Practice Examination One
Part One
You will have two hours and 30 minutes to complete Part One.
1. The nurse is instructing an unlicensed assistant on how to
collect a urine specimen from an indwelling catheter. Which of the
following statements indicates that the assistant understands the
instructions?
A. "I will empty the catheter drainage bag, have the client drink
some water, and an hour later collect the urine that drains into the
bag. "
B. "I will get a sterile syringe and remove urine from the
catheter through the collection port to place in the specimen
container. "
C. "I should collect urine from the catheter drainage bag at the
end of the shift and place it in the specimen container. "
D. "I will disconnect the drainage tube from the catheter and let
urine run from the catheter into the specimen container. "
2. Linda is a 19-year-old primipara who delivered a viable male
neonate 2 hours ago. She has decided to breast-feed. Her 22-year-old
husband supports her decision. She tells the nurse, "My mother
breast-fed all of her children, but I'm going to need lots of help
with breastfeeding. I'm worried that I won't be able to do this. "
Which of the following should the nurse include when assessing the
client?
A. Determine the client's level of motivation to breast-feed.
B. Perform a complete physical examination to determine her need
for help.
C. Assess her body-to-fat ratio and nutritional status before
beginning breast-feeding.
D. Ask the client if she has read any literature about breastfeeding.
3. Mrs. Cray, an African American, is admitted to the hospital
after sustaining a hip fracture. She is 5 ft. , 4 inches tall and
weighs 96 lbs. She has five children and has used estrogen
replacement therapies for 10 years. She told the nurse that she "just
stepped forward and fell. " The results of her bone density tests
indicate she has osteoporosis. Which of the following is the greatest
risk factor for osteoporosis for this woman?
A. Her long-term use of estrogen.
B. Her weight.
C. Her family.
D. Her race.
4. The physician has ordered Oxtriphyllin (Choledyl SA) 0.2 g.
Available tablets of the medicine are 100 mg. How many tablets should
be given?
A. 0.5 tablets.
B. 2.0 tablets.
C. 2.5 tablets.
D. 5.0 tablets.
5. The nurse is instructing a client with angina about sublingual
nitroglycerin. Which of the following points should be included?
A. The shelf life of nitroglycerin is long, it keeps for up to 2
years.
B. Store the tablets in a tight, light-resistant container.
C. Use the tablets only when the pain is severe.
D. The drug will cause increased urine output.
6. An agitated client demands to see his chart so that he can
read what has been written about him. Which of the following
statements is the nurse's best response in this situation?
A. "I'm sorry the chart is the property of the facility. We don't
permit clients to read them. "
B. "You have the right to see your chart. Please discuss this
with your primary care provider. "
C. "You may see your chart after you're discharged. "
D. "Please discuss this matter with your attorney. "
7. Which part on the wave deflection corresponds to ventricular
muscle repolarization in the following ECG graph?
A. A
B. B
C. C
D. D
8. Nursing measures for the client who has had an MI include
helping the client to avoid activity that results in Valsalva's
maneuver. Valsalva's maneuver may cause cardiac dysrhythmias,
increased venous pressure, increased intrathoracic pressure, and
thrombi dislodgment. Which of the following actions would help
prevent Valsalva's maneuver?
A. Have the client drink fluids through a straw.
B. Have the client avoid holding her breath during activity.
C. Have the client assume a side-lying position.
D. Have the client clench her teeth while moving in bed.
9. The parents of a 3-year-old boy call the clinic to report
chickenpox. When teaching the parents about how to care for the
lesions, the nurse would advise which of the following?
A. Soak in a hot tub for 30 minutes three times a day.
B. Take an antihistamine and use calamine lotion on the lesions.
C. Take acetaminophen and use an antibiotic ointment on the
lesions.
D. Remove lesions crusts as they form.
10. Which of the following goals would be appropriate for the
client with hepatitis B?
A. The client will verbalize the importance of using sedatives to
provide adequate rest.
B. The client will avoid social activities with friends after
discharge from the hospital.
C. The client will adhere to measures to prevent the spread of
infection to others.
D. The client will adhere to a low sodium, low protein diet.
11. The nurse has assisted a multigravida with a precipitous
delivery of a viable neonate in a local grocery store. Because a
precipitous delivery can lead to decreased uterine tone, which of the
following nursing actions would help to prevent this complication?
A. Place the neonate on the client's fundus.
B. Place the mother in a supine position.
C. Encourage the mother to breast-feed the infant.
D. Massage the client's fundus continuously.
12. A client is prescribed 1000 mL of an antibiotic solution to
be given over 6 hours. What would be the flow rate? The infusion set
administers 15 gtts/mL.
A. 28 gtts/min.
B. 35 gtts/min.
C. 42 gtts/min.
D. 45 gtts/min.
13. A primipara is under nursing care during the first hour after
a vaginal delivery of a viable neonate under lumbar epidural
anesthesia and intravenous fluids. The client has a pulse rate of 65
bpm, temperature of 99.9°F (37.7℃), fundus firm at one finger
breath above the midline, and a slow trickle of dark red vaginal
bleeding on the perineal pad. The client's legs are still somewhat
numb. What should the nurse do?
A. Discontinue the client's intravenous fluids if the client is
drinking fluids.
B. Notify the anesthesiologist who performed the lumbar epidural
anesthesia.
C. Massage the fundus and contact the client's physician
immediately.
D. Continue to monitor the client's temperature on an hourly
basis.
14. The nurse is caring for a child with leukemia. Which of the
following should the nurse priority pay more attention to?
A. Preventing injury.
B. Monitoring the child's platelet count.
C. Monitoring the child's temperature.
D. Encouraging increased fluid intake.
15. During the evening shift on the day of the client's surgery,
the nurse notices that the nasogastric tube drains 500 mL of greenbrown fluid. What should the nurse do?
A. Record the amount of drainage on the client's chart.
B. Irrigate the tube with normal saline solution.
C. Call the physician immediately.
D. Increase the intravenous infusion rate.
16. The nurse is caring for a client who has generalized anxiety
disorder. Which statement is true about this client?
A. The client has regular obsessions.
B. Relaxation techniques and psychotherapy are necessary for cure.
C. Nightmares and flashbacks are common in individuals who suffer
from generalized anxiety disorder.
D. Generalized anxiety disorder is characterized by anxiety that
lasts longer than 6 months.
17. The client is taking carbamazepine (Tegretol) to treat his
trigeminal neuralgia. While preparing the client's teaching plan,
which of the following instructions should the nurse include?
A. Limit physical activity while taking the drug.
B. Eliminate caffeine from the diet while taking drug.
C. Arrange to have a CBC drawn weekly.
D. Take the drug on an empty stomach.
18. A 14-month-old child returns from surgery for undescended
testicle, and his postanesthesia recovery period is uneventful. When
planning for the child's discharge, which of the following goals
would the nurse expect to emphasize to the parents?
A. Absence of redness or swelling at the incision site.
B. Intake clear liquids well within 24 hours.
C. Passage of normal bowel movement within 24 hours.
D. Ability to ambulate after 48 hours.
19. The nurse is preparing a gastric lavage for a comatose victim
of the car accident. Which of the following positions would be most
appropriate for the client during this procedure?
A. Trendelenburg's.
B. Lithotomy.
C. Lateral.
D. Supine.
20. A 34-year-old multigravida is admitted in 36 weeks gestation
in active labor with diagnosis of Rh sensitization. The fetus is in a
frank breech presentation. The client's membranes rupture
spontaneously, and the nurse documents the color of the fluid as
yellowish. Which of the following can explain the yellowish fluid?
A. Amniotic fluid embolism.
B. Oligohydramnios.
C. Rh sensitization.
D. Abnormal presentation.
21. Trimethobenzamide (Tigan) 150 mg IM has been ordered to treat
a client's nausea and vomiting. The nurse has an ampule of Tigan
labeled 200 mg/mL. How many mL should the nurse prepare to give the
client?
A. 0.50 mL.
B. 0.75 mL.
C. 1.0 mL.
D. 1.5 mL.
22. A client with ulcerative colitis is chatting with the nurse.
Which of the following statements indicates the client understands
the lifestyle modifications he needs to make?
A. "I will have to stop smoking. "
B. "I can eat popcorn for an evening snack. "
C. "I may have coffee with my meals. "
D. "I am allowed to have alcohol as long as I only drink wine. "
23. A client is having autonomic dysreflexia. What should the
nurse do first?
A. Place the client in Fowler's position.
B. Send a urine sample for culture.
C. Administer nitroprusside sodium (Nipride) intravenously.
D. Call the physician.
24. The nurse uses 30 mL of solution to irrigate a nasogastric
tube and notes that 20 mL returns promptly into the drainage
container. When the nurse records the results of the irrigation, how
much solution should be recorded as intake?
A. 10mL.
B. 20mL.
C. 30mL.
D. 50mL.
25. The physician prescribes clomiphene citrate (Clomid) for a
woman who has been having difficulty getting pregnant. When preparing
the teaching plan for the client about this drug's potential side
effects, which of the following would the nurse include in the
teaching plan?
A. Increase in fibrocystic breast disease.
B. Increase in congenital anomalies.
C. Multiple pregnancies.
D. Increase in spontaneous abortions.
26. Which of the following findings is suggestive of myocardial
infarction (MI)?
A. Below-normal erythrocyte sedimentation rate.
B. Elevated white blood cell count.
C. Elevated serum cholesterol value.
D. Elevated creatine phosphokinase (CPK) value.
27. A voluntary client in a health care facility decides to leave
the unit before treatment is complete. To detain the client, the
nurse refuses to return the client's personal effects. This is an
example of which of the following?
A. False imprisonment.
B. Violation of confidentiality.
C. Limit setting.
D. Slander.
28. A client with diabetes is explaining to the nurse how he
cares for his feet at home. The nurse could judge from which of the
following statements that the client needs further instruction on how
to care for his feet properly?
A. "I inspect my feet once a week for cuts and redness. "
B. "I am not allowed to use a heating pad on my feet. "
C. "It is important to dry my feet carefully after my bath. "
D. "I should not go barefoot, even in my home. "
29. A mother is discussing with the nurse her 4-year-old boy's
strange eating habits including not finishing meals and eating the
same food for several days in a row. She would like to develop a plan
to correct this situation. When developing such a plan, which of the
following should the nurse and mother consider?
A. Deciding on a good reward for finishing the meal.
B. Allowing him to make some decisions about the foods he eats.
C. Restricting the availability of foods to those served at meal
times.
D. Not allowing him to leave the table until he has eaten the
food.
30. As the nurse helps the client prepare for discharge, the
client says, "You know, I've been in lots of hospitals and I know
when I'm sick enough to be there. I'm not that sick now. You don't
need to worry about me. " Which of the following would be the most
therapeutic response by the nurse?
A. "We're concerned about you. How can we help you before you
leave?"
B. "We could have helped you more if you had told us more. "
C. "Is there any information you need before you leave the
hospital?"
D. "Okay, you know best. "
31. Mr. Smith has had a cast applied to his arm as an outpatient
in the emergency room. Which of the following home care instructions
should the nurse advice for his cast care?
A. Use a ruler to reach inside and scratch under the cast.
B. Apply a heating pad to the arm for 24 hours after the injury.
C. Use powder on the skin around the cast.
D. Smell the cast for foul odors.
32. Which of the following laboratory tests should be monitored
closely by the nurse while the client is receiving heparin therapy?
A. International normalized ratio (INR).
B. Activated partial thromboplastin time (APTT).
C. Prothrombin time (PT).
D. Thrombin time.
33. A client asks the nurse to help her make out her will. In
this situation, what should be the nurse's best response?
A. "I don't believe in getting involved in legal matters, but
maybe I can find another nurse who'll help you. "
B. "You need to consult an attorney because I'm not trained in
such matters. Is there a family lawyer I can call for you?"
C. "I'm not a lawyer, but I'll do what I can for you. "
D. "You have a long way to go before you'll need to do that.
Let's wait on it a while, shall we?"
34. The nurse is assessing a client with an ileal conduit. She
notes that the client's urinary appliance contains pale yellow urine
with large amounts of mucus. How would the nurse best interpret these
data?
A. These findings are normal for the client.
B. There is irritation of the stoma.
C. The client is developing an infection of the urinary tract.
D. The mucus is caused by elevated levels of glucose in the urine.
35. A multigravid client in active labor is about to deliver. The
nurse has no help immediately available. What should the nurse do
first?
A. Prepare a clean area on which to deliver the neonate.
B. Lower the head of the bed to a flat position.
C. Have the client push with a contraction.
D. Ask the client to take a deep breath and hold it.
36. Which of the following denotes the primary reason that the
nurse inserts an indwelling urinary (Foley) catheter in a child with
severe burns?
A. Monitoring for a urinary tract infection.
B. Measuring urine output accurately.
C. Preventing urinary retention.
D. Assessing urine specific gravity.
37. Which one of the following nursing interventions should be
included in a plan of care for a client with a T tube?
A. Maintain client in a supine position while T tube is in place.
B. Keep T tube clamped except for during mealtimes.
C. Inspect skin around the T tube daily for irritation.
D. Irrigate the T tube every 4 hours to maintain patency.
38. When preparing to give a neonate the first feeding by nipple,
the nurse uses a 5 mL feeding of sterile water first. Which of the
following is the reason for doing so?
A. Ensure that the neonate has the energy to take oral feedings.
B. Ensure that the mother will be able to feed the neonate.
C. Ascertain the patency of the neonate's esophagus.
D. Determine if the neonate can retain the feeding.
39. The community health nurse develops a health education
program about preventing the transmission of hepatitis B. The nurse
evaluates that the teaching has been effective when the community
residents identify which of the following activities to be high risk
for acquiring hepatitis B?
A. Sharing needles for drug use.
B. Ingestion of contaminated seafood.
C. Frequent use of marijuana.
D. Ingestion of large amounts of acetaminophen (Tylenol).
40. A woman seeking help at a community mental health center
complains of fatigue, sensitivity to criticism, decreased libido, and
feeling self-conscious. She also has aches and pains. Which of the
following might be a nursing diagnosis for this client?
A. Delayed growth and development.
B. Ineffective role performance.
C. Posttrauma syndrome.
D. Chronic low self-esteem.
41. Which of the following would be an appropriate expected
outcome of nursing care for the client with ulcerative colitis?
A. The client experiences decreased frequency of constipation.
B. The client accepts that an ileostomy will be necessary.
C. The client maintains an ideal body weight.
D. The client verbalizes the importance of restricting fluids.
42. The nurse plans to administer an injection of heparin to a
client. Which of the following techniques for heparin administration
is appropriate?
A. Selects a 1.5-inch, 21-gauge needle for the injection.
B. Makes the injection into the deltoid muscle.
C. Applies gentle pressure to the site for 5 to 10 seconds after
the injection.
D. Aspirates with the plunger to check for entry into the blood
vessel before injecting the heparin.
43. While caring for the client with a burn injury, the nurse
should observe for signs and symptoms of which complication believed
to be due primarily to hypersecretion of gastric acid?
A. Paralytic ileus.
B. Gastric distention.
C. Hiatal hernia.
D. Gastrointestinal ulceration.
44. When instructing the client with severe burns about proper
nutrition, the nurse would encourage him to eat which of the
following meals?
A. Chicken breast, salad, iced tea.
B. Roast beef sandwich, milkshake, cottage cheese.
C. Hamburger, orange, coffee.
D. Pasta salad, carrots, iced tea.
45. Which of the following serum electrolyte levels would the
nurse expect to find in an infant with persistent vomiting?
A. K+, 3.2 mEq/L; Cl-, 92 mEq/L; Na+, 120 mEq/L.
B. K+, 3.4 mEq/L; Cl-, 120 mEq/L; Na+, 140 mEq/L.
C. K+, 3.5 mEq/L; Cl-, 90 mEq/L; Na+, 145 mEq/L.
D. K+, 5.5 mEq/L; Cl-, 110 mEq/L; Na+, 130 mEq/L.
46. When helping the client who has had a cerebrovascular
accident (CVA) learn self-care skills, the nurse should use which of
the following interventions to help him learn to dress himself?
A. Encourage the client to wear clothing designed especially for
people who have had a CVA.
B. Dress the client, explaining each step of the process as it is
completed.
C. Teach the client to put on clothing on the affected side first.
D. Encourage the client to ask his wife for help when dressing.
47. A client with heart failure loses 3.2 kg while hospitalized.
Approximately how many pounds has the client lost?
A. 1 pound.
B. 3 pounds.
C. 5 pounds.
D. 7 pounds.
48. The client delivers a viable male neonate who is given a
score of 9 at 5 minutes on the Apgar rating system. The client asks
the nurse what it means. The nurse interprets this finding as
indicating that the neonate's physical condition is which of the
following?
A. Good.
B. Fair.
C. Poor.
D. Critical.
49. In providing discharge teaching for the client after a
modified radical mastectomy, the nurse should instruct the client
that she might need to modify or avoid which of the following
activities?
A. Shampooing her dog.
B. Caring for her tropical fish.
C. Working in her rose garden.
D. Taking a late-evening swim.
50. A priority nursing diagnosis during the first 24 hours
following an MI is
A. Ineffective cardiac tissue perfusion.
B. Risk for infection.
C. Deficient fluid volume.
D. Constipation.
51. The client exhibits signs of sleep disturbance. Which
intervention should the nurse try first?
A. Administer sleeping medication before bedtime.
B. Provide the client with normal sleep aids, such as pillows,
back rubs, and snacks.
