. At least twice during the transfusion.

The answers are A, B, and C. Changes in vital signs are early indications of reactions to the blood. Therefore baseline vital signs should be taken prior to starting the transfusion.

Subsequently vital signs should be taken every 15 minutes during the first hour, periodically during the rest of the transfusion and then upon completion of the transfusion.





540. The nurse is administering Cyanocobalamin (vitamin

B12) to a client with pernicious anemia, secondary to a gastrectomy. Which route should the nurse use to most effectively administer the vitamin?

A. topical route

B. enteral route

C. parenteral route

D. transdermal route

The answer is C. Cyanocobalamin is administered IM or SC.

The other routes are incorrect.


ENVIRONMENT


Delegation

Assure appropriate education, skills, and experience of personnel performing delegated task

541. There are three clients on the unit who are receiving chemotherapy. Which type of assignment of care is appropriate?

A. Care divided among two newly hired and one experienced registered nurses

B. Care divided among three experienced registered

nurses

C. Care assigned to an experienced Licensed Practice

Nurse

D. Care assigned to a chemotherapy certified pregnant nurse

The answer is B. Chemotherapy administration should be divided among a number of nurses rather than assigning all chemotherapy to one nurse to decrease the cytotoxic chemical exposure. Chemotherapy certified nurse would be the best option, but because the nurse is pregnant, she

CHAPTER 34 Practice Test for NCLEX-RN® 1203 should protect her fetus by avoiding all exposure possible.

The nurse administering chemotherapy does not have to be certified.



Elimination

Assess and intervene with a client who has an alteration in elimination

542. Which intervention would be included in the plan of care for a client who is post operative from pelvic surgery?

A. Administer stool softeners to prevent constipation

B. Teach a low fat diet.

C. Limit fluid intake to reduce bladder filling.

D. Encourage pelvic tilt exercises.

The answer is A. Constipation will cause straining which will cause discomfort and pressure on the suture lines. There is no rationale for a low fat diet. Fluid intake is important to reduce urinary stasis. Pelvic tilt exercises are not appropriate at this time.



Assist the family in crisis and under stress to adapt and change

543. An elderly woman was diagnosed with Alzheimer ’ s disease several years ago. Her confusion is increasing.

During AM care, the woman tells the nurse about something that happened to her years ago. The husband, who overheard, immediately corrects the woman and explains the correct information to the nurse. The nurse would talk to the husband in private to encourage him to:

A. continue to correct her stories to help her stay in touch with reality.

B. discourage his wife from talking so that listeners will not be confused.

C. allow her to tell stories as she remembers them to reduce risk of agitation.

D. ignore all of the woman ’ s rantings as everyone is aware of her confusion.

The answer is C. Clients with Alzheimer ’ s are aware of their confusion and try to mask their loss of memory. That is why they spend so much time talking about the past. Eventually the past memories also become confused. Repeated corrections will increase the woman ’ s agitation and may affect her self-esteem. In addition, it will not keep the woman in touch with reality. Discouraging the woman from talking will further isolate the woman from the world as will ignoring her.


MAINTENANCE


544. During the later part of her pregnancy, a woman was treated for pregnancy-induced hypertension. The woman delivered a healthy infant 6 hours ago. Why is close monitoring of this client during the first two postpartum days an important nursing action?

The client

A. will have problems bonding to her infant.

B. could have heart damage from the hypertension.

C. is at high risk for renal failure in the postpartal period.

D. may become eclamptic for up to 48 hours after delivery.

The answer is D. Eclampsia or seizures could occur for up to

48 hours after delivery. The other responses are not correct.



Adverse effects/contraindications/side effects

545. A woman is getting married and asks for birth control pills. Which assessment finding suggests that “ the pill ” may not be the best choice of birth control for this client because of the associated risk of heart disease?

The client

A. is a heavy smoker.

B. is 22 years old.

C. had an abortion as a teenager.

D. has a sexually transmitted disease.

The answer is A. Smokers on oral contraceptives are significantly more at risk for the development of heart disease. This risk increases with age. The other findings are not significant risk factors.





546. A client receives a dose of penicillin and has an anaphylactic reaction. Which is the priority nursing intervention for this client?


A. Monitoring vital signs

B. Maintaining a patent airway

C. Assessing for adequate circulating blood volume

D. Treating symptoms of vascular overload

The answer is B. Maintaining a paten airway is essential for the maintenance of tissue oxygenation. Monitoring vital signs and assessing for adequate circulating blood volume are both assessments and will not provide any relief to the client. The client will have circulatory collapse.


ENVIRONMENTS



Verify appropriateness and/or accuracy of a treatment order

547. A newborn with a diaphragmatic hernia and respiratory distress is admitted to the pediatric unit. The admitting physician writes the following orders:

• Position in semi- to high Fowlers

• Position on affected side.

• Diet for age.

• NG tube to suction

Which order should the nurse question in the preoperative period?

A. Position in semi- to high Fowlers

B. Position on affected side.

C. Diet for age.

D. NG tube to suction

The answer is C. Feeding the infant would increase the contents in the GI tract. Since bowel material is in the chest, this would increase the contents of the chest further compressing the unaffected lung. Semi to high Fowlers would use gravity to decrease the contents of the chest which would help respirations. Position on the affected side so the unaffected lung has full expansion ability. NG tube to suction is used to decompress the gastric contents and is appropriate.





548. A client is admitted with third degree burns. On the second day post burn, the physician orders the client to receive albumin. The nurse will know that the treatment was successful when the client:

A. loses weight

B. feels less pain

C. doesn ’ t develop a burn infection

D. has an increased hemoglobin and hematocrit

The answer is A.With a burn injury, the integrity of the vessels is lost and fluid escapes into the tissues. Albumin is a hypertonic solution which draws fluids from the tissues to the

plasma from where it can be excreted by the kidneys. Weight loss indicates fluid loss in this manner. Albumin will not affect pain sensation. Although albumin does contain antibodies, this is not the reason for administering it. Albumin contains no red blood cells.




Apply knowledge of related nursing procedures and psychomotor skills when caring for clients undergoing diagnostic testing

549. A woman 9 months pregnant is admitted for a Non-

Stress Test. How will the nurse position the woman?

A. Prone

B. Supine

C. With legs elevated

D. With right hip tilted with a pad.

The answer is D. The client is positioned with a pad used to slightly elevate the right hip. This position will prevent vena cava syndrome, a side effect of lying supine. When in the supine position, the pregnant uterus lies on the inferior vena cava reducing blood flow to the heart. The other options are incorrect.




Use clinical decision making/critical thinking when addressing expected Effects/Outcomes of medications

550. A client is receiving levothyroxine (Synthroid) for hypothyroidism. Occurrence of which symptom would cause the nurse to suspect the dosage is too high?

A. Weight gain

B. Hypotension

C. Diarrhea

D. Round the clock sleepiness.

The answer is C. Symptoms of overdose would be those of hyperthyroidism. All the listed symptoms are those of hypothyroidism except for diarrhea.



ENVIRONMENTS




551. Which type of precautions would be used when caring for a client with H. influenzae?





The answer is C. Droplet precautions are used when the mechanism of transmission is by large droplets spread by coughing, sneezing, or talking. This is the mechanism of spread of H. influenzae.

A is incorrect — Standard precautions are used to decrease the risk of transmission from bloodborne pathogens and moist body substances. Moist body substances include blood, urine, feces, sputum, saliva, wound drainage, and all aspirated fluids. B is incorrect — Airborne precautions are used when the mode of spread of an organism is by small particle droplets borne on air currents.

Airborne precautions require a private room with negative airflow and adequate filtration; those entering the room wear a mask and if the client leaves the room, a mask is worn. D is incorrect — Droplet precautions require a private room or a room shared with someone infected with the same organism. Those entering the room and coming within 3 feet of the client need to wear a mask and the client wears a mask if taken out of the room. Contact precautions are used when organisms causing serious disease are easily transmitted through direct contact. Contact precautions require a private room or a room shared with someone infected with the same organism. Gloves are worn at all times and gowns and protective barriers are used if direct contact is required.



Assess client for alterations in mood, judgment, cognition, and reasoning as evidence of psychopathology

552. Which type of personality disorder presents a challenge to treatment because it is characterized by a charming manner often used to manipulate staff into agreeing with or granting client demands?

A. dependent

B. histrionic

C. antisocial

D. narcissistic

The answer is C. Clients with antisocial personality disorder are typically intelligent, charming, manipulative and with outstanding verbal and nonverbal communication skills. As a result, staff must be on guard against being inadvertently manipulated by these clients and must consistently set firm limits to avoid reinforcing the clients maladaptive behaviors.




553. Which assessment findings would the home care nurse interpret as increasing a new client ’ s risk for problems related to polypharmacy? (Select all that apply.)

A. Uses several practitioners

B. Currently being treated for several chronic conditions

C. Has switched health care providers frequently

D. Has a history of cataracts

E. Currently is on an antibiotic for an acute UTI

The answers are A, B, and C. Using several physicians, and switching physicians both can lead to multiple conflicting prescriptions. Multiple chronic conditions will be treated with numerous medications. History of cataracts is not a significant factor in polypharmacy. Short term use of antibiotic for UTI is not a problem.


ENVIRONMENT


Error prevention

554. A client is admitted with a draining wound. MRSA is suspected as the causative agent. The physician writes the following orders. Which order should the nurse question?

A. Diet as tolerated

B. Contact isolation

C. D5

1 ⁄ 4 NS at keep vein open

D. Procaine Penicillin G 150,000 units every 4 hours IV

The answer is D. Procaine is an additive that is to slow the absorption of the medication from the muscle. Procaine is never administered intravenously. The intravenous form of

penicillin is Aqueous penicillin.


Physiologic Adaptation


Identify client status based on pathophysiology

555. An infant in the newborn nursery has been cyanotic since birth. Which type of congenital problem could account for the cyanosis?


A. A left to right shunt

B. A right to left shunt

C. Congestive heart failure

D. Red blood cell deficiency

The answer is B. A right to left shunt is a cyanotic heart defect. A left to right shunt is acyanotic. The presence of cyanosis does not provide any information about congestive heart failure. A child with inadequate red blood cells would be hypoxic but not cyanotic as cyanosis is unoxygenated hemoglobin.


MAINTENANCE



556. What is the nurse assessing when, with the client ’ s eyes closed, the nurse places a key in the client ’ s hand and

asks the client to identify what it is?


B. Stereognosis

C. Position sense

D. Light touch

The answer is B. Stereognosis is asking the client to identify a familiar object such as a key when it is placed in the client ’ s hand with the client ’ s eyes closed.

A, C, and D are incorrect — Two-point discrimination involves touching the skin simultaneously with two sterile needles at closer and closer distances to each other until the client perceives only one touch. Position sense is tested by moving the client ’ s toes up or down one by one and asking the client, whose eyes are closed, to say in which direction each was moved. Light touch is tested by stroking an area of the client ’ s skin with a wisp of cotton.





Educate client and family about home management of care

557. The nurse is preparing a client with a full leg cast for discharge. Discharge instructions on cast care have been provided. Which statement by the client indicates the need for more information?

A. “ I will not get my cast wet.

”

B. “ I will contact my physician immediately if the cast breaks.

”

C. “ Keeping my toes still will reduce my pain.

”

D. “ I should put nothing into the cast.

”

The answer is C. The client would be encouraged to wiggle his toes. All other responses would be correct responses by the client.




Provide care for a client with a central venous access device

558. A client is admitted to the hospital unit with a PICC that was placed at another facility. Although the client has documentation indicating the PICC has been x-ray verified, there is no information about whether the catheter is valved or non-valved. Which is an appropriate nursing action?

A. Flush the line with normal saline only.

B. Do not flush the line.

C. Ask the client what other nurses have done with the line.

D. Flush the line with heparin flush solution per hospital protocol.

The answer isD. Flushing the line with heparin flush solution will not harm a valved catheter but failure to flush with heparin in a non-valved line will result in occlusion of the line.


MAINTENANCE


559. A client with known cardiac disease becomes pregnant.

The nurses monitor the woman throughout her pregnancy. At what point during her pregnancy is the client at greatest risk of developing congestive heart failure?

A. First trimester

B. 20 weeks gestation

C. As the woman approaches 30 – 32 weeks gestation

D. As she goes into labor

The answer is C. The blood volume and workload for the heart reaches its maximum at 30 – 32 weeks. If the pregnant cardiac client makes it beyond this point, she will probably complete the pregnancy.



ENVIRONMENT



Assess/triage clients to prioritize the order of care delivery

560. The nurse is working in the emergency room. On what basis should the nurse determine the order that clients in the reception room should be seen?

A. Triage

B. Time of arrival

C. Comprehensive assessment

D. Age

The answer is A. Triage identifies the clients who need medical attention first. Order of arrival is not appropriate because it does not address immediacy of need for care.

Comprehensive assessment takes substantial time and slows the organization of client interventions. Age is not appropriate because by itself it does not determine the severity of a problem or the immediacy of the need for care.





561. A client with sickle cell anemia has been treated with several blood transfusions. Now deferoxamine (Desferal) has been ordered and the client asks the nurse the purpose of this medication. Which is the correct answer for the nurse to give?

The medication will:

A. prevent the RBCs from sickling

B. remove excessive iron from the body

C. improve the longevity of the red blood cells.

D. increase the oxygen carrying capacity of the blood.

The answer is B. When repeated blood transfusions are given, the RBCs will eventually be broken down. The body retains the iron from these donated cells leading to iron toxicity. All other responses are incorrect.





562. A nurse stops at the scene of a car accident and provides first aid to the victim who has a neck injury. Which is the most appropriate way to open the airway of this victim?

A. jaw-thrust

B. head lift

C. neck thrust

D. neck tilt.

The answer is A. A jaw thrust will prevent damage to the spinal cord that could occur with other methods of opening the airway.


MAINTENANCE


563. A 3-year-old child is scheduled for surgery. The nurse

is explaining the procedure to the child. Which is the most appropriate statement for the nurse to make about the anesthesia?

“ The doctor will give you some special medicine that:

A. “ Will help you take a nap.

”

B. “ Will put you to sleep.

”

C. “ Make you unconscious.

”

D. “ Mommy wants you to have.

”

The answer is A. Children may be familiar with animals which have been “ put to sleep ” and never returned.

Unconscious is a word that would not be in their vocabulary

Telling the child that mommy wants them to take the medicine does not explain what will happen.





564. Which statement made by a client with Multiple

Sclerosis indicates that the nurse needs to clarify self care instructions with the client?

A. “ When I am tired, I lay down and rest.

”

B. “ When I feel stressed, I get in the hot tub.

”

C. “ I try to avoid conflicts with my husband.

”

D. “ I ’ m thinking of changing jobs to reduce stress.

”

The answer is B. Heat increases the risk of exacerbations in

Multiple Sclerosis so hot tubs should be avoided. All the other statements will promote wellness in the client.


MAINTENANCE

Immunizations

565. While administering the hepatitis vaccine to a group of medical students, the nurse is asked: “ Is this going to

1208 PART III: Taking the Test produce active or passive immunity?

” Which is the correct response?

A. This is passive immunity because I am giving you the vaccine.

B. This is passive immunity because this shot contains the antibodies.

C. This is active immunity because you did not get it from your mother.

D. This is active immunity because your body must respond to the vaccine.

The answer is D. Most vaccinations contain toxins or attenuated organisms. Your body views the vaccine as an antigen and produces antibodies against it. That is what makes it active.

A, B, and C are incorrect — Vaccination produces active immunity. Antibodies received from the mother provides passive immunity.




Implement interventions to manage client recovering from an illness

566. A client is experiencing severe respiratory distress. The nurse would perform which of the following activities to promote gas exchange? Select all that apply

A. Sit the client up in bed

B. Support both arms on a pillow

C. Encourage the client to drink clear liquids

D. Keep the room temperature somewhat warmer than usual

The answers are A and B. Sitting the client up in bed with both arms supported on pillows allows for better lung expansion by reducing pressure from abdominal contents and removing the weight of the arms from the chest. The client would not be encouraged to drink because the severe respiratory distress could cause aspiration. Keeping the room warm would raise the client ’ s basal metabolism rate increasing the body ’ s requirement for oxygen and should be avoided. The room should be kept cool.




567. An immunocompromised client is to receive a blood

transfusion for anemia. Which type of blood product would the nurse expect the physician to order?

A. Platelets

B. Whole blood

C. Filtered packed cells

D. Irradiated packed cells

The answer is C. An immunocompromised client is at risk for graft versus host disease. Irradiated packed blood cells will reduce this risk. Whole blood is rarely administered as packed cells provide the needed cells without the volume.


ENVIRONMENTS



Understand communicable diseases and the modes of organism transmission

568. A college student has been admitted to the hospital unit with a diagnosis of meningococcal meningitis.

The client should be placed in:

A. droplet isolation

B. airborne isolation

C. protective isolation

D. no isolation as universal precautions is sufficient

The answer is A. Meningococcal meningitis is spread by droplets and is the only meningitis form that is readily transmitted to

others. Droplet transmission involves contact with a large particle in the conjunctivae or mucous membranes of the nose or mouth. Transmission by large particle requires close contact whereas airborne can be transmitted through the air. Protective isolation protects the client from others and is not appropriate.



Palliative/comfort Care

Assess client for nonverbal signs of pain/discomfort

569. A client is seen in the emergency room following a fall at home. The client is known to have late stage

Alzheimer ’ s disease. A fractured hip is diagnosed and surgery is scheduled for the next morning. When asked, the client denies pain. Which symptoms would cause the nurse to suspect the client is in pain?

A. Client yells for her long deceased husband

B. Client ’ s hands finger the sheets continuously.

C. Blood pressure is elevated from admission findings

D. Client reaches for the nurse ’ s hand when the nurse approaches the client.

The answer is C. Elevation in blood pressure may indicate an increase in pain.

Clients with Alzheimer ’ s disease often call for individuals from their past, finger sheets, and other material and want physical contact.





570. A newborn has been diagnosed with osteogenesis imperfecta. Which assessment findings would the nurse expect? Select all that apply.

A. Blue sclera

B. Simian crease

C. Hyperbilirubinemia

D. Multiple fractures apparent at birth

E. Cephalohematoma developed within hours of birth

The answers are A and D. Blue sclerae and multiple fractures at birth are signs of osteogenesis imperfecta. Simian crease is a soft neurologic sign associated with Down ’ s syndrome.

Hyperbilirubinemia is not a symptom of osteogenesis imperfecta although it could result from bleeding injuries secondary to the broken bones. Cephalohematoma is not a symptom of osteogenesis imperfecta.




571. Which is the most important question to ask a 36- year-old woman prior to having a bone scan?

A. Do you have an allergy to seafood?

B. Did you have anything to eat or drink after midnight?

C. Are you claustrophobic?

D. Are you pregnant?

The answer is D. With a bone scan, there is a risk of radiation exposure to the fetus.

A is incorrect — this question is asked of any client receiving an isotope. B is incorrect — the client does not have to be NPO for this diagnostic test. C is incorrect — not all CT or MRI machines are full enclosures.




572. A 68-year-old female is admitted with a chief complaint of low back pain. Spinal x-ray indicates that the client has intervertebral disc disease. When asked by the client ’ s family, the nurse would explain the etiology of this disease as:

A. caused by weakening of the bone due to loss of calcium from the bone.

B. the degeneration of the spine due to dehydration of the intervertebral discs.

C. caused by inflammation of the joints and surrounding tissues.

D. the displacement and loss of contact of articulating surfaces.

The answer is B.

A is incorrect — Weakening of bone due to loss of calcium occurs with osteoporosis. C is incorrect — Inflammation of joints and surrounding tissue occurs with arthritis. D is incorrect —

Displacement and loss of contact of articulating surfaces occurs with dislocation of a joint.


ENVIRONMENT




573. The nurse is working on the pediatric unit when a call is received from a school teacher asking about the condition of one of her students who is hospitalized on the unit. The nurse should:

A. give only general information about the child.

B. encourage the teacher to contact the child ’ s parents.

C. transfer the call to the hospital administrator.

D. answer her questions if the nurse can verify that the person on the phone is the child ’ s teacher.

The answer is B. No information can be given to the teacher.

Only the guardians may receive information about the child.





574. Gentamicin is known to be nephrotoxic. The nurse administering gentamicin should independently evaluate the client ’ s:

A. BUN

B. Urinary output

C. Fluid intake

D. Creatinine clearance

The answer is B. Urinary output provides information about renal functioning. BUN and Creatinine clearance also evaluate

1210 PART III: Taking the Test renal functioning but require a physician ’ s order so may not be available for monitoring.


MAINTENANCE


Identifies deviations from normal in the newborn

575. After a difficult vaginal delivery, a newborn is admitted to the newborn nursery. During the assessment, it is noted that the baby ’ s moro reflex does not include the right arm. Which problem would the nurse suspect?

A. Brain damage

B. Fractured radius

C. Erb Duchenne palsy

D. Cephalohematoma

The answer is C. Erb Duchenne Palsy usually is due to pulling the head away from the shoulder. The palsy, which may be permanent, prevents movement of the shoulder and upper arm. There is no evidence of brain damage. A fractured radius would not affect shoulder movement. Cephalohematoma is bleeding into the periosteum of the skull bone.




Provide care for client with a central venous access device

576. A client ’ s PICC line will not flush. The nurse is unable to aspirate blood from the line. Which is an appropriate nursing action to restore patency?

A. Instill heparin into the line

B. Increase the pump pressure setting

C. Use increased pressure to flush the line with saline.

D. Contact the physician for orders for Activase

(alteplase)

The answer is D. Activase is a thrombolytic which breaks down clots. Heparin prevents the formation of clots, it does not break down clots. Increased pressure may cause the clotted line to release an embolus into the client ’ s circulation. Increasing the pump ’ s pressure setting would not cause the clot to disintegrate.



577. A client has developed a pulmonary embolism. Which factors predispose a client to this problem? (Select all that apply.)

A. Bradycardia

B. Hypertension

C. Hypercoagulability

D. Fluid volume overload

E. Venous stasis in the lower extremities

The answers are C and E. Hypercoagulability and venous stasis in the lower extremities predispose to development of a pulmonary embolism. The other options are unrelated to pulmonary embolism.





578. A client is admitted to the hospital unit with a diagnosis of hemophilia A. The nurse reviews the client ’ s lab report. Which lab result should the nurse interpret as unexpected and requiring further investigation?

A. Low platelet count

B. Low factor VIII values

C. Prolonged bleeding time

D. Prolonged partial thromboplastin time

The answer is A. The client with hemophilia A has insufficient levels of factor VIII which is a component of the clotting cascade.