C. Ask the client each morning to describe the quality of sleep
during the previous night.
D. Teach the client relaxation techniques, such as guided imagery,
meditation, and progressive muscle relaxation.
52. Which of the following health-promoting activities should the
nurse teach the client with a new laryngectomy?
A. Cleanse the mouth three times a day.
B. Avoid taking tub baths.
C. Develop an aggressive program of exercise to increase airway
functioning.
D. Dehumidify the air for comfort.
53. A primigravida at 28 weeks' gestation is admitted with a
diagnosis of preterm labor. The client's contractions are occurring
every 15 to 20 minutes, lasting 25 seconds. The membranes are intact.
What should the nurse do?
A. Request assistance from the neonatal resuscitation team.
B. Place the client on bed rest on her left side.
C. Obtain equipment for an amniotomy.
D. Prepare terbutaline in an intravenous solution of normal
saline.
54. A client has been placed on levodopa to treat his Parkinson's
disease. Which of the following is a common side effect of levodopa
that the nurse should include in the client's teaching plan?
A. Pancytopenia.
B. Peptic ulcer.
C. Orthostatic hypotension.
D. Weight loss.
55. The head nurse is observing a new graduate nurse instill eye
drops into a client's eyes. The head nurse evaluates that the new
graduate is using appropriate technique when which of the following
steps is incorporated into the procedure?
A. The client is instructed to apply pressure to the eyes after
instillation of the eye drops.
B. The nurse's hand is stabilized on the client's forehead while
instilling the drops.
C. The medication is placed onto the client's sclera.
D. The client is instructed to look at the nurse while the drops
are being instilled.
56. One-year-old Susan, the second child to have sickle cell
disease in a family of five children, is admitted to the hospital
with sickle cell crisis. When preparing the plan of care for her,
which of the following treatments would the nurse most likely expect
to include in the plan?
A. Intravenous fluid therapy.
B. Fast-acting anticoagulant therapy.
C. Parenteral iron therapy.
D. Exchange transfusion.
57. The correct procedure for auscultating the client's abdomen
for bowel sounds would include
A. palpating the abdomen first to determine correct stethoscope
placement.
B. encouraging the client to cough to stimulate movement of fluid
and air through the abdomen.
C. placing the client on the left side to aid auscultation.
D. listening for 5 minutes in all four quadrants to confirm
absence of bowel sounds.
58. Assertive behavior involves which of the following elements?
A. Expressing an air of superiority.
B. Saying what is on your mind at the expense of others.
C. Avoiding unpleasant situations and circumstances.
D. Standing up for your rights while respecting the rights of
others.
59. While suctioning a client's laryngectomy tube, the nurse
should insert the catheter
A. about 1 to 2 inches.
B. as the client exhales.
C. until resistance is met, then withdraw it 1 to 2 cm.
D. until the client begins coughing.
60. David, a hyperkinetic 5-year-old, exhibits signs of extreme
restlessness, short attention span, and impulsiveness. In order to
alter the child's milieu that would likely be most therapeutic for
him, what could the nurse do?
A. Define behaviors of the child that will be acceptable and
those that will be unacceptable.
B. Allow the child freedom to choose activities in which to
participate and other children with whom to associate.
C. Increase the child's sensory stimulation and activity.
D. Limit the child's opportunities to display anger and
frustration.
61. The most significant sign of acute renal failure is
A. elevated body temperature.
B. increased blood pressure.
C. decreased urine output.
D. increased urine specific gravity.
62. An adolescent is admitted to the hospital for headaches. She
approaches the nurse and confides that she is being sexually abused
by a family friend. Which of the following would be the nurse's best
initial response?
A. "Can you tell me what happened?"
B. "I believe you; you were right to tell me. "
C. "Have you told your mother and father about this?"
D. "Who else have you told about this?"
63. The client is taking medication to control his cancer pain.
Which of the following statements indicates that the client needs
further instruction?
A. "I should take my medication around-the-clock to control my
pain. "
B. "I should skip doses periodically so I don't get hooked on my
drugs. "
C. "It is okay to take my pain medication even if I am not having
any pain. "
D. "I should contact the oncology nurse if my pain is not
effectively controlled. "
64. Which of the following interventions will assist the client
in taking phenytoin as prescribed?
A. Calling him daily for the first week after hospital discharge.
B. Having a family member monitor him to ensure compliance.
C. Providing him with written and verbal instructions about the
medicine.
D. Emphasizing that embarrassing seizures may occur again if he
does not take the medicine.
65. A client is taking chlorpropamide (Diabenese). Which of the
following side effects should be nurse expect from the medication?
A. Hypoglycemia.
B. Oral candidiasis.
C. Dumping syndrome.
D. Extrapyramidal symptoms.
66. A pregnant client with premature rupture of the membranes has
had contractions every 10 minutes. After 48 hours, the contractions
stop and the client is to be discharged with home monitoring. The
nurse discusses with the client about preterm labor symptoms. Which
of the following statements made by the client indicates that she
needs further instruction?
A. "I should report contractions that occur every 10 minutes in 1
hour. "
B. "I should lie in bed on my left side if contractions begin. "
C. "I should call the doctor if my contractions occur every hour
for 6 hours. "
D. "If I start having contractions, I should empty my bladder. "
67. A client with a seizure disorder has been prescribed
phenytoin (Dilantin). Which of the following should the nurse include
in the teaching plan?
A. It will be necessary for the client to take potassium
supplements to prevent hypokalemia.
B. The client should use a soft toothbrush and floss teeth daily.
C. The use of phenytoin can lead to the development of diabetes.
D. It is appropriate to substitute various brands of phenytoin as
long as the dosage is the same.
68. During the assessment stage, a client with schizophrenia
leaves his arm in the air after the nurse has taken his blood
pressure. Which of the following explains his action?
A. Somatic delusions.
B. Waxy flexibility.
C. Neologisms.
D. Nihilistic delusions.
69. An unconscious client has been admitted with a head injury.
Which of the following nursing diagnoses would receive the greatest
priority in the plan of care?
A. Disturbed sensory perception related to decreased level of
consciousness.
B. Ineffective airway clearance related to inability to remove
respiratory secretions.
C. Impaired gas exchange related to shallow irregular breathing.
D. Risk for injury related to disorientation and decreased level
of consciousness.
70. Antipsyehotie medications may cause which of the following
adverse effects?
A. Increased production of insulin.
B. Lower seizure threshold.
C. Increased coagulation time.
D. Increased risk of heart failure.
71. The nurse would evaluate that the client understands his home
care instructions after scleral buckling for a detached retina if the
client says which of the following statements?
A. "I should avoid abrupt movements of the head. "
B. "I should exercise the eye muscles each day. "
C. "I should turn the entire head rather than just the eyes for
sight. "
D. "I should avoid activities requiring good depth perception. "
72. A 10-month-old girl with bronchitis is taken out of the 30%
oxygen tent for breakfast because she refuses to eat unless in a high
chair. During the feeding, the nurse notes that the child's
respiratory rate has increased, she is becoming more irritable, and
she is using accessory muscles to breathe. Which of the following
should be the nurse's first action?
A. Perform postural drainage then complete the feeding.
B. Suction the child's nose with a bulb syringe.
C. Discontinue the feeding and place the child back in the tent.
D. Assess the pulse rate and respirations and notify the
physician.
73. A client is at risk for developing a pressure ulcer. The
first warning of an impending pressure ulcer is when pressure applied
to skin it turns
A. whitish.
B. yellowish.
C. bluish.
D. reddish.
74. The nurse is caring for a client in an acute manic state.
What's the most effective nursing action for this client?
A. Assigning him to group activities.
B. Reducing his stimulation.
C. Assisting him with self-care.
D. Helping him express his feelings.
75. During a home visit 4 days after delivery, the breast-feeding
client tells the nurse that her breasts are hard and tender. The
nurse suspects breast engorgement. Which of the following action
should the nurse instruct the client to do?
A. Take a moderately strong analgesic after the infant breastfeeds on both sides.
B. Use her hand or a pump to express a small amount of breast
milk before breast-feeding.
C. Discontinue breast-feeding immediately and replace it with
bottle-feeding during the night.
D. Apply ice packs to the breasts for 20 minutes just before
breast-feeding the newborn.
76. Which of the following symptoms would indicate that a client
is at risk for autonomic dysreflexia?
A. Sudden, severe hypertension.
B. Hot, dry skin.
C. Paralytic ileus.
D. Bradycardia.
77. Which of the following signs or symptoms would the nurse
expect to see in a client with pancreatitis?
A. Bradycardia.
B. Hypertension.
C. Decreased white blood cell count.
D. Left upper quadrant abdominal pain.
78. A 24-year-old primipara decides to breast-feed her baby but
says, "I'm worried that I won't be able to breast-feed my baby
because my breasts are so small. " Which of the following is
appropriate response by the nurse?
A. Because her breasts are small, she will have to feed the baby
more often.
B. Breast size poses no influence on a woman's ability to breastfeed a baby.
C. Breast milk can be enhanced by occasional formula feeding.
D. The woman's motivation to breast-feed is less important than
breast size.
79. A client has had a total gastrectomy for gastric cancer.
Which one of the following is the most appropriate expected outcomes
about nutrition?
A. The client will learn to self-administer enteral feedings
every 4 hours.
B. The client will maintain adequate nutrition through oral or
parenteral feedings.
C. The client will regain any weight lost within 4 weeks of the
surgical procedure.
D. The client will eat three full meals a day without
experiencing gastric complications.
80. The nurse notices that a depressed client taking
amitriptyline (Elavil) for 2 weeks has become very outgoing, cheerful,
and talkative. The nurse would suspect which of the following?
A. The client is responding to the antipsychotic.
B. The client may be experiencing increased energy and is at an
increased risk for suicide.
C. The client is ready to be discharged from treatment.
D. The client is experiencing a split personality.
81. The development of laryngeal cancer is most clearly linked to
which of the following factors?
A. High-fat, low-fiber diet.
B. Alcohol and tobacco use.
C. Low socioeconomic status.
D. Overuse of artificial sweeteners.
82. A preschool-aged child who is hospitalized with
gastroenteritis has been NPO. The physician has written an order to
advance the diet as tolerated. Which of the following food is the
most appropriate for the first feeding the nurse should offer the
child?
A. Clear lemon carbonated beverage.
B. Toast.
C. Cooked cereal.
D. Ice cream shake.
83. Mrs. S with preterm labor will be under Terbutaline (Brethine)
therapy. Before beginning the therapy, which of the following
assessments would be most important?
A. Estimated fetal size.
B. Maternal heart rate.
C. Contraction intensity.
D. Deep tendon reflexes.
84. The nurse is evaluating a client's lung sounds. Which of the
following breath sounds indicate adequate ventilation when
auscultated over the lung fields?
A. Vesicular.
B. Bronchial.
C. Bronchovesicular.
D. Adventitious.
85. The client experiences a wound evisceration on day 2 after
the abdominal hysterectomy. What should the nurse immediately do?
A. Approximate the wound edges by applying strips of adhesive
over the wound.
B. Cover the exposed tissues with sterile dressings moistened
with normal saline solution.
C. Replace the abdominal contents into the wound carefully while
wearing gloves.
D. Apply a loose-fitting sterile abdominal binder over the wound.
86. A client with iron-deficiency anemia is prescribed liquid
iron supplements. The nurse teaches the client's about how to take
this drug. Which of the following statements by the client indicates
that the education is effective?
A. "I will report any black stools to the physician. "
B. "I will dilute the medication and drink it with a straw. "
C. "I will check my gums for any bleeding. "
D. "I can use antidiarrheal drugs if I develop diarrhea. "
87. Three weeks after the application of the spica cast following
surgery for an infant, the mother told the nurse that the infant's
toes are swollen and cool to the touch. Which of the following would
the nurses suspect?
A. Cotton wadding lining of the cast has shrunk.
B. An infection has developed under the cast.
C. Child's feet were in a dependent position.
D. Child has outgrown the spica cast.
88. The nurse is developing a discharge plan for a client who had
cataract removal. Which of the following should be included in the
discharge plan?
A. Wear cataract glasses that correct vision by magnifying
objects.
B. Wear corrective glasses or contact lenses.
C. Wear glasses only until the eye heals.
D. Relearn to judge distances accurately.
89. A client has a diagnosis of borderline personality disorder.
She has attached herself to one nurse and refuses to speak with other
staff members. She tells the nurse that the other nurses are mean,
withhold her medication, and mistreat her. The staff is discussing
this problem at their weekly conference. Which intervention would be
most appropriate for the nursing staff to implement?
A. Provide an unstructured environment for the client.
B. Rotate the nurses who are assigned to the client.
C. Ignore the client's behaviors.
D. Bend unit rules to meet the client's needs.
90. Mrs. Wilson, a primigravida, was admitted to the hospital at
12 weeks' gestation. She is complaining of abdominal cramping,
exhibits bright red vaginal spotting without cervical dilation. The
nurse determines that the client is most likely experiencing which of
the following types of abortion?
A. Complete.
B. Threatened.
C. Inevitable.
D. Missed.
91. The nurse is assessing a 15-year-old female who is being
admitted for treatment of anorexia nervosa. Which of the following
clinical manifestation is the nurse most likely to find from the
client?
A. Tachycardia.
B. Coarse hair growth.
C. Parotid gland tenderness.
D. Warm, flushed extremities.
92. The nurse evaluates the client's understanding of myasthenia
gravis. The nurse would judge that the client has formed a realistic
concept of her condition when she says
A. "By taking medication and pacing activities, I will live
longer, but ultimately the disease will cause my death. "
B. "By taking medication and pacing activities, my fatigue will
be relieved, but I should expect occasional periods of muscle
weakness. "
C. "By taking medication and pacing activities, my symptoms will
be controlled and eventually the disease will be cured. "
D. "By taking medication and pacing activities, I should be able
to control the disease and enjoy a healthy lifestyle. "
93. Which of the following interventions would likely be most
effective for the client to use at home when managing the discomfort
of rhinoplasty the initial 2 days after surgery?
A. Applying ice compresses.
B. Applying warm, moist compresses.
C. Lying in a prone position.
D. Blowing the nose gently.
94. A community nurse is performing a physical assessment on an
18-month-old child. Which of the following would be best?
A. Carry out the assessment from head to toe.
B. Assess motor function by having the child run and walk.
C. Have the mother hold the toddler on her lap.
D. Assess the respiratory and cardiac systems first.
95. After abdominal surgery, a client is reluctant to turn in bed.
Which of the following interventions would be most appropriate?
A. Remind her that she must follow her doctor's orders.
B. Tell her family to encourage her to turn.
C. Allow the client to turn when she wants.
D. Explain the importance of turning to the client.
96. Which of the following is the single most reliable indicator
of the existence and intensity of acute pain?
A. The client's vital signs.
B. The client's self-report of pain.
C. The nurse's assessment of the client.
D. The severity of the condition causing the pain.
97. When developing a teaching plan for the mother of a child
diagnosed with spastic cerebral palsy, which of the following
descriptions would the nurse include?
A. Wide-based gait and poor muscle coordination.
B. Tremors and lack of active movement.
C. Increased muscle tone and stretch reflexes.
D. Slow, wormlike writhing movements.
98. The nurse is caring for a client with late-stage Alzheimer's
disease. The client's wife tells the nurse that the client has become
very dependent. The client's wife feels guilty if she takes any time
for herself because the client cries out for her. The nurse should
develop which outcome to assist the client's wife?
A. The caregiver learns to explain to the client why she needs
time for herself.
B. The caregiver distinguishes obligations she must fulfill from
those that can be controlled or limited.
C. The caregiver leaves the client at home alone for short
periods of time to encourage independence.
D. The caregiver avoids asking other family members to help for
fear of imposing on them.
99. Which of the following is an early sign of laryngeal cancer?
A. Difficulty swallowing.
B. Chronic foul breath.
C. Persistent mild hoarseness.
D. Nagging unproductive cough.
100. The most common symptom associated with bladder cancer is
A. burning on urination.
B. frequent infections.
C. painless hematuria.
D. decreasing urine output.
101. The nurse is caring for several clients who have eating
disorders. Based on appearance, how would the nurse distinguish
bulimic clients from anorectic clients?
A. By their teeth.
B. By body size and weight.
C. By looking for Mallory-Weiss tears.
D. The clients are indistinguishable upon physical examination.
102. Which of the following nursing diagnoses would be most
appropriate when teaching the mother of a toddler?
A. Activity intolerance.
B. Risk for injury.
C. Delayed growth and development.
D. Impaired mobility.
103. Which of the following interventions would be most helpful
in preventing pressure ulcer formation in at-risk client?
A. Massaging reddened areas on the sacrum.
B. Ensuring a generous fluid intake.
C. Repositioning every hour.
D. Providing a low protein diet.
104. The nurse is planning a genetic counseling with the parents
of a child with Down syndrome, which of the following would the nurse
include as the primary role of the genetic team when working with a
family?
A. Preparing the parents psychologically for the birth of a
defective child.
B. Prescribing birth control or abortion measures for the parents
as needed.
C. Providing parents with information about the risks of birth
defects.
D. Reporting the findings of chromosome analysis of the amniotic
cells.
105. A client has had a cerebrovascular accident (CVA). Because
the CVA affected the left side of the client's brain, the nurse
should anticipate that the client would most likely experience
A. dyslexia.
B. apraxia.
C. agnosia.
D. expressive aphasia.
106. The client with a lumbar laminectomy asks to be turned onto
his side. What should the nurse do?