The platelet counts are normal. The other laboratory values would be prolonged due to the inadequacy of the clotting cascade.


ENVIRONMENT


Home safety

579. A client is brought to the emergency room for acute lead poisoning. When determining the source of the lead poisoning, the nurse will question the client about which topic?

A. Eating lead pencils

B. Recent house painting

C. Using homemade pottery or ceramic dishes.

D. Eating unwashed vegetables from the garden.

The answer is C. Poorly fired pottery and ceramics may be improperly glazed allowing the lead to leak out of the clay. Lead pencils are made of carbon. Paint is now

CHAPTER 34 Practice Test for NCLEX-RN® 1211 lead free. Unwashed vegetables do not contribute a risk of lead.





Provide nursing care that includes interventions designed to reduce post procedure complications

580. A client has returned to the cardiac unit following a cardiac catheterization performed through the left femoral artery. Which item is an appropriate part of the nursing care plan for this client?

A. Out of bed as soon as awake from anesthesia

B. Neurovascular check to the insertion site times two

C. Pressure dressing and immobility for the insertion site

D. Range of motion exercises to the left leg every two hours.

The answer is C. The site is kept immobile for up to 24 hours after cardiac catheterization to reduce the risk of a severe arterial bleed. Range of motion exercises would be contraindicated.

The client would be on bedrest. Neurovascular checks should be performed at least hourly for the first 24 hours due to the risk of thrombosis.





581. A client with multiple myeloma is beginning chemotherapy. The client ’ s serum calcium level is 15 mg/dl. For which clinical manifestations related to this laboratory finding would the nurse assess?

A. Abdominal cramps

B. Confusion and anxiety

C. Lethargy and weakness

D. Muscle twitching

The answer is C. Normal serum calcium range is 8.5

– 10.5 mg/dL so the client has hypercalcemia. Symptoms of hypercalcemia include lethargy and weakness as well as depressed deep tendon reflexes, anorexia, nausea, vomiting, constipation and dysrhythmias.

A, B, and D are incorrect — Abdominal cramping occurs with hyponatremia; confusion and anxiety occur with hypocalcemia; muscle twitching occurs with hyponatremia.


MAINTENANCE


582. The nurse is working on the postpartum unit and is assigned to four clients. Which of the four clients is most likely to suffer afterbirth pain based on their obstetrical history?

A. Mother of twins

B. Bottle feeding mother.

C. Multipara with a premature infant

D. Primipara with an average for gestational age infant

The answer is A. Factors which increase afterbirth pain include overdistended uterus such as in twins or large infants, breast feeding, and multiparas.




Provide pre- and/or postoperative education

583. A client with a recent below the knee amputation of the left lower extremity is admitted to the rehabilitation unit and will be fitted with a prosthesis. Which is the priority self care instruction to be given to the client?

A. Keep a diary of time and type of activity related to the use of the prosthesis.

B. Assess skin integrity of the stump daily.

C. Apply cold compresses to the residual extremity bid.

D. Take analgesics if needed for phantom pain.

The answer is B. Preserving the integrity of the skin over the residual extremity is critical to use of the prosthesis and resumption of mobility. Thus the client is instructed to assess the skin at least daily so any problem is identified and treated early.

A is incorrect — a diary related to the use of the prosthesis is not a standard recommendation. C is incorrect — application of cold is not a standard part of residual extremity care.

D is incorrect — although self-administration of analgesic may be required secondary to phantom limb pain it is not considered a priority in client education at this time.



Pathophysiology

584. A client arrives in the emergency room with a chief complaint of new onset stiff neck and muscle aches. A physical exam reveals erythema migrans on the right

1212 PART III: Taking the Test upper arm. Which is the most likely cause of the client ’ s signs and symptoms?

A. Gout

B. Lyme disease

C. Lupus erythematosis

D. Polymyositis

The answer is B. Lyme disease, caused by the spirochete

Borrelia burgdorferi carried and transmitted by ticks, is characterized by erythema migrans or the “ bull ’ s eye ” rash. Other symptoms of Stage I disease are muscle and joint pain and stiffness. Symptoms of gout are acute pain and inflammation of one or more small joints. Lupus erythematosis can affect virtually every body system. It can cause joint inflammation and myositis. It also can cause a rash but the rash is the dry, scaly, raised “ butterfly ” rash typically involving the cheeks

and bridge of the nose resulting in the butterfly shape. The rash is not a bull ’ s eye rash. Polymyositis is an inflammation of striated muscle causing symmetrical weakness and atrophy.

It is not characterized by erythema migrans.


ENVIRONMENTS


Principles of Management

Supervise care provided by others

585. The charge nurse is observing a newly hired nurse measure jugular venous pressure. Which action on the part of the new nurse requires correction by the charge nurse?

The newly hired nurse

A. positions the client supine.

B. raises the head of the bed 30 – 45 degrees.

C. shines a light tangentally across the client ’ s neck.

D. measures the vertical distance from the manubrium to the meniscus of the internal jugular vein.

The answer is D. The distance is measured vertically is from the sternal angle (angle of Louis) to the meniscus of the internal jugular vein. This distance which is measured in centimeters equals the jugular venous pressure which usually does not exceed 4 cm.




586. When examining a two and a half year old, which assessment findings would the nurse interpret as consistent with fetal alcohol syndrome?

A. ___ strabismus

B. ___ Irritability

C. ___ Absence of teeth

D. ___ Hyperactivity

E. ___ Developmental delay

The answers are A, B, D, and E. Abnormalities associated with fetal alcohol syndrome which would be evident on assessing a two and one half year child include strabismus, myopia, irritability, hyperactivity, poor attention span, developmental delay and growth deficiency. Teeth are malformed not absent. Once in school, poor school performance is characteristic.



Mobility/immobility

587. You are caring for a 40-year-old male who is on complete bed rest following a traumatic injury to his pelvis. The data collected during your morning assessment include elevated oral temperature (100 ° F), diminished lung sounds in right lower lobe and oxygen saturation of 90% on room air. The most likely

cause of these findings:

A. hypostatic pneumonia

B. atelectasis

C. bronchitis

D. asthma

The answer is A. immobility results in respiratory complications which include pooling of respiratory secretions.

B is incorrect — atelectasis is a collapse of a single lobe or an entire lung. C is incorrect — bronchitis is the acute inflammation of airway passages. D is incorrect — asthma is not caused by immobility.


MAINTENANCE


Modify approaches to care in accordance with client’s developmental stage

588. An 11-year-old boy is admitted to the hospital unit following a bicycle accident. A fractured femur is diagnosed and the child is placed in traction. The best room assignment for this child would be a room:

A. with other boys of the same age as roommates.

B. near the nurse ’ s station so the child can be closely supervised.


C. away from other children so that the child can rest adequately.

D. with an alert adult roommate who can respond to the child ’ s needs.

The answer is A. Boys of this age are usually active. This child has restricted activity and will be easily bored. The child will enjoy the company of the other children.

This child ’ s condition is not a high risk condition so any room location on the unit would be acceptable. It is not the job of other clients to care for a client who is immobilized so option D would be incorrect.




589. Which statement made by the parent of a 15-year-old girl receiving doxorubicin (Adriamycin) to treat leukemia indicates that information regarding side effects of the medication was understood?

A. “ My daughter is lucky that the major side effects of her medication are headache and drowsiness; they could be a lot worse.

”

B. “ It will be hard to see my daughter confused and hallucinating from the medication but at least these side effects won ’ t last forever.

”

C. “ I hope my daughter ’ s heart isn ’ t damaged from this

medication; she is already going through so much that would just be awful for her.

”

D. “ I worry about the effect of the medication on my daughter ’ s kidneys but the important thing is to cure the cancer then we will deal with the rest.

”

The answer is C. heart damage is one of several side effects of doxorubicin (Adriamycin) so this statement indicates the client ’ s parent understands this fact.

Answer A is incorrect — headache and drowsiness are side effects of methotrexate. Answer B is incorrect — hallucinations and confusion are side effects of ifsoamide (Ifex). Answer D is incorrect — kidney damage is a side effect of carboplatin

(Paraplatin).


Reduction of Risk

Potential for complications of diagnostic Tests/Treatments/

Procedures

590. A client is admitted for an arthrogram of the right knee. Which is the most important information to obtain as part of the admission history?

A. Allergies to iodine, seafood, or local anesthetic

B. Current pain level to right knee

C. Previous experience with arthrogram

D. Time of last meal or fluid intake

The answer is A. it is important to know if the client has any

of these allergies because a radiopaque dye, administered IV, is given to visualize the joint.

B and C are incorrect — Although collecting information related to pain and previous experience with an arthrogram should be included, it is not the most important information.

D is incorrect — The client does not have to be NPO prior to this diagnostic test.


Therapeutic Communication


591. A woman has recently been diagnosed with a terminal illness. Although her physical condition is stable at this time, the client seems depressed. Which approach by the nurse would be most effective in encouraging the client to talk about her feelings?

A. “ You seem down today.

”

B. “ Why are you feeling so depressed?

”

C. “ What can I do to make you feel better?

”

D. “ Would you like to talk to the hospital chaplain?

”

The answer is A. The nurse has made a statement of his or her perceptions. The client can agree or deny these perceptions.

The client is never asked to explain feelings so asking why is a incorrect response. In option C, the nurse offers his or her self but this does not get at the client ’ s feelings. Option

D limits the conversation and is a way for the nurse to get out of an uncomfortable situation.




592. A client is admitted to the hospital with a diagnosis of disseminated intravascular coagulation (DIC).

The physician orders the client treated with heparin. A family member asks why heparin is being given to the client who is bleeding internally.

The nurse ’ s response is based on the knowledge that heparin:

A. increases the production of clotting factors.

B. preserves the platelets to prevent the client from bleeding out.


C. activates the clot disintegration process which breaks up the clots that have formed.

D. promotes neutralization of thrombin and prevents the conversion of fibrinogen to fibrin.

The answer isD. This action blocks the coagulation cascade at the common pathway and stops the intravascular coagulation disorder. The other responses do not accurately describe the effect of heparin.





593. A client is being placed on long-term corticosteroid therapy. Which information should be included as part of the client ’ s discharge teaching?

A. Drink lots of water daily

B. Do not stop the medication suddenly

C. The medication may cause weight loss

D. It is critical not to not smoke while on corticosteroid therapy

The answer is B. Corticosteroids depress the body ’ s natural production of corticosteroids. Sudden stopping of the medication could be fatal. The other responses are not correct.




594. In caring for a client with a serum calcium level of 15 mg/dl, which instruction would be given to the client?

A. Increase the amount of calcium rich foods eaten each day

B. Incorporate fiber into the daily diet to decrease constipation

C. Avoid foods high in sodium content

D. Limit fluid intake of water

The answer is B. Normal serum calcium range is 8.5

– 10.5 mg/dl so the client has hypercalcemia. Hypercalcemia can cause constipation.

A, C, and D are incorrect — Increasing calcium food consumption is indicated for hypocalcemia; a decrease in sodium intake is appropriate for hypernatremia; free water intake is indicated with hyponatremia.


ENVIRONMENT



Educate client/family/staff on infection control measures

595. A client goes to a clinic requesting to be tested for

Acquired Immunodeficiency Syndrome (AIDS). The test was positive. Instructions to avoid spreading the infection will include:

A. Avoid sharing toothbrushes and razors

B. Do not share a bathroom with other individuals

C. Keep your dishes seperate

D. Keep fresh flowers and plants out of the home to reduce the accumulation of mold.

The answer is A. Body fluids can be spread by sharing toothbrushes and razors. Sharing a bathroom is acceptable. Others do not need to wear gloves during casual contact with the client.





596. A client with sickle cell anemia has been treated with several blood transfusions. Now Deferoxamine

(Desferal) has been ordered and the client asks the nurse the purpose of this medication. Which is the correct answer for the nurse to give?

The medication will:

A. prevent the RBCs from sickling.

B. remove excessive iron from the body.

C. improve the longevity of the red blood cells.

D. increase the oxygen carrying capacity of the blood.

The answer is B. When repeated blood transfusions are given, the RBCs will eventually be broken down. The body retains the iron from these donated cells leading to iron toxicity. All other responses are incorrect.





597. A client has a cesarean section and delivers a healthy infant. Which of the following interventions are useful

CHAPTER 34 Practice Test for NCLEX-RN® 1215 in preventing pulmonary embolism in the postoperative mother?

A. Low salt diet and exercise

B. Compression stockings and leg exercises

C. Daily aspirin and daily breathing exercises

D. Low fat diet and rehabilitation therapy

The answer is B. Pulmonary emboli would result from thrombus formation. The pregnant woman is at greater risk for the development of thrombus. All surgical clients would also have this risk while bed ridden. Compression stockings and leg exercises would be most effective in preventing circulatory stasis.



Assess client for alterations in mood, judgment, cognition, and reasoning as evidence of psychopathology

598. Nurses working with a client with which type of personality disorder must be particularly alert for splitting behavior?

A. Antisocial

B. Borderline

C. Narcissistic

D. Histrionic

The answer is B. Splitting is an unconscious mechanism characteristic of the client with an borderline personality disorder.

The client is unable to accept imperfections in others and sees people as all good or all bad with the result that persons are set up against one another. For example, nurses may be good if they say only positive things to the client; nurses are bad if they provide negative feedback even when appropriate. Splitting is a coping behavior.



Mobility/immobility

Provide nursing care that incorporates knowledge of the risks associated with immobility

599. A client has been bed ridden for several months due to the effects of Alzheimer ’ s Disease. For which musculoskeletal problem is the client at risk?

A. Deep vein thrombosis

B. Osteoporosis

C. Avascular necrosis of hip

D. Embolism

The answer is B. prolonged bed rest result in loss of calcium leading to osteoporosis.

A is incorrect — this is a complication of the vascular system due to bed rest. C is incorrect — avascular necrosis is due to trauma and/or chronic steroid use. D is incorrect — an embolism is a cardiovascular complication from long term bed rest.




600. An elderly client develops disuse osteoporosis. The client ’ s adult son asks why his parent has this disease.

The nurse would explain that disuse osteoporosis occurs because of:

A. a decrease in calcium intake.

B. contractures to the lower extremities.

C. lack of stress to weight-bearing activity.

D. stiff and painful joints of the extremities.

The answer is C. calcium loss in the bones occurs due to lack of weight-bearing activity to the bones.

A is incorrect — a decrease in calcium content does not directly have an impact on disuse osteoporosis. B is incorrect — contractures of lower extremities can be the result of immobility. D is incorrect — immobility will eventually result in stiff and sore joints.




601. A 13-month-old child is to receive an oral medication.

The child starts crying as soon as the nurse enters the room with the medication despite the fact that his mother is telling him a story. After checking the child ’ s

identification bracelet, how should the nurse proceed with administering the medication?

A. Blow gently across his face with a soft whistling sound to stop the crying.

B. Allow the mother to administer the medication.

C. Delay giving the medication until the child is calmer.

D. Hold the child on his or her lap in a semi-Fowler ’ s position.

The answer is B. After the nurse checks the bracelet, the mother can be allowed to administer the medication while the nurse watches. The nurse would not blow across the child ’ s face; microorganisms can be spread in this way. Medication must be given in a timely fashion to

1216 PART III: Taking the Test be effective. The child would be held upright to prevent choking.


MAINTENANCE


Assist the client to achieve an appropriate outcome

602. A mother asks the nurse when she should begin toilet training her toddler. Which is an appropriate response for the nurse to give?

An indication that a child is ready to begin toilet training

is that the child

A. pulls on the diaper when it is wet.

B. has a BM at the same time every day.

C. doesn ’ t want to lay down for diaper changes.

D. hides behind the living room chair when having a

BM

The answer is D. This indicates the child is aware that he is about to have a BM, a necessary step in toilet training. A indicates the child is aware that he has eliminated, but does not show anticipation of the event. Having a BM at the same time every day makes toilet training easier for mother, but does not indicate readiness. Toddlers are so busy they often complain about the need to have diapers changed. It doesn ’ t indicate readiness.




Use clinical decision making/critical thinking when calculating dosages

603. What is the maximum daily dose of acetaminophen in mg/Kg of body weight that can safely be given to children? Record your answer in a whole number.

_____ mg/Kg.

The answer is 90 mg/Kg. The maximum daily dose for adults is 4 gm.


Pharmacological and Parenteral Therapy


604. The nurse is comparing laboratory results on admission with laboratory results following treatment of a client with DIC. Which change in laboratory values from admission indicates a positive response to therapy?

A. Decrease in platelet count

B. Increase in fibrinogen level

C. D-dimer assay increase

D. Decreased bleeding time

The answer is B. Heparin is used in the treatment of DIC. If therapy is effective, the heparin should stop the process of intravascular coagulation thereby allowing the fibrinogen level in the blood to increase. Platelet count would increase not decrease with effective therapy. D-dimer assay is a global marker of coagulation activation measuring a fibrin degradation product. Clotting time, not bleeding time, is a reliable indicator of effective therapy for DIC.




605. A woman has given birth to a preterm infant. The infant is doing well in the high risk nursery. The

woman states to the nurse: “ I am so worried about my baby.

” The best response by the nurse would be:

A. “ You ’ re worried about your baby?

”

B. “ Don ’ t be worried, your baby is doing fine.

”

C. “ God will take care of your baby if it is meant to be.

”

D. “ Babies born at the gestation of your baby usually do very well.

’

The answer is A. It is reflective and encourages the mother to provide more information. The other responses are not therapeutic.



Parenteral/Intravenous Therapy

Monitor and maintain infusion site(s) and rate(s)

606. The nurse is scheduled to administer 500 mg of ampicillin

IV by secondary line. The drug is to be infused over 20 minutes. The ampicillin is in a 50 ml baggie of

D5W. The IV drop factor for this IV is 15. How many drops per minute should the nurse regulate the IV to infuse at over the required 20 minutes?

A. 20 gtts/min

B. 30 gtts/min

C. 40 gtts/min

D. 60 gtts/min


The answer is B. 50 ml in 20 minutes or 21 ⁄ 2 ml per minute.

Each ml contains 12 drops so 12 times 21 ⁄ 2 _ 30 gtts/min.




607. When performing the Heimlich maneuver on a pregnant or markedly obese client, the nurse should position her hands in which area? Mark the spot with the letter “ X ” .

Correct response:

X





608. A child has been admitted to the pediatric unit with gastroenteritis. Which laboratory finding indicates the child is dehydrated?

A. Elevated reticulocyte count

B. Elevated white blood cell counts

C. Decreased urine-specific gravity

D. Elevated hemoglobin and hematocrit

The answer is D. Since both hemoglobin and hematocrit are comparisons of solids to liquids, dehydration causes an increase in these values. The other responses do not indicate dehydration.


MAINTENANCE


Choose physical assessment equipment and technique appropriate for client

609. A client is transferred from the operating room to the postpartum unit following a cesarean section for fetal distress. When the nurse performs the postpartum assessment, the client complains of pain and asks the nurse not to palpate the fundus. Which is the appropriate nursing action?

A. Ask a more experienced nurse to palpate the fundus.

B. Palpate the fundus anyway while avoiding the incision area.

C. Avoid palpating the fundus as long as the vital signs are stable.

D. Explain the need for fundal palpation and then palpate the fundus from the side.

The answer is D. Fundal palpation is essential for the wellbeing of the client. Contraction of the fundus occludes open blood vessels and prevents excessive bleeding from the site of placental implantation. The client will be more cooperative if the client understands the rationale.




610. An 84-year-old female is brought to the E.R. presenting with confusion, restlessness and altered mental status.

Which nursing action is appropriate?


A. Ask the client about the medications she is currently taking.

B. Give electrolyte replacing fluids.

C. Refer the client for a psychiatric evaluation.

D. Prepare for a physical exam including a chest x-ray,

EKG, UA, and CBC.

The answer is D. Changes in mental status such as confusion and restlessness are typical signs of acute illness in older adults requiring physical exam and lab work to r/o UTI, MI, pneumonia.



Mobility/immobility

611. An elderly client has been hospitalized for two weeks and develops the beginning of a pressure ulcer on the coccyx. The nurse recognizes that pressure ulcers in older adults are considered:

A. primary changes

B. secondary changes

C. normal changes

D. expected changes when hospitalized

The answer is B. Primary, normal, and expected changes are the same thing and pressure ulcers are not a normal sign, rather a pathological one.


ENVIRONMENT


Accident Prevention

Identify and facilitate correct use of infant and child safety seats

612. The nurse is teaching a prenatal class on child safety.

Where would the nurse instruct the expectant mothers to put their baby ’ s car seat?

A. Front passenger seat

B. Middle of the back seat

C. Back seat behind the driver

D. Back seat behind the passenger

The answer is B. The middle of the back seat is the safest place for the infant car seat.




613. A client had a left total knee replacement two days ago and is now having dyspnea and appears to be very

apprehensive. Pulse rate is 110 and she is diaphoretic.

Which problem does the nurse suspect?

A. Infection

B. Pneumonia

C. Fat embolus

D. Anaphylaxis

The answer is C. These are symptoms of a fat embolus which is a risk when the marrow cavities of long bones are opened due to accidental trauma or surgery.

A is incorrect — the symptoms listed are not indicators of infection, B is incorrect — Data collected does not include temperature.

D is incorrect — information provided does not include drug history.




614. A client with schizophrenia says “ skipping, whipping, tripping ” over and over during his waking hours.

Which would be a correct label for the nurse to use when documenting this communication?

A. word salad


C. neologism

D. echolalia

The answer is B. Clang association. Clang association refers to

repeating words and phrases which sound alike but are otherwise unconnected. Word salad refers to the meaningless connection of words and phrases. A neologism is a new word coined by the client and with meaning only to the client. Echolalia is the repetition of words or phrases heard from another person.


Pharmacological and Parenteral Therapy


615. A client is on anticoagulant therapy following a pulmonary embolism. During the first visit to the client ’ s

CHAPTER 34 Practice Test for NCLEX-RN® 1219 home, the home health nurse asks the client to take out all the medications that he has on hand. Which medication is a cause for concern when taken by a client on an anticoagulant?

A. Ferrous sulfate (Iron)

B. Acetylsalicylic acid (Aspirin)

C. Isoniazid (INH)

D. Phenytoin (Dilantin)

The answer is B. Aspirin can potentiate the effects of anticoagulants.

Ferrous sulfate does not affect anticoagulants; it is used for RBC production. INH is an antitubercular product and does not affect clotting time. Phenytoin is an antiseizure med and does not affecting clotting time.