A. Inform the client that because of his laminectomy, he may only
lie supine.
B. Ask the client to help by using an overhead trapeze to turn
himself.
C. Turn the client's shoulders first, followed by his hips and
legs.
D. Get another nurse to help log roll the client into position.
107. While managing the separation anxiety during hospitalization
for a two-year-old boy, which of the following suggestions would be
most helpful to the parents?
A. Tell the child the time they are leaving and returning.
B. Bring the child's favorite toys from home.
C. Leave while the child is sleeping.
D. Keep the visit time short.
108. Which of the following is of the nurse's the primary concern
for a client after cataract removal surgery?
A. The client states her vision is clear.
B. The client states her infection is under control.
C. The client states she is able to administer parenteral pain
medication.
D. The client describes methods to prevent an increase in
intraocular pressure.
109. The mother of a child with flat feet asks the nurse why her
child needs to wear corrective shoes. Which of the following is the
most appropriate reason that the child needs to wear corrective shoes?
A. Preventing the development of internal tibial torsion.
B. Strengthening the arches of the feet.
C. Keeping the legs in proper alignment.
D. Delaying the development of femoral anteversion.
110. The nurse administers a preoperative intramuscular
medication at the ventrogluteal site. The nurse will inject the
medication into which muscle?
A. Rectus femoris.
B. Gluteus maximus.
C. Gluteus minimus.
D. Vastus lateralis.
111. The nurse would plan to use an abduction pillow (or splint)
after a total hip replacement. What is the purpose for this activity?
A. To prevent hip flexion.
B. To prevent dislocation of the prosthesis.
C. To increase peripheral circulation.
D. To decrease formation of sacral pressure ulcers.
112. When caring for an adolescent client diagnosed with
depression, the nurse should remember that depression manifests
differently in adolescents and adults. In an adolescent, signs and
symptoms of depression are likely to include which of the following?
A. Helplessness, hopelessness, hypersomnolence, and anorexia.
B. Truancy, a change of friends, social withdrawal, and
oppositional behavior.
C. Curfew breaking, stealing from family members, truancy, and
oppositional behavior.
D. Hypersomnolence, obsession with body image, and valuing of
peers' opinions.
113. Which of the following nursing interventions is most
important postoperatively for an infant who has received a
ventriculoperitoneal shunt?
A. Monitoring intake and output.
B. Allowing the infant to rest undisturbed.
C. Providing age-appropriate diversionary activities.
D. Initiating oral feedings.
114. Susan is an adolescent client with pregnancy-induced
hypertension (PIH). The physician orders 5% dextrose in Ringer's
solution and magnesium sulfate intravenously for her. Before the
magnesium sulfate is administered, which of the following assessments
would be the priority?
A. Maternal urinary output.
B. Fetal position.
C. Fetal heart rate variability.
D. Maternal respiratory rate.
115. To encourage adequate nutritional intake for a client with
Alzheimer's disease, what should the nurse do?
A. Stay with the client and encourage him to eat.
B. Help the client fill out his menu.
C. Give the client privacy during meals.
D. Fill out the menu for the client.
116. The nurse is evaluating the effectiveness of airway
suctioning. Which of the following outcome criteria is most
appropriate?
A. Respirations unlabored.
B. Decreased mucus production.
C. Hollow sound on chest percussion.
D. Breath sounds clear on auscultation.
117. A client with rheumatoid arthritis has been taking large
doses of aspirin to relieve her joint pain. The nurse should assess
the client for which important symptom of aspirin toxicity?
A. Chest pain.
B. Drowsiness.
C. Dysuria.
D. Tinnitus.
118. The nurse plans to teach a client who is receiving radiation
therapy how to care for his skin at home. Which of the following
should be included in the nurse's instructions?
A. "Apply a heating pad to the area to relieve pain. "
B. "Keep the area covered when you go outdoors. "
C. "You may use deodorant soap if you wish to cleanse the area. "
D. "Put baby oil on the area after each treatment to keep it from
getting dry. "
119. Lily, a 23-month-old, pulled a pan of hot water off the
stove and spilled it onto her chest and arms. Her mother was right
there when it happened. Which of the following is the most
appropriate that the mother should have done immediately?
A. Call the neighbor to come over and help her.
B. Place the child in the bathtub of cool water.
C. Apply antibiotic ointment to the burned areas.
D. Apply ice directly to the burned areas.
120. A client with diverticulitis is treated as an outpatient
with drug therapy. Which of the following medication would most
probably be included in the drug therapy?
A. Broad-spectrum antibiotics.
B. Opioid analgesics.
C. Tranquilizers.
D. Laxatives.
121. Emergency restraints or seclusion may be implemented without
a physician's order under which of the following conditions?
A. When a written order will be obtained from the primary
physician within 1 hour.
B. If a voluntary client wants to leave against medical advice.
C. When a minor child is out of control.
D. Never.
122. The nurse noticed that an 8-month-old child's posterior
fontanel is slightly open. Which of the following should the nurse do
next?
A. Check the child's head circumference.
B. Question the mother about the child's delivery.
C. Schedule an X-ray of the child's head.
D. Document this as a normal finding.
123. The client is advised by the physician to have mammography
screening annually. Which of the following is the best measure to
improve adherence with mammography screening?
A. Making sure that the individual barriers to screening are
minimized.
B. Emphasizing that mammography screening can prevent breast
cancer.
C. Emphasizing that mammography screening is a low-cost approach
to cancer prevention.
D. Informing the client that she is at high risk for breast
cancer and needs to follow the physician's recommendation.
124. Which of the following symptoms would the nurse most likely
observe in a client with cholecystitis from cholelithiasis?
A. Black stools.
B. Decreased white blood cell count.
C. Nausea after ingestion of high-fat foods.
D. Elevated temperature of 103°F(39.4℃).
125. Mrs. Brown, who is breast-feeding, asks the nurse if she
should supplement breast- feeding with formula feeding. The nurse
bases the response on which of the following?
A. Formula feeding should be avoided to prevent interfering with
the breast milk supply.
B. Primarily, water supplements should be used to prevent
jaundice.
C. Formula supplements can provide nutrients not found in breast
milk.
D. More vigorous sucking is needed for a bottle-feeding, so
supplements should be avoided.
126. Discharge instructions for clients receiving tricyclic
antidepressants include which of the following information?
A. Don't consume alcohol.
B. Restrict fluid and sodium intake.
C. It's safe to continue taking during pregnancy.
D. Discontinue if dry mouth and blurred vision occur.
127. A pregnant client is admitted to the hospital at 34 weeks
gestation and is receiving intravenous tocolytic therapy for preterm
labor. The physician orders betamethasone (Celestone) intramuscularly
for her. After administering the drug, the nurse would assess the
client for which of the following as a possible side effect?
A. Decreased skin turgor.
B. Infection.
C. Urinary frequency.
D. Hypoglycemia.
128. Which of the following techniques is appropriate for
irrigating an adult client's ear to move cerumen?
A. After instilling the solution, pack the ear canal tightly with
cotton pledgets.
B. Allow the irrigating solution to run down the wall of the ear
canal.
C. The irrigating solution should be cool.
D. Use sterile solution and equipment.
129. Pancrelipase (Viokase), an enzyme replacement, has been
prescribed for a client with chronic pancreatitis. The nurse
evaluates the client's understanding of how to take this drug. Which
of the following statements indicates the client has adequate
knowledge?
A. "The enzyme mixture should be taken after each meal. "
B. "The enzyme mixture should be stored in the refrigerator to
keep it fresh. "
C. "I should be careful not to inhale the powder when mixing it
with food. "
D. "I should chew the capsule thoroughly. "
130. A client is suffering from short-term memory loss after a
head injury. Which of the following nursing actions would be
appropriate to help him cope with his memory loss?
A. Instruct family members to ignore his behavior.
B. Place a single-date calendar where he can view it.
C. Explain that he will have to try harder to remember things.
D. Tell him every morning what activities he will be expected to
perform that day.
131. The mother of a new-born asks the nurse how often she should
breastfeed her baby. Which of the following responses by the nurse
would be best?
A. "Newborns should breastfed at least every 3 hours during the
day. "
B. "Newborns should be fed when they cry. "
C. "As long as the baby feeds four times a day, he will get
enough. "
D. "Newborns may breastfeed continuously until they stabilize. "
132. At an outpatient clinic, a client asks the nurse how she can
prepare for pregnancy. Which of the following responses by the nurse
would be best?
A. "Begin an iron supplement of 100 mg daily. "
B. "Supplement your diet with 400 meg of folio acid. "
C. "Avoid raw eggs and cats until conception. "
D. "Receive immunization against toxoplasmosis. "
133. A 9-year-old child is in diabetes. The nurse offers to meet
with the mother and the child's teacher before school to discuss the
teacher's responsibilities in relation to the child's diabetes. Which
of the following would the nurse expect to discuss in this meeting?
A. How to perform a glucometer test.
B. How to give an insulin injection.
C. Signs and symptoms of hypoglycemia.
D. The American Diabetic Association (ADA) diet.
134. The nurse is caring for a client in the first 4 weeks of
pregnancy. The nurse should expect to collect which assessment
findings?
A. Presence of menses.
B. Uterine enlargement.
C. Breast sensitivity.
D. Fetal heart tones.
135. A client is prescribed Gentamycin (Garamycin) IV to treat
infection. It is important to monitor the client for the development
of which of the following side effects from the medication?
A. Ascites.
B. Confusion.
C. Ototoxicity.
D. Cardiac dysrhythmias.
136. A client with a retinal detachment does not understand what
happened to his eye and asks the nurse's explanation. Which of the
following would be the nurse's best response to describe the
pathology of retinal detachment?
A. "The optic nerve is damaged when it is exposed to vitreous
humor. "
B. "A tear in the retina permits the escape of vitreous humor
from the eye. "
C. "The two layers of the retina separate, allowing fluid to
enter between them. "
D. "Retinal injury produces inflammation and edema that increase
intraoeular pressure. "
137. A young man is remanded by the courts for psychiatric
treatment. From his police record the nurse notices that the client
has records of delinquency, running away, auto theft, and vandalism
in his early teenage years. He dropped out of school at age 16 and
has been living on his own since then. His history suggests
maladaptive coping. Which of the following problems is most
associated with maladaptive coping?
A. Antisocial personality disorder.
B. Borderline personality disorder.
C. Obsessive-compulsive personality disorder.
D. Narcissistic personality disorder.
138. A client is admitted to the labor and delivery department in
preterm labor. To help manage preterm labor the nurse would expect to
administer which of the following medication?
A. Ritodrine (Yutopar).
B. Bromocriptine (Parlodel).
C. Betamethasone (Celestone).
D. Magnesium sulfate.
139. The mother of a 3-year-old calls the emergency room nurse at
3.00 AM and reports her child has a temperature of 101.1°F (38.4℃),
a runny nose, and a barky cough that "gets going and won't stop. "
The mother states that she just gave the child acetaminophen
(Tylenol). Which of the following should the nurse recommend next?
A. Giving the child an over-the-counter decongestant.
B. Administering aspirin in 2 hours.
C. Sitting with the child in a steamy warm bathroom.
D. Running a steam vaporizer near the child's bedside.
140. A pregnant client who is diabetic is at risk for having a
large-for-gestational-age infant because of which of the following?
A. Excess sugar causing reduced placental functioning.
B. Insulin acting as a growth hormone on the fetus.
C. Maternal dietary intake of high calories.
D. Excess insulin reducing placental functioning.
141. The nurse at a substance abuse center answers the phone. A
probation officer asks if a client is in treatment. The nurse
responds, "No, the client you're looking for isn't here. " Which of
the following statements best describes the nurse's response?
A. Correct because she didn't give out information about the
client.
B. A breech of the principle of veracity because the nurse is
misleading the officer.
C. Illegal because she's withholding information from law
enforcement agents.
D. A violation of confidentiality because she informed the
officer that the client wasn't there.
142. A mother of an ill child tells the nurse that her child
"isn't eating well. " Which of the following strategies devised by
the mother to help increase the child's intake is not appropriate?
A. Asking the child to say why he is not eating.
B. Telling the child he must eat or else he will not get better.
C. Allowing the child to choose his meals from an acceptable list
of foods.
D. Letting the child to substitute items on his tray for other
nutritious foods.
143. An infant is admitted to the hospital because of having
frequent diarrheal stools with acute rotaviral infection. The nurse
notes 40 to 60 bowel sounds per minute. The child has poor skin
turgor, and the mucous membranes are dry. The nurse would make a
nursing diagnosis of Deficient fluid volume related to
A. insufficient antidiuretic hormone.
B. inability to metabolize nutrients.
C. decreased gastric emptying.
D. increased gastrointestinal motility.
144. The client with a head injury receives mannitol (Osmitrol)
during surgery to help decrease intracranial pressure. Which of the
following nursing observations would most likely indicate that the
drug is having the desired effect?
A. Urine output increases.
B. Pulse rate decreases.
C. Blood pressure decreases.
D. Muscular relaxation increases.
145. The nurse instructs the female client concerning hormone
replacement therapy for menopausal symptoms. Which of the following
points should the nurse include in the client's teaching plan?
A. Estrogen therapy eliminates the need for supplemental calcium
intake.
B. Estrogen therapy can reduce the risk of menopausal bone loss.
C. The risk of uterine cancer is decreased after menopause.
D. Smoking is associated with a later onset of menopause.
146. While a client with hypertension is being assessed, he says
to the nurse, "I really don't know why I'm here. I feel fine and
haven't had any symptoms. " Which of the following would be the
nurse's best response?
A. "Symptoms of hypertension are often not present. "
B. "Symptoms of hypertension signify a high risk of stroke. "
C. "Symptoms of hypertension occur only with malignant
hypertension. "
D. "Symptoms of hypertension appear after irreversible kidney
damage has occurred. "
147. Which of the following fluid and electrolyte imbalances
would the nurse anticipate that the client would be particularly
susceptible to in the emergent phase of burn care?
A. Metabolic alkalosis.
B. Hemodilution.
C. Hypernatremia.
D. Hyperkalemia.
148. A client who has stress incontinence has been given a
pamphlet that describes Kegel exercises. Which of the following
statements indicates that the client has understood the instructions
in the pamphlet?
A. "It will probably take a year before the exercises are
effective. "
B. "I should perform these exercises every evening. "
C. "I can do these exercises sitting up, lying down, or standing.
"
D. "I need to tighten my abdominal muscles to do these exercises
correctly. "
149. Positive symptoms of schizophrenia include which of the
following?
A. Waxy flexibility, alogia, and apathy.
B. Flat affect, avolition, and anhedonia.
C. Hallucinations, delusions, and disorganized thinking.
D. Somatic delusions, echolalia, and a flat affect.
150. A multigravida at 37 weeks' gestation tells the nurse that
she has frequent heartburn. The nurse teaches the client with
suggestions for obtaining relief from the heartburn. Which of the
following statements by the patient indicates that she has understood
the nurse's instructions?
A. "I can take a teaspoon of baking soda in water occasionally. "
B. "I should eat only three large meals and drink plenty of
fluids. "
C. "It's all right for me to have a fried hamburger and fries. "
D. "I should eat smaller, more frequent meals with fluids. "
Part Two
You will have one hour and 50 minutes to complete Part Two.
151. Which of the following is the nurse's goal in crisis
intervention?
A. To provide medication to sedate the client.
B. To provide nondirective techniques such as free association.
C. To provide problem-solving techniques and structured
activities.
D. To provide an insight-oriented analytic approach.
152. The client with benign prostatic hypertrophy is prepared for
admission to the hospital Which of the following information reported
by the emergency room nurse would be most helpful to the nurse
responsible for admitting the client?
A. "A urine specimen was obtained from the client and sent to the
laboratory for analysis. "
B. "The client was catheterized, and 1100 mL of urine was
obtained. The urine appeared cloudy, and a specimen was sent to the
laboratory. "
C. "The client is very cooperative. He is comfortable now that
his bladder has been emptied. He had no ill effects from
catheterization. "
D. "The client was in the emergency room for 3 hours because of
bladder distention. He is fine now but is being admitted as a
possible candidate for surgery. "
153. Nitroglycerin is also available in ointment or paste form.
Before applying nitroglycerin ointment, what should the nurse do
first?
A. Cleanse the skin with alcohol where the ointment will be
placed.
B. Obtain the client's pulse rate and rhythm.
C. Remove the ointment previously applied."
D. Instruct the client to expect pain relief in the next 15
minutes.
154. The nurse is making a plan of care for the child with
juvenile rheumatoid arthritis to reduce joint pain in the morning
just after arising. Which of the following interventions would be
included in the plan?
A. Awakening the child once nightly to exercise the joints.
B. Having the child sleep in a sleeping bag.
C. Having the child sleep with the joints flexed.
D. Increasing pain medication at bedtime.
155. A client has just expelled a hydatidiform mole. She's
visibly upset over the loss and wants to know when she can try to
become pregnant again. Which of the following would be the nurse's
best response?
A. "I can see you're upset. Why don't we discuss this with you at
a later time when you're feeling better. "
B. "I can see that you're upset; however, you must wait at least
1 year before becoming pregnant again. "
C. "Let me check with your physician and get you something that
will help you relax. "
D. "Pregnancy should be avoided until all of your testing is
normal. "
156. The nurse is caring for a client after a closed renal biopsy.
Which of the following nursing measures should be included in the
plan of care?
A. Maintaining the client on strict bed rest in a supine position
for 6 hours.
B. Administering intravenous narcotic medications to promote
comfort.
C. Inserting an indwelling catheter to monitor urine output.
D. Applying a sandbag to the biopsy site to prevent bleeding.
157. In caring for the client with hepatitis B, which of the
following situations would most likely expose the nurse to the virus?
A. Contact with fecal material.
B. A blood splash into the nurse's eyes.
C. Disposing of syringes and needles without recapping.
D. Touching the client's arm with ungloved hands while taking
blood pressure.
158. During a conversation with the client, the nurse observes
the client shaking his leg and tapping his fingers on the table next
to him. The nurse's best statement is.
A. "I'll get you something to help you feel less anxious. "
B. "I know that you feel anxious. Let's discuss something more
pleasant. "
C. "I see that you're anxious. I'll be back later when you're
calmer. "
D. "I noticed that your leg is shaking and you're tapping your
fingers on the table. How are you feeling now?"
159. A client with cirrhosis should be encouraged to follow which
of the following diet regime?
A. High-calorie, restricted protein, low-sodium diet.
B. Bland, low-protein, low-sodium diet.
C. Well-balanced normal nutrients, low-sodium diet.
D. High-protein, high-calorie, high-potassium diet.
160. A client receiving morphine for long-term pain management
develops tolerance. When the client asks the nurse what it means,
which of the following should the nurse response?
A. "Tolerance is an allergic reaction to a medication. "
B. "Tolerance is an ability to take the same drug for extended
periods of time. "
C. "Tolerance is an increased response to a medication. "
D. "Tolerance is a diminished response to a drug so that more is
required to reach the same effect. "
161. Which of the following signs and symptoms is classic for a
patient with rheumatoid arthritis?
A. Joint swelling, joint stiffness in the morning, and bilateral
joint involvement.
B. Crepitus, development of Heberden's nodes, and anemia.
C. Pain on weight-bearing, rash, and low-grade fever.
D. Fatigue, leukopenia, and joint pain.
162. Which nursing diagnosis would the nurse anticipate as having
the highest priority for the client with gestational diabetes in
labor?
A. Risk for infection related to invasive procedures during labor.
B. Risk for injury to fetus related to the effects of diabetes on
uteroplacental functioning.
C. Deficient knowledge related to lack of information about care
during labor.
D. Interrupted family processes related to diabetes increasing
the client's risk of complications.
163. A client diagnosed with schizoaffective disorder is
suffering from schizophrenia with elements of which of the following
disorders?
A. Thought disorder.
B. Amnestic disorder.
C. Personality disorder.
D. Mood disorder.
164. The parents of a neonate with a cleft lip are shocked when
they see their child for the first time. In order to help the parents
accept their infant's anomaly, which of the following should be
included in the neonate's plan of care?
A. Reassuring them that surgery will correct the defect.
B. Encouraging the parents to visit more frequently.
C. Showing them pictures of babies before and after corrective
surgery.
D. Allowing them to complete their grieving process before seeing
the infant again.
165. A woman seeking help at a community mental health center
complains of fatigue, sensitivity to criticism, decreased libido, and
feeling self-conscious. She also has aches and pains. A nursing
diagnosis for this client might include
A. Delayed growth and development.
B. Ineffective role performance.
C. Posttrauma syndrome.
D. Chronic low self-esteem.
166. To obtain a good monitor tracing on a client in labor, the
mother lies on her back. Suddenly, she complains of feeling lightheaded and becomes diaphoretic. Which of the following should be the
nurse's first action?
A. Reposition the client to her left side.
B. Immediately take the client's blood pressure and call the
physician.
C. Start oxygen at 6 L via nasal cannula.
D. Increase the IV fluids to correct the client's dehydration.
167. A client diagnosed with tuberculosis is taking the
prescribed chemotherapy of isoniazid, rifampin, and pyrazinamide. The
nurse should evaluate the client for signs of which of the following
commonly occurring toxicities?
A. Ototoxicity.
B. Nephrotoxicity.
C. Optic neuritis.
D. Hepatotoxieity.
168. A client with recurred cancer is planned to take internal
radiation treatment with a radium implant. The client tells the nurse
that she is concerned about being radioactive and has been having
nightmares about the treatment. What would be a reasonable
explanation for the nurse to give to the client?
A. "Careful shielding prevents the area above your waist from
radioactivity. "
B. "These nightmares indicate that you're in the denial phase of
accepting the diagnosis. "
C. "The radioactive material is controlled and stays with the
source; once the material is removed, no radioactivity will remain. "
D. "The radioactivity will gradually decrease, and you will be
discharged when the radioactive material reaches its half-life. "
169. Mr. W is with bipolar disorder, manic phase, with a nursing
diagnosis of Imbalanced nutrition: less than body requirements. In
order to help the client meet recommended daily allowances of
nutrients, which of the following nursing interventions should be
included in the plan of care?
A. Tell the client to sit alone at mealtime so that he won't be
distracted by others.
B. Teach the client about proper nutrition.
C. Give the client half of a meat and cheese sandwich between
meals.
D. Inform the client that snacks are available only if he eats
properly at mealtime.
170. In developing a plan of care for a client with rheumatoid
arthritis, the nurse should consider that clients with rheumatoid
arthritis should be positioned so as to
A. prevent flexion deformities of the joints.
B. decrease edema around the joints.
C. promote maximum comfort.
D. prevent venous stasis.
171. One nurse strongly believes that all psychiatric medication
is a form of chemical mind control. When the client's wife asks about
the efficacy of antidepressant medications, which of the following
courses of action would be best for this nurse to take?
A. Give an honest opinion of the treatment.
B. Explain that there are not enough current statistics about the
efficacy of the treatment.
C. Provide a package insert for the wife to read.
D. Refer the client's wife to another knowledgeable person for
information about the treatment.
172. The nurse is preparing an elderly client to get out of bed
on the first postoperative day after a total hip replacement. Which
of the following activities would be most helpful to the client?
A. Demonstrate the use of a walker with partial weight bearing.
B. Explain to the client that she will be lifted out of bed to a
chair.
C. Reassure the client that she will be assisted to walk to the
hall.
D. Demonstrate the swing-through crutch-walking gait with limited
weight hearing.
173. A breast-feeding neonate will turn his head toward the
mother's breast in a natural instinct to find food. What is the name
of this reflex?
A. Tonic neck reflex.
B. Moro's reflex.
C. Grasp reflex.
D. Rooting reflex.
174. Which one of the following observation would the nurse
evaluate as an expected outcome for a client who has undergone
surgical repair of an inguinal hernia?
A. The client will remain on a soft diet until the wound is
healed.
B. The client's voiding patterns will return to normal within 6
months after surgery.
C. The client will use a cane for assistance with ambulation for
2 to 6 weeks after surgery.
D. The client will verbalize understanding of instructions to
avoid lifting for 2 to 6 weeks
175. After the nurse has taught the parents of a 5-year-old boy
who has leukemia how to talk with their child about death and dying,
which of the following would indicate that the parents have ageappropriate expectations about their child's reaction to his
impending death?
A. "He is too young to understand what is happening to him. "
B. "He might think he can cause his death because he has
misbehaved. "
C. "He will accept his death as caused by his disease. "
D. "He will understand how much his siblings will miss him. "
176. A client exhibits confusion and severe memory loss. At 11:30
AM, he tells the nurse that he is going to work and proceeds to walk
toward the door. Which of the following actions should be the nurse
take?
A. Remind him that he retired from his job 10 years ago.
B. Tell him that she'll accompany him for a short walk outdoors.
C. Divert his attention toward the dining room where lunch is
being served.
D. Tell him that he does not have to go to work today.
177. The parents report that the child has a runny nose, fever,
cough, and is irritable and constantly rubbing his ears. Which
findings of the tympanic membrane would the nurse would expect to see?
A. Bulging and red.
B. Clear and inverted.
C. Pearly gray.
D. Scarred.
178. Cindy is a newborn who has undergone corrective surgery for
a tracheoesophageal fistula (TEF). When preparing for her discharge
plan, the nurse teaches the parents about the need for long-term
health care because Cindy would have a high probability of developing
which of the following?
A. Gastric ulcers.
B. Esophageal stricture.
C. Speech problems.
D. Recurrent mild diarrhea with dehydration.
179. Of the following signs and symptoms of bowel obstruction,
which is related primarily to small bowel obstruction rather than
large bowel obstruction?
A. Profuse vomiting.
B. Cramping abdominal pain.
C. Abdominal distention.
D. High-pitched bowel sounds above the obstruction.
180. Immediately after a spontaneous rupture of the membranes,
the nurse observes a loop of umbilical cord protruding from the
vagina. What should the nurse do first?
A. Administer oxygen.
B. Notify the physician.
C. Document the deceleration.
D. Elevate the hips on two pillows.
181. A client has a perforated nasal septum. The nurse correctly
judges the client to be a user of which of the following substances?
A. Heroin.
B. Cocaine.
C. LSD.
D. Marijuana.
182. The nurse teaches a client about the relationship between
body position and gastroesophageal reflux. Which of the following
statements by the client would indicate that he understands measures
to avoid problems with reflux while sleeping?
A. "I can elevate the head of the bed 4 to 6 inches. "
B. "I can elevate the foot of the bed 4 to 6 inches. "
C. "I can sleep on my back without a pillow under my head. "
D. "I can sleep on my stomach with my head turned to the left. "
183. To prevent external rotation of the client's hips while he
is lying on his back, it would be best for the nurse to place
A. firm pillows under the length of his legs.
B. sandbags alongside his legs from knees to ankles.
C. troehanter rolls alongside his legs from ilium to midthigh.
D. a footboard that supports his feet in the normal anatomic
position.
184. The nurse is teaching a student nurse in a mental health
unit about how to establish a therapeutic nurse-client relationship.
Which of the following is of prior importance in the therapeutic
nurse-client relationship?
A. Nurse's self-awareness and understanding.
B. Nurse's sound knowledge of psychiatric nursing.
C. Nurse's sincere desire to help others.
D. Nurse's acceptance of others.
185. The client complains a continuous bladder irrigation after a
transurethral resection. Which of the following is the major goal of
nursing interventions related to the irrigation?
A. Recognize signs of prostate cancer.
B. Perform activities of daily living.
C. Maintain catheter patency.
D. Reduce incisional bleeding.
186. On initial assessment of a 7-year-old with rheumatic fever,
which of the following would require the nurse to contact the
physician immediately?
A. Heart rate of 150 bpm.
B. Twitching in the extremities.
C. Red rash on the trunk.
D. Swollen and painful knee joints.
187. A client receiving haloperidol (Haldol) complains of a stiff
jaw and difficulty swallowing. Which of the following should be the
nurse's first action?
A. Reassure the client and administer as-needed lorazepam (Ativan)
IM.
B. Administer as-needed dose of benztropine (Cogentin) by mouth
as ordered.
C. Administer as-needed dose of benztropine (Cogentin) IM as
ordered.
D. Administer as-needed dose of haloperidol (Haldol) by mouth.
188. Which of the following is not a contributory factor to
thermoregulation in the preterm neonate?
A. Immature central nervous system (CNS).
B. Large skin surface area.
C. Lack of subcutaneous (S. C. ) and brown fat.
D. Tendency toward capillary fragility.
189. The nurse in the substance abuse unit is trying to encourage
a client to attend Alcoholics Anonymous (AA) meetings. When the
client asks the nurse what he must do to become a member, which of
the following the best response from the nurse?
A. "Admit you're powerless over alcohol and that you need help. "
B. "You must bring along a friend who will support you. "
C. "You must first stop drinking. "
D. "Your physician must refer you to this program. "
190. When developing the postoperative plan of care for a child
who is scheduled to have a tympanostomy tubes inserted into the right
ear, which of the following interventions would the nurse identify to
accomplish the goal of facilitating drainage?
A. Applying warm compresses to the right ear.
B. Applying a gauze dressing to the left ear.
C. Applying an ice pack to the left ear.
D. Positioning the child to lie on the right side.
191. While caring for pregnant adolescents, the nurse should
develop a plan of care that incorporates which health concern?
A. Age of menarche.
B. Family and home life.
C. Healthy eating habits.
D. Level of emotional maturity.
192. Which of the following nursing measures would the nurse
institute to help reduce eyelid edema in a child with nephrotic
syndrome?
A. Instill eye drops every 8 hours.
B. Limit the child's television watching.
C. Apply cool compresses to the child's eyes.
D. Elevate the head of the child's bed.
193. Which of the following findings would indicate that the
goals for total parenteral nutrition (TPN) are being achieved for the
client?
A. Serum glucose level of 96.
B. Weight gain of 0.5 pounds/day.
C. Urine negative for glucose.
D. Serum potassium level of 4 mEq/L.
194. An 20-month-old with acquired immunodeficiency syndrome
(AIDS) is seen in the clinic for health maintenance. Which of the
following vaccines would the nurse anticipate administering to this
toddler?
A. Diphtheria-tetanus-acellular pertussis.
B. Varicella.
C. Measles, mumps, and rubella.
D. Hemophilus influenza.
195. Mr. Smith is admitted to the psychiatric hospital for
evaluation after numerous incidents of threatening, angry outbursts
and two episodes of hitting a coworker at the grocery store where he
works. He is very anxious and tells the nurse, "I didn't mean to hit
him. He made me so mad that I just couldn't help it. I hope I don't
hit anyone here. " Which of the following is the nurse's best
response?
A. "It sounds like you were angry. When you feel angry here, talk
to the staff about it instead of hitting. "
B. "I'm sure you didn't mean to hit him and that it won't happen
here. "
C. "You'd better not hit anyone here, even if you do get mad. "
D. "Tell me more about what happened. "
196. The mother of a 4-year-old asks about dental care for her
child. "I help brush her teeth every day and her teeth look healthy.
When should I take her to see a dentist?" Which of the following
responses would be most appropriate?
A. "Because you help brush her teeth, there's no need to see a
dentist right now. "
B. "Ideally she should have seen a dentist already, but it's
still not too late. "
C. "Your child doesn't need to see the dentist until she starts
school. "
D. "A dental checkup is a good idea even if no problems are
noticeable. "
197. A client with heart failure asks the nurse about the reason
for taking enalapril maleate. The nurse would explain that the
medication is prescribed for which of the following reason?
A. Lower the blood pressure by increasing peripheral
vasoconstriction.
B. Lower the heart rate by slowing the conduetion system.
C. Block the conversion of angiotensin Ⅰ to angiotensin Ⅱ.
D. Increase myocardial contractility, thereby improving cardiac
output.
198. A mother asks the nurse about how to manage her child's
morning hyperglycemia. Which of the following would be most
appropriate response by the nurse?
A. Question the mother if her child has been avoiding sweets.
B. Tell the mother that this is normal and to continue with the
ordered doses.
C. Ask the mother what her child's blood glucose levels have been
for the last few days.
D. Inform the mother that this is unusual and the child needs to
be seen in the emergency room now.
199. A woman tells the nurse that her 6-year-old daughter has
severe nosebleeds. Which of the following instructions should the
nurse give this woman to manage nosebleeds?
A. Help the child assume a comfortable position with her head
tilted backward.
B. Tilt the child's head backward and place firm pressure on the
nose.
C. Help the child lie on her stomach and collect the blood on a
clean towel.
D. Place the child in a sitting position with her neck bent
forward and apply firm pressure on the nasal septum.
200. A hospitalized client craves a drink while withdrawing from
alcohol. Which of the following measures is the best way to help the
client resist the urge to drink?
A. A routine search of visitors.
B. A locked-door policy.
C. One-to-one supervision by the staff.
D. Support from other alcoholic clients.
201. The nursing care plan for a client after gynecologic surgery
includes nursing orders intended to help reduce the risk of
thrombophlebitis. Which is not appropriate among the following
nursing interventions?
A. Ambulate the client.
B. Massage the client's legs.
C. Have the client wear elasticized stockings.
D. Have the client perform range-of-motion exercises in bed.
202. The nurse is interviewing a client who is currently under
the influence of a controlled substance and shows signs of becoming
agitated. Which measure should the nurse take first when caring for
this client?
A. Be aware of hospital security.
B. Communicate a scolding attitude to intimidate the client.
C. Use confrontation.
D. Express disgust with the client's behavior.
203. After staying several hours with her 10-year-old daughter
who is admitted to the hospital with an asthmatic attack, the mother
leaves to attend to her other children. The child exhibits continued
signs and symptoms of respiratory distress. Which of the following
findings would lead the nurse to make a nursing diagnosis of Anxiety
related to respiratory distress?
A. Complaints of an inability to get comfortable.
B. Frequently requests for someone to stay in the room.
C. Inability to remember his exact address.
D. Verbalization of a feeling of tightness in his chest.
204. When caring for a client during the second stage of labor,
which action would be least appropriate?
A. Assisting the client with pushing.
B. Ensuring the client's legs are positioned appropriately.
C. Allowing the client clear liquids.
D. Monitoring the fetal heart rate.
205. The immobile adolescent with a recent fractured femur
suddenly complains chest pain, dyspnea, diaphoresis, and tachycardia.
Which of the following would the nurse suspect?
A. Atelectasis.
B. Pneumonia.
C. Pulmonary edema.
D. Pulmonary emboli.
206. A 28-year-old client delivered a full-term male neonate one
hour ago. Which finding should the nurse expect when palpating the
client's fundus?