Access implanted venous access devices

616. While visiting the area from another state, a client presents to the emergency room with severe pain secondary to a kidney stone. The physician orders an IV line started with 125 ml per hour of D5 1 ⁄ 4 NS and morphine for pain. The client shows the nurse his chest where he states he has a Subcutaneous venous port and asks the nurse to start the IV there. Prior to starting an IV line in this port, the nurse would need to verify that the:

A. Brand of subcutaneous port.

B. Medications can be given by central line.

C. Port internal tip lies in the superior vena cava.

D. Intravenous fluids can be administered by central line.

The answer is C. Prior to administering anything through a central line, the location of the internal tip must be verified.

Since this client is not known in the area, the tip location can be verified by x-ray if the client does not have a card documenting this information. Any medication and intravenous fluids that can be administered by peripheral line can be administered in a central line.


ENVIRONMENT


Standard/Transmission Based/Other Precautions

Evaluate infection control precautions implemented by staff members

617. A client is on contact isolation due to a MSRA abscess.

The charge nurse observes all of the following nursing activities. Which nursing activity fails to safely protect others from the client?

The nurse:

A. washes hands after removing gloves.

B. does not wear gloves when changing the bed.

C. does not wear a gown when checking the IV level.

D. covers the client with a sheet when being transported to x-ray.

The answer is B. The abscess could have drained onto the bedding.

The nurse does not need to wear a gown unless contact with items in the room is expected. Hands should always be washed or disinfected after removing gloves. Covering the client with a sheet when out of the room will reduce exposure to others.




618. The nurse is assessing an elderly client and notes the

following findings. Which assessment findings would the nurse identify as a normal signs of aging? Mark all that apply.

A. Increase in diastolic blood pressure

B. Reduced lens elasticity

C. Reduced vital capacity

D. Decreased force of myocardial contraction

The answers are B, C, and D. Decreases in lens elasticity, vital capacity and force of myocardial contraction all occur normally with aging. Mild increase in systolic BP also occurs, however an increase in diastolic BP is pathological and requires monitoring.



Adverse Effects/Contraindications

Provide nursing care that incorporates knowledge of adverse effects of selected pharmaceutical agents

619. A client presents to the emergency department, dehydrated and with metabolic acidosis. An overdose of which drug can result in these problems?

A. Digitalis

B. Aspirin

C. Insulin

D. Acetaminophen


The answer is B. Aspirin toxicity causes hyperventilation leading to respiratory alkalosis which leads to metabolic acidosis and dehydration. In digitalis toxicity, the major symptoms would be bradycardia. Insulin overdose would lead to hypoglycemia.

Acetaminophen toxicity would result in symptoms of liver damage including AST and ALT elevations.


ENVIRONMENT




620. The charge nurse is orienting a new nurse to the mother baby unit. The charge nurse explains that gloves should be worn (select all that apply):

A. when changing diapers.

B. for the initial newborn bath.

C. when changing the bag of IV fluids.

D. while performing initial assessment on a newborn.

E. when assisting the new mother to the bathroom for the first time after delivery.

The answers are A, B, D, and E. The nurse would be at risk for exposure to bloodborne pathogens during all these events.

Newborns are covered with amniotic fluid and blood.

Diaper changes might expose the nurse to body fluids. The first time the mother is out of bed, a large amount of blood

usually escapes from the vagina. Combine that with the fact that many new mothers become weak or faint when first up, gloves at this time provide protection for the nurse.




Provide care for a client with a central venous access device

621. A client has had a PICC line for 2 weeks which is being used for intermittent infusion of an antibiotic. Between uses, the PICC line is heparinized and locked. The nurse is ready to administer the PM dose of antibiotic.

The nurse flushes the line which flushes easily, but is unable to aspirate blood. The nurse should:

A. administer the medication as planned.

B. ask for x-ray verification of the PICC placement.

C. discontinue this PICC line and insert a new PICC line.

D. hold the dose until the physician sees the client in the AM.

The answer is A. PICC lines have a very small lumen and blood aspiration is often not possible after several weeks of use. The easy flush with no other complaints usually indicates that the PICC is intact. X-ray verification is used whenever the location of the tip is in question. Only specially trained nurses can insert PICC lines. Holding the dose until

the next day would allow the client ’ s blood level to drop and could allow the organism to become resistant.



Assist client/family/significant others to integrate new members into family structure

622. A young teenage girl has just given birth to a baby girl.

She has decided to keep her baby. The nurses are concerned about bonding between mother and infant. To promote bonding, the nurse will:

A. tell the mother her baby is beautiful.

B. delay eye prophylaxis immediately after birth.

C. leave the mother and baby alone to get acquainted.

D. keep the lights in the room on bright so the mother can see her infant clearly.

The answer is B. Bonding is supported when the mother looks at her infant and the infant looks back. Delaying eye prophylaxis and lowering the lights in the room will promote the infant looking back.

The mother may be afraid to be alone with her infant.

Telling the mother the baby is beautiful is not the best intervention to promote bonding.





623. A 4-year-old child with cystic fibrosis has difficulty maintaining adequate nutrition and has had a subcutaneous venous port surgically implanted for home administration of total parenteral nutrition. The child receives the TPN for 8 hours each night and is disconnected from the IV line during the day. The home health nurse teaches the mother to:

A. Calculate the drip rate since a pump will not be needed.

B. Check the child ’ s blood glucose every two hours during the night.

C. Limit the child ’ s intake during the day so the child will not become obese.


D. Start the TPN slow and taper up to the desired rate each night and then taper off each morning.

The answer is D. TPN is always tapered on and tapered off.

Sudden onset will cause hyperglycemia, sudden stopping will cause hypoglycemia. An electronic infusion pump is always used with TPN. It is not necessary to check the child ’ s glucose as often as every two hours. Limiting the child ’ s daily intake would be inappropriate as the child is malnourished.



Pathophysiology

624. A 67-year-old female is returning to the medical clinic for a follow-up visit due to complaints of back pain, frequent fevers and weight loss. CBC and serum chemistry disclosed high serum calcium and protein levels and low levels of hemoglobin, red blood cells, platelets, and white blood cells. With which problem are these signs and symptoms consistent?

A. Anemia

B. Arthritis

C. Multiple myeloma

D. Systemic lupus erythematosis

The answer is C. Multiple myeloma is correct.

A is incorrect — there is only a decrease in hemoglobin and hematocrit with anemia. B is incorrect — these tests would not be performed to diagnose arthritis. D is incorrect — these tests are not performed to diagnose lupus erythematosis.


MAINTENANCE

Principles of Teaching/Learning

Assess readiness to learn, learning preferences, and barriers to learning

625. A nurse is preparing to teach a newly diagnosed diabetic about the disease. Which is the initial step the

nurse should take?

A. Identify the client ’ s willingness to learn.

B. Find out what the client knows about the disease.

C. Determine the client ’ s level of formal education.

D. Select written material available for the client ’ s use.

The answer is B. The initial step is always to begin where the client is. All other responses may be helpful, but initially determining the client ’ s current knowledge is most important.




Perform focused assessment

626. The nurse is checking Homan ’ s sign on a client suspected of having a venous thrombosis. Which action should the nurse take?

A. Flex the client ’ s hip and the knee

B. Flex the client ’ s hip while extending the knee

C. Ask the client to point the toes while bending the knee

D. Push the client ’ s foot forward toward the knee while maintaining the knee in extension

The answer isD. A positive Homan ’ s sign is calf pain on dorsiflexing the foot while maintaining the knee in extension. If

Homan ’ s is positive, a venous thrombosis is suspected. The

other responses do not describe the appropriate technique to assess for Homan ’ s sign.




Use precautions to prevent further injury when moving a client with a musculoskeletal position

627. A client has had spinal surgery and the physician has ordered the client to be “ log-rolled.

” To be log rolled, the nurse will:

A. have the client turn slowly and stiffly.

B. use a draw sheet to maintain body alignment.

C. only position the client prone or supine to prevent spinal trauma.

D. ask for assistance from another nurse to maintain the body alignment.

The answer is D. Log rolling will require two nurses or more to maintain alignment of the spine and prevent trauma. The other actions are not the correct methods for log-rolling.




628. The nurse would expect to encounter withdrawal and odd eccentric behaviors when caring for a group of clients with which cluster of personality disorders?

A. Paranoid, schizoid, schizotypal

B. Antisocial, borderline, histrionic, narcissistic


C. Avoidant, dependent, obsessive-compulsive

D. Passive-aggressive, masochistic

The answer is A. Withdrawal and odd, eccentric behaviors are characteristic of clients with paranoid, schizoid, and schizotypal personality disorder. Attention seeking and erratic behaviors are characteristic of clients with antisocial, borderline, histrionic and narcissistic personality disorders.

Clients with avoidant, dependent or obsessive compulsive personality disorder are attempting to avoid or minimize anxiety or fear.

Clients with passive-aggressive or masochistic personality disorder are covertly aggressive against self or others.




629. A woman is admitted to the emergency room with bleeding from a stab wound in the right chest area.

Which assessment findings would the nurse interpret as indicating the initial phase of hypovolemic shock?


A. Increased hematocrit

B. Narrowed pulse pressure

C. Elevated heart rate

D. Oxygen saturation of less than 80%

E. Increased rate and depth of respiration

F. Absent superficial peripheral pulses

G. Slowed capillary refill

The answers are B, C, and G. Pulse pressure narrows because in the initial stage of hypovolemic shock the body attempts to compensate for the blood loss through vasoconstriction which decreases the size of the vascular bed. Vasoconstriction increases the diastolic blood pressure but not the systolic, thus the pulse pressure is decreased or narrowed before the systolic pressure drops from loss of volume. Heart rate also increases as part of the compensatory effort. The increased heart rate is an attempt to maintain cardiac output despite the fact that stroke volume is decreased. Capillary refill or the time taken for color to return to the nail bed after being pressed until it blanches is slow or even absent in shock.

Hematocrit and hemoglobin are decreased in shock caused by hemorrhage; they are increased in other types of hypovolemic shock. Oxygen saturation of less than 80% is not a sign of initial shock; it is a sign of later progressive shock. Increased respiratory rate is a sign of initial shock but depth does not increase until shock has progressed to the point that lactic acidosis is present. Superficial peripheral pulses may be difficult to locate and easily obliterated in initial

shock but absent superficial peripheral pulses are a sign of later shock.




Provide preoperative care

630. A child is scheduled for surgery. Which are nursing actions to be carried out prior to surgery? (Select all that apply.)

A. Check the child for loose teeth.

B. Remove finger nail polish from fingers and toes.

C. Have appropriate lab reports available on the chart.

D. Verify that the parents have signed an informed consent.

E. Check that the child has been NPO for a specified period of time.

The answers are A, B, C, D, and E. All responses are correct and should be included in the presurgery routine.



Alterations in Body System

631. A 44-year-old client is admitted to the emergency department with burns to the neck and face received from an explosion while working on a gas pipeline.

During the nurse ’ s initial assessment, highest priority

should be given to:

A. Noting signs of increased intracranial pressure (ICP)

B. Monitoring hourly intake and output

C. Assessing changes in circumference of the neck

D. Replacing fluid loss since based on weight

The answer is C. Assessing circumference of the neck will identify increases in girth and potential restriction of the airway from edema. ICP not pertinent in the absence of head injury and would not replace maintenance of a patent airway as a priority. Monitoring I&O is important but not the initial priority. Replacing fluid is essential in burn therapy but not a priority over airway.


ENVIRONMENTS




632. Which precaution measures would be instituted when a client has a Mycoplasma pneumoniae infection?

(Mark all that apply.)


A. ___ Client is placed in a private, negative airflow pressure room.

B. ___ Client is placed in a private room or with other clients with infection caused by the same organism.

C. ___ Use mask at all times while in the client ’ s room.

D. ___ Use mask when working within 3 feet of the client

E. ___ Use gown and protective barriers when giving direct care.

F. ___ Mask on client if transported out of room.

G. ___ Use gloves at all times when caring for clients.

H. ___ Use gloves when there is risk of exposure to blood or body fluids.

The answers are B, D, F, and H. Mycoplasma pneumoniae is spread by droplet transmission. Transmission-based precautions for droplet transmission require a private room or a room shared with someone infected with the same organism. Those entering the room and coming within 3 feet of the client need to wear a mask and the client wears a mask if taken out of the room. Standard precautions, which involve wearing gloves whenever there is the risk of touching something wet that comes from the body surface or a body cavity, i.e., when there is the risk of contact with blood or body fluids, are used at all times for all clients.





633. A client comes into the Emergency Room with a heavily bleeding thigh wound. Which is the priority nursing action?

A. Start oxygen

B. Put pressure on the wound

C. Establish an IV line

D. Determine the cause of the wound

The answer is B. The first priority is to put pressure on the wound to stop the bleeding and prevent further blood loss which can lead to hypovolemic shock. Oxygen is given to aid maintenance of tissue oxygenation. An IV line is established for fluid replacement and the cause of the wound would be determined as a guide to management. However none of these is the first priority.



Dosage calculations

634. Using the Parkland formula (4 ml of lactated ringer ’ s solution/% TBSA burn/kg body weight/24 hours), the nurse would calculate fluid replacement for a 70-kg client with a 50% TBSA burn over 24 hours as

A. 1400 ml

B. 14,000 ml

C. 6720 ml

D. 700 ml

The answer is B. 14,000 ml is the correct number. 4 _ 50 _

200 ml/kg. Client weighs 70 kilograms so 70 _ 200 _

14000 ml.


ENVIRONMENT



Ensure that client has given informed consent for treatment

635. The physician has ordered IVIG (intravenous immunoglobulins) to be administered to a client on a monthly basis. Prior to starting this therapy, the nurse would make certain that the client:

A. is aware of the importance of being NPO the morning of the infusion.

B. has signed an informed consent for a blood product.

C. understands that once started, the therapy cannot be stopped.

D. recognizes that he or she will be contagious for 2 days after receiving the IVIG product.

The answer isB. IVIG are antibodies removed from the blood of blood donors. One dose of IVIG can contain antibodies from

60,000 individuals. All other statements are not correct.




Educate client and family about medications

636. Due to a severe asthma attack, a client has been on corticosteroids for more than 2 weeks. Which information should the nurse give the client about when the time comes to stop the medication?


A. Fluid intake will need to be limited.

B. The dose of medication will be tapered down slowly.

C. Extra calcium will be needed for a week to ten days.

D. Vitamin supplements will be needed to prevent bone loss.

The answer is B. Corticosteroids suppress the body ’ s own production of corticosteroids by the adrenal gland. Sudden stopping of the medication could be fatal. The other responses are incorrect.




637. Which symptoms would the nurse expect to find when assessing a client in the prodromal stage of schizophrenia?

A. social isolation and withdrawal

B. impaired role function

C. Speech aberration

D. peculiar beliefs

E. markedly odd behavior

The answers are A, B, C, D, and E. Social isolation withdrawal, impaired role function, speech aberration, peculiar beliefs, and markedly odd behavior are all symptoms that can occur in the prodromal phase of schizophrenia. Speech disturbance may be manifested as vague or circumstantial speech, over elaborate speech, or poverty of speech and content. Other prodromal symptoms include unusual perceptual experience and marked lack of initiative, interests and energy. At least two of these symptoms persisting continuously for six months must occur for the diagnosis of prodromal schizophrenia to be made.


Physiological Adaptations

Fluid and electrolyte imbalances

638. A client arrives in the emergency department after having been burned with hot oil over the upper entire anterior chest and right leg. When the client is being triaged, which is the most important question for the nurse to ask?

A. “ What time did the burn occur?

”

B. “ Have you had any pain meds since the burn?

”

C. “ How did you stop the burning process?

”

D. “ What caused this burn initially?

”

The answer is A. The time the burn occurred will determine the amount of fluid replacement.

The other questions may be asked but none is more important than the time of the burn because fluid replacement is of critical importance and none of the other questions provide information needed to determine it. Pain assessment is important but fluid replacement is priority.

Knowing how the burning process was stopped is not critical in fluid replacement. Option D is important but not priority.




639. A visitor falls to the floor in front of the nursing station.

Which assessment findings are indicative of sudden cardiac death?

A. Fixed, dilated pupils

B. Absent respirations

C. Absent pulses

D. Absent blood pressure

E. Loss of consciousness

The answers are B, C, D, and E. Absence of respirations,

pulses and blood pressure along with loss of consciousness are signs of full cardiac arrest. Pupils become fixed but not necessarily dilated.


ENVIRONMENT


Use of Restraints/Safety Devices

Comply with federal/state/institutional policy regarding the use of client restraints and/or safety devices

640. A 2-year-old child has had a cleft palate repair. Elbow restraints have been placed on the child ’ s arms to prevent the child from damaging the suture line. How does the nurse manage the restraints?

The nurse

A. never removes the restraints.

B. removes both restraints at the same time every 2 hours.

C. removes the restraints one at a time when providing range of motion.


D. removes the restraints only when there is another adult present to prevent suture damage.

The answer is C. The restraints are removed every two hours, one at a time. At that time the underlying skin is evaluated and range of motion exercises are provided.

A is incorrect as the restraints need to be removed periodically.

B is incorrect as the restraints would be removed one at a time. D is incorrect as the nurse does not need another adult to remove the restraints.




Counsel/teach client/family/significant others about managing client health problem

641. A 3-month-old infant has been diagnosed as being at risk for sudden infant death and apnea monitors are being used in the home. Parent teaching will include:

A. infant CPR.

B. heimlich maneuver for infancy.

C. postural drainage techniques.

D. use of portable oxygen.

The answer is A. Unless the parents know infant CPR, they will be unable to respond if their child has an apneic period.

The other responses are incorrect.


MAINTENANCE


642. A newborn infant has been diagnosed with Down ’ s syndrome. The parents have been informed that the

child will have mental retardation. The parents ask the nurse what they can expect of their child ’ s development.

The best response by the nurse would include the information that their child will:

A. develop in an undeterminable pattern.

B. never develop basic skills due to the mental retardation.

C. develop in the same pattern as other children but at a slower rate.

D. will follow the same developmental time frame as other children but will stop developing before the other children.

The answer is C. Mentally retarded children develop in the same order as other children — they will learn to sit before they stand, stand before they walk, etc. The other answers are incorrect.





643. A child has been diagnosed with scabies. In addition to washing the child with the prescribed medication, the nurse would instruct the mother to:

A. wash all bed linens in hot soapy water.

B. wash all fruits and vegetables before use.

C. have the family ’ s dog checked for evidence of infestation.

D. discard all of the child ’ s clothing and replace with new clothing.

The answer is A. All bed linens and clothing should be washed in hot soapy water to kill the itch mites. This itch mite is not acquired from food sources. The dog does not transmit the itch mite to humans. It is not necessary to discard all clothing.




644. An industrial nurse responds to an emergency in the plant where a worker is burned. Which is the correct sequence of nursing actions?

A. Eliminate the source of the burn, ensure airway patency, observe for and treat associated injuries, treat burn shock.

B. Eliminate the source of the burn, ensue airway patency, cool the burn wound, apply topical antibiotic cream.

C. Ensure airway patency, insert a nasogastric tube, insert a bladder catheter, stare IV fluid infusion.

D. Treat burn shock, ensure airway patency, start IV antibiotics and put the client in reverse isolation.

The answer is A. The appropriate sequence of nursing actions for clients with major burn injuries is to eliminate the source

of the burn, ensure airway patency, assess for and treat associated injuries, and treat burn shock. Options B, C, and D may be appropriate during care of such a client, but response (A) represents the correct sequence for initial assessment.





645. Why are clients who have had back surgery, such as a laminectomy or spinal fusion, turned by log rolling?

A. Guard against wound dehiscence

B. Prevent excess pressure on the operative site

C. Maintain body alignment

D. Protect against skin breakdown

The answer is C. In log rolling, the client is turned all at once with the back as straight as possible. This maintains proper body alignment and avoids disruption of the surgical site.

Other answers are incorrect.


ENVIRONMENT




646. The nurse is working in the emergency department when a call is received from a police officer asking about the condition of one his colleagues who has been injured while on duty. Which is an appropriate nursing action?

A. Give only general information about the client.

B. Encourage the officer to contact a member of the client ’ s family.

C. Transfer the call to the hospital administrator.

D. Answer his questions once the identity of the officer is confirmed.

The answer is B. Sharing of a client ’ s health information is governed by the HIPPA regulations. No information can be given to a friend or coworker. Referring the officer to a family member does not guarantee that this person has or will share information but does not violate the privacy requirements.




647. Your client has an external fixator to the right lower extremity to stabilize an open fracture of the tibia and fibia with extensive soft tissue damage. The client is complaining of a tingling sensation in the foot. Which is the priority nursing action in response to the client ’ s

new complaint?

A. Administer pain medication

B. Assess pain level using a pain scale

C. Notify physician of client ’ s status

D. Perform neurovascular assessment

The answer is D. Prior to any of the other interventions, the nurse will need to do a full assessment of the status of the leg. The physician will need the additional information to determine the appropriate medical intervention.




648. A client suffered blunt trauma to the chest in a motor vehicle accident (MVA) and is later diagnosed with adult respiratory distress syndrome (ARDS). The nurse is formulating a plan of care for this client and knows that the nursing goal with the highest priority should relate to which area?

A. Improving nutritional status and decreasing protein wasting

B. Administering diuretics and antibiotics to combat infection

C. Maintaining oxygenation and eliminating underlying cause of ARDS

D. Monitoring the client ’ s blood pressure and PaCO2

levels

The answer is C. Airway and oxygenation are always the first priority. Maintaining oxygenation takes the priority over monitoring blood pressure and ensuring good nutrition.




649. The nurse would expect to encounter attention seeking and erratic behaviors when caring for a group of clients with which cluster of personality disorders?






The answer is B. Attention seeking and erratic behaviors are characteristic of clients with antisocial, borderline, histrionic and narcissistic personality disorders. Withdrawal and odd, eccentric behaviors are characteristic of clients with paranoid, schizoid, and schizotypal personality disorder. Clients with avoidant, dependent or obsessive compulsive personality disorder are attempting to avoid or minimize anxiety or fear.

Clients with passive-aggressive or masochistic personality disorder are covertly aggressive against self or others.




650. The nurse is caring for a client with ARDS. To reduce oxygen consumption in this client, the nurse should provide

A. ample time for rest and relaxation

B. 100% oxygen per nasal cannula

C. increased daily caloric intake

D. 21% oxygen per mask as needed

The answer is A. It is the only response that considers and reduces oxygen consumption.




651. A suicidal client has ingested a large amount of an unknown poison. The client has no signs of injury to the mouth but is difficult to arouse. Which would be the appropriate intervention for this client?