A. Soft, at the level of the umbilicus.
B. Firm, 2 cm below the umbilicus.
C. Firm, at the level of the umbilicus.
D. Boggy, midway between the umbilicus and symphysis pubis.
207. Sedative-hypnotic drugs are used to treat which of the
following problems?
A. Hallucinations and delusions.
B. Anxiety and insomnia.
C. Obsessive-compulsive disorder (OCD).
D. Attention deficit hyperactivity disorder (ADHD).
208. After a gastrectomy, the client will have a nasogastric tube
in place for several days postoperatively. The nurse explains to the
client that the nasogastric tube is for which of the following
reasons?
A. Prevent excessive pressure on suture lines.
B. Prevent the development of ascites.
C. Provide enteral feedings in the immediate postoperative period.
D. Enable administration of antacids to promote healing of the
anastomosis.
209. The nurse is caring for a 35-year-old multipara who
delivered a full-term infant by cesarean delivery because of a breech
presentation. The nurse recognizes that which of the following events
would be the most important contribution to preventing
thromboembolism?
A. Increasing oral fluid intake.
B. Providing oxygen therapy.
C. Encouraging frequent ambulation.
D. Administering pain medications as needed.
210. The nurse observes that a depressed client has bathed, is
wearing a clean blouse and slacks, and has combed her hair. Which
statement by the nurse would be most helpful for the client?
A. "I like your blouse and slacks. "
B. "You look good today. "
C. "I'm glad you're feeling better today. "
D. "I'm glad you combed your hair today. "
211. A 30-year-old primigravida tells the nurse that her
hemorrhoids have become itchy and painful. The nurse instructs the
client about relief measures. From which of the following statements
by the client would the nurse suspect that the client needs further
instructions?
A. "I should sit in a warm sitz bath daily. "
B. "I can use a topical ointment for relief. "
C. "I should apply an ice pack at night. "
D. "I should decrease my fluid intake. "
212. A client takes prednisone for an acute exacerbation of her
rheumatoid arthritis. The nurse teaches the client about how to take
this drug. Which of the following statements by the client indicates
that the education is effective?
A. "I can stop taking the prednisone as soon as my joints feel
better. "
B. "It is important for me to increase my sodium intake while I
am taking this medication. "
C. "I should not be concerned if I lose a little weight while I
take the prednisone. "
D. "It is best if I take this medication with some food. "
213. The parents of a child being discharged from the day surgery
center after insertion of tympanostomy tubes ask the nurse. "What
will happen to the tubes in my child's ears?" Which of the following
would be the nurse's best response?
A. "The tubes usually dissolve on their own in about 1 year. "
B. "The tubes must remain permanently in place. "
C. "You'll probably see them fall out in about 6 months. "
D. "Call for an appointment to have them removed in about 6
months. "
214. A multigravida at 36 weeks' gestation visits the emergency
department because her boyfriend has beaten her severely. What should
the nurse do first?
A. Contact the authorities.
B. Ensure the client's safety.
C. Identify a support person.
D. Photograph the client's injuries.
215. A parent group is discussing different types of punishment.
The parents ask the nurse to discuss corporeal punishment. What would
be the nurse's response?
A. "Corporeal punishment does not physically harm the child. "
B. "Corporeal punishment can result in children becoming
accustomed to spanking. "
C. "Corporeal punishment can be beneficial in teaching children
what they should do. "
D. "Corporeal punishment reinforces the idea that violence is not
acceptable. "
216. The infant's skin is inelastic and the upper abdomen is
distended. To palpate the olive like mass most easily, the nurse
palpates the epigastrium just to the right of the umbilicus at which
of the following times?
A. Just before the infant vomits.
B. While the infant is eating.
C. When infant is lying on the left side.
D. When the stomach is empty.
217. A community nurse visits a family living in a rural area
where the drinking water is not fluoridated. Which of the following
would the nurse suggest to the family as the most appropriate means
for obtaining a significant amount of fluoride?
A. Tea.
B. Yogurt.
C. Citrus juices.
D. Natural cheeses.
218. The nurse is caring for a client hospitalized on numerous
occasions for complaints of chest pain and fainting spells, which she
attributes to her deteriorating heart condition. No relatives or
friends report ever actually seeing a fainting spell. After
undergoing an extensive cardiac, pulmonary, GI, and neurologic workup,
she's told that all test results are completely negative. The client
remains persistent in her belief that she has a serious illness. What
diagnosis is appropriate for this client?
A. Exhibitionism.
B. Somatoform disorder.
C. Degenerative dementia.
D. Echolalia.
219. A client calls the physician's office 2 days after a
herniorrhaphy to report that his scrotum is swollen and painful.
Which of the following instruction by the nurse could promote comfort
for the client?
A. Apply a snug binder on his abdomen.
B. Have him wear a truss to support the scrotum.
C. Have him lie on his side and place a pillow between his legs.
D. Elevate the scrotum and place ice bags on the area
intermittently.
220. A primigravida at 34 weeks' gestation is diagnosed with
hydramnios. After delivery of the neonate, a priority for the nurse
is to assess the neonate for which problem?
A. Kidney disorders.
B. Cardiac defects.
C. Diabetes mellitus.
D. Esophageal atresia.
221. The nurse teaches the parents of a child being treated with
antibiotics for an ear infection for a follow-up visit after the
child completes the course of therapy. Which of the following
statements by the parents indicates that they understand the reason
for the follow-up visit?
A. "Her hearing needs to be checked to see if the infection has
done any damage. "
B. "The doctor wants to make certain she has taken all the
antibiotics. "
C. "We need to make sure that her ear infection has completely
cleared. "
D. "She needs to get another prescription for second course of
antibiotics. "
222. A 34-year-old client is 34 weeks pregnant and is
experiencing bleeding caused by placenta previa. The fetal heart
sounds are normal and the client isn't in labor. Which of the
following nursing interventions should be of priority?
A. Monitor the amount of vaginal blood loss.
B. Allow the client to ambulate with assistance.
C. Perform a vaginal examination to cheek for cervical dilation.
D. Notify the physician for a fetal heart rate of 130
beats/minute.
223. A client is admitted to the psychiatric unit with a
diagnosis of anorexia nervosa. Although she is 5'7" and weighs only
100 lb, she keeps on telling the nurse about how fat she is. What
should the nurse do first?
A. Discuss cultural stereotypes regarding thinness and
attractiveness.
B. Explore the reasons why the client doesn't eat.
C. Teach the client about nutrition, calories, and a balanced
diet.
D. Establish a trusting relationship with the client.
224. The neonate's big toe dorsiflexes and the other toes fan
when the nurse gently strokes the sole of the foot. The nurse should
interpret this positive finding as which of the following?
A. Stepping reflex.
B. Plantar grasp.
C. Galant reflex.
D. Babinski sign.
225. A patient who is admitted for treatment of an eating
disorder displays controlling behaviors, takes responsibility for
others' actions, and has difficulty identifying feelings. These
manifestations suggest
A. dependency.
B. manipulation.
C. learned helplessness.
D. codependency.
226. Which of the following situations is more likely to
predispose a client to postpartum hemorrhage?
A. Birth of a 7 lb (3,175g) infant.
B. Prolonged first stage of labor.
C. Pregnancy-induced hypertension (PIH).
D. Birth of twins.
227. The second morning after surgery for a below-the-knee
amputation of the left leg, the client says, "This sounds weird, but
I feel pain on my left feet. " The nurse knows the client is
experiencing a
A. denial reaction.
B. hallucination.
C. phantom-limb sensation.
D. body image disturbance.
228. A client who was found huddled in her apartment by the
police is admitted to the clinic. The client stares toward one corner
of the room and seems to be responding to something not visible to
others. She appears hyperalert and scared. Which of the following
conclusion by the nurse is most appropriate according to the
situation?
A. Nothing is wrong because the client isn't a threat to society.
B. The client is malingering.
C. The client may be hallucinating.
D. The client is suicidal.
229. Which of the following is the most important aspect of
nursing care in the postpartum period?
A. Supporting the mother's ability to successfully feed and care
for her neonate.
B. Providing group discussions on infant care.
C. Monitoring the normal progression of lochia.
D. Involving the family in the teaching.
230. By age 7 months, an infant most likely will develop which of
the following motor skill?
A. Walk with one hand held.
B. Eat successfully with a spoon.
C. Stand while holding onto furniture.
D. Sit alone using the hands for support.
231. The nurse is teaching a client who is 28 weeks pregnant and
has gestational diabetes how to control her blood glucose levels.
Diet therapy alone has been unsuccessful in controlling this client's
blood glucose levels, so she has started insulin therapy. Which of
the following statements indicates the client has adequate knowledge?
A. "I won't use insulin if I'm sick. "
B. "I need to use insulin each day. "
C. "If I give myself an insulin injection, I don't need to watch
what I eat.
D. "I'll monitor my blood glucose levels twice a week. "
232. A client with a history of alcoholism returns to the
hospital 3 hours later than he supposed to be. His breath smells of
alcohol and his gait is unsteady. Which of the following would be the
best response by the nurse?
A. "I'm disappointed that you weren't responsible with your day
pass. "
B. "Please go to bed now. We'll talk in the morning. "
C. "Why are you 3 hours late?"
D. "How much did you drink tonight? Drinking is against the rules.
"
233. The nurse is caring for a client with acute osteomyelitis in
the right tibia. Which of the following measures is most appropriate
when repositioning the client's leg?
A. Hold the leg by the ankle when repositioning to avoid touching
the tibia.
B. Support the leg above and below the affected area when
positioning.
C. Have the client move the leg by himself to decrease pain.
D. Apply warm moist compresses to the leg before repositioning.
234. Which of the following signs or symptoms would be of least
importance when the nurse evaluates the client for postoperative
peripheral nerve damage?
A. Pain.
B. Bleeding.
C. Altered sensation.
D. Pulselessness.
235. Which pregnancy-related physiologic change would place the
client with a history of cardiac disease at the greatest risk for
developing severe cardiac problems?
A. Decreased heart rate.
B. Decreased cardiac output.
C. Increased plasma volume.
D. Increased blood pressure.
236. The nurse is teaching a new mental health aide. For which of
the following clients is setting limits most important?
A. A depressed client.
B. A manic client.
C. A suicidal client.
D. An anxious client.
237. After determining that a pregnant client is Rh-negative, the
physician orders an indirect Coombs'test. What's the purpose of
performing this test on a pregnant client?
A. To determine the fetal blood Rh factor.
B. To determine the maternal blood Rh factor.
C. To detect maternal antibodies against fetal Rh-positive factor.
D. To detect maternal antibodies against fetal Rh-negative factor.
238. Which of the following is an appropriate health promotion
activity to reduce the incidence of osteoporosis?
A. Teaching women to maintain adequate calcium intake.
B. Teaching women how to administer pain medication safely.
C. Avoiding estrogen replacement therapy when postmenopausal.
D. Teaching women to increase caffeine intake as a preventive
measure.
239. When magnesium sulfate is administered to a client in labor,
its action occurs at which of the following sites?
A. Neural-muscular junctions.
B. Distal renal tubules.
C. Central nervous system (CNS).
D. Myocardial fibers.
240. Which of the following measures would the nurse take into
consider to help minimize joint pain in a child with rheumatic fever?
A. Massaging the affected joints.
B. Applying ice to the affected joints.
C. Limiting movement of the affected joints.
D. Encouraging progressive weight bearing.
241. When caring for a client who has had a cesarean birth, which
of the following nursing interventions is least appropriate?
A. Removing the initial dressing for incision inspection.
B. Monitoring pain status and providing necessary relief.
C. Supporting self-esteem concerns about delivery.
D. Assisting with parental neonate bonding.
242. Which abnormal laboratory value is most indicative of
aplastic anemia?
A. A decreased hemoglobin.
B. An elevated white blood cell count.
C. An elevated red blood cell count.
D. A decreased erythrocyte sedimentation rate.
243. A child with leukemia presents with peteehiae; gums, lips,
and nose that bleed easily; and bruising on various parts of her body.
Which of the following laboratory test results would the nurse
correlate with these findings?
A. Platelet count of 80×103/mm3.
B. Serum calcium level of 5 mg/dL.
C. Fibrinogen level of 75 mg/dL.
D. Partial thromboplastin time (PTT) of 38 seconds.
244. A 15-year-old girl with anorexia refuses to eat in a mental
health unit. Which of the following statements is the best response
from the nurse?
A. "Why do you think you're fat? You're underweight. Here--look
in the mirror. "
B. "You really look terrible at this weight. I hope you'll eat. "
C. "You don't have to eat. It's your choice. "
D. "I hope you'll eat your food by mouth. Tube feedings and IV
lines can be uncomfortable. "
245. A mother brings her 2-year-old adopted Korean child to the
clinic for an initial checkup. The child has been living with the
adopted family for several weeks. The nurse notes an irregular area
of deep blue pigment on the child's buttocks extending into the
sacral area. What should the nurse do?
A. Ask the mother in private how the bruise occurred.
B. Notify social services of a case of possible child abuse.
C. Question the mother about the family's discipline style.
D. Do nothing concerning this finding.
246. If none of the following bed positions is contraindicated,
which position would be preferred for the client with hypovolemic
shock?
A. Supine.
B. Semi-Fowler's.
C. Trendelenburg's.
D. Supine with the legs elevated 15 degrees.
247. Which of the following findings in a client's history would
be most likely to predispose her to renal calculi?
A. The client takes large doses of vitamin E.
B. The client drinks one to two glasses of fluid daily.
C. The client had a urinary tract infection within the last 6
months.
D. The client eats a diet that meets the daily requirements for
calcium.
248. Assessment of a client in active labor reveals meconiumstained amniotic fluid and fetal heart sounds in the upper right
quadrant. Which of the following is the most likely cause of this
situation?
A. Breech position.
B. Late decelerations.
C. Entrance into the second stage of labor.
D. Multiple gestation.
249. A client who recently developed paralysis of the arms is
diagnosed with conversion disorder after tests fail to uncover a
physical cause for the paralysis. When preparing the plan of care for
the client, which of the following interventions should be included
in the plan?
A. Teaching the client how to use nonpharmacologic pain-control
methods.
B. Exercising the client's arms regularly.
C. Insisting that the client eat without assistance.
D. Working with the client rather than the family.
250. Which of the following functions would the nurse expect to
be unrelated to the placenta?
A. Production of estrogen and progesterone.
B. Detoxification of some drugs and chemicals.
C. Exchange site for food, gases, and waste.
D. Production of maternal antibodies.
251. To assess the client's dorsalis pedis pulse, the nurse
should palpate the
A. medial surface of the ankle.
B. lateral surface of the ankle.
C. ventral aspect of the top of the foot.
D. medial aspect of the dorsum of the foot.
252. The nurse is assessing an elderly client for dementia. Which
of the following is a primary symptom of dementia?
A. Neurosis.
B. Loss of impulse control.
C. Psychosis.
D. Memory loss.
253. During the first 48 to 72 hours of fluid resuscitation
therapy after a major burn injury, the intravenous infusion rate will
be adjusted by evaluating which of the following observation?
A. Daily body weight.
B. Hourly urine output.
C. Hourly urine specific gravity.
D. Hourly body temperature.
254. Which assessment would the nurse perform to validate that
the membranes are ruptured?
A. Observe for a pink, mucus vaginal discharge.
B. Test the leaking fluid with nitrazine paper.
C. Assess the client's temperature, pulse, and blood pressure.
D. Send a urine specimen from the client to be cultured.
255. The clinic nurse is instructing a group of parents about
emergency treatment for accidental poisoning and injury. Which of the
following statements by one of the mothers indicates that she needs
further instruction?
A. "I should flush my child's eye with room temperature tap water
for 15 to 20 minutes if a caustic material gets into it. "
B. "I should save the emesis if my child vomits. "
C. "I should call the poison control center if there are any
symptoms. "
D. "I should give 2 to 5 teaspoons of clear fluids after
administering ipecac. "
256. The nurse is caring a client in an acute care mental health
program. The client refuses his morning dose of an oral antipsychotic
medication and believes he's being poisoned. What should the nurse do?
A. Crushing the medication and putting it in his food.
B. Consulting with the physician about a plan of care.
C. Administering the medication by injection.
D. Omitting the dose and trying again the next day.
257. A nurse in a prenatal clinic is assessing a 28-year-old
woman who is 24 weeks pregnant. Which of the following findings would
lead this nurse to suspect that the client has mild preeclampsia?
A. Hypertension, edema, proteinuria.
B. Glycosuria, hypertension, seizures.
C. Hematuria, blurry vision, reduced urine output.
D. Burning on urination, hypotension, abdominal pain.
258. Which of the following signs and symptoms would be an early
indication that the client's serum potassium level is below normal?
A. Diarrhea.
B. Tingling in the fingers.
C. Sticky mucous membranes.
D. Muscle weakness in the legs.
259. The nurse is teaching the client how to use a cane. Which of
the following statements is most inaccurate?
A. The client should hold the cane on the involved side.
B. The client should hold the cane close to his body.
C. The stride length and the timing of each step should be equal.
D. The nurse should stand behind the client to prevent falls.
Multiple-correct answer item
Directions: The question below is followed by six choices
numbered 260-265. If a choice is correct, mark A in the space
provided. If a choice is not correct, mark B. Blacken one circle on
your answer sheet for each number.
The nurse is explaining the Bill of Rights for psychiatric
patients to a client who has voluntarily sought admission to an
inpatient psychiatric facility. Which of the following rights should
the nurse include in the discussion?