A. Administer syrup of ipecac immediately

B. Initiate gastric lavage after assessment

C. Give milk or water orally to dilute gastric content

D. Call the poison control center for an antidote

The answer is B. Gastric lavage would be instituted to remove the poison. Gastric lavage would not be used if signs of injury from a corrosive poison are present because the lavage tube might perforate the burned esophagus. Syrup of ipecac should not be given to induce vomiting with a difficult to arouse client because of the risk of aspiration. Giving oral fluids also is contraindicated because of the risk of aspiration.

Since the poison is unknown, calling the Poison control center for an antidote is not possible.


MAINTENANCE



652. The nurse is observing a group of preschoolers in a day care. The nurse recognizes that the child who is showing signs of a developing conscience is the child who:

A. tattles on a classmate.

B. stays close to the teacher.

C. ignores other children ’ s toys.

D. carries a security object with them at all times.

The answer is A. When a child is developing a sense of conscience, they often tattle because of their recognition of right

and incorrect in others. None of the other behaviors are related to the development of conscience.





653. A newborn was diagnosed with osteogenesis imperfecta.

When handling the infant, the nurse would:

A. wear gloves to prevent contamination.

B. maintain the infant in semi-fowler ’ s position.

C. restrain the infant to prevent trauma to the bones.

D. use the palms of the hands to handle the infant ’ s extremities.

The answer is D. Children with osteogenesis imperfecta have fragile bones and must be handled by the palms of the hands. None of the other responses are appropriate for this child.


MAINTENANCE


654. Which of the following principles of growth and development is being addressed when the nurse explains to the parent that the infant will develop control of the head before control of the torso and legs?

A. Cephalocaudal

B. Proximodistal


C. Mass to specific

D. Simple to complex

The answer is A. Cephalocaudal means head to tail and refers to the fact that development occurs from the head downward.

Normal development simultaneously occurs from midline to periphery which is proximodistal. Mass to specific refers to differentiation. Simple to complex refers to operations in which simple precedes complex ones and is similar to mass to specific.



655. A 78-year-old male in the late stages of Alzheimer ’ s disease is in an extended care facility. He complains to the nurse that he is tired and his neck is sore from working in the field all day. Which of the following is the best response from the nurse?

A. “ You know you don ’ t work in the field anymore ”

B. “ What type of motion caused the soreness ”

C. “ You ’ re 78-years-old, You ’ ve been here all day with me, you haven ’ t worked in the field in years ”

D. “ Would you like me to rub your neck and apply a warm compress?

”

The answer is D. Validating the client ’ s reality is the most

appropriate intervention for later stages of Alzheimer ’ s disease.

He is not a candidate for reality orientation. The nurse is responding to what she can help with, his sore neck. The other answers are confrontational and close off communication.




656. A client is transported to the emergency department following multiple traumatic fractures from a motor vehicle accident. Which assessment findings would be a priority for the nurse to report to the physician 6 hours after a spica body cast has been applied?

A. Pedal pulses are equal but weak.

B. The lower extremities are cool to touch.

C. The client is complaining of itch under the cast.

D. The client complains of pain with respirations

The answer is D. Pain with respirations could mean restricted lung expansion and compartment syndrome. This is the priority because it involves airway and oxygenation.



Palliative/comfort care

657. The client in the burn unit is complaining of severe pain in the first 24 hours following the burn injury.

Which of the following is the usual method of dealing with pain during this period?

A. Liquid narcotics are given via the NG (nasogastric) tube as needed.

B. Narcotics are administered via the intramuscular route into non-burned tissue.

C. Intravenous narcotic agents are administered for pain as needed.

D. No medications are given during this period because of respiratory depression.

The answer is C. The client will have IV access as a component of the resuscitation process. Intravenous administration allows for quick results of the narcotic. Narcotics administered through the NG or IM route would be slower in providing relief. Although respiratory depression would be monitored, narcotic pain relief would still be given.




658. A client is seen in the emergency room following an industrial accident involving chemical burns. The nurse recognizes that the severity of a chemical burn depends on which factors?

A. The mechanisms of action.

B. Penetrating strength and concentration.

C. The amount and duration of exposure.

D. The age of the client

E. The occupation of the client

The answers are A, B, C, and D. Factors related to the chemical itself, type of chemical, concentration, amount and duration of exposure, all affect the severity of the burn. The age of the skin affects how easily it is injured as well as healing ability. Age affects general condition of client. The occupation will have no effect.




659. When assessing a client newly admitted with a diagnosis of active phase schizophrenia, which are positive

CHAPTER 34 Practice Test for NCLEX-RN® 1229 symptoms at least one of which the nurse would expect to find?


A. ___ disorganized speech

B. ___ flat affect

C. ___ delusion

D. ___ impaired attention

E. ___ bizarre behavior

F. ___ hallucination

The answers are A, C, E, and F. The positive signs of active phase schizophrenia are delusion, hallucination, disorganized speech, and bizarre or disorganized behavior. At least one of these positive signs must be present for at least one month for a diagnosis of active phase schizophrenia to be made. Flat affect and impaired attention are negative symptoms of schizophrenia.




660. A client with burns on the face and neck is at risk for airway obstruction. Which of the following would be most indicative of a potential airway obstruction?

A. Singed nasal hairs

B. Neck and face pain

C. PaO2 of 80 mm Hg

D. Coughing up large amounts of thick, white sputum

The answer is A. Singed nasal hairs indicate the client breathed in hot gases. This can lead to edema of the oral mucus membranes. Pain in these areas does not indicate airway problems. PaOx of 80 is low normal. Thick white sputum would not indicate airway burns.



Pathophysiology

661. A client with a suspected pulmonary embolus is admitted to a medical unit from the emergency department.

The client complains of shortness of breath and severe chest pain. Which other signs and symptoms would support the diagnosis of pulmonary embolism?

A. Low grade fever

B. Productive white sputum

C. 2 degree AV block

D. Frothy sputum

E. Tachycardia

F. Blood-tinged sputum

The answers are A, E, and F. Chest pain and dyspnea are cardinal signs and symptoms of pulmonary embolism. Clients may also have a low grade fever, tachycardia which is a compensatory mechanism for decreased oxygen supply, and blood tinged sputum. Productive white sputum is not suggestive of pulmonary embolism. Frothy sputum would indicate pulmonary edema.




662. An older gentleman reports that he has needed to use more salt than usual to make his food taste good. He asks the nurse what this could mean. The nurse ’ s

response should be based on the knowledge that

A. the number of taste buds decreases with age.

B. older persons need more sodium to ensure good kidney function.

C. increased sodium is needed to compensate for lost fluids.

D. the client may be confused due to his advancing age.

The answer is A. The taste buds begin to atrophy at age 40 and after age 60 there is an insensitivity to taste qualities.

There are also studies that indicate that there are changes in the salt threshold in some elderly individuals. The other options are incorrect.


MAINTENANCE


Identify common developmental patterns of a pediatric client

663. When observing a two year old in the hospital playroom, which type of play would the nurse interpret as representative of normal development?

A. Solitary

B. Parallel

C. Associative

D. Dramatic

The answer is B. Solitary play is seen in the infant, associative play is seen in a preschooler. A school age child may demonstrate dramatic play.





664. The client is admitted to the emergency room with massive bleeding and a gunshot wound to the chest in severe respiratory distress. Which nursing action has the highest priority when managing the emergency?

A. Establish and maintain an open airway

B. Start cardiopulmonary resuscitation

C. Initiate oxygen therapy via nasal cannula

D. Apply pressure to wound to control bleeding

The answer is A. Establish airway is the correct response.

Without a patent airway, all other measures are not critical.

CPR is not appropriate since the client is not pulseless.

Oxygen therapy via nasal cannula is not appropriate for severe respiratory distress. Applying pressure to the wound to control bleeding is critical but does not take priority over establishing and maintaining an airway.




665. A client is being discharged home on anticoagulant therapy. Which instructions should the nurse include as part of discharge teaching? (Select all that apply.)

A. ___ Avoid use of aspirin containing drugs while receiving Coumadin.

B. ___ Do not keep fresh flowers in the home.

C. ___ Report dark, tarry stools to primary health care provider.

D. ___ Avoid brushing teeth to prevent bleeding gums.

E. ___ Avoid inactivity for prolonged periods of sitting with legs crossed.

F. ___ Change positions frequently while traveling; walk occasionally; exercise legs and ankles.

G. ___ Continue anticoagulants for length of time ordered.

The answers are A, C, and G. Aspirin has an anticoagulant effect and as a result enhances the effect of Coumadin. Therefore it is contraindicated for clients taking Coumadin. Dark tarry stools need to be reported because bleeding is an adverse effect of anticoagulation and bleeding in the upper GI tract can present as dark, tarry stools as a result of the presence of blood which has been exposed to digestive secretions. It is important that clients for whom anticoagulants are prescribed follow the directions for taking the medications precisely; this includes taking the medication for the length of time ordered. Fresh

flowers are not contraindicated for clients on Coumadin; they are contraindicated for clients who are immunocompromised.

Brushing the teeth should be done regularly, not avoided.

However, a soft bristled toothbrush should be used. Moving and avoiding inactivity are instructions that would be given to clients at risk for venous thrombosis.




666. A client suffered deep partial-thickness and full-thickness burns over 40% of his body approximately 12 hours ago. Urine output is 22 ml/hour and the hematocrit is 50%. ABG values show pH, 7.32; paO2, 95 mm

Hg; PaCo2, 35 mm Hg; and HCO3-, 18 mEq/L. Based on this data, which conclusion can the nurse draw about the client ’ s status?

The client

A. is hypovolemic from fluid shift and has metabolic acidosis.

B. is in the early stages of heart failure caused by over hydration.

C. is adequately hydrated, but in acute renal failure and respiratory acidosis

D. has developed a polycythemia as the body attempts to compensate for metabolic acidosis and renal failure.

The answer is A. During the first 24 hours after a burn injury, fluid is lost from the intravascular space into the tissues causing hemoconcentration and diminished urine output.

There is no indication of over hydration. The client does not show symptoms of respiratory alkalosis. The condition is hemoconcentration not polycythemia.




667. When examining a neonate on admission to the newborn nursery, which assessment findings would the nurse interpret as consistent with fetal alcohol syndrome?


A. ___ Elongated palpebral fissures

B. ___ Strawberry hemangioma

C. ___ Thick upper lip

D. ___ Cleft palate

E. ___ Congenital hip dislocation

The answers are B, D, and E. Malformations associated with fetal alcohol syndrome which would be evident in the neonate include strawberry hemangioma, low set posteriorly rotated

CHAPTER 34 Practice Test for NCLEX-RN® 1231 ears, cleft lip/cleft palate, pointy chin, thin upper lip, short palpebral fissures, microcephaly, joint dysfunction including

congenital hip dislocation, abnormal palmar creases, thoracic cage abnormalities, atrial and ventricular septal defects.




668. The client is admitted to the emergency room for acetaminophen overdose. The nurse should prepare to

A. place an intravenous catheter and administer

1000cc D5W intravenously.

B. induce gastric emptying by inserting a nasogastric tube for lavage.

C. give syrup of ipecac and follow with activated charcoal.

D. insert a Foley catheter and start diuresis immediately.

The answer is C. Removal of the poison by inducing vomiting followed by preventing absorption is standard treatment for a non-caustic poisoning. Gavage would be unnecessary as a way to remove the poison. The other two options have nothing to do with poison removal.


MAINTENANCE



669. When examining a 3-year-old, which part of the health assessment should be done first?

A. Abdominal palpation

B. Otoscopic examination

C. Oral examination

D. Chest auscultation

The answer is D. Chest auscultation is the least intrusive part of the physical examination and should be done first to provide time for the child to adjust somewhat to being examined and to delay upsetting the child.



Pathophysiology

670. An 18-year-old client is brought to the emergency room for a hornet sting. Which symptoms suggest that the client is having an anaphylactic reaction?

A. rhinorrhea

B. wheezing

C. local edema

D. urticaria

E. angioedema

F. generalized pruritus

The answers are A, B, D, E, and F. Signs of anaphylaxis which is a hypersensitivity reaction, typically begin with feelings of apprehension and impending doom. Generalized pruritus, urticaria, and sometimes swelling of the eyes, lips, and tongue (angioedema) follow. Respiratory congestion, rhinorrhea,

wheezing and dyspnea occur as a result of bronchoconstriction, mucosal edema and production of excess mucus. Laryngeal edema is associated with hoarseness and stridor. Full blown shock may ensue.


Therapeutic Environment

671. A new mother of a 1-month-old infant is concerned that she is spoiling the baby “ because she carries her around the house in an infant sling against her chest.

”

The nurse ’ s best response would be:

A. “ You should not carry her in the sling except when you are going out and need to take her.

”

B. “ She should spend at least half of her waking time on a firm surface by herself.

”

C. “ Spoiling an infant is difficult; cuddling and holding are essential for normal development.

”

D. “ Carrying an infant in a sling is not advised because of potential problems with development of the spine.

”

The answer is C. Cuddling and holding along with meeting other basic needs builds trust and is essential for normal growth and development. The child can be carried in the infant sling at home as well as when the mother goes out. There is no set time the infant should be alone and on a flat surface. Use of a sling has not been shown to cause problems with the spine.





Provide nursing care in a safe and effective manner

672. The nurse would question an order for a mydriatic medication to be administered to a client with which disorder?

A. Narrow angle glaucoma

B. Drug overdose


C. Blunt force head injury

D. Suspected spinal cord injury

The answer is A. A mydriatic medication dilates the pupils.

Pupil dilation is contraindicated with narrow angle glaucoma so an order for a mydriatic would be questioned because of its ability to cause harm. Pupil dilation does not have the potential for injury in relationship to the other disorders.


MAINTENANCE

Expected Body Image Changes

673. During the routine well check up of an 18 month old, the mother asks the nurse about her son ’ s protruding abdomen. Which fact should form the basis of the nurse ’ s response?

A. The abdomen protrudes as a result of increased food intake at this age

B. Underdeveloped abdominal muscles are the reason for the protruding abdomen.

C. A protruding abdomen indicates a possible abnormal curvature of the spine.

D. A protruding abdomen is uncommon in toddlers and requires further assessment.

The answer is B. Undeveloped abdominal musculature gives the toddler the characteristic protruding abdomen.

A is incorrect because during toddlerhood food intake decreases. C is incorrect because, although it ’ s normal, it doesn ’ t provide the answer to the mother ’ s question. D is incorrect as protruding abdomen is common in toddlers.




674. The client with which problem would be at greatest risk for developing a pulmonary artery thrombosis?

A. Fluid volume overload

B. Ventricular fibrillation

C. Increased cardiac output

D. Polycythemia

The answer is D. Polycythemia predisposes to stasis of blood as a result of increased viscosity secondary to the increased

numbers of red blood cells. None of the other problems predispose to thrombosis.





675. A client presents to the emergency department with a foreign object in the eye. Which action should the nurse take?

A. Remove the object after an x-ray is taken.

B. Remove the object after notifying the ophthalmologist.

C. Leave the object untouched while awaiting the ophthalmologist..

D. Flush the eye with saline to dislodge the object.

The answer is C. The nurse would make no attempt to remove the foreign body until the client has been examined by an ophthalmologist.


MAINTENANCE



676. The nurse is admitting a 2-year-old child to the hospital unit for a minor surgical procedure. When examining the child, which approach is most appropriate?

A. Have the parent wait in the next room

B. Have the toddler sit on the parent ’ s lap

C. Allow the child to remain clothed.

D. Keep equipment to be used out of sight

The answer is B. The child will be more cooperative if his or her parent holds the toddler on lap for the exam.

Separating the child from the parent will most likely increase the child ’ s distress and there is no reason to do so.

It is not possible to perform an effective physical examination with clothing in place. The child should not only see but be allowed to handle equipment to decrease fear and anxiety.




677. The nurse would expect to encounter clients who are covertly aggressive against self or others when working with a group diagnosed with which types of personality disorder?






The answer is D. Clients with passive-aggressive or masochistic personality disorder are covertly aggressive against self

or others. Withdrawal and odd, eccentric behaviors are characteristic of clients with paranoid, schizoid, and schizotypal personality disorder. Attention seeking and erratic behaviors are characteristic of clients with antisocial, borderline, histrionic and narcissistic personality disorders.

Clients with avoidant, dependent or obsessive compulsive personality disorder are attempting to avoid or minimize anxiety or fear.




678. Which statement made by a client taking methotrexate for rheumatoid arthritis indicates that information regarding side effects of the medication was understood?

A. “ It ’ s too bad medications have to have side effects but I guess I can deal with headache and nausea.

”

B. “ I don ’ t know how my husband will cope if I become confused and hallucinate from this medication.

”

C. “ I already have a heart murmur; I am afraid that this medication will make it worse and I will end up needing heart surgery.

”

D. “ I know this medication is very likely to cause kidney damage but the symptoms of the rheumatoid arthritis are so bad that I have to take it anyway.

”

The answer is A. Side effects of methotrexate include

headache and nausea and this statement indicates the client understands that fact. Heart damage is one of several side effects of doxorubicin (Adriamycin). Hallucinations and confusion are side effects of ifsoamide (Ifex). Kidney damage is a side effect of carboplatin (Paraplatin).




679. While being helped out of bed to a chair, a client who is two days postoperative from abdominal surgery starts to cough forcefully and the surgical wound eviscerates. What is the priority nursing intervention?

A. Cover the wound with a moist sterile dressing

B. Start intravenous fluids and antibiotics

C. Apply an abdominal binder

D. Notify the physician.

The answer is A. The wound should be covered with a moist sterile dressing. Moisture prevents the wound from drying out and becoming necrotic prior to surgery. Wound evisceration is a surgical emergency and while one nurse is with the client and covering the wound, a second should be notifying the surgeon. If a client is at known risk for evisceration, sterile dressing and sterile saline should be available in the client ’ s room. Intravenous fluids and antibiotics will be part

of the client ’ s care but are not the immediate priority.

Abdominal binders are not appropriate and could cause damage to wound.


MAINTENANCE


680. A toddler is hospitalized for medical treatment. When the mother leaves, the child screams and cries for his mother. He refuses to be comforted and will not eat while mother is not present. The nurse interprets the child ’ s behavior as indicative of which stage of toddler hospitalization reaction?

A. Protest

B. Despair

C. Detachment

D. Regression

The answer is A. Protest is a stage of anger at the separation from the parent. Despair is mourning the loss of the parent.

The child would no longer display anger but would be saddened by the loss. Detachment is a stage where the toddler appears to be the “ good client ”— appears happy with the parent present.




681. The client is diagnosed with a life-threatening condition characterized by inadequate blood flow to the tissues and cells of the body to meet metabolic demands.

Nursing care should focus on:

A. restoring circulating volume

B. maintaining adequate IV access


C. monitoring intake and output

D. weighing daily

E. observing for fluid overload

The answers are A and B. These activities are designed to restore circulation while observing for complications of nursing interventions.

Responses C, D and E are assessment tools to evaluate the success of the interventions.



Rest and sleep

682. Which information should the nurse include when teaching the parent of an 8-year-old child about bedtime schedules?

A. The child ’ s need for sleep is greater now than in adolescence.

B. Minimum requirement for optimal growth and development is 10 hours of sleep a night.

C. The child is often unaware of his own fatigue level.

D. Nightmares and night tremors are common in this age group.

The answer is C. School-age children are often unaware of their own fatigue level. If allowed to stay awake they will be tired the next day.

Because of slowed growth rate, during the school-age period less sleep, not more, is required than in adolescence.

Eight-year-old children do not require a minimum of 10 hours of sleep. Nightmares and night terrors are common in the preschool period.




683. A client is requiring resuscitation secondary to a respiratory arrest. During the code, epinephrine is ordered. The most effective route of administration would be:

A. Intravenously

B. Endotracheally

C. Intradermally

D. Subcutaneously

The answer is B. The quickest and most effective route would be via endotracheal tube.

The IV route is slower but effective. Subcutaneous or

intradermal administration is inappropriate.


MAINTENANCE


684. The nurse is discussing readiness for toileting with a child ’ s parents. Which factor would the nurse identify as a contraindication to beginning toilet training at this time?

A. The toddler wakes up dry from a nap

B. The toddler stays dry for up to 3 hours

C. The toddler wants to have a soiled diaper changed promptly.

D. The toddler has a toilet adjacent to his bedroom in the family ’ s brand new home.

The answer is D. Moving is a stressful and toilet training should not be initiated during stressful period.

Choices A, B, and C are all signs of readiness for toilet training.




685. A child is admitted to the emergency room with multiple blunt trauma to the chest, and crushing wounds to the abdomen, and legs. Which are the priority nursing assessments?

A. Level of consciousness and pupil size

B. Abdominal contusions and other wounds

C. Pain, respiratory rate, and blood pressure

D. Quality of respirations and presence of pulses

The answer is D. These are top priorities in trauma management; basic life functions must be maintained or reestablished.

Level of consciousness and pupil size are part of the assessment for head injury. Assessment for head injury and assessment for abdominal injury and pain follow appraisal of airway, breathing, and circulation.




686. Which instructions would the nurse give to a client starting on Pentoxifylline (Trental)? Mark all that apply.

A. ___ Take on an empty stomach

B. ___ Report any unusual bleeding or bruising


C. ___ There may be toxic drug effects if taken with

Theophylline

D. ___ Drug reduces red blood cell aggregation

The answers are B, C, and D. Pentoxifylline (Trental) should be taken with food to decrease GI symptoms. Information in all other answers should be included in client teaching regarding

self administration of Pentoxifylline (Trental).


ENVIRONMENTS




687. Which precaution measures would be instituted when a client has tuberculosis? (Mark all that apply.)




D. ___ Use mask when working within 3 feet of the client.





The answers are A, C, F, and H. Tuberculosis is spread in small particle droplets by airborne transmission. Airborne precautions

require a private room with negative airflow and adequate filtration; those entering the room wear a mask and if the client leaves the room, a mask is worn. Standard precautions, which involve wearing gloves whenever there is the risk of touching something wet that comes from the body surface or a body cavity, i.e., when there is the risk of contact with blood or body fluids, are used at all times for all clients.



Alteration in body systems

688. A client is admitted to the emergency room with a diagnosis of acute respiratory distress syndrome.

Which assessment findings would the nurse expect?

A. A systolic blood pressure greater than 170

B. Tenacious thick greenish yellow sputum

C. An altered level of consciousness

D. Slow abdominal breathing

The answer is C. Cognition and level of consciousness are reduced secondary to cerebral hypoxia which accompanies

ARDS. Blood pressure may be reduced. Sputum is not tenacious, but may be frothy if pulmonary edema is present.