260. (Select A or B. ) Right to select health care team members.
261. (Select A or B. ) Right to refuse treatment.
262. (Select A or B. ) Right to a written treatment plan.
263. (Select A or B. ) Right to obtain disability.
264. (Select A or B. ) Right to confidentiality.
265. (Select A or B. ) Right to personal mail.
Answers and Rationales
1. B When obtaining a urine specimen from an indwelling catheter,
a sterile syringe and needle should be used to access the catheter
port that allows removal of urine from the closed system. This
technique preserves sterility of the system and the urine specimen.
2. A Successful breast-feeding depends on the client's
willingness and motivation to breast-feed. Women who have a strong
desire to breast-feed tend to continue breast-feeding longer and are
often more tolerant of the discomforts of breast-feeding and more
accepting of the need for frequent feedings.
3. B Heavier body weights and some body fat stress bones and
promote their maintenance. Osteoporosis is most often associated with
being underweight. Women who are thin throughout their lives are
twice as likely to develop hip fractures.
4. B Convert grams to milligrams. 0.2g=200mg. 200mg/x
tablets=100mg/tablet, x= 2 tablets.
5. B Clients should be instructed to keep nitroglycerin in a
tightly closed, dark container and to replenish it frequently because
it deteriorates rather rapidly.
6. B The Bill of Rights for Psychiatric Clients includes the
right for clients to access their medical records unless doing so
would be detrimental to their health. To determine if information
might be detrimental to the client, the primary care provider should
be informed of the client's request. The client doesn't need an
attorney to view his chart. He also doesn't need to wait until after
discharge to view it.
7. C The T wave represents ventricular muscle repolarization as
shown in the accompanying figure.
8. B Valsalva's maneuver, or bearing down against a closed
glottis, can best be prevented by instructing the client to exhale
during activities such as having a bowel movement or moving around in
bed.
9. B Use of an antihistamine and calamine lotion are recommended
to help decrease the itching.
10. C The client should be taught how to prevent the spread of
hepatitis B to others.
11. C The nurse should encourage the mother to breast-feed the
infant. Neonatal sucking will induce the release of natural oxytocin
which will help contract the uterus and control uterine bleeding.
12. C The IV flow rate is determined by the rate of infusion and
the number of drops/mL of the fluid being administered. Flow Rate =
(Volume×Calibration) /Time (minutes). In this case, the
Rate=15gtts/mL×1000mL/360min=42gtts/min.
13. C A slow, dark-red trickle of blood after a delivery is a
symptom of postpartum hemorrhage; it should be reported and treated
immediately. If the cause is due to uterine atony, the nurse should
gently massage the fundus, call for assistance, and prepare to
administer oxytocic drugs. If the cause is due to massive blood clots
in the uterus, the client may need to have the clots manually
extracted.
14. C The most common cause of death in children with leukemia is
infection. The child should be monitored for any signs of infection,
including temperature.
15. A Because peristalsis has not been reestablished, this amount
of gastric drainage would be expected. The green-brown color would
also be expected. The appropriate nursing action is to chart the
amount and color of output and continue monitoring the client.
16. D Constant patterns of anxiety that affect the client for
more than 6 months and interfere with normal activities are
characteristic of generalized anxiety disorder. Frequently,
pharmaceutical therapy with benzodiazepines can help. Clients having
regular obsessions are probably suffering from obsessive-compulsive
disorder. Nightmares and flashbacks are typical symptoms of
posttraumatic stress disorder.
17. C Carbamazepine (Tegretol) can cause potentially fatal
hematological disorders. To detect pancytopenia, it is important that
the client have weekly CBC checks during the first few months of
therapy. The client should be told to report any indications of bone
marrow depression such as bleeding, easy bruising, sore throat, fever,
or mouth ulcers.
18. A As with any surgery or invasive procedure, a priority goal
at this time would be to prevent infection at the operative site.
19. C An unconscious client is best positioned in a lateral or
semiprone position because these positions allow the jaw and tongue
to fall forward, facilitate drainage of secretions, and prevent
aspiration.
20. C Amniotic fluid is normally clear. Yellowish fluid indicates
Rh sensitization. The yellowish color is related to fetal anemia and
bilirubin in the amniotic fluid.
21. B 150mg/x mL=200mg/mL; x=0.75mL.
22. A Tobacco is a gastrointestinal stimulant and should be
avoided by clients with ulcerative colitis.
23. A Autonomic dysreflexia is a medical emergency. The rising
blood pressure can cause cerebrovascular accident, blindness, or even
death. Placing the client in Fowler's position lowers blood pressure.
24. C The nurse records the total amount of solution used to
irrigate a gastric tube as intake and the total amount of return in
the drainage container as output.
25. C Clomiphene citrate (Clomid) is a fertility drug that
induces ovulation in women desiring pregnancy. One of the drug's most
common side effects is multiple gestation (twins, triplets, or more).
26. D Common laboratory findings in the client who has suffered a
MI include elevated CPK level. CPK is also released during muscle
injury and brain injury. The CPK isoenzyme CPK-MB elevates only in
response to myocardial damage.
27. A Confining a voluntary client against his will may be
considered false imprisonment. Slander is oral defamation of
character. The nurse hasn't given out any information about the
client, so confidentiality hasn't been violated.
28. A Clients with diabetes should be taught to visually inspect
their feet on a daily basis.
29. B Allowing a child to make some decisions about the foods he
eats and not insisting that he finish meals can avoid power struggles.
Refusing to finish meals and to eat certain foods is normal behavior
for a preschool-aged child. It is important to avoid tension at
mealtime and to avoid confrontation about food.
30. A It is most therapeutic to let the client know of the
staff's continued concern and to ask her what might be useful to her.
31. D The client should be instructed to smell the cast to note
foul odors, a sign of potential infection.
32. B Activated partial thromboplastin time (APTT) is used to
measure the clotting status when the client is receiving heparin.
33. B A will is an important legal document. It is best to have
one prepared with the help of an attorney.
34. A A segment of the terminal ileus is used to form the conduit
that collects urine from the ureters. Hence, the client with an ileal
conduit can be expected to excrete urine that contains mucus from
this intestinal mucous membrane.
35. A Because the birth is imminent and no additional help is
available, the nurse should immediately prepare a clean area for
delivery. Most agency labor units have emergency delivery packs with
sterile towels, a bulb syringe, and a cord clamp.
36. B Accurate determination of urine output is a crucial factor
in the care of a burn victim. The benefits of using an indwelling
catheter to measure urine output to the nearest milliliter outweigh
the risk of infection and other problems associated with use.
37. C Bile is erosive and extremely irritating to the skin.
Therefore, it is essential that skin around the T tube be kept clean
and dry.
38. C Small amounts of sterile water are given to a neonate first
to ascertain if the esophagus is patent and to prevent the aspiration
of formula if it is not.
39. A Sharing needles is associated with increased incidence of
blood-borne diseases such as hepatitis.
40. D All symptoms define chronic low self-esteem. There isn't
enough information to determine delayed growth and development. The
question doesn't describe the client's ability to perform in her
roles. Posttrauma syndrome occurs after experiencing a traumatic
event and doesn't coincide with the data in the question.
41. C An appropriate expected outcome for a client with
ulcerative colitis is maintaining an ideal body weight.
42. C Gentle pressure should be applied after the injection, but
the area must not be massaged.
43. D Gastrointestinal ulceration, also known as Curling's ulcer,
occurs in about half of clients suffering from severe burns. The
incidence of ulceration appears proportional to the extent of the
burns and is believed to be due to hypersecretion of gastric acid and
compromised gastrointestinal perfusion.
44. B A roast beef sandwich, milkshake, and cottage cheese would
provide the burn victim with the extra protein and calories needed
for healing.
45. A The serum electrolyte values in an infant with persistent
vomiting reflect hypokalemia (K+ level of 3.2mEq/L), hypochloremia
+
(Cl level of 92mEq/L), and hyponatremia (Na level of 120mEq/L).
Chloride and sodium function together to maintain fluid and
electrolyte balance. With vomiting, sodium chloride and water are
lost in gastric fluid. As dehydration occurs, potassium moves into
the extracellular fluid.
46. C When dressing, the client should put clothing on the
affected side first.
47. D 1kg=2.2 pounds; therefore, 3.2×2.2=7.04 pounds.
48. A The Apgar rating system evaluates the neonate on the basis
of heart rate, respiratory effort, muscle tone, reflex irritability,
and color at 1- and 5-minute intervals after birth. The neonate
receives a score between 0 and 10. The higher the score, the better
the neonate's condition. An Apgar score of 9 out of a possible score
of 10 means that the neonate is in good condition.
49. C After a mastectomy, every effort should be made to avoid
cuts, bruises, and burns on the affected arm because normal
circulation has been impaired. Working in a rose or cactus garden is
a risk because of the danger of skin pricks. The client should be
advised to wear protective clothing to prevent cuts, bruises, and
burns.
50. A Ineffective Cardiac Tissue Perfusion related to myocardial
damage and inadequate cardiac output is a major problem immediately
after a heart attack. Therapy is directed toward improving cardiac
output and decreasing myocardial workload.
51. B The nurse should begin with the simplest interventions,
such as pillows or snacks, before interventions that require greater
skill, such as relaxation techniques. At some point, the nurse should
do a thorough sleep assessment, especially if common-sense
interventions fail.
52. A Oral hygiene is an important aspect of self-care for the
laryngectomy client, who is less able to detect mouth odor.
Additionally, the mouth harbors bacteria. Good mouth care reduces the
risk of infection.
53. B This client is experiencing early signs of preterm labor.
The nurse should plan to place the client on bed rest on her left
side which promotes uterine placental perfusion and increased oxygen
supply to the fetus.
54. C Orthostatic hypotension resulting in lightheadedness,
dizziness, and fainting is a common side effect of levodopa. Clients
should be taught to change positions slowly.
55. B Correct technique for instilling eye drops includes the
nurse bracing his or her hand on the client's forehead while
instilling the medication.
56. A During a sickle cell crisis, increasing the transport and
availability of oxygen to the body's tissues is paramount.
Administering a high volume of intravenous fluid and electrolytes to
help compensate for the acidosis resulting from hypoxemia associated
with sickle cell crisis is one way to accomplish this. Fluid
administration also helps overcome dehydration, a possible
predisposing factor common in clients with sickle cell crisis.
57. D Because of the irregularity of bowel sounds, the nurse
should listen for 5 minutes in each quadrant to confirm the absence
of bowel sounds.
58. D The basic element of assertive behavior includes the
ability to express your feelings and thoughts while respecting the
rights of others. Options A and B describe aggressive behavior, and
option C describes passive behavior.
59. C The proper suctioning technique is to insert the suction
catheter until resistance is met, withdraw the catheter 1 to 2 cm,
then begin applying intermittent suction while withdrawing the
catheter.
60. A Children need to know what behaviors are acceptable and
what behaviors are unacceptable. They feel more secure when
boundaries are clear and when policies concerning their behavior are
consistently enforced.
61. C A sudden change in urine output is typical of acute renal
failure. Most commonly, the initial change is greatly decreased urine
output. Later in the course of acute renal failure, the client may
have marked diuresis (nonoliguric failure).
62. B Regardless of the child's age, a child who reports abuse
must be believed because confiding this information is frightening
and takes courage. Establishing trust is essential.
63. B The client should not skip his dosages of pain medication
to prevent addiction. Clients with cancer pain do not become
psychologically dependent on the medication and should not fear
becoming addicted. The nurse should allow the client and family
members to verbalize their concerns about drug addiction.
64. C Providing the client with written and verbal instructions
will increase understanding of the medication regimen
65. A Chlorpropamide is an antidiabetic agent. Clients should be
observed for signs and symptoms of hypoglycemia. Other common side
effects include anorexia, nausea, vomiting and heartburn.
66. C It is not necessary for the client to call the health care
provider if she experiences contractions every hour for 6 hours, but
she should continue to monitor the contraction pattern to determine
if the contractions are increasing in frequency.
67. B With long- term use phenytoin can cause gingival
hyperplasia, so it is essential that the client understand how to
provide proper oral hygiene.
68. B The correct answer is waxy flexibility, which is defined as
retaining any position that the body has been placed in. Somatic
delusions involve a false belief about the functioning of the body.
Neologisms are invented meaningless words. Nihilistic delusions are
false ideas about self, others, or the world.
69. B A major goal of nursing care of the unconscious client with
a head injury is to establish and maintain an open airway. An
obstructed airway can lead to hypoxia and carbon dioxide retention
which will further increase intracranial pressure.
70. B Antipsychotic medications exert an effect on brain
neurotransmitters that lowers the seizure threshold and can,
therefore, increase the risk of seizure activity. Antipsychotics
don't affect insulin production or coagulation time. Heart failure
isn't an adverse effect of antipsychotic agents.
71. A During recovery, the client should be instructed to avoid
abrupt or jarring head movements. Activities such as shampooing or
brushing hair may be restricted.
72. C The child who has increasing respiratory difficulty after
being removed from an increased oxygen environment should be placed
back in the environment. The child's pulse rate will most likely be
increased.
73. D When pressure is applied to the skin, the area first
becomes blanched, or whitish. When pressure is relieved, the
circulation tends to carry excess blood to the area to make up for
the temporary decrease in blood supply. This effect, called reactive
hyperemia, causes the skin to redden. Such a reddened area is a
precursor of a pressure sore.
74. B Reducing stimuli helps to reduce hyperactivity during a
manic state. Group activities would provide too much stimulation.
Trying to assist the client with self-care could cause increased
agitation. When in a manic state, these clients can't express their
inner feelings in a productive, introspective manner. The focus of
treatment for a client in the manic state is behavior control.
75. B The client should be instructed to express milk from the
nipples either by hand or with a breast pump to stimulate milk flow
and relieve the engorgement. As soon as the areola is soft, the
client should begin to breast-feed. Frequent feedings with complete
emptying of the breasts should alleviate engorgement.
76. A With a cervical injury, the client has sympathetic fibers
that can be stimulated to fire reflexively. The firing is cut off
from brain control and is both reflexive and massive. It classically
produces pounding headache and dangerously elevated blood pressure,
"goose bumps," and profuse sweating.
77. D The most common symptom of pancreatitis is intense
abdominal pain in the mid-epigastric area or the left upper quadrant.
The pain may radiate to the back.
78. B Breast size is not important as long as there is glandular
tissue to secrete the milk, although various factors can influence
milk supply, such as suckling, emptying of the breasts, diet,
exercise, rest, level of contentment, and stress. The fat in breast
tissue plays no role in milk production.
79. B An appropriate expected outcome is for the client to
maintain nutrition either through oral or total parenteral feedings.
Oral and total parenteral nutrition may also be used concurrently.
80. B As antidepressants take effect, individuals suffering from
depression may begin to feel energetic enough to mobilize a suicide
plan. Option A is incorrect because Elavil is an antidepressant, not
an antipsychotic. Option C is incorrect because the client shouldn't
be discharged until the risk of suicide has diminished. Option D
indicates a response to the antidepressant, not a split personality.
81. B Predisposing factors for laryngeal cancer include chronic
irritants such as alcohol, tobacco, and exposure to noxious fumes.
About 75% of people who develop laryngeal cancer are smokers. The
combination of smoking and heavy alcohol intake is even more strongly
implicated as a causative agent in the laryngeal cancer.
82. C A child with gastroenteritis should start to receive soft
foods first after resting the bowel and rehydration. Cooked cereals,
vegetables, and meats are recommended.
83. B Terbutaline, a beta-2 selective adrenergic agonist, is used
to suppress labor by relaxing the pregnant uterus. In some cases, its
beta-2 selectivity is lost, causing cardiac overstimulation.
Generally, the drug is contraindicated for a client with a heart rate
greater than 130 beats/minute or any cardiac arrhythmias. Therefore,
the nurse would need to assess the client's heart rate.
84. A Vesicular breath sounds are normal breath sounds heard over
all lung fields except the main bronchi.
85. B If the wound opens and tissues are exposed (wound
evisceration), the nurse should cover the exposed tissues with
sterile dressings moistened with sterile normal saline solutions. The
nurse should also cover an eviscerated wound with sterile dressings
moistened with sterile normal saline solution. The physician should
be notified immediately when a wound dehisces or eviscerates.
86. B Liquid iron supplements should be diluted and taken through
a straw to help decrease the likelihood of staining the teeth.
87. D Infants grow rapidly. A cast adequate for a infant after
surgery may be outgrown in less than 1 month. The cast becomes too
tight, impairing circulation evidenced by toe swelling and coolness
to touch.
88. D Even with glasses, the client who has had cataract surgery
may have changes in depth perception. The client may need to relearn
to judge distances accurately to walk safely.
89. B Rotating staff members who work with a client with a
borderline personality disorder keeps the client from becoming
dependent on any one nurse and reduces the use of splitting and her
fear of abandonment. Firm rules and consistency among staff members
will help control the client's behavior. Ignoring splitting behaviors
can cause the client to increase the behavior by trying to get a
response from the staff. Unit rules must be consistently enforced and
followed by each nurse to help the client control behavior.
90. B In a threatened abortion, vaginal bleeding or spotting
occurs and abdominal cramping may occur. However, the cervix is not
dilated. Termination of the pregnancy may or may not be prevented.
91. C Frequent vomiting causes tenderness and swelling of the
parotid glands. The reduced metabolism that occurs with severe weight
loss produces bradycardia and cold extremities. Soft, downlike hair
(called lanugo) may cover the extremities, shoulders, and face of an
anorexic client.