Breathing will be rapid and shallow not slow and abdominal.


MAINTENANCE


689. After administering an IM injection to 3-year-old child the nurse puts an adhesive bandage on the site. The reason for applying the bandage is based on the fact that:

A. the child will “ pick ” at the injection site.

B. the bandage will relieve pain at the site.

C. the preschool child is afraid his “ insides will fall out ” and the bandage prevents “ insides from leaking.

”

D. the bandage will remind the nurses that the child has received an injection recently.

The answer is C. Preschoolers want a bandage on any scrape or bruise to prevent their insides from leaking out. Most children will not pick at the site, bandages do not relieve pain, and nurses should not need a reminder that a child has received an injection.




690. Which type of delivery system would the nurse use when administering oxygen to a client who has experienced a cardiac arrest?

A. A nasal cannula at l liter per minute.

B. A 100% non-rebreather mask.

C. A 28% venti-mask

D. A face mask at 4 liters per minute

The answer is B. A non-rebreather mask provides the highest concentration of oxygen available. All other choices would provide insufficient oxygen. With a simple face mask, the flow rate must be at least 5 liters per minute to flush the mask of carbon dioxide.




Assist client/family/significant others to integrate new members into family structure

691. A very young teenager has just given birth to a healthy infant. The nurse is concerned about bonding. To promote bonding, the nurse would:

A. Encourage early parent – infant interaction and close body contact.

B. Allow mother infant interaction only when a nurse can be present.

C. Require the new mother to breastfeed the infant.

D. Tell the new mother how bright and alert her baby is.

The answer is A. Studies have shown that immediately after birth is the best time for maternal infant bonding.

B, C, and D are incorrect because maternal-child contact would not be limited; the mother has the right to choose to breast feed or not; telling the mother her baby is bright

and alert does not promote bonding.



Pathophysiology

692. A client with disseminated intravascular coagulation has a severe reaction to a unit of packed cells and develops a humoral immunity. The nurse knows that humoral immunity:

A. Is produced by T-cell activity

B. Involves immunoglobulins

C. Occurs only in anaphylactic reactions

D. Involves the thymus

The answer is B. Humoral immunity is mediated by B lymphocytes and is involved in an anaphylactic reaction. A is incorrect as it is B cell activity. Humoral immunity can also involve immunocomplex hypersensitivities. The thymus is not involved.



Pathophysiology

693. Which symptoms occurring in a 4-week-old male infant are consistent with a diagnosis of pyloric stenosis?

A. Metabolic alkalosis

B. Uninterested in feeding

C. Vomiting bile stained fluid.

D. 2 ounce weight loss over last 3 days.

E. Peristalsis observed over the abdomen.

The answers are A, D, and E. A and D are related to the vomiting that occurs. Peristalsis may be visible on the abdomen as the stomach tries to push formula past the obstruction.

The infant will be hungry, vomiting will not be bile stained.




694. A client has been admitted to the hospital unit for stasis venous ulcers. Which nursing intervention would be included in the plan of care?

A. Performing Burger-Allen Exercises

B. Providing bedrest with legs in a dependent position

C. Placing a foot board on the bed

D. Placing the client in a high fowler ’ s position

The answer is C. Use of a footboard keeps pressure off of the ulcer. Burger-Allen Exercises are done for Buerger ’ s disease.

Keeping legs in a dependent position increases edema. High

Fowler ’ s position increases pressure and kinking on the vascular system.


Sensory/Perceptual Alterations

Assess needs of clients with altered sensory perception

695. When planning care for a client with hallucinations, the nurse would consider that the client is most likely to harm self or others in which stage of the hallucinatory process?

A. comforting

B. condemning

C. threatening

D. controlling

The answer is D. Controlling. There are four stages in the hallucinatory process. In stage 1, the hallucination is familiar and comforting and anxiety level is mild. In stage 2, the hallucination is condemning; it is accusing and makes the person feel guilty and isolated. In stage 3, the hallucination is threatening and begins to rule all different aspects of behavior.

In the fourth or controlling stage, anxiety has increased to the panic level and the individual is unable to control behavior. It is in this stage that the risk of harm to self or others is greatest.




Pathophysiology

696. A maternity client is seen for her regular checkup at 20 weeks gestation. On assessment, the nurse notes that the uterus is at the level of the xiphoid process. The

nurse would suspect:

A. Oligohydramnios

B. Multiple Gestation

C. Intrauterine growth retardation

D. Fetal demise

The answer is B. At 20 weeks gestation, the fundus should be at the level of the umbilicus. This finding indicates the fundus is above the expected location. The only response that would cause the fundus to be higher than normal is B. All other conditions would lead to a fundus below the expected level.


MAINTENANCE


697. The parent of a 3-year-old child tells the nurse that she is worried because the child has irrational fears. “ My child is afraid to go to bed, afraid of the neighbor ’ s gentle

Golden Retriever, every day there ’ s a new fear ” Which of the following is the best response from the nurse?

A. “ Preschool children have the most fears; try a night light to help going to bed and know that being afraid of large dogs is very common in this age group.

”

B. “ Your child should be growing out of these irrational fears by now, let ’ s get her involved in some play and see what seems to be going on.

”

C. “ Don ’ t make too much of it; just be patient; this

phase will pass soon ”

D. “ Going to bed is often a problem, let her fall asleep in your bed and then carry her back to her bed when she is sleeping ”

The answer is A. The preschool years are the time when children have the most fears. Option A reassures the mother her child ’ s behavior is normal and it gives the mother information that will help her deal with the child ’ s fear.




698. A 4-month-old infant puts a toy in their mouth and begins to choke. Which is the appropriate nursing action?

A. Position infant head down and provide back blows.

B. Elevate the infant ’ s head and provide back blows.

C. Position the fist below the navel, then using both fists perform four abdominal thrusts.

D. Place one fist on the sternum and perform chest thrusts.

The answer is A. The infant is positioned head down and back blows are given. Back blows are used on the conscious infant. Trendelenburg position is used to assist with foreign body removal. The other responses are incorrect.


MAINTENANCE


699. Which suggestion could the school nurse make to the parents of a 10-year-old child who want to promote their child ’ s psychosocial development?

A. Encourage the child to start a collection of model cars, baseball cards, or other similar items.

B. Meet the needs of the child in a consistent manner.

C. Avoid disciplining the child during this difficult period.

D. Reinforce that the child is a good person even if behavior is bad.

According to Erikson, the school age child ’ s task is to develop industry vs. inferiority. A child ’ s sense of industry is enhanced by building a collection. Being consistent helps meet the needs of the infant. Informing the child that he is a good person even if his behavior is bad is appropriate for a toddler. All children need discipline as they are uncomfortable when there are no rules.




700. While providing nursing care, the client has a respiratory arrest. Which are the priority interventions for the resuscitation of this client?

A. Intubating with an endotracheal tube

B. Starting 100% oxygen

C. Drawing serial arterial blood gases

D. Checking the Glasgow coma scale

E. Monitoring oxygen saturation level

The answers are A and B. Both of these actions would promote oxygenation.


C and D are assessment measures that would be done but they are not the priority. Response E is unrelated to a respiratory arrest.




701. A client returns to the hospital unit following an appendectomy. Which finding on the postoperative admission assessment should be reported to the physician immediately?

A. Oral temperature 99_F

B. Pulse 98 and thready

C. Complaints of nausea

D. Absent bowel sounds

The answer is B. A pulse of 98 and thready is suggestive of hemorrhage. Oral temperature may be slightly elevated as a result of the procedure. Nausea is common in the post operative

period. Absent bowel sounds are common in the immediate post operative period.


MAINTENANCE

Aging Process

702. An 89-year-old man came to the clinic for his annual checkup. Which finding related to pulmonary function would the nurse expect?

A. An increase in functional alveoli

B. A reduction of residual volume

C. A decrease in vital capacity

D. Blood gases that show mild acidosis

The answer is C. A decrease in vital capacity because loss of elastic forces in the lung lead to an increase in residual volume, and a decrease in vital capacity.




703. A client in the emergency department is intubated and connected to a mechanical ventilator. She becomes extremely anxious, and the pressure alarm sounds with each inspiration. Which is the priority nursing intervention?

A. Increase the tidal volume

B. Increase the oxygen concentration

C. Disconnect the ventilator and manually ventilate the client using a ventilator bag for a few breaths.

D. Administer the prescribed diazepam or morphine sulfate as needed.

The answer is C. This allows the nurse to assess for a mucus plug which would occlude the ET tube causing the increased pressure alarm. The other interventions would be inappropriate.



Hemodynamics

704. The nurse is teaching self care to a client who has been diagnosed with Raynaud ’ s disease. Which instruction best meets the goal of maintaining optimal tissue perfusion?

A. Inspect skin daily for breakdown

B. Alleviate factors that increase pain

C. Wear mittens when going out into the cold

D. Elevate extremities when color changes occur due to vasoconstriction

The answer is C. Keeping the hand warm enhances vasodilation and tissue perfusion. Inspection of the skin is important to prevent complications but does not enhance vasodilation.

Alleviating factors that increase pain promotes comfort and may help prevent further decreases in tissue perfusion but does not optimize it. Elevating extremities decreases circulation to the extremity.




705. The nurse says to a schizophrenic client “ Swallow your pills, John.

” The client responds by saying “ Swallow your pills John; swallow your pills John; swallow your pills John; swallow your pills John ” Which would be a correct label for the nurse to use when documenting this communication?

A. word salad


C. neologism

D. echolalia

The answer is D. Echolalia. Echolalia is the repetition of words or phrases heard from another person. Word salad refers to the meaningless connection of words and phrases.

Clang association refers to repeating words and phrases which sound alike but are otherwise unconnected. A neologism is a new word coined by the client and with meaning only to the client.





706. A teenager has been admitted to the hospital unit with a diagnosis of appendicitis. While awaiting the start of surgery, it becomes apparent that the appendix has ruptured. At this time, in what position will the nurse maintain the client?

A. Prone

B. High Fowlers

C. Left side-lying

D. Trendelenburg

The answer is B. High Fowlers position utilizes gravity to collect the infectious material in one area of the abdomen reducing the extent of peritonitis. The other responses would not be correct.



Pathophysiology

707. A client is admitted to the emergency room with a blood pressure of 72/42 mm HG and a diagnosis of septic shock. Which assessment finding would best confirm this diagnosis?

A. Hot, dry skin with poor skin turgor

B. ABG analysis revealing metabolic alkalosis

C. Temperature of 105_F (40.6_C) and a pulse rate of

122 beats/minute

D. Urine output of 30 ml/hour and central venous

pressure of 8 cmH2O

The answer is C. Septic shock is related to the presence of endotoxins or exotoxins released from bacteria. Symptoms include fever, tachycardia, increased respiratory rate and shock and coma. The other responses are not related to septic shock.


MAINTENANCE



708. When planning care for a 4-year-old, the nurse considers the fact that the child does not yet comprehend which concepts?

A. Alternative points of view

B. Conservation

C. Reversibility

D. Object permanence

The answers are A, B, and C. A 4-year-old child is egocentric and doesn ’ t understand another ’ s view yet. Conservation, which is permanence of mass and volume, is not comprehended nor is the concept of reversibility i.e. if 2 _ 3 _ 5, then 5 _ 3 _ 2. Object permanence is mastered and understood in toddlerhood.



Hemodynamics

709. A client is experiencing septic shock and the attending physician wants to titrate medications to be regulated so that a mean arterial pressure (MAP) between 75 and

85 mmHg is maintained. When evaluating the response of the drug, which of the blood pressure readings meet the goal?

A. 135/90

B. 125/80

C. 115/70

D. 110/60

The answer is C. The formula for mean arterial pressure

(MAP) is SBP _2 DBP divided by 3. The blood pressure with mean arterial pressure between 75 and 85 is 115/70 (MAP),

(115 _ 70 _ 70 _ 255/3 _ 85) is 85.

A, B, and C are incorrect.




710. A 24-year-old post partum client is transferred to the

ICU after developing disseminated intravascular coagulation

(DIC). The nurse develops a care plan in collaboration with the physician knowing that the care of a client with a bleeding(clotting disorder usually includes:

A. Monitoring core body temperature

B. Initiating heparin therapy

C. Administering blood

D. Restricting dairy products in the diet

The answer is B. Heparin is given because the abnormal clotting that occurs with DIC uses up available clotting factor. Heparin inhibits clotting and therefore allows clotting factor to be replenished. Monitoring core body temperature is not a priority with DIC. Blood is not administered because the problem is clotting, not bleeding. Dairy products are unrelated to DIC.



MAINTENANCE

Aging Process

711. Which finding when reviewing the record of an elderly client would the nurse interpret as a normal occurrence with aging?

A. Very concentrated urine

B. Microscopic hematuria

C. Occasional urinary incontinence

D. Decreased glomerular filtration rate

The answer is D. Changes in the renal tubules cause a dramatic decrease in the glomerular filtration rate. Hematuria, either microscopic or gross, is always abnormal. Incontinence is also abnormal.




712. After diagnosis of diverticulitis, a client has been taught about the appropriate dietary changes. Which statements by the client indicate that teaching was successful?

A. “ I will eat a low-fiber diet.

”

B. “ Milk will increase my episodes of diverticulitis.

”

C. “ Whole grains are better for me than refined grains.

”

D. “ Starches, fruits and vegetables will increase my flatus and diarrhea.

”

The answers are B and C. A diet to prevent constipation is recommended.

Milk can be constipating so it can contribute to increase episodes of diverticulitis. Whole grains are better than refined grains because they provide more fiber. Option

A is incorrect because a high fiber not a low fiber diet is needed to prevent constipation. Starches, fruits and vegetables are good sources of fiber so they decrease not increase symptoms.





713. A 20-year-old male suffered a broken jaw in an automobile

accident. The jaw has been wired shut. The nurse will ensure that which of the following equipment will be available at the client ’ s bedside for safety?

A. Call light

B. Wire cutters

C. Clear liquids

D. Paper and pencil

The answer is B. If the client should vomit, he could choke and aspirate. Wire cutters would need to be immediately available. The call light is appropriate for all clients. Clear liquids would not be a safety feature. Paper and pencil may aid communication but are not emergency supplies.



Provide symptom management for clients experiencing withdrawal or toxicity

714. When planning care for a client withdrawing from cocaine, which is a critical nursing intervention?

A. Monitor for seizures

B. Protect from self harm

C. Orient to time and place

D. Monitor for hypotension

The answer is D. Protect from self harm. The client withdrawing from cocaine or another central nervous stimulant

experiences severe dysphoria, anxiety, disturbed sleep and is at significant risk for suicide. Hence a priority nursing intervention is to prevent self harm. Seizures and confusion can occur with withdrawal from alcohol, sedatives/hypnotics, and anxiolytic drugs. Hypertension, not hypotension is a risk with cocaine withdrawal.




715. A client is brought into the emergency department complaining of severe back pain. He is diaphoretic, pale, tachycardic, and has absent pedal pulses. Which is the immediate nursing intervention?

A. Start an IV with a 16 gauge catheter

B. Get a stat back x-ray

C. Prepare the client for insertion of hemodynamic monitoring

D. Get a 12 lead ECG

The answer is A. The client is showing signs of shock and needs immediate vascular access. The other interventions could be done later.






716. A 2-week-old infant has returned from surgery for repair of a unilateral cleft lip. The nurse instructs the mother to comfort the baby when the baby becomes upset and starts to cry. The mother asks why it is important that the baby not cry. The nurse ’ s response would be based on the knowledge that crying:

A. puts strain on the suture line.

B. may prevent the infant from developing trust.

C. causes the infant to swallow air and may cause vomiting.

D. simulates coughing in the post operative infant.

The answer is A. A crying infant will open the mouth wide putting strain on the sutures in the upper lip. Although meeting the infant ’ s needs in a timely fashion is important in the development of trust, it is not the correct response in this situation.

Crying does cause the infant to swallow air, but that is not the primary reason for comforting the child. Crying stimulates coughing but is not appropriate for this child.



717. A 15-year-old boy was admitted to the pediatric unit following an injury to his leg. When told that the complicated fracture would require surgical repair and prevent a return to the football team for an unknown

extended period of time, the boy throws an apple from the lunch tray at the nurse. Which type of coping behavior is the teenager exhibiting?

A. Reaction formation

B. Projection

C. Denial

D. Displacement

The answer is D. Displacement is shifting focus from an undesired object or feeling to a more acceptable object or feeling.

Reaction formation is acting opposite to how one feels.

Projection occurs when one attributes ones own unacceptable feelings to another. In denial one ignores unacceptable realities.




718. A client is suspected of having osteoporosis. Which test will provide the best information regarding this problem?

A. Serum calcium

B. X-ray of pelvis

C. CT scan of spine

D. DEXA scan

The answer is D. Dual energy x-ray absorptiometry

(DEXA) measures bone mineral density. It allows detection of early osteoporotic changes in the wrist, spine and/or hip. It is the best diagnostic tool available for

osteoporosis. There are no laboratory tests that definitively diagnose primary osteoporosis. Serum calcium is one of a battery of laboratory tests used to rule out secondary osteoporosis or other metabolic disease. X-rays and CT scans do not provide an accurate picture of the mineral content in bone that denotes bone density and do not detect early bone changes.


MAINTENANCE

Aging Process

719. Which assessment finding on a 78-year-old woman most likely reflects age-related decreased blood vessel elasticity and increased peripheral resistance?

A. An irregular peripheral pulse

B. An increase in blood pressure

C. Night time confusion

D. Wide QRS complexes on the ECG

The answer is B. Thickening of the blood vessels and less distensible arteries and veins cause impeded blood flow and increased vascular resistance, leading to hypertension.




720. The nurse is pushing IV medications during a “ code blue.

” Which is a critical step in the procedure?

A. Check the orders with the chart

B. Inspect the IV site for infiltration

C. Evaluate the peripheral pulses

D. Flush the line with dextrose between drugs

The answer is B. Inspecting the IV site for infiltration is critical because medication will not be effective if administered into the tissue rather than the blood stream. Orders are usually verbal during a code situation. Pulses are generally absent if in a code blue situation. Lines should be flushed with sodium chloride.




Develop and maintain therapeutic relationships with client/family/significant others

721. Which is an appropriate guideline for the nurse to utilize when communicating with an adolescent?

A. Reassure that what he or she is going through is understood.

B. Invite the parents to be present when talking with the adolescent.

C. Ask meaning of expressions if not clearly understood as a result of teen culture.

D. Share with the parents information received in their absence.

The answer is C. Understanding the meaning of the adolescent ’ s expression will aid in understanding the communication and display interest in the adolescent ’ s point of view.

A is incorrect as this statement will discourage further comments. B is incorrect as the adolescent may not be willing to talk in front of his parents. The child will feel betrayed if the nurse reports the conversation to the parents.




722. A child is admitted to the hospital unit with a diagnosis of pyloric stenosis, On admission, the nurse would expect to see which electrolyte imbalance?

A. Hypokalemia

B. Hypernatremia

C. Hyperchloremia

D. Hypomagnesemia

The answer is A. Potassium is lost by vomiting. All other responses are incorrect.




723. A client is being treated for Gastroesophageal Reflux

Disease (GERD). When the nurse administers famotidine

(Pepcid) to the client, the client asks how this

medication will help. The nurse ’ s reply will be based on the knowledge that the medication will:

A. Decrease gastric acidity reducing irritation to the esophagus.

B. Relax the lower esophageal sphincter (LES) preventing further reflux.

C. Increase intraabdominal pressure to maintain positive pressure in the esophagus.

D. Decrease the intra-gastric pressure putting less strain on the lower esophageal sphincter (LES).

The answer is A. Symptoms of the disease are due to the regurgitation of stomach acids into the esophagus. By reducing the acidity of stomach contents, symptoms will be reduced.

The other responses are incorrect. The activity described in B and C would increase the symptoms.


MAINTENANCE

Disease Prevention

724. Working on a geriatric unit, the nurse knows that the bed bound hospitalized older adult is at risk for pressure ulcers. Which factors seen in the unit ’ s clients would increase the risk for pressure ulcers?

A. Diminished sensory perception

B. Dry fragile skin

C. Decreased mobility

D. Indwelling urinary catheter

E. Decreased appetite since hospitalization

F. Nursing assessment every shift

The answers are A, B, C, and E. Dry fragile skin increases the risk for skin breakdown. Diminished sensory perception diminishes the amount of normal shifting and movement, not allowing for the relief of pressure, increasing the risk for skin breakdown. This is true with decreased mobility as well.

Incontinence, not an indwelling catheter would increase the risk of pressure ulcers. Nursing assessment and interventions including a turning and positioning schedule, bed bath and massage, ROM exercises, and providing appetizing nutritious foods with adequate protein that the client likes, is key to the prevention of pressure ulcers.



Alterations in Body System

725. In preparing a discharge teaching plan for a client diagnosed with thrombophlebitis and being treated with warfarin, which instructions would the nurse include?

A. Eat a diet high in fiber and leafy green vegetables

B. Start a progressive exercise program

C. Drink at least eight glasses of fluid daily

D. Do not use oral contraceptives


The answers are B, C, and D. The instruction to eat a diet high in leafy green vegetables would not be included because green leafy vegetables contain vitamin K, which can affect the needed dose of warfarin. All other instructions are appropriate and would be included in discharge plan.




726. The nurse would expect to encounter clients who are attempting to avoid or minimize anxiety or fear when working with a group diagnosed with which types of personality disorder?





The answer is C. Clients with avoidant, dependent or obsessive compulsive personality disorder are attempting to avoid or minimize anxiety or fear. Withdrawal and odd, eccentric behaviors are characteristic of clients with paranoid, schizoid, and schizotypal personality disorder.

Attention seeking and erratic behaviors are characteristic of clients with antisocial, borderline, histrionic and narcissistic personality disorders. Clients with passive-aggressive or masochistic personality disorder are covertly aggressive

against self or others.



Pathophysiology

727. The nurse is caring for a client with Alzheimer ’ s disease

(AD), the most common form of dementia in older adults. Which factors are associated with AD? Select all that apply:

A. Acute onset

B. Impaired memory

C. Confusion

D. Difficulties with language

E. Reversible organic disorder

F. Amyloid plaques

The answers are B, C, D, and F. AD is a progressive, irreversible, organic disorder, characterized by confusion, disorientation, impaired memory and cognition. Personality changes are seen, and in later stages eventual dependency for all ADLs and IADLs. Amyloid plaques and neurofibrillary tangles are found in the brains of AD clients.