92. D With a well-managed regimen, a client with myasthenia
gravis should be able to control symptoms, maintain a normal
lifestyle, and achieve a normal life expectancy.
93. A The most effective way to decrease discomfort is to
decrease local edema. Cold application, such as an ice compress or
ice bag, is effective.
94. C The best strategy for assessing a toddler is to have the
parent hold the toddler. Doing so is comforting to the toddler.
95. D The most appropriate intervention for the nurse is to
reinforce for the client that turning in bed will decrease the
likelihood for developing postoperative complications.
96. B The client's self-report of pain is the single most
reliable indicator of the amount of pain the client is experiencing.
Pain tolerance and the expression of pain can vary a great deal among
clients.
97. C Spastic cerebral palsy, the most common clinical type,
represents an upper motor neuron muscular impairment resulting in
increased muscle tone and stretch reflexes, persistent reflexes, and
a lack or delay of postural control.
98. B The caregiver must learn to distinguish obligations that
she must fulfill and limit those that aren't necessary. The caregiver
can tell the client when she leaves but she shouldn't expect that the
client will remember or won't become angry with her for leaving. The
caregiver shouldn't leave the client home alone for any length of
time because it may compromise the client's safety. The nurse can
provide support to the primary caregiver if she needs to ask other
family members for assistance.
99. C Hoarseness occurs early in the course of most laryngeal
cancers because the tumor prevents accurate approximation of the
vocal cords during phonation.
100. C Painless hematuria is the most common symptom associated
with bladder cancer. Bleeding from the lesions occurs fairly early in
the disease process, but bladder cancer is basically asymptomatic in
early stages.
101. B Behaviors of the anorectic client and the bulimic client
are commonly similar, especially because both implement rituals to
lose weight; however, the bulimic client tends to eat much more, due
to the binge episodes, and therefore can be near-normal weight. Not
all persons with the purge disorder have loss of enamel on teeth,
especially if the disorder has developed recently. Mallory-Weiss
tears are small tears in the esophageal mucosa caused by forceful
vomiting, but they aren't always present in bulimic clients.
102. B The most appropriate nursing diagnosis would be Risk for
injury because a toddler is typically engaged in exploring the
environment while becoming increasing mobile. Safety issues are an
important part of anticipatory guidance with parents of toddlers.
103. C Because pressure ulcers (decubitus ulcers) are caused by
pressure to the tissues, the most important measure in preventing
them is to relieve the pressure by repositioning the client every 1
to 2 hours.
104. C The primary aim of genetic counseling is to inform clients
of birth defect risks and the disorder to help the family understand
and adjust to the disorder.
105. D Broca's area, which controls expressive speech, is located
on the left side of the brain. Therefore, a client with a
cerebrovascular accident in this area is likely to exhibit expressive
or motor aphasia.
106. D After a laminectomy, the client's spine must be maintained
in proper alignment. The client who had a laminectomy may be turned
to his side by logrolling him in one unit while keeping his back
straight. It takes at least two people to perform this procedure
correctly.
107. B Bringing a child's favorite toys, security blanket, or
familiar objects from home can make the transition from home to
hospital less stressful. The child receives comfort and reassurance
from these items.
108. D Preventing an increase in intraocular pressure is the
primary concern after cataract removal.
109. C Although there is no treatment for flat feet, corrective
shoes are often prescribed to keep the legs in proper alignment.
110. C When using the ventrogluteal site, the nurse injects the
medication into the gluteus minimus muscle.
111. B After a total hip replacement, it is important to maintain
the hip in a state of abduction to prevent dislocation of the
prosthesis.
112. B In adolescents, depression typically manifests as truancy,
a change of friends, social withdrawal, and oppositional behavior. In
adults, it usually produces helplessness, hopelessness,
hypersomnolence, and anorexia. Drug use may lead to curfew breaking,
stealing, truancy, and oppositional behavior. It's normal for
adolescents to display hypersomnolence, an obsession with body image,
and valuing of peers' opinions.
113. A In the postoperative period, intake and output are
carefully monitored to prevent fluid overload that could lead to
increased intracranial pressure.
114. D Magnesium sulfate is a central nervous system depressant
used as an anticonvulsant for severe PIH. It may depress respirations
to a dangerously low and even life-threatening level. Therefore, the
nurse must assess the client's respiratory rate before administering
the drug. If the client's respiratory rate is below 12 to 14 breaths/
minute, the physician should be notified and the drug should be
withheld.
115. A Staying with the client and encouraging him to feed
himself will ensure adequate food intake. A client with Alzheimer's
disease can forget how to eat. Allowing privacy during meals, filling
out the menu, or helping the client to complete the menu doesn't
ensure adequate nutritional intake.
116. D Auscultating for clear breath sounds is the most accurate
way to evaluate the effectiveness of tracheobronchial suctioning.
Auscultation should also be done to determine whether or not the
client needs suctioning.
117. D Tinnitus (ringing in the ears) is a common symptom of
aspirin toxicity.
118. B Radiated skin is sensitive to the sun and cold
temperatures so it should be protected.
119. B The emergency treatment of both minor and major burns
includes stopping the burning process by immersing the burned area in
cool, but not cold, water. Thus, the mother should place the child in
a bathtub of cool water.
120. A Clients with diverticulitis are usually treated with
broad-spectrum antibiotics. Mild analgesics and anticholinergics may
also be administered.
121. A The primary physician in charge of a client's care must
write an order for the restraint within 1 hour. In an emergency, a
client who is a threat to himself or others may be restrained without
an order. Voluntary clients have the right to leave against medical
advice. A minor is treated the same as an adult regarding restraints.
122. A The posterior fontanel usually closes by age 2 to 3 months.
Therefore, the nurse should measure the head circumference to
determine if the child's head is larger than the established norms
because hydrocephalus can cause separation of the cranium sutures.
123. A Reducing barriers to mammography is the best way to
improve adherence with screening.
124. C A client with cholecystitis from cholelithiasis may
experience nausea, vomiting, abdominal discomfort, and other
gastrointestinal symptoms after eating high-fat foods. This is due to
decreased fat absorption related to lack of normal bile flow from the
gallbladder.
125. A Bottle supplements tend to cause a decrease in the breast
milk supply and demand for breast-feeding and should be avoided. Once
in a while if the client is tired, a bottle supplement may be given
to the neonate by another caregiver.
126. A Drinking alcohol can potentiate the sedating action of
tricyclic antidepressants. Dry mouth and blurred vision are normal
adverse effects of tricyclic antidepressants. Fluid and sodium intake
must be monitored during lithium (Lithobid) treatment. Safe use
during pregnancy and lactation hasn't been established.
127. B Maternal side effects of betamethasone (Celestone,
Soluspan) include increased risk of infection, initiation of
lactation, gastrointestinal bleeding, weight gain, edema, and
pulmonary edema when used concurrently with tocolytic agents.
128. B The irrigating solution should not be allowed to drop
directly on the tympanic membrane because this may cause discomfort
or damage.
129. C When mixing the enzyme (lipase, protease, amylase) powder
into food, the client should be careful not to inhale it as the
powder may trigger an asthma attack.
130. B It is not unusual for a client to be disoriented and
suffer short-term memory loss after a head injury. Clocks, singledate calendars, and other items to help orient the client should be
provided. Frequent reassurance and orientation by the nurse and
family members will help the client understand the reason for his
hospitalization and recognize that he is in a safe environment.
131. A Newborns should breastfed at least every 3 hours during
the day.
132. B Folic acid is very important to pregnancy.
133. C Because an insulin reaction can be life threatening and
may occur while the child is in school, the nurse and mother should
discuss hypoglycemia's seriousness and evaluation in the child with
the child's teachers. The teachers also need to know what measures to
take if an insulin reaction occurs.
134. C Breast sensitivity is the only sign assessed within the
first 4 weeks of pregnancy. Amenorrhea is expected during this time.
The other assessment findings don't occur until after the first 4
weeks of pregnancy.
135. C Ototoxicity is a serious side effect of gentamycin.
Tinnitus and dizziness are common; irreversible deafness can develop
if the onset of ototoxicity is not detected early. Gentamycin is also
known to be nephrotoxic and hepatoxic.
136. C In retinal detachment, the two layers of the retina
separate as a result of a small hole or tear, trauma, or degeneration.
Vitreous humor seeps into the tear and separates the retinal layers.
137. A The client's history of delinquency, running away from
home, vandalism, and dropping out of school are characteristic of
antisocial personality disorder. This maladaptive coping pattern is
manifested by a disregard for societal norms of behavior and an
inability to relate meaningfully to others. In borderline personality
disorder, the client exhibits mood instability, poor self-image,
identity disturbance, and labile affect. Obsessive-compulsive
personality disorder is characterized by a preoccupation with
impulses and thoughts that the client can't control, even though he
realizes they're senseless. Narcissistic personality disorder is
marked by a pattern of self-involvement, grandiosity, and demand for
constant attention.
138. A Ritodrine reduces frequency and intensity of uterine
contractions by stimulating vitamin B12 receptors in the uterine
smooth muscle. It's the drug of choice when trying to inhibit labor.
Bromocriptine, a dopamine receptor agonist and an ovulation stimulant,
is used to inhibit lactation in the postpartum period. Magnesium
sulfate, an anticonvulsant, is used to treat preeclampsia and
eclampsia--a life-threatening form of pregnancy-induced hypertension.
Betamethasone, a synthetic corticosteroid, is used to stimulate fetal
pulmonary surfactant (administered to the mother).
139. C Based on the mother's description, the child most likely
is exhibiting signs and symptoms of laryngotracheal bronchitis. The
mother should try to decrease the inflammation in the upper airway by
exposing her child to a warm, steamy environment. The safest method
is to steam up the bathroom and stay with the child.
140. B Insulin acts as a growth hormone on the fetus. Therefore,
pregnant diabetic clients must maintain good glucose control. Large
babies are prone to complications and may have to be delivered by
cesarean section. Neither excess sugar nor excess insulin reduces
placental functioning. A high-calorie diet helps control the mother's
disease and doesn't contribute to neonatal size.
141. D The nurse violated confidentiality by informing the
officer that the client wasn't in treatment. Even with law
enforcement agents, the nurse must be a client advocate and protect
the client's confidentiality. Information can be legally withheld
when a court order isn't in place.
142. B Although nutrition plays a large part in the healing
process, it is not advisable to tell a child that he will not get
better if he does or does not do a particular activity. Not only is
this dishonest, it also makes the child believe that his own actions
are causing the illness.
143. D Rotavirus is a type of viral infection that affects the
gastrointestinal tract. It causes diarrhea which results in fluid
loss. This type of infection can be very serious in infants who,
because of their immature kidneys, cannot adjust to fluid loss as
readily as adults.
144. A Mannitol is an osmotic diuretic that helps decrease
intracranial pressure through its dehydrating effects. The drug is
acting in the desired manner when urine output increases.
145. B Research studies have demonstrated that estrogen has been
effective in decreasing bone loss.
146. A Most people with hypertension, even those with dangerous
elevations in blood pressure, have no symptoms. Therefore, the
presence or absence of symptoms is not an accurate reflection of a
person's status.
147. D Owing to the massive cellular destruction that occurs in
burns, potassium is released into the extracellular fluid which leads
to hyperkalemia.
148. C The client can perform the Kegel exercises anytime in any
position listed.
149. C The positive symptoms of schizophrenia are distortions of
normal functioning, including hallucinations, delusions, disorganized
thinking, somatic delusions, echolalia, and waxy flexibility. A flat
affect, alogia, apathy, avolition, and anhedonia refer to the
negative symptoms. Negative symptoms list the diminution or loss of
normal function.
150. D The client who complains of heartburn should eat smaller,
more frequent meals with fluids. Baking soda in water should be
avoided because of the sodium in baking soda. Large meals and fried
foods should also be avoided.
151. C Individuals in a crisis need immediate assistance. They're
unable to solve problems and need structure and assistance in
accessing resources. Clients in a crisis don't need lengthy
explanations or have time to develop insight on their own. They might
need medication but, in most cases, support and direction can be most
helpful.
152. B A report about the client's condition should be as clear,
pertinent, and concise as possible. It should be free of subjective
information that could be interpreted differently by different
caregivers.
153. C When applying nitroglycerin ointment to a client's skin,
the nurse should first remove the ointment applied during previous
administration. Otherwise the client will be receiving too much
medication.
154. B Sleeping in a sleeping bag keeps the joints warm,
therefore more flexible. Thus, joint pain in the morning would be
lessened.
155. B Clients who develop a hydatidiform mole must be instructed
to wait at least 1 year before attempting another pregnancy, despite
testing that shows they have returned to normal. A hydatidiform mole
is a precursor to cancer, so the client must be monitored carefully
for 12 months by an experienced health care provider. Discussing this
situation at a later time and checking with the physician to give the
client something to relax ignore the client's immediate concerns.
Saying to wait until all tests are normal is vague and provides the
client with little information.
156. A After a renal biopsy, the client is maintained on strict
bed rest in a supine position for at least 6 hours to prevent
bleeding. If no bleeding occurs, the client typically resumes general
activity after 24 hours.
157. B Hepatitis B virus is spread through contact with blood,
body fluids contaminated with blood, and such body fluids as
cerebrospinal, pleural, peritoneal, and synovial fluids; semen; and
vaginal secretions.
158. D The nurse helps the client to recognize that he is feeling
anxious by pointing out his behaviors to him The nurse then attempts
to help the client recognize his anxiety and describe his feelings to
help him connect behaviors with feelings.
159. C Cirrhosis is a slowly progressive disease. Inadequate
nutrition is the primary ongoing problem. Clients are encouraged to
eat normal, well-balanced diets and to restrict sodium to prevent
fluid retention.
160. D Tolerance occurs when the body requires higher doses of
substances, such as alcohol, opioids, or benzodiazepines, to achieve
desired effects. Increased response indicates a need for less of a
drug to achieve the same effects. Allergic reactions are autoimmune
responses to a particular drug or class of drugs.
161. A Classic signs and symptoms of rheumatoid arthritis include
joint pain, swelling, and warmth. Symptoms are typically bilaterally
symmetric. Joint stiffness in the morning lasting longer than 30
minutes is another classic symptom. Rheumatoid arthritis is a
systemic disease. Other symptoms can include fatigue, low-grade fever,
anemia, and weight loss.
162. B The priority for care would be to monitor the fetal
response to the contractions because pregnancy may have accelerated
the progress of vascular disease. The gestational diabetic is at
higher risk for the development of preeclampsia, therefore increasing
the risk of uteroplacental insufficiency. All of the remaining
nursing diagnoses are appropriate for the gestational diabetic during
labor, but the priority remains close observation of the client's
glucose level and the fetal response to labor contractions.
163. D According to the DSM-IV, schizoaffective disorder refers
to clients suffering from schizophrenia with elements of a mood
disorder, either mania or depression. The prognosis is generally
better than for the other types of schizophrenia, but it's worse than
the prognosis for a mood disorder alone. Option C is incorrect
because personality disorders and psychotic illness aren't listed
together on the same axis. Option A is incorrect because
schizophrenia is a major thought disorder and the question asks for
elements of another disorder. Option B is incorrect because clients
with schizoaffective disorder aren't suffering from schizophrenia and
an amnestic disorder.
164. C Preoperative and postoperative pictures of babies with
cleft palates and lips provide clear and concrete images of what to
expect after corrective surgery. Providing these pictures is specific
to the parents' behavior because the parents reflect societal values
that emphasize an infant's facial appearance and responsive
expressiveness.
165. D All symptoms define chronic low self-esteem. There isn't
enough information to determine delayed growth and development. The
question doesn't describe the client's ability to perform in her
roles. Posttrauma syndrome occurs after experiencing a traumatic
event and doesn't coincide with the data in the question.
166. A This client is hypotensive because of decreased blood flow
through the aorta. By turning the client to her left side, the nurse
removes the weight of the uterus from the aorta and increases the
maternal blood flow. Taking blood pressure, summoning the physician,
starting oxygen, and increasing IV fluids aren't necessary unless
repositioning doesn't relieve the symptoms.
167. D The major side effect of these three drugs is hepatitis.
While the client is undergoing chemotherapy for TB, the nurse should
carefully monitor the client's liver function tests.
168. C The radioactivity comes from a radioactive material such
as radium or cesium. Radioactivity affects tissues but does not make
them radioactive. Once the radioactive source is removed, no
radioactivity remains. Accurate information can help alleviate
ungrounded fears.
169. C The best nursing intervention is giving the client fingerfoods high in protein and calories that he can eat while he paces or
walks.
170. A Proper positioning to prevent flexion deformities of the
joints is an ongoing need for clients with rheumatoid arthritis and
should be included in the care plan.
171. D When strongly opposed to a type of therapy, the nurse
should refer people who ask about the therapy to another
knowledgeable person.
172. A It would be most helpful to demonstrate the use of a
walker with partial weight bearing. Partial weight bearing will be
required while the hip is healing.
173. D The rooting reflex is a neonate's response to having his
cheek stroked. The neonate will turn his head to the side of the
stroked cheek and will open his mouth in anticipation of having a
nipple placed in it. The tonic neck reflex is elicited by turning the
neonate's head to the side when he's lying on his back. The
extremities on the same side extend and those on the other side flex.
Moro's reflex is the startle reflex. For example, when the neonate's
crib is jolted, the neonate abducts his arms and extends them. The
grasp reflex occurs when the neonate curls his fingers around another
person's fingers.