728. A child has been admitted to the hospital unit for gastroenteritis.

The child has been having diarrhea for 3 days

and is moderately severely dehydrated. The stool cultures indicate a rotovirus as the cause of the diarrhea. The mother questions the nurse why her child isn ’ t on antibiotics like the other children on the unit with GE. The nurse ’ s response would be based on the knowledge that:

A. antibiotics will make the diarrhea worse.

B. the diarrhea has probably already run its course.

C. antibiotics are not used for rotovirus gastroenteritis.

D. the child is too dehydrated for antibiotics to be effective.

The answer is C. Antibiotics are used to treat bacterial infections not viral. Diarrhea is often a side effect of antibiotics but is not the correct response here. The other responses are incorrect.


MAINTENANCE


Recognize behaviors associated with psychosocial development

729. Which of the following behaviors indicates a 3 month old infant is developing a sense of trust?

A. Eats and sleeps well

B. Makes cooing noises

C. Has developed object permanence

D. Clings to mother and cries when she is not present

The answer is A. A sense of trust indicates trust in the world around them that basic needs will be met. Cooing noises

occur because a child can hear himself. Object permanence is a component of Piaget ’ s theory and not related to trust versus mistrust. Clinging to the mother occurs after object permanence develops in a much older infant.



Develop and maintain therapeutic relationships with client/family/significant others

730. A toddler is hospitalized for minor surgery. The parents are unable to stay with the child. The child reacts to the separation with a saddened expression, refusal to eat and continues to cry for momma. How should the nurse respond?


A. Encourage the child to forget mom and dad.

B. Hold the child and tell him mommy loves him and will come back.

C. Ignore his cries as they do not represent physical discomfort.

D. Avoid mentioning parents while holding and comforting the child.

The answer is B. This is the despair phase of toddler hospitalization reaction. The appropriate response is for the nurse to provide physical comfort and reinforce that the parents will return. The child ’ s psychological needs can not

be ignored. The child needs the parents for healthy development.




731. After an infant has a barium enema reduction of intussception, the nurse will know the reduction was successful when the infant:

A. smiles at mother.

B. passes a solid stool.

C. falls asleep without medications.

D. takes his regular amount of formula.

The answer is B. In addition to pain, the symptoms of intussception include passing a “ currant jelly ” stool followed by intestinal obstruction. Passing a solid stool would indicate the obstruction has cleared. The other responses do not address the pathology.




732. A 22-year-old man has accidentally ingested about

200 ml of a lye-based liquid drain cleaner. Which treatment should the nurse be prepared to administer when the client arrives at the emergency department?

A. A cathartic to promote elimination of the poisonous substance

B. 30 ml of ipecac syrup followed by 240 ml of water to induce vomiting

C. 150 ml of milk or water to dilute the ingested substance

D. 75 g of activated charcoal to absorb the ingested chemical

The answer is C. The goal is to dilute the lye based product because it is caustic and tissue burn can result from contact with the agent. Diluting the product decreases the burn.

Vomiting is contraindicated because the caustic product would come into contact with tissues of the esophagus, throat and mouth a second time and do more damage.

Absorption of the chemical into the body is not the immediate concern so activated charcoal is not used.


MAINTENANCE

Health and Wellness

733. A home health nurse sees many elderly clients and is concerned about their nutritional status. The nurse recognizes that the following factors contribute to the risk of malnutrition in older adults:

A. Gastrointestinal changes including diminished saliva, decreased gastric acid and digestive enzyme secretions

B. Chronic illness

C. Poor dentition

D. Inadequate financial resources

E. Decline in functional ability

F. Moving to an Assisted Living Facility

The answers are A, B, C, D, and E. Poor dentition, GI changes, and chronic illness result in inadequate intake, poor ingestion and digestion of food. The older adult may believe that limited resources will prevent them from purchasing nutritional foods and eat junk food instead. The nurse needs to educate regarding affordable nutritional foods and work as case manager and arrange for food stamps. Functional ability is the extent to which one is able to perform Activities of Daily Living (ADLs) & Instrumental

Activities of Daily Living (IADLs). Decline in ADLs includes the ability to prepare meals; a decline in IADLs includes the ability to go food shopping. With functional limitations, the nurse as case manager can arrange for meals on wheels.

Assisted living provides balanced meals that promotes good nutrition.




Use the “six rights” when administering client medications

734. A dose of intravenous acyclovir should be administered over what period of time? Record your answer as a whole number of minutes in the space provided.

___________minutes


Answer is 60 minutes.

Acyclovir is nephrotoxic. It is excreted primarily by glomerular filtration and tubular secretion. To decrease the risk of nephrotoxicity, the client must be well hydrated; the drug must be administered over a period of 60 minutes; and urinary output must be measured for two hours after the infusion. Output of less than 500 mL of urine per gram of acyclovir must be reported immediately.




735. The nurse preparing a client for a cardiac catheterization and revascularization should include which information in the pre-op teaching.

A. The client will be asleep during the procedure

B. The client may experience a hot flash as the dye is injected

C. There may be a sand bag placed over the cannulated site following the procedure

D. The client will be on fluid restrictions until the gag reflex returns

E. The client may experience chest pain when the balloon is inflated

F. The client will experience a headache as the dye is injected

The answers are B, C, and E. The client is generally awake during the procedure and fluid intake is encouraged in order to assist the kidneys with excretion of the dye. Generally a client may experience a metallic taste in the mouth or a hot flash when the dye is injected.



Assess client response to illness

736. An 8-year-old child is hospitalized and undergoing diagnostic testing. Her parents can spend very little time with her because of the demands of work and four younger children at home. Nonetheless the child appears calm, does not complain, and seems unperturbed by all the stress. How would the nurse interpret this behavior?

A. The child is mature for her age and is dealing well with hospitalization.

B. A child of this age is not invested in health or family matters; peers are the concern and she will be receiving a lot of attention from them.

C. The child is employing reaction formation which is a primary defense mechanism for her age.

D. The child is coping by regressing.

The answer is C. The primary defense mechanism at this stage is reaction formation, which is acting brave, when really being quite frightened.

A, B, and D are incorrect — The child is interested in peers, but the rest of the comments are not true. Regression is seen in younger children and the symptoms of this child are not those of regression but are typical in reaction formation.




737. The client is receiving Heparin IV at 1200 units/hour as part of the treatment regime for pulmonary embolism.

The nurse notes that the urine has become bright red in color. The nurse would prepare to administer which of the following medications?

A. Protamine Sulfate

B. Aquamephyton (vitamin K)

C. Warfarin (Coumadin)

D. Acetylcysteine (Mucomyst)

The answer is A. The antidote for Heparin is protamine sulfate.

Bright red urine suggests hematuria which is a potential adverse effect of anticoagulation. Aquamephyton is the antidote for Coumadin overdose and Acetylcysteine is the antidote for acetaminophen poisoning.


MAINTENANCE


Incorporate knowledge of theories of development in planning care for the client

738. A chronically ill adolescent has been hospitalized frequently for extended periods of time. Because of the severity of the illness and as a result of the hospitalization, the adolescent has been unable to develop a sense of who he is or what he will become. According to Erikson, these deficiencies will result in which of the following:

A. role diffusion

B. inferiority

C. isolation

D. stagnation

The answer is A. The adolescent is working on developing a sense of identity. Other answers are for other stages.





739. A client who is in the Cardiac Care Unit complains of mediastinal chest pain, dyspnea, and anxiety. The nurse gives the client a nitroglycerine tablet sublingual.

The client now complains of being dizzy. Which is the priority nursing intervention?

A. Get a 12 lead ECG

B. Raise the side rails on the bed

C. Open the D5W IV to 100 cc per hour

D. Take vital signs including pulse oximetry

The answer is B. Safety is the priority.

C would not be correct because it is not an isotonic solution and would not help to maintain circulating volume. A would be done but would not be the priority. D is not the priority.


MAINTENANCE

Aging Process

740. Which of the following would the nurse identify as normative signs of aging, as opposed to pathologic signs?

A. Increase in diastolic blood pressure

B. Decrease in glomerular filtration rate

C. Reduced lens elasticity

D. Reduced vital capacity

E. Dulled sense of taste

F. Pressure ulcers

The answers are B, C, D, and E. A mild increase in systolic BP is expected, however an increase in diastolic BP is pathological.

Normative changes in renal tubules cause a dramatic decrease in glomerular filtration rate. There is a normal decrease in lens elasticity. A normative decrease in chest wall compliance and atrophy of respiratory muscles contributes to

reduced vital capacity. There is a normative dulled sense of taste, touch, and pain. Pressure ulcers are a pathological sign.




741. Which is an indication of a successful outcome for a client who is recovering from an abdominal aortic aneurysm repair?

A. Capillary refill of the toes _5 seconds

B. Pulse Oximetry of the foot _ 88%

C. BP diastolic _ 80 mm Hg.

D. Urine output _ 15 cc per hour

The answer is C. Diastolic blood pressure of 80 mm Hg.. High

BP puts pressure on the surgical site. Capillary refill should be _3 seconds. Pulse oximetry should be _95%. Urine output should be _30 cc per hour.



Assist client with achieving and maintaining self-control of behavior

742. Which statement made by the parent of a suicidal client indicates the need for further explanation about a “ no suicide ” contract?

A. The contract provides a boundary.

B. The contract gives the client responsibility for control.

C. These contract serve to reinforce to the client that life is valuable.

D. Verbal as well as written contracts have been shown to be effective.

The answer is C. No suicide contracts do not directly reinforce that life is valuable. Therefore this is an incorrect statement and indicates that the parent needs further explanation.

All other statements about a no suicide contract are correct.

A “ no suicide ” contract is a way of providing boundaries.

Contracts help place control in the domian of the client. Both verbal and written “ no suicide ” contracts have proven effective.




743. Which symptoms identified during the assessment of a

4-week-old male infant are consistent with the diagnosis of pyloric stenosis?

A. Metabolic alkalosis

B. Lack of interest in feeding

C. Vomiting bile stained fluid.

D. 2 ounce weight loss over last 3 days.

E. Peristalsis observed over the abdomen.

The answers are A, D, and E. Metabolic alkalosis, weight loss, and visible peristalsis are signs of pyloric obstruction.

Metabolic alkalosis and weight loss result from vomiting that occurs with pyloric stenosis. A and D are related to the vomiting that occurs. Peristalsis may be visible on the abdomen as the stomach tries to push formula past the obstruction. The infant will be hungry, vomiting will not be bile stained.



MAINTENANCE

Aging Process

744. When doing an intake assessment on the older adult, which factor should the nurse consider?

The older adult

A. responds with increased emotion to questions related to family history.

B. often has diminished auditory acuity and may impede communication.

C. is uncomfortable with the physical assessment because of multiple physical changes.

D. has an increased response to pain requiring extreme caution with the physical assessment.

The answer is B. Diminished auditory acuity is common and communication is affected. Response to pain is decreased.

Other responses are incorrect.




745. A two week old infant has had several periods of apnea.

After work-up, the physician diagnoses the infant with

GERD and instructs the nurse to teach the mother feeding techniques to diminish reflux. The nurse will teach the mother to:

A. avoid burping the baby to discourage reflux.

B. keep the infant in an upright position after feeding.

C. rock the baby during the feeding to keep him calm.

D. place the baby prone after feeding to prevent aspiration if reflux occurs.

The answer is B. Upright position uses gravity to assist in formula retention. Burping would be more frequent in the

GERD infant. Rocking will mix air with the formula making vomiting more likely. Prone position would put pressure on the abdomen and may increase vomiting.


MAINTENANCE

Aging Process

746. The nurse knows the older adult has an increased risk for drug toxicity. Which of the following contributing factors increase the risk for drug toxicity?

A. Impaired renal function

B. Decrease in blood flow to the kidneys

C. Polypharmacy

D. Urinary incontinence

E. Possibility of multiple chronic conditions requiring medications

F. Using many physicians and lack of communication between physicians

The answers are A, B, C, E, and F. The decline in renal function in the older adult results in inefficient excretion of active drug, allowing toxic levels of drug to accumulate, placing the older adult at risk for drug toxicity. Polypharmacy is the concurrent use of many drugs, which is common in older adults as a result of: increased number of chronic conditions, using many physicians, changing physicians frequently, using more than one pharmacy, lack of information about over the counter medications, and assumption that once a drug is started it must be finished.




Instruct client on medication self-administration procedures

747. Which information/instruction would the nurse include when teaching the mother of child diagnosed with ADD about the proper use of the prescribed stimulant medication?

A. Take the medication before a meal.

B. If a dose is missed, take it as soon as remembered.

C. Expect heavy sweating and heat intolerance as side

effects of the medication.

D. Follow up visits for lab tests or other monitoring are needed.

The answer is D. Follow up visits are critical so that the effects of the prescribed medication can be monitored. Monitoring may include laboratory studies, vital sign checks or EKGs.

Stimulant medications should be taken after eating to avoid problems with appetite or indigestion. If a dose is missed, it is not “ made up ” , the next dose is simply taken as scheduled.

Side effects of stimulant medications are anorexia, nausea and vomiting, insomnia, tachycardia and chest pain, headache, and irritability, nervousness or confusion.




748. An elderly client in an extended care facility hollers from her bed “ Nurse, help me. They are throwing

1248 PART III: Taking the Test dishes at me.

” Which is the best response on the part of the nurse?

A. “ What kind of dishes is someone throwing at you?

”

B. “ Have a drink of water and by then it will be over.

”

C. “ I don ’ t see anyone throwing dishes but it must be scary for you; you are safe here.

”

D. “ Why do you think anyone would want to throw dishes at you? You have never hurt anyone have you?

The answer is C. This response is empathetic; acknowledges the client ’ s feeling; and offers reassurance. Responses A and

D encourage the client to get more involved and add detail to the delusion and this is not therapeutic. Response B makes light of the client ’ s experience and has an element of false reassurance.




749. A client has just had an arthroscopy of the right knee for diagnostic evaluation of chronic knee pain. Which assessment finding has the highest priority for being reported to the surgeon?

A. Report of pain is 7 out of 10 on pain scale

B. Strength of right pedal pulse is decreased.

C. Capillary refill time is 3 seconds..

D. Pain is unrelieved by application of ice.

The answer is B. The decrease in pedal pulse could be indicative of obstruction to arterial flow to the foot.

A, C, and D are not correct because pain immediately following the arthroscopy is expected. Capillary refill time of three seconds is normal and indicates good blood flow through the capillaries. In older individuals, up to 5 seconds is considered normal.




750. A 35-year old man is brought to the emergency department by EMS personnel after he was found sitting in the car in an enclosed garage with the motor running.

He is unresponsive and hypotensive, and his skin is bright red. Which intervention would have the greatest priority?

A. Administration of oxygen

B. Placing the client in a prone position.

C. Administration of Narcan

D. Initiating CPR.

The answer is A. Being found in an enclosed space in a car with its motor running with symptoms of bright red skin and unresponsiveness is indicative of carbon monoxide poisoning.

The immediate intervention is to remove the client from exposure to carbon monoxide and administer oxygen.

Oxygenation is always the first priority. Placing the client in a prone position is inappropriate. Narcan is an opiate antagonist;

it is not used in the treatment of carbon monoxide poisoning.

The client does not need CPR because his heart is beating if he is hypotensive.



Unexpected response to therapies

751. The nurse is performing post operative assessments on a client who has had a femoral artery revascularization.

Which is the most critical finding?

A. A quarter sized area of bright red drainage on the dressing

B. An apical pulse of 100 beats per minute

C. Complaint of numbness of the toes on the operative leg

D. An ankle-brachial index (ABI) of 1.0

The answer is C. Numbness is a symptom of arterial occlusion therefore it is the most critical finding as it can result in death of tissue. A quarter size area of bright red drainage on the dressing is not immediately critical; the nurse would circle the area and observe for continued bleeding. The apical pulse of 9 and the ABI pf 1.0 are both within normal range.


Abuse/Neglect

752. The home care nurse is providing an in-service on elder abuse to the home health aides that will be going out in the field. Which should be identified as potential

signs of abuse? (Select all that apply.)

A. Bruises in various stages of healing

B. Malnutrition and dehydration

C. Poor personal hygiene, disheveled unkempt appearance

D. Burns and broken bones

The answers are A, B, C, and D. All responses are possible signs of abuse.





753. A nurse is a guest on a health related radio show. A listener calls in and asks what is the most common symptom of esophageal cancer. Which is the correct reply?

A. Projectile vomiting.

B. Progressive indigestion.

C. Progressive dysphagia.

D. Hoarseness progressing to loss of voice.

The answer is C. Progressive dysphagia is the most common symptom of esophageal cancer. It is insidious in onset and often the client simply eliminates foods from the diet which are difficult to swallow and so remains unaware of the problem until suddenly realizing that only liquids can be swallowed.

Projectile vomiting is associated with increased intracranial

pressure, not with cancer. Progressive indigestion is associated with GERD and hiatal hernia. Hoarseness and ultimately voice loss is associated with laryngeal cancer.


MAINTENANCE

High Risk Behaviors

754. When teaching about accidental injury to adolescents, what does the nurse identify as the most common cause of injury?

Answer: Motor vehicle accidents.

The adolescent is prone to Motor Vehicle Accidents due to reckless driving and speeding to show off, driving under the influence of drugs or alcohol (doing drugs and alcohol to be part of the gang), and failure to use seatbelts because it isn ’ t ‘ cool ’ .




755. The nurse is reviewing laboratory findings for a client who has Congestive Heart Failure. Which laboratory value should be reported to the physician immediately?

A. Cholesterol level of 240 mg/dl

B. Digoxin level of 2.5ng/ml

C. Troponin 1 level of 0.30 ng/ml

D. Triglyceride level of 160 md/dl

The answer is B. Normal digoxin level is 2ng/ml and 2.5 ng/ml is a toxic level. Cholesterol level is slightly high but not critical. Troponin 1 level is normal. Triglyceride level is borderline high but not critical.


ENVIRONMENT


Home safety

756. The home care nurse is concerned with reducing the risk of falling for an 86-year-old client. Which statement represents the most appropriate approach to the problem?

A. “ I understand that you are concerned about finances, however adequate non glare lighting is very important to keep you safe. Can I speak to your son about trying the new florescent bulbs that are much less expensive to use.

”

B. “ This house is not safe, it has years of accumulated clutter. Why don ’ t you consider selling the house and move to a nursing home, where you will be safe and well fed.

”

C. “ The old rug in the dining room under the table will have to go, it ’ s worn out anyway.

”

D. “ Never leave your room, when you are home alone,

sit in the lounge chair or stay in bed, I ’ ll set up a bed side commode for you.

”

The answer is A. When reading questions on communication listen to the tone of the response, abrupt, impolite, overly paternalistic responses can be eliminated. Responses with absolute terms such as all or never can be eliminated. Option

A offers not only information needed but helps discover options within the client ’ s means.




757. A nurse is speaking to a community group on the early detection of cancer. A member of the audience asks what is a symptom of cancer of the larynx. Which is the correct response for the nurse to give?

A. Projectile vomiting.

B. Progressive indigestion.

C. Progressive dysphagia.

D. Hoarseness progressing to loss of voice.

The answer is D. Hoarseness and ultimately voice loss is associated with laryngeal cancer.


Projectile vomiting is associated with increased intracranial pressure, not with cancer. Progressive indigestion is associated with GERD and hiatal hernia. Progressive dysphagia

is the most common symptom of esophageal cancer.


MAINTENANCE

Health Screening

Perform targeted screening examination

758. The nurse is performing health screening at the local junior high school for scoliosis. Which test should the nurse perform?

A. Ask the child to stand on one foot to see if the pelvis shifts down.

B. Have the child bend at the waist to see if there is a difference between the sides.

C. Have the child twist at the waist from side to side to see if there is pain with the motion.

D. Ask the child to stretch toward the ceiling first with the left, then with the right side to see if one hand reaches higher.

The answer is B. This test is called the Adam ’ s Forward Bend

Test. Children with scoliosis will have a prominence on one side or the other. The other responses are not tests for scoliosis.




759. A registered nurse and an LPN are working as a team to provide care for a group of clients. Which action by

the LPN requires the RN to intervene?

A. The LPN raises the knee gatch on the bed of a client who has an intraaortic balloon pump in order to relieve pressure on the client ’ s back.

B. The LPN prepares to administer Lasix (furosimide) to a client whose potassium level is 4.2 mEq/L

C. The LPN returns a client to bed after the client ’ s heart rate increases from 72 to 96 beats per minute while ambulating in the hall

D. The LPN brings breakfast to a client who is scheduled for an echocardiogram later in the morning.

The answer is A. The knee gatch should not be raised because it could cause the balloon catheter to be kinked off. All other actions are appropriate and do not require corrective intervention by the RN.



Pathophysiology

760. Which disorder places the client at risk for tissue necrosis and breakdown of bone structure with decalcification?

A. Osteoarthritis

B. Osteomyelitis

C. Osteoporosis

D. Osteogenesis

The answer is B.

A is incorrect — osteoarthritis or degenerative joint disease.

C is incorrect — osteoporosis is a loss of bone density. D is incorrect — osteogenesis refers to the formation of bone in the body.




761. A 5-year-old child has just returned from a tonsillectomy.

The child ’ s mother is at the bedside and caring for her child. Which observation made by the nurse while taking vital signs, requires nursing intervention?

A. The child is lying supine.

B. An ice collar is lying on the child ’ s neck.

C. The mother is offering the child ice chips from a spoon.

D. The child is drooling and the mother is wiping the child ’ s mouth with a wash rag.

The answer is A. The child should not be in a supine position because of the risk of aspirating blood if the surgical wound should ooze. Nursing intervention is required to reposition the child in a side lying position and to explain to the mother the importance of maintaining the child in this position. None of the other options indicate the need for nursing intervention.


MAINTENANCE

Aging Process

762. Many body systems manifest deteriorative changes to a greater or lesser degree with aging. The expected, normal signs of aging are called —— changes.

Answer: Primary.

Primary changes are the expected normal changes associated with aging. An example of a primary change is

CHAPTER 34 Practice Test for NCLEX-RN® 1251 decreased elasticity of the skin. Pathological or disease related changes are referred to as secondary changes.




763. A client has rheumatoid arthritis and is receiving hydroxychloroquine (Plaquenil). Which instruction should be given to the client prior to discharge home?

A. Take this medication on an empty stomach.

B. Expect your urine to be greenish-yellow in color while taking this medication.

C. Report a weight gain of more than 5 lbs. to your physician.

D. Notify your physician if you experience any changes in vision.

The answer is D. because hydroxychloroquine can produce over time changes in vision due to ocular toxicity or retinopathy.

These manifest as episodes of misty or foggy vision, “ disappearing words ” when reading, light flashes before the eyes, or seeing only half of the visual field. Hydroxychloroquine can be taken with meals to minimize gastrointestinal side effects.

Hydroxychloroquine may discolor urine red or brown not green. Weight gain is not related to use of hydroxychloroquine.




764. The CCU nurse notices that a client ’ s T wave has become inverted. Which is the priority nursing intervention?

A. Give the client nitroglycerine sublingual, 1 tablet every

5 minutes three times

B. Start oxygen at 2 – 4 liters per minute via nasal cannula

C. Check for T wave elevation in the V1 lead

D. Check the client and verify lead placement

The answer is D. The leads may have gotten moved. It is priority to always check your client to verify that monitoring data is correct.


MAINTENANCE


765. You are assessing an infant brought to the pediatric clinic. Which assessment finding would indicate that follow up is needed because of possible developmental

dysplasia of the hip?

A. Outward turning of both legs

B. Limited range of motion in the hip joint

C. Crying and other signs of pain on flexing the hips

D. Asymmetrical thigh and buttock skin creases

The answer is D. Asymmetrical thigh and buttock skin creases are an obvious sign of developmental dysplasia of the hip.

A is incorrect — there is no outward turning of the legs. B is incorrect — there is no limited range of motion in the hip. C is incorrect — developmental hip dysplasia is not painful.




Identify client status based upon pathophysiology

766. Which interpretation should the nurse assign to assessment findings of delayed capillary refill, cyanosis and clubbing?

A. Arterial oxygen levels are chronically low.

B. Carbon dioxide levels in the blood are elevated.

C. Compensatory polycythemia has developed.

D. Vital capacity has progressively decreased over time.

The answer is A. Delayed capillary refill, cyanosis and clubbing are signs of chronically decreased arterial oxygen levels.

Elevated carbon dioxide levels (hypercarbia) is not always associated with hypoxemia and does not cause these signs.

Polycythemia is an increase in red blood cells which does occur as a compensatory effort in clients with chronic hypoxemia; it does not cause the signs. Changes in vital capacity which is the amount of gas that can be expired after a maximum inspiration do not cause delayed capillary refill, cyanosis or clubbing.




767. On assessing a client who has had coronary artery bypass grafting the nurse finds: T 100.2_F; pulse 110 beats per minute; BP 96/60 mm Hg; Respirations 20 per minute; distended neck veins; muffled heart sounds.

Based on this assessment data, which is the priority nursing action?

A. Increase frequency of client monitoring.

B. Ask the client about pain.

C. Report findings immediately to the physician

D. Call the lab to draw blood cultures


The answer is C. The client is displaying signs and symptoms of cardiac tamponade which is a medical emergency.

Increased monitoring will occur but calling the physician is the priority. Pain may cause tachycardia but it wouldn ’ t cause JVD. Lab cultures are usually not done until the temperature

is 102_F or above.


Chemical and Other Dependencies

768. A client in a methadone program, is admitted with a broken pelvis following an automobile accident.

Which fact should be considered when planning care for this client?

A. The client is likely to be euphoric at intervals.

B. Methadone should continue to be given while the client is in the hospital.

C. The client will not need pain medication if he is receiving methadone.

D. If methadone is stopped, delusions or hallucinations may ensue.

The answer is B. Methadone maintenance should be continued while the client is in the hospital if at all possible.

Methadone does not cause euphoria so if it is continued, the client will not have intervals of euphoria. Methadone does not adequately relieve acute pain so it will not eliminate the need for pain medication; it can be used with success in the management of chronic pain. Delusions and hallucinations are not symptoms of withdrawal from methadone and other opiates; delusions and hallucinations are associated with withdrawal from alcohol, sedatives/ hypnotics, and anxiolytics.




769. Which is the most common side effect of salicylates and NSAIDs used in the management of the pain and swelling associated with rheumatoid arthritis?

A. Anorexia

B. Dizziness

C. Gastrointestinal distress

D. Weight loss

The answer is C. Long term use can result in irritation of the stomach lining.

Answers A, B, and D are incorrect because they are side effects for different classes of medication.




770. The nurse is providing discharge instructions for a client who has been diagnosed with stable angina and has a prescription for nitroglycerine sublingual tablets.

Which statement by the client indicates that further teaching is needed?

A. “ I should keep my pills in the original container.

”

B. “ I need to replace my pills every month.

”

C. “ I should go to the hospital if the pain is not relieved after taking a nitroglycerine.

”

D. “ I should stop all activity and rest when having chest pain.

”

The answer is B. Pills should be replaced every 3 – 6 months.

A, C, and D are all correct.


MAINTENANCE

Developmental Stages and Transitions

771. According to Piaget ’ s theory of cognitive development which of the following cognitive developmental skills are mastered between the ages of 7 and 11 (school-age years)?

A. Concrete thought

B. Conservation

C. Complex classification

D. Abstract thinking

E. Sees another ’ s point of view

The answers are A, B, C, and E. The stage of concrete operations is between 7 and 11 years of age. Thought becomes logical, concrete, and based on tasks in the here and now.

The school-age child masters conservation and complex classification and is also starting to understand that other ’ s have a different point of view form their own. Abstract thinking and reflecting on theoretical matters begins in the

preadolescent years.




772. The nurse on the hospital unit receives a call from admitting stating a client with a question of an intestinal obstruction is being admitted. In preparing for

CHAPTER 34 Practice Test for NCLEX-RN® 1253 the arrival of the client, the nurse will gather equipment for:

A. Gastric lavage

B. Morphine drip

C. Gastric decompression

D. Soap suds enema

The answer is C. The client will be NPO in preparation for surgery and a NG tube will be inserted for gastric decompression.

There is no reason to lavage the stomach.

Morphine and other opioids are generally withheld until after the diagnosis is established. Soap suds enema are contraindicated.


ENVIRONMENT

Management of Care

Establishing priorities

773. Which client being treated in the emergency room requires the most immediate intervention?

A. A client whose initial assessment disclosed elevated

T waves and a serum potassium level of 6.1.

B. A client whose x-ray showed a fractured radius.

C. A client with a stab wound to the thigh covered with a bloody gauze pad.

D. A woman who is 30 weeks pregnant with abdominal pain.

The answer is A. An elevated T wave is suggestive of a cardiac problem and the potassium is dangerously elevated. Thus this client is in a potentially life threatening situation and requires rapid intervention. All of the other clients are in need of treatment for significant problems but none are in immediate danger.



System-specific assessment

774. Which assessment findings would the nurse expect when examining a client with chronic low arterial oxygen levels? Mark all that apply.

A. ___ cyanosis

B. ___ skin tenting

C. ___ positive Cullen ’ s sign

D. ___ delayed capillary refill

E. ___ clubbing

F. ___ muffled heart sounds

The answers are A, D, and E. Delayed capillary refill, cyanosis and clubbing are signs of chronically decreased arterial oxygen levels. Skin tenting is an indicator of dehydration. A positive Cullen ’ s sign is bluish discoloration around the umbilicus and is indicative of bleeding into the peritoneal cavity. Muffled heart sounds are not a sign of chronic low arterial oxygen levels.


MAINTENANCE


775. The nurse is doing the neurologic assessment of the newborn infant. Which would be normal findings?

A. ___ Sucking in response to touching infant ’ s lips; strong and coordinated

B. ___ Blinking in response to light or touch

C. ___ Gag in response to stimulation of the posterior pharynx by food or tube

D. ___ Asymmetrical sporadic movement of the extremities

E. ___ Extremities extended when prone

F. ___ Minimal head lag when pulled to a sitting position

The answers are A, B, and C. Sucking, blinking, and gag reflexes are present at birth. Sucking reflex disappears at 3 – 4 months, blinking and gag reflexes persist for life.

Movements are symmetrical, sporadic and involve all

extremities. Extremities are flexed and knees are flexed under abdomen in the newborn. The neonate has minimal head control therefore there is significant head lag when pulled to a sitting position.



Fluid and electrolyte imbalance

776. A client has a CVP reading of 12mmHg. Which physical assessment finding is consistent with this measurement?

A. Increased JVD

B. 1_ peripheral pulses

C. Tachycardia

D. Crackles in the lung bases

The answer is A. Increased JVD is an indication of volume overload. Tachycardia, not bradycardia, is the physiologic response to decreased cardiac output. Crackles in the lung bases are indicative of pulmonary overload.





777. The nurse teaches new parents about nutrition for the first year of life. What information does the nurse include in her teaching plan?

A. Breast milk is a complete and healthful diet for first

6 months of life.

B. Commercially prepared fortified infant formula is a good alternative if breast feeding is not desirable or feasible.

C. No additional fluids are needed for first 4 – 6 months with breast or formula fed infant.

D. In the second 6 months skim or regular cow ’ s milk may be used depending on infant ’ s weight pattern.

E. Solid foods are started with cereals at 2 months, and then fruits, vegetables and meats are gradually introduced over next 4 months.

F. Honey is not given for the first year because it is a source of botulism.

The answers are A, B, C, and F. Breast feeding and fortified commercially prepared infant formulas are the best and only sources of nutrition appropriate for the first 6 months of life and continue to be the primary source of nutrition in the second six months of life as well. Cows ’ milk, skim or regular, and imitation milks are not acceptable during the first year, as they are difficult to digest and lack the nutrients needed for growth. Solid foods are generally introduced at 5 to 6 months starting with cereals and progressing and gradually progressing to fruits, vegetables and meats. Honey is not given in the first year as it is associated with botulism.




778. While shopping the nurse observes a school age child put something in his mouth and immediately begins coughing. Which would be an appropriate initial action for the nurse to take?

A. Ask the child if he is choking.

B. Place the child in reverse Trendelenburg position.

C. Perform the Heimlich maneuver.

D. Check pulse and respirations.

The answer is A. Asking for a response is a method of determining if the airway is obstructed and immediate emergency intervention is needed. If a person can speak the airway is not obstructed. Reverse Trendelburg position in which the client is supine with feet lower than the head would serve no purpose. A Heimlich maneuver is performed if a foreign body is occluding the upper airway. Checking pulse and respirations serves no purpose in the immediate situation.



Fluid and electrolyte imbalance

779. A client has a CVP reading of 12mm Hg. Which physician order for fluids would the nurse question?

A. 5% Dextrose and Normal Saline IV at 100 cc hr

B. Oral fluid restrictions of 1500 cc per 24 hours

C. Normal Saline at 20 cc hr.

D. Nitroglycerine IV drip at 5 mcg per minute

The answer is A. D5NS is a hypertonic IV solution and would pull more fluid into the vascular system which is already overloaded. Fluid restrictions would help decrease fluid overload. Normal Saline at 20 cc/hr would only keep the vein open and would not add to overload. Nitroglycerine would cause vasodilation and decrease circulating volume.


ENVIRONMENT

Management of Care


780. The nurse has just received report on assigned clients.

Which client should the nurse see first?

A. A 23-year-old admitted two hours ago with a gunshot wound; 3 cm area of dark drainage noted on the dressing.

B. A 38-year-old with a collapsed lung due to an accident; no drainage noted in the previous 3 hours.

C. A 47-year-old who had a stab wound to the abdomen one day ago; client complains of chills and fever.

D. A 34-year-old with a mastectomy two days ago; 15 cc of serosanguineous fluid noted in the Hemovac

drain. Complaining of pain in axilla.

The answer is C. Because the client is at risk for internal bleeding, infection, or peritonitis. This client should be assessed for further symptoms of infection.

The client in option A would not be first because there is apparently no active bleeding as indicated by the small amount of drainage on the dressing. The client in option B has no more than the expected amount and color of drainage. The client in option D has no unexpected signs or symptoms.





781. Which problem associated with Hirschsprung ’ s

Disease in a newborn is the most critical?

A. Respiratory distress.

B. Abdominal distention.

C. Vomits several feedings.

D. Failure to pass meconium by 48 hours of life.

The answer is A. Respiratory distress can occur with

Hirschsprung ’ s disease as a result of abdominal distention.

Because respiratory distress can be immediately life threatening it is the most critical problem associated with the disease.

All of the other responses are symptoms of

Hirschsprung ’ s Disease but none are immediately life

threatening.


ENVIRONMENT


Disaster planning

782. As a nurse manager at the area medical center you have been asked to participate as a member of the team to develop the community ’ s disaster preparedness plan. As you begin to think through the steps of a sound plan you identify the following key phases in a disaster management program:

A. Preparedness, mitigation, response, recovery, and evaluation

B. Planning, organizing, leading, controlling

C. Assessment, analyzes planning, implementation, evaluation

D. Prevention, warning, rehabilitation, reconstruction

The answer is A. There are five basic phases to a disaster management program, there may be some overlapping between the phases but each phase has a specific component relating to disaster management.

B lists the four concepts of the management process, C lists the components of the nursing process, and D is a listing of terms that are not related to each other.





783. How would the nurse best evaluate the effectiveness of a client ’ s oxygen therapy?

Monitor change in

A. Hematocrit

B. Hemoglobin

C. Arterial blood gases

D. Pulmonary function tests

The answer is C. Oxygen is used to treat hypoxemia and hypoxia. The best measure of its effectiveness in reversing these conditions is ABG analysis.




784. A client standing in the doorway to his room, screams at the nurse as she comes down the hall

“ How long am I supposed to wait for someone to straighten my bed? Do you know how much this room is costing me per day? I want my bed fixed and I want it done now.

” How should the nurse respond?

A. Say “ I don ’ t think you need your bed straightened

this minute. . .

”

B. Place a hand on the client ’ s arm and lead him to a chair in his room.

C. Ask the client if he really thinks this type of behavior will help him feel better.

D. Acknowledge the distress and obtain more information about what the pateint needs.

The answers is D. Acknowledging a person ’ s distress is therapeutic.

Dismissing a person ’ s feelings is nontherapeutic and interferes with establishing an effective nurse – client relationship.

Obtaining more information about the situation allows for discussion of a solution.

A is incorrect — Disagreeing/arguing with the angry client can lead to escalation of angry behavior. B is incorrect —

Touching an angry client or entering the client ’ s personal space can also escalate anger. C is incorrect — it is patronizing and this type of response increases anger.



Hemodynamics

785. A client has a pulmonary artery pressure catheter inserted for hemodynamic monitoring. The client ’ s cardiac output reading is 2 liters per minute. Which physical assessment finding is consistent with this measurement?

A. Increased JVD

B. 1_ peripheral pulses

C. Bradycardia

D. Crackles in the lung bases


The answer is B. 1_ peripheral pulses. The normal CO is 4 – 7 liters per minute so the client would display signs and symptoms of decreased cardiac output. Increased JVD is an indication of volume overload. Tachycardia, not bradycardia, is the physiologic response to decreased cardiac output. Crackles in the lung bases are indicative of pulmonary overload.



Fluid and electrolyte imbalances

786. A 4-week-old infant boy has been admitted to the pediatric unit with a diagnosis of “ rule out pyloric stenosis.

”

For signs of which electrolyte imbalance would the nurse monitor the infant?

A. Hypokalemia

B. Hypernatremia

C. Metabolic acidosis

D. Respiratory alkalosis

The answer is A. Vomiting causes the loss of potassium, hence hypokalemia would occur as well as metabolic alkalosis from the loss of stomach acids.




787. A physician writes the following orders for a client being evaluated for a possible bowel obstruction.

Which order would the nurse question?

A. Intake and Output

B. NG tube to suction

C. IV, D51/4 NS at 125 ml/hr

D. Morphine q 3 hours prn pain

The answer is D. Morphine suppresses peristalsis and would increase the bowel obstruction. Morphine and other opioid analgesics are usually withheld during the diagnostic period because of the effect on peristalsis and also because they can cause vomiting. Vomiting can complicate the diagnosis and determination of the plan of care because vomiting is also a sign of worsening bowel obstruction and of N/G tube obstruction.


MAINTENANCE


788. The nurse is assessing a newborn. A sudden noise causes the newborn infant to extend and then flex the arms and fingers. The nurse would document this as a positive:

A. Moro reflex

B. Gag reflex

C. Babinski reflex

D. Tonic neck reflex

The answer is A. The Moro reflex occurs in response to a sudden noise or movement. The infant extends arms and legs and then flexes them. The infant ’ s hands form a C with the thumb and fingers.





789. Which would be an expected effect of resistive breathing training in a client with COPD?

A. Energy conservation

B. Increased oxygen saturation

C. Decreased hypercarbia

D. Increased respiratory muscle strength

The answer is D. Resistive breathing training is used for clients with exercise induced dyspnea and may be done as part of a pulmonary rehabilitation program. In resistive breathing the client breathes against a set resistance with the goal of developing strength and endurance in the respiratory muscles. The goal of resistive breathing is not energy conservation, increased oxygen saturation, or decreased hypercarbia.




790. The daughter of a nursing home client comes to the nurse ’ s station and shouts angrily “ My mother ’ s condition is a disgrace – this place should be closed down and you all should lose your licenses.

” How should the nurse respond?

A. Say “ I was just into your mother and there is nothing disgraceful about her condition.

”

B. Place a hand on the daughter ’ s arm and lead her to a chair.

C. Ask the daughter if she really thinks this is a proper way for an adult to behave.

D. Acknowledge the distress and obtain more information about the problem.

The answer is D. Acknowledging a person ’ s distress is therapeutic; dismissing a person ’ s feelings is non-theraCHAPTER

34 Practice Test for NCLEX-RN® 1257 peutic and interferes with establishing an effective nurseclient relationship. Determining the immediate trigger of the daughter ’ s anger allows the possibility of addressing the problem and opening the door to discussion of underlying issues.

Response A is inappropriate because it disagrees/argues with the angry daughter and this can lead to escalation of

angry behavior. Similarly response B is incorrect because touching an angry client or entering the client ’ s personal space can also escalate anger.

Response C is incorrect because it is patronizing and this type of response increases anger.




791. The parents of a child with Tetralogy of Fallot are very upset by the cyanotic “ tet ” spells and asks the nurse what causes them. Which fact should be the basis of the nurse ’ s response?

A. The aorta carries mixed deoxygenated and oxygenated blood into the systemic circulation.

B. Low hemoglobin and circulating iron levels of the newborn cause low oxygen saturation.

C. A left to right shunt increases blood return to the lungs.

D. Increased heart rate causes a ventilation/perfusion mismatch when the child becomes stressed.

The answer is A. Increased right ventricular pressure creates right to left shunt. The hemoglobin and iron levels are not one of the factors associated with Tetralogy of

Fallot. A left to right shunt involves an acyanotic defects.

Ventilation/perfusion mismatch occurs in pulmonary

embolisms.




792. The CCU nurse admits a client from ER who has been diagnosed with an evolving MI and has received thrombolytic therapy with T-PA, tissue plasminogen activator, and heparin. Which is an expected client outcome?

A. ST elevation of 2 mm in two chest leads

B. PTT level of 1.5

– 2.5 times the control

C. An INR value of 2 – 3

D. A cardiac ejection fraction of 30%

The answer is B. PTT level of 1.5

– 2.5 times the control is the therapeutic range during heparin therapy. ST elevation is an indication of cardiac tissue injury. INR is for warfarin

(Coumadin) therapy. Normal cardiac ejection fraction is

60% or higher.


ENVIRONMENT


Legal rights and responsibilities

793. A nurse is explaining to a client that she has the right to be treated in a certain manner, receive adequate information, and have her confidentiality maintained

while hospitalized. The client asks what gives her these rights. Which document should the nurse refer to in responding to the client ’ s question?

A. Client Constitution

B. Client Bill of Rights

C. Client Medical Record

D. Client Self-Determination Act

The answer is B. The Client Bill of Rights is a document published by the American Hospital Association to promote the rights of hospitalized clients.

Client Constitutions is not a document but is a form of law – constitutional law. The Medical Record is the record of the hospitalization includes medical tests, procedures and nursing documentation. The Client Self-Determination Act is a legal act that requires every competent adult be informed in writing upon admission to a health care institution about the client ’ s rights to accept or refuse treatment.




Provide nursing care of surgical clients

794. A client has just returned from surgery for colorectal cancer. In assessing the client, the nurse notes that the perineal dressing is soaked with bright red drainage.

Which action should the nurse take?

A. Reinforce the existing dressing.

B. Change the dressing using sterile technique.

C. Apply a pressure dressing using clean technique.

D. Cover the existing dressing with waterproof material.

The answer is A. The first dressing following surgery is changed by the surgeon. The nurse would reinforce the dressing. If the drainage continues, the nurse would notify the surgeon. The other responses are incorrect.





795. The mother of an 8-week-old infant is telling the pediatric nurse that her baby has colic and cries all the time. The mother is visibly tired and frustrated. In helping the mother to cope with an infant with colic, the nurse can remind the mother that colic usually disappears by the age of:

A. 3 months

B. 6 months

C. 9 months

D. 12 months

The answer is A. Colic is a short-term complaint and the infant usually outgrows it by 3 months of age.




Use clinical decision making/critical thinking when addressing actions of prescribed pharmacological agents on clients

796. A client receiving chemotherapy for cancer also has epoetin alfa prescribed. The client ’ s spouse asks what the epoetin alfa will do for the client. The nurse ’ s response is based on the knowledge that the therapeutic goal of therapy with epoetin alfa for clients receiving chemotherapy for cancer is to:

A. Potentiate the chemotherapy drugs

B. Decrease the need for transfusions.

C. Bolster immune system activity

D. Protect against renal damage

The answer is B. Epoetin alfa is used to treat chemotherapy induced anemia and reduce the need for transfusions in clients with cancer who will receive chemotherapy for two months or more. It does not potentiate chemotherapeutic drugs. Like endogenous erythropoietin, It stimulates the production of red blood cells not immune system cells. Epoetin alfa is used to treat the anemia associated with chronic renal failure; it does not protect against kidney damage.


MAINTENANCE

Disease Prevention

797. The nurse teaches new parents about infant dentition and care of the teeth.

Which of the following will the nurse include in the teaching plan?

A. Beginning signs of tooth eruption are not seen before 10 – 11 months

B. A frozen teething ring may be used to reduce inflammation and relieve discomfort

C. Prevent dental carries by avoiding having infant fall asleep with bottle

D. Fluoride should not be supplemented in the first year

E. Infant Tylenol may be given with practitioners approval, for teething pain disrupting sleep and feeding

F. Teeth may be cleaned with damp cloth

The answers are B, C, E, and F. Beginning signs of tooth eruption are commonly seen by 5 or 6 months. In areas where water supply is not adequately fluorinated, supplemental fluoride begins at around 6 months. A frozen teething ring is used to reduce inflammation and manage pain. Infant

Tylenol may be used for severe pain disrupting function with practitioners order. Teeth may be cleaned with a damp cloth.





798. The nurse is giving a client instructions on the use of an inhaled beta 2 agonist for mild symptoms associated with emphysema and chronic bronchitis. The nurse cautions that the maximum number of puffs to be taken in 24 hours is how many?

A. 12 – 16

B. 8 – 12

C. 6 – 10

D. 4 – 8

The answer is B. For mild symptoms 1 – 2 puffs of a beta 2 agonist can be taken every 2 to 6 hours PRN not to exceed 8 to 12 puffs in any 24 hour period.


MAINTENANCE

Health and Wellness

799. The nurse is teaching parents of toddlers about nutritional needs, food preferences and expected appetite patterns. Which information would the nurse include in the teaching plan?

A. ___ Do not overwhelm the toddler with large portions.

B. ___ Serve stews with meat and vegetables in one bowl to maximize nutrition with minimal fuss.


C. ___ It is important to encourage eating because growth is increasing and appetite is decreasing.

D. ___ Toddlers are very concerned with the plate or cup used.

E. ___ Serve foods that are new and interesting to the toddler as often as possible.

F. ___ Substitute cow ’ s milk if meat isn ’ t eaten.

The answers are A and D. Toddlers are easily overwhelmed by large portions. Toddler ’ s prefer single foods and often refuse mixtures such as stews. The toddler will even refuse foods that are touching each other. In toddlerhood growth slows, and appetite is diminished, with periods of physiologic anorexia. The toddler has a favorite cup, spoon, dish, and will often refuse a well-liked food because it ’ s not served in the favorite dish. Repeat a set of nutritious foods often so they will be recognized by the toddler, and better received.

Cow ’ s milk is a poor source of iron and interferes with iron absorption leading to iron deficiency anemia if not curtailed.


ENVIRONMENTS




800. Which precaution measures would be instituted when a client has shigella? Mark all that apply.




D. ___ Use mask when working within 3 feet of the client.





The answers are B, E, and G. Shigella is a serious disease that is easily transmitted through direct contact. Contact precautions require a private room or a room shared with someone infected with the same organism. Gloves are worn at all times and gowns and protective barriers are used if direct contact is required. Since gloves are worn at all times, the requirements of standard precautions, which involve wearing gloves whenever there is the risk of touching something wet that comes from the body surface or a body cavity, i.e., when there is the risk of contact with blood or body fluids, are met.




801. A client who has Rheumatic Fever is being admitted to your floor. Admitting has assigned the client to share a room with a client who is a fresh post-operative client.

As the charge nurse, you would

A. arrange for the new client to be reassigned to a private room.

B. ask that the new client be assigned to a room with a non-surgical client.

C. admit the client to the room assigned.

D. move the postoperative client to a room with another postoperative client.

The answer is C. The client can be admitted to the room assigned because rheumatic fever is an autoimmune response to a streptococcal infection and is not contagious.




802. A client is admitted for hemorrhagic gastritis of prolonged standing. The nurse reviews the lab results on this client. Which lab result would the nurse question?

A. Hematocrit 29

B. Hemoglobin 9.9

C. Guaiac negative

D. Reticulocyte count elevated

The answer is C. Guaiac evaluates blood in the stool which should be positive. The client with hemorrhagic gastritis would likely be anemic from chronic bleeding so low hemoglobin and hematocrit would be expected. An elevated reticulocyte count is the body ’ s attempt to replace lost blood cells.





803. Guarding against suicide is a priority nursing intervention for which client?

A client who is withdrawing from

A. Methylphenidate (Ritalin)

B. Alprazolam (Xanax)


C. Propoxyphene (Darvon)

D. Butabarbital (Butisol)

The answer is A. Methylphenidate (Ritalin) is a central nervous system stimulant and like other CNS stimulants such as cocaine and the amphetamines, clients who are withdrawing from it are severely dysphoric, anxious and at risk for suicide. Suicide is not a withdrawal effect of any of the other drug options.


MAINTENANCE


804. When teaching new mothers about play and stimulation for the first 6 months, which of the following toys would be recommended?

A. Unbreakable mirror in a soft black and white frame

B. Large brightly colored balloon

C. 5" doll with removable clothing and shoes

D. Push-pull toy

E. Soft cuddly stuffed toy

F. Musical Mobile

The answers are A, E, and F. Balloons are a choking hazard. Pushpull toys will be useful later on when the child can manipulate the toy. With a 5 ’ doll the removable shoes and possibly other accessories are too small and therefore a choking hazard.

Mirrors, toys with contrasting colors, musical mobiles and soft stuffed toys are appropriate for the first 6 months.





805. Which directions should be given to a patient taking

Fosamax?


A. ___ Take with a full glass of water

B. ___ Take at bedtime

C. ___ Take on an empty stomach

D. ___ Avoid fatty foods.

E. ___ Avoid heavy lifting

F. ___ Do not lie down until after eating once the pill is taken.

G. ___ Do not eat for 30 minutes

The answers are A, C, F, and G. Fosamax should be swallowed, not chewed or sucked, with a full glass of water on an empty stomach after getting up for the day. After taking Fosamax, the client should not eat, drink, or take another medication for at least 30 minutes. Clients should not lie down once the pill is taken until 30 minutes has passed and they have eaten.

Fosamax should not be taken at bed time or before getting up for a day. If a dose is missed, a tablet should be taken the morning after the client remembers and then the usual dosage schedule followed. Two tablets should not be taken on the same day.


ENVIRONMENT


Disaster planning

806. During a disaster the director of the command post sends a nurse to the emergency department to assist in triaging causality victims as they arrive. Which is the priority concern of this nurse?

A. Meet the needs of the largest number of victims

B. Provide care to the most seriously injured

C. Record names of victims as they arrive

D. Place victims in zones according to their color coded tags

The answer is A. Triage is the process of prioritizing which clients are to be treated first during a disaster. Triage is based on making decisions that will do the greatest good for the greatest number. Treating the most seriously injured is describing

“ daily triage.

” The victim is expected to arrive at the hospital with a tag already filled out. Victims are evaluated and a color coded tag is applied for easy identification of the victims status.




807. A client with delusions says to the nurse “ The aliens are after me because they think I am going to take over their planet.

” Which is the most appropriate response for the nurse to make?

A. “ I don ’ t know anything about aliens. Do you feel afraid that people are trying to harm you?

”

B. “ Why would the aliens think you are going to take over their planet?

”

C. “ You are a good person; no one wants to kill you.

”

D. “ What makes you think the aliens want to kill you?

”

The answer is A. This is an empathetic response that acknowledges the client ’ s feeling.

Responses B and D encourage the client to get more involved and add detail to the delusion and this is not therapeutic.

Response C has an element of false reassurance and cliche as well as disagreement with the client ’ s delusion.

Disagreeing can result in a defensive reaction with the client sticking even more firmly to the delusion.





808. After being diagnosed with diverticulitis, a client has been taught about the appropriate dietary changes.

The nurse recognizes that additional teaching is needed when the client states:

A. “ I will follow a high-fiber diet.

”

B. “ Milk will decrease my episodes of diverticulitis.

”

C. “ Whole grains are better for me than refined grains.

”

D. “ Fruits and vegetables are good for me but not nuts and seeds.

”

The answer is B. A diet to prevent constipation is recommended.

Milk can be constipating. A high fiber diet helps to prevent constipation.

Whole grains are a good source of fiber. Fruits and vegetables are good sources of fiber but nuts and seeds should

be avoided because of the risk of them getting trapped in a diverticulum and serving as a source of inflammation.



Pathophysiology

809. A client has recently been diagnosed with cancer of the tongue. Client teaching about oral cancer has been completed. Which comment by the client indicates the need for additional client teaching?

A. “ My type of cancer metastasizes quickly because of the rich lymph and blood supply in the area.

”

B. “ Like me, most clients don ’ t have early symptoms of tongue cancer.

”

C. “ The doctor may need to do a neck resection to get to the lymph nodes there.

”

D. “ I never thought that smoking would get me, but they tell me that studies show a direct link between smoking and cancer of the tongue.

”

The answer is D. Smoking has been linked to all oral cancers except that of the tongue. All other responses are correct.



Elimination

810. The nurse is teaching a group of pregnant clients about hemorrhoid prevention. Which risk factors would the

nurse identify?

A. Constipation

B. Straining on elimination

C. Sitting for prolonged periods

D. Excessive roughage in the diet.

E. Standing for prolonged periods

The answers are A, B, C, and E. Constipation and straining on elimination increases the pressure in the rectal area.

Maintaining one position for an extended period will cause stasis of circulation. Roughage is encouraged to prevent constipation so is not a risk factor for hemorrhoids.


MAINTENANCE


811. The nurse teaches parents about fears in the preschool years. Which information does the nurse include in the teaching plan?

A. Past fears of the toddlerhood years are gradually disappearing

B. The preschool child is no longer bothered by imagined fears; fears are more realistic

C. The preschool child is no longer afraid to go to bed as in the toddler years

D. The preschool child finds large dogs and other animals frightening

E. The preschool child is afraid of mutilation and pain

F. Playing out fears with dolls that helped in toddlerhood is not effective for the pre-schooler.

The answers are D and E. The preschool child experiences a greater number of real and imagined fears than in any other time of childhood. The child is afraid of the dark, being alone at bedtime, large dogs, ghosts, thunderstorms, pain, and mutilation. Playing out fears with dolls is useful in alleviating fears as well as desensitization.





812. What is the primary reason why the nurse teaches a client to wear a glove or finger cot when applying topical acyclovir to a herpetic lesion?

A. Prevent suprainfection

B. Prevent autoinoculation

C. Prevent overdose from excess absorption

D. Prevent unnecessary staining of the skin

The answer is B. Herpes can spread by autoinoculation.

Wearing a glove to apply medication to the lesions helps

1262 PART III: Taking the Test prevent this. Even when wearing a glove or finger cot, clients must also be taught the importance of hand washing

before and after each application of medication. Use of a barrier also helps prevent possible bacterial contamination and suprainfection but is not the primary reason for teaching the use of a barrier rather than just hand washing alone.




813. The nurse asks a client with Alzheimer ’ s Disease

“ Do you want some orange juice?

” The client responds “ Wha. . . .

” . What should be the nurse ’ s response?

A. “ Do you want a glass of orange juice?

”

B. “ Are you thirsty – do you want some juice?

”

C. “ Have a nice cold glass of juice; it will taste good.

”

D. “ Do you want some orange juice?

”

The answer is D. “ Do you want some orange juice?

” This is the same question the nurse asked first. When communicating with a client with Alzheimer ’ s disease one guideline to be followed is repeat questions if needed but do not rephrase them because this would only further confuse the client.

Other guidelines for communicating with the client with

Alzheimer ’ s disease are: use simple words and short sentences; ask only one question at a time; give only one direction

at a time; speak slowly and clearly.


MAINTENANCE


814. The nurse teaches new parents about gross motor and fine motor development of the infant. What can the mother expect by 6 months?

A. Head lag at 6 months

B. Can usually roll from prone to supine and supine to prone

C. Can transfer cube from one hand to the other hand

D. Can pull self to stand

E. Crude pincer grasp

F. Palmer grasp with fingers encircling object

The answers are B, C, and F. Head lag at 6 months is an ominous sign and should be reported for follow up. The 6 month old can roll from the prone to supine and supine to prone position. With the new practice of placing infants on their backs for sleep, as opposed to the abdomen, because of SIDs, there is a noted delay in many infants in rolling from abdomen to back, but by 6 months infants have accomplished this task. The 6-month-old has a palmer grasp and is beginning to transfer a cube from one hand to the other. The infant pulls himself to stand, and develops a crude pincer

grasp at 9 months.



Monitoring conscious sedation

815. The nurse is caring for a client who has received conscious sedation for elective cardioversion. Following the procedure the arterial blood gas results are as follows: pH 7.32; PaO2 95mm Hg; PaCO2 62 mm Hg;

HCO3 19 meq/L; O2 Sat 95%. Based on these values which action would the nurse take?

A. Chart the values and continue assessing the client

B. Start supplemental oxygen at 2 liter per minute via nasal cannula

C. Have the client perform deep breathing exercises

D. Have the client breathe into a paper bag

The answer is C. Deep breathing exercises will help the client blow off carbon dioxide and bring down the PaCO2 level.

A is incorrect because the blood gas results are showing respiratory acidosis.

O2 is not needed because the Os 2 level is within the normal range. Breathing into a paper bag is used when the client is experiencing respiratory alkalosis.


ENVIRONMENT



816. The nurse assigned to a client being admitted for rectal bleeding, must establish priorities of care. In which order would the nurse carry out the following care activities?

A. Start an intravenous

B. Observe the client ’ s level of anxiety

C. Continue to monitor the client for rectal bleeding

D. Teach the client self care in preparation for her discharge

E. Assess the client ’ s skin, blood pressure, heart rate, and urine output

F. Teach the client about the diagnostic tests ordered during the next 48 hours


Record your answer by placing the letter of each activity in proper sequence in the space provided.

Correct order of priorities: E, A, B, C, F, D. Physical needs precede psychological needs. Client teaching would be the last priority in this situation.




817. A 3-week-old infant has been diagnosed with

Hirschsprung ’ s Disease and has just returned from surgery with a double barreled colostomy. The mother

cries when she sees the colostomy stoma and says: “ My poor baby, to have to go through life with that thing on his abdomen.

” The nurse ’ s response would be based on the knowledge that

A. colostomy care is not as difficult as it may seem.

B. the colostomy will not be permanent.

C. the child will never have known anything but the colostomy.

D. colostomy stomas are hidden easily under clothing.

The answer is B. A double barreled colostomy indicates the intention to reconnect the bowel at a later time so the mother ’ s misconception needs to be addressed. All the other options are inappropriate as the basis of the nurse ’ s response because the colostomy is not going to be permanent. Colostomy care during infancy is relatively simple as the child would not be continent anyway. Stomas can be hidden under clothing. The child would eventually know that he or she is different.


MAINTENANCE


818. The nurse is planning a class to promote effective parenting of toddlers. Which topics should the nurse plan to discuss?

A. Negativism

B. Ritualism

C. Egocentrism

D. Temper Tantrums

E. Possessiveness

F. Altruism

The answers are A, B, C, D, and E. These are all topics pertinent to toddler behavior. Negativism refers to strongly expressed emotions: ‘ no ’ . Ritualism is seen as the toddler having a favorite doll, favorite blanket and various rituals of behavior, especially at bedtime. Egocentrism refers to the fact that the toddlers can not comprehend that others think differently than they do.

Temper Tantrums which are characteristic of toddlers are attention seeking and best dealt with by ignoring them.

Possessiveness indicates the toddler ’ s beginning awareness of ownership, as shown by the use of the word “ mine.

” Altruism is not a characteristic of toddlerhood.





819. Which is the priority factor for the nurse to assess when a client is receiving IV acyclovir?

A. mental status

B. cardiac rhythm

C. urinary output

D. temperature

The answer is C. Monitoring urinary output is critical when acyclovir is given systemically because it is excreted primarily by glomerular filtration and tubular secretion and therefore can be nephrotoxic. To decrease the risk of nephrotoxicity, the client must be well hydrated; the drug must be administered over a period of 60 minutes; and urinary output must be measured for

2 hours after the infusion. Output of less than 500 mL of urine per gram of acyclovir must be reported immediately.

Confusion and hallucinations along with tremors and seizures are some of the serious adverse reactions to systemic acyclovir but they are uncommon. Cardiac rhythm is unaffected.

Temperature may be monitored because of existing infection but not directly because of the acyclovir; it does not present an immediate threat so does not take priority over monitoring urinary output.

SAFE AND EFFECTIVE

ENVIRONMENT



820. Vital signs on a client who has just been admitted to the unit are: BP 162/84, Pulse 100 and irregular,

Respirations 16, and Pulse Oximetry 88%. Which would be the immediate nursing intervention?

A. Place the client on cardiac telemetry

B. Call the physician to report the vital signs

C. Start a saline lock for IV medication access

D. Start oxygen at 2 – 4 liters per minute per nasal cannula per protocol


The answer is D. The client ’ s oxygen level is very low. All other interventions would be done later.



Evaluate appropriateness/accuracy of medication order for client

821. A nurse would question an order for misoprostol to prevent gastric ulcers for which client?

A. A client allergic to shellfish

B. A pregnant client

C. A client taking warfarin sodium

D. A client with a history of hepatitis

The answer is B. Misoprostol is a synthetic form of prostaglandin E which is used to prevent NSAID-induced gastric ulcers in high risk clients. It is a pregnancy category

X drug because of its abortifacient action and therefore the order would be questioned if the client is pregnant. Before beginning treatment with misoprostol women of childbearing age must have a negative serum pregnancy test within two weeks of start of treatment which should be on day 2 or

3 or menses. They must also be warned both orally and in writing that the drug causes uterine contractions and miscarriage and be able and willing to use an effective form of contraception.


MAINTENANCE

Health Promotion Programs

822. The nurse teaches new parents about nutrition for the first year of life. What information does the nurse include in her teaching plan?

A. Breast milk is a complete and healthful diet for the first 6 months of life.

B. Commercially prepared fortified infant formula is a good alternative if breast feeding is not desirable or feasible.

C. No additional fluids are needed for the first 4 – 6 months when the infant is breast or formula fed.

D. In second 6 months skim or regular cow ’ s milk used depending on infant ’ s weight pattern.

E. Solid foods starting with cereals at 2 months, and gradually introducing fruits, vegetables and meats over next 4 months.

F. Honey is not given for the first year because it is a source of botulism.

The answers are A, B, C, and F. Breast feeding and fortified

commercially prepared infant formulas are the best and only sources of nutrition appropriate for the first 6 months of life and continues to be the primary source of nutrition in the second 6 months of life as well. Cows ’ milk, skim or regular, and imitation milks are not acceptable during the first year, as they are difficult to digest and lack the nutrients needed for growth. Solid foods are generally introduced at 5 – 6 months starting with cereals with gradual introduction of fruits, vegetables and meats. Honey is not given in the first year as it is associated with botulism.



Hemodynamics

823. The nurse is caring for a client when the cardiac monitor shows that cardiac pattern has changed from a normal sinus rhythm. QRSs are now widened and bizarre at a rate of 160 beats per minute. The client begins complaining of being dizzy. Which is the nurse ’ s immediate action?

A. Call a code

B. Administer a precordial thump

C. Give Lidocaine 50 – 100 mG. IV push

D. Assess the client ’ s vital signs

The answer is D. The nurse needs to assess the client to determine cardiac perfusion and to be sure of what the monitor is

showing. The nurse would not call a code because the client has not arrested. Precordial thump is only used with a witnessed arrest. Lidocaine would be the drug of choice if the client were in a sustained Ventricular Tachycardia and was symptomatic.


ENVIRONMENT


Handling hazardous and infectious materials

824. The nurse is serving on a safety committee which is currently examining policies regarding the proper handling and storage of dangerous chemicals. Which guidelines would the nurse expect the policies to address?

A. ___ Label the containers containing materials

B. ___ Maintain an inventory list of the materials

C. ___ Keep older products in the front, newer products in the back

D. ___ Store chemicals on open shelves

E. ___ Segregate chemicals alphabetically


The answers are A, B, and C. Containers containing hazardous chemicals need to be clearly labeled with the full chemical name. Current hazard waste inventory list is required to be maintained. Older chemicals need to be used before newer

products.

Chemicals stored on open shelves could be accidentally knocked off the shelf. Chemicals also need to be stored based on compatibility and not necessarily alphabetically.




825. A client has a permanent colostomy for colon cancer.

The client is struggling to learn colostomy care. In frustration, the client throws the equipment and says,

“ It ’ s not worth it. I might as well be dead.

” Which interpretation of this behavior should be the basis of the nurse ’ s initial response to the client?

A. The client has not developed an adult level of self control.

B. The client does not want to learn.

C. The approach to teaching is incorrect for this client.

D. The client is having difficulty coping.

The answer is D. The most likely interpretation of this behavior and the one that should serve as the basis of the nurse ’ s first response is that the client is displaying signs of inadequate coping with his life threatening disease and the need for a colostomy. It is possible that the client is lacking in self control or doesn ’ t want to learn but these are not as likely as difficulty coping given the client ’ s health problems. It is also

possible that the approach to teaching is not ideal for this client and this may need to be addressed but it is not the most likely cause of the behavior.


MAINTENANCE


826. The nurse at a day care is observing pre-school children at play. Which types of play observed would the nurse evaluate as normal for a preschooler?

A. Playing house and doing housekeeping chores.

B. Jumping, running or climbing

C. Riding a tricycle

D. Having an “ imaginary playmate ”

E. Playing dress up

The answers are A, B, C, D, and E. Imitative, imaginary and dramatic play are characteristic of the pre-school period.

Playing house, dress up, and housekeeping chores are examples of imitative, imaginary and dramatic play. Imaginary playmates are a normal healthy and useful part of the preschoolers play. Parents can even set a place setting for a

“ friend, ” but can not allow the child to avoid responsibility by blaming “ friend ” for mess.

Activities for motor development should also be encouraged including: running, jumping, climbing and tricycle riding. Reading or watching an educational video

are examples of mutual activities that can be enjoyed with a parent.



System-specific assessment

827. To calculate central venous pressure from the jugular venous pressure, how many centimeters are added to the JVP? Record your answer as a whole number in the space provided.

The answer is 4 cm. Four centimeters are added to the jugular venous pressure to obtain the central venous pressure.




828. What is the most important reason for monitoring a client with a borderline personality disorder and depression for a sudden change in mood?

A. Mood change can be the first indication that therapeutic gains are being made.

B. Mood change can indicate a need for change in medication.

C. Mood change can herald a decision to commit suicide.

D. Mood change can signal the appropriate time to

introduce group therapy.

The answer is C. A mood change can indicate a decision to commit suicide. Client safety is always the priority hence this is the most important reason for monitoring mood.

Change in mood may indicate any of the other options but they are not the priority over protecting the client ’ s life.




Potential for Complication of Diagnostic


829. Following eye surgery, the client is told by the physician that care must be taken to avoid elevating intraocular pressure. Which activities would the nurse identify as those the client needs to avoid? Mark all that apply.

A. ___ Blowing the nose

B. ___ Straining at stool

C. ___ Wearing a tight collar

D. ___ Bending over at the waist

E. ___ Coughing

F. ___ Keeping the head down

The answers are all A, B, C, D, E, and F. All of these activities increase pressure within the eyeball as does sneezing, vomiting and sexual intercourse.

Test for all specialty in nursing FILL IN THE BLANKS

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