174. D The client should be instructed to avoid straining and
lifting for 2 to 6 weeks after surgery.
175. B A 5-year-old child is in the preoperational stage of
cognitive development and thinks of death as temporary. Also, for a
child of this age, thinking about behavior often is believed to be
magical; thus, the child may think that his behavior can cause death.
176. C The client who is a fantasy or reminiscent wanderer can be
helped most by diverting his attention toward an activity to relieve
boredom or tension.
177. A Based on the report of the child's signs and symptoms, the
nurse would suspect otitis media. On assessment, the tympanic
membrane would appear bulging and bright red (because of increased
middle ear pressure), typically indicative of otitis media. Other
characteristic findings include rhinorrhea, fever, cough,
irritability, pulling at the ears, earache, vomiting, and diarrhea. A
reddened, nonbulging tympanic membrane may indicate otitis media if
the membrane has ruptured.
178. B After corrective surgery for repair of TEF, the risk for
esophageal stricture is high because scar tissue forms at the site of
the esophageal anastomosis, often requiring dilation at the
anastomosis site during the first years of childhood in about half
the children.
179. A Profuse vomiting is the classic sign of small bowel
obstruction and rarely occurs with large bowel obstruction.
180. D The first nursing action would be to elevate the hips on
two pillows. The primary goal with prolapse of the umbilical cord is
to remove the pressure from the cord. Changing the maternal position
is the first intervention. Acceptable positions include knee-chest,
side-lying, and elevation of the hips. The nurse may also perform a
vaginal examination and attempt to push the presenting part of the
cord while being careful not to add any pressure to the cord.
181. B Nasal septal perforation is associated with cocaine uses.
When the cocaine is inhaled into the nares, it causes
vasoconstriction and impairs the blood supply to the septurn. With
frequent repeated use, this leads to tissue necrosis.
182. A Sleeping with the head of the bed elevated encourages
movement of food through the esophagus by gravity. By fostering
esophageal acid clearance, gravity helps keep the acidic pepsin and
alkaline biliary secretions from contacting the esophagus.
183. C Trochanter rolls placed alongside the client's legs from
the ilium to midthigh are recommended to prevent external rotation of
the hips.
184. A Although all of the choices are desirable, knowledge of
self is the basis for building a strong, therapeutic nurse-client
relationship. Being aware of and understanding personal feelings and
behavior is a prerequisite for understanding and helping clients.
185. C Maintaining catheter patency during the immediate
postoperative period after a transurethral resection is a priority
because postoperative bleeding can occlude the catheter. Catheter
occlusion can lead to urinary retention, pain, bladder spasm, and the
need to replace the catheter.
186. A A heart rate of 150 bpm is very high for a 7-year-old
child and may indicate carditis. For this age group, the normal heart
rate while awake is 70 to 110 bpm.
187. C The client is most likely suffering from muscle rigidity
due to haloperidol. I.M. Benztropine should be administered to
prevent asphyxia or aspiration. Lorazepam treats anxiety, not
extrapyramidal effects. Another dose of haloperidol would increase
the severity of the reaction.
188. D Tendency toward capillary fragility has nothing to do with
thermoregulation. The hypothalamus is the site of temperature
regulation. In preterm neonates, the CNS is poorly developed, so
these neonates may be more prone to temperature instability. The
large skin surface area provides the perfect medium for heat loss
through evaporation and convection. Lack of S. C. and brown fat are
also contributors to temperature instability. Without S. C. fat,
there is nothing to insulate the infant from heat loss. Brown fat
provides calories that help with heat production.
189. A The first of the 12 steps of AA is for an individual to
admit that he's powerless over alcohol and that life has become
unmanageable. Although AA promotes total abstinence, a client will
still be accepted if he drinks. A physician referral isn't necessary
to join. New members are assigned a sponsor who may be called upon
when the client has the urge to drink.
190. D Positioning the child on the affected side, in this case
the right side, will promote drainage from the middle ear by gravity.
191. D When assessing an adolescent initially, the nurse should
try to determine the client's level of emotional maturity. This forms
the basis for the nursing plan of care. Age of menarche, family and
home life, and healthy eating habits, though important, aren't as
significant as determining the emotional maturity of the client.
192. D Elevating the head of the bed allows gravity to increase
the downward flow of fluids in the body and away from the face.
193. B Steady and progressive weight gain is the best indication
that the client's nutritional goals are being met by TPN.
194. A Diphtheria, acellular pertussis, and tetanus are killed
vaccines and may be given to this toddler. Live virus vaccines are
not routinely administered to anyone with an altered immune system
because multiplication of the virus may be enhanced, causing a severe
vaccine-induced illness.
195. A Describing acceptable behavior to the client focuses on
the immediate problem.
196. D Routine dental examinations should begin when a child is
young, usually after the age of 2 years, before any obvious problems
develop.
197. C Enalapril maleate is an angiotensin-converting enzyme (ACE)
inhibitor that prevents conversion of angiotensin Ⅰ to angiotensin
Ⅱ. Angiotensin Ⅱ is a potent vasoconstrictor and also contributes
to aldosterone secretion. Thus, enalapril decreases blood pressure
through systemic vasodilation.
198. C Management of children with early morning hyperglycemia
depends on whether the hyperglycemia is due to insulin-waning, a
progressive rise in blood glucose throughout the day, or rebound
hyperglycemia (Somogyi effect; an increase in blood sugar glucose at
bedtime, a drop at about 2. 00 AM, then a rebound rise early in the
morning). Information about the child's blood glucose levels would
provide clues to determine which event is occurring.
199. D For the initial management of nosebleed, the client should
sit up and lean forward with the head tipped downward. The soft
tissues of the nose should be compressed against the septum with the
fingers. The traditional head-back position allows blood to flow down
the throat and can trigger vomiting.
200. D Group support has proved more successful than individual
attention from the staff in influencing positive behavior in
alcoholics.
201. B Massaging the legs postoperatively is contraindicated
because it may dislodge small clots of blood, if present, and cause
even more serious problems.
202. A The nurse, for her own protection, should be aware of
hospital security and other assisting personnel. The other options
may cause a relatively docile client to become belligerent.
203. B A 10-year-old should be able to tolerate being alone.
Frequently asking for someone to be in the room indicates a degree of
psychological distress at this age suggesting Anxiety.
204. C During this time, the client is usually offered ice chips
rather than clear liquids. Nursing care for the client during the
second stage of labor should include assisting the mother with
pushing, helping position her legs for maximum pushing effectiveness,
and monitoring the fetal heart rate.
205. D Chest pain and dyspnea in an immobilized adolescent with a
large bone fracture suggest a fat embolus. With this condition, fat
droplets, rather than a thrombus, are transferred from the marrow
into the general blood stream by the venous-arterial route, possibly
reaching the lung or brain.
206. C Within 1 hour after delivery, the fundus should be firm
and at the level of the umbilicus. A soft or boggy fundus isn't
contracting well because of such factors as a full bladder or
retained pieces of placenta, and places the postpartum client at risk
for hemorrhage.
207. B Sedative-hypnotic drugs aren't linked to the treatment of
a specific disorder. They're used to treat anxiety and insomnia,
which can occur in a range of psychiatric disorders. Antidepressants
are used to treat OCD. Psychostimulants are used to treat ADHD.
Hallucinations and delusions are treated with antipsychotics.
208. A Nasogastric suctioning is ordered to remove accumulated
gas or fluid (secretions). Excessive fluid can cause pressure on
suture lines, resulting in injury, rupture, or dislodgment. The
gastrointestinal tract should remain empty (no food or fluids) until
peristalsis returns and suture lines have healed adequately, at which
time the nasogastric tube is removed.
209. C Encouraging frequent ambulation would be the most
important contribution to the prevention of thromboembolism. Clotting
factors and fibrinogen are increased in the immediate postpartum
period. When the client is in this hypercoagulable state, the vessel
damage that occurs with birth and immobility predisposes her to
developing thromboembolism. Although increasing oral fluid intake
also is important, encouraging frequent ambulation is most important.
Providing oxygen therapy and administering pain medications don't
prevent thromboembolism formation.
210. D Relating to the client that she combed her hair points out
a visible accomplishment and reinforces positive self-care behavior.
211. D The client needs further instructions when she says she
should decrease her fluid intake. Constipation further aggravates
hemorrhoid pain and should be avoided through increased fluid and
fiber intake. Warm sitz baths, topical ointments, and ice packs all
can be helpful measures to reduce the pain, swelling, and itchiness.
212. D Prednisone is a gastrointestinal irritant that is best
taken with food.
213. C The tympanostomy tubes, made of a polyurethane material
that does not change in structure or composition while in the ear,
usually remain in place for about 6 months then are spontaneously
ejected from the ear. Parents should be told about the tubes
appearance so they can observe them if they fall out.
214. B The first nursing intervention is to ensure the client's
safety because these clients are terrified that the abuser will
arrive and continue the cycle of violence. After this has been done,
the nurse can contact the authorities, identify a support person, and
ensure confidentiality. Photographing the client's injuries requires
the client's consent.
215. B Corporeal punishment is an aversion technique that teaches
children what not to do. Children can often become accustomed to
physical punishment, so the punishment must be more severe to get the
same results.
216. B The pyloric olive-like mass is most easily palpated when
the abdominal muscles are relaxed, the stomach is empty, and the
infant is quiet. During eating, the stomach still is empty and the
infant is relaxed and comfortable.
217. A Most foods contain limited amounts of fluoride. However,
tea contains a significant amount of fluoride and would be the most
appropriate suggestion.
218. B Somatoform disorders are characterized by recurrent and
multiple physical symptoms that have no organic or physiologic base.
Exhibitionism involves public exposure of genitals. Degenerative
dementia is characterized by deterioration of mental capacities.
Echolalia is a repetition of words or phrases.
219. C A swollen, painful scrotum after herniorrhaphy is
relatively common. Elevating the scrotum, as on a rolled towel, and
intermittently placing ice bags on the area are helpful.
220. D Esophageal fistula and anencephaly are associated with
hydramnios, which is an excess of amniotic fluid. Oligohydramnios, or
a decreased amount of amniotic fluid, is associated with renal
defects. Diabetes mellitus and cardiac defects aren't associated with
either oligohydramnios or hydramnios.
221. C Because ear infections are sometimes difficult to treat,
determining if the antibiotic has resolved the infection is essential.
If the client is not rechecked, it will be difficult to determine if
another infection is a continuation of a previous infection or a
separate new infection.
222. A Estimate the amount of blood loss by such measures as
weighing perineal pads or counting the amount of pads saturated over
a period of time. The physician should be notified of continued blood
loss, an increase in blood flow, or vital signs indicative of shock
(hypotension and tachycardia). The woman should be placed on bed rest
and not allowed to ambulate. A pelvic examination should never be
performed when placenta previa is suspected because manipulation of
the cervix can cause hemorrhage.
223. D A client with an eating disorder may be secretive and
unwilling to admit that a problem exists. Therefore, the nurse first
must establish a trusting relationship to elicit the client's
feelings and thoughts. The anorexic client may spend many hours
discussing nutrition or handling and preparing food in an effort to
stall or avoid eating food; the nurse shouldn't reinforce her
preoccupation with food. Although cultural stereotypes may play a
prominent role in anorexia nervosa, discussing these factors isn't
the first action the nurse should take. Exploring the reasons why the
client doesn't eat would increase her emotional investment in food
and eating.
224. D A positive Babinski sign involves dorsiflexion of the big
toe and fanning of the other toes. Although normal in infants, this
response is abnormal after about age 1 year or when walking begins.
225. D Co-dependents are individuals who allow another's behavior
to affect them while being obsessed with controlling the other
person's behavior. Co-dependents try to control events and people
around them because they feel that everything around them and inside
them is out of control.
226. D Multiple gestation causes overdistention of the abdomen,
which can lead to uterine atony and, thus, uterine hemorrhage. A
weight of 3,175 g (7 lb) is classified as normal for an infant. A
macrocosmic infant [-4,000g (8 lb,
oz)] could cause uterine
atony. Neither long labor nor PIH causes postpartum hemorrhage.
227. C Descriptions of sensations, painful and otherwise, in the
amputated part are common and are known as phantom-limb sensations.
The client should be reassured that these sensations are normal and
are not a sign of a mental problem.
228. C The scenario is typical of a client who is hallucinating.
Not enough information is available to suggest that she's a threat to
herself or to society. Malingering refers to a medically unproven
symptom that is consciously motivated.
229. A Most of the nursing interventions during the postpartum
period are directed toward helping the mother successfully adapt to
the parenting role. Although family involvement in teaching, group
discussions on infant care, and lochia monitoring are important
aspects of care, the mother's ability to feed and care for her infant
takes priority.
230. D By age 6 months, an infant can sit alone, leaning forward
on the hands for support. The ability to sit follows progressive head
control and straightening of the back.
231. B When dietary treatment for gestational diabetes is
unsuccessful, insulin therapy is started and the client will need
daily doses. The client shouldn't stop using the insulin unless first
obtaining an order from the physician for insulin adjustments when
ill. Diet therapy continues to play an important role in blood
glucose control in the client who requires insulin. Diet therapy is
important to achieve appropriate weight gain and to avoid periods of
hypoglycemia and hyperglycemia when taking insulin. Fasting,
postprandial, and bedtime blood glucose levels need to be checked
daily.
232. B The client can best discuss his behavior when he's no
longer under the influence of alcohol. Option c encourages the client
to invent excuses. Option A is judgmental and discourages open
communication, and option D is also judgmental.
233. B The most appropriate action when moving an extremity with
acute osteomyelitis is to ensure that the extremity is carefully
supported above and below the affected area. A splint may be useful
to decrease discomfort. Acute osteomyelitis can be very painful.
Therefore, the extremity must be handled carefully and moved slowly.
234. B Neurovascular damage may be indicated by the presence of
any of the "five Ps" pain, pallor, pulselessness, paresthesia, and
paralysis. Bleeding does not indicate neurovascular damage.
Neurovascular damage can occur after almost any orthopedic surgery.
235. C Pregnancy increases plasma volume and expands the uterine
vascular bed, possibly increasing the heart rate and cardiac output.
These changes may cause cardiac stress, especially during the second
trimester. Blood pressure during early pregnancy may decrease, but it
gradually returns to prepregnancy levels.
236. B Setting limits for unacceptable behavior is most important
in a manic client. Typically, depressed, suicidal, or anxious clients
don't physically or mentally test the limits of the caregiver.
237. C The indirect Coombs'test measures the level of antibodies
against fetal Rh- positive factor in maternal blood. Although this
test may determine the fetal blood Rh factor, the physician doesn't
order it primarily for this purpose. The maternal blood Rh factor is
determined be{ore the indirect Coombs’test is done. No maternal
antibodies against fetal Rh-negative factor exist.
238. A To reduce the risk of osteoporosis, women should have an
intake of 1000 to 1500 mg of calcium per day.
239. A Because magnesium has chemical properties similar to those
of calcium, it will assume the role of calcium at the neural muscular
junction. It doesn't act on the distal renal tubules, CNS, or
myocardial fibers.
240. C In rheumatic fever, the joints--especially the knees,
ankles, elbows, and wrists--are painful, swollen, red, and hot to the
touch. Limiting movement of the affected joints typically minimizes
pain.
241. A Nursing care should never include removing the initial
dressing put on in the operating room. Appropriate nursing care for
the incision would include circling any drainage, reporting findings
to the physician, and reinforcing the dressing as needed. The other
options are appropriate.
242. A A decreased hemoglobin is indicative of aplastic anemia.
In addition to a decreased hemoglobin and red blood cell count, the
client will also have a decreased white blood cell count and
decreased platelets.
243. A In leukemia, megakaryocytes, from which platelets are
derived, are decreased. Normal platelet counts range from 150 to
300×103/mm3. A platelet count of 80×103/ mm3 is low, predisposing the
child to bruising and bleeding easily.
244. D Clients with anorexia can refuse food to the point of
cardiac damage. Tube feedings and IV infusions are ordered to prevent
such damage. The nurse is informing her of her treatment options.
Option C doesn't tell the client about the consequences of choosing
not to eat. Because a client with an eating disorder usually has a
distorted self- concept and low self-esteem, options A and B are
incorrect because they won't change the client's self-image.
245. D This lesion is a mongolian spot, which is common in
children of Asian or African American heritage.
246. D A client in hypovolemic shock is best positioned supine in
bed with the feet elevated 15 degrees to bring peripheral blood into
the central circulation.
247. B Low fluid intake can predispose an individual to stone
formation due to the increased urine concentration. Other causes
include repeated urinary tract infections, high doses of vitamin C or
D, immobility, and large doses of calcium.
248. A Fetal heart sounds in the upper right quadrant and
meconium-stained amniotic fluid indicate a breech presentation. The
staining is usually caused by the squeezing actions of the uterus on
a fetus in the breech position, although late decelerations, entrance
into the second stage of labor, and multiple gestation may contribute
to meconium-stained amniotic fluid.
249. B To maintain the integrity of the affected areas and
prevent muscle wasting and contractures, the nurse should perform
regular passive range-of-motion exercises to the client's arms. The
nurse shouldn't insist that he eat without assistance because he
can't consciously control symptoms and move his arms; furthermore,
such insistence may anger the client and endanger the therapeutic
relationship. The nurse should include family members because they
may be contributing to his stress or conflict, and they're essential
in helping the client regain function of his arms. Because the client
isn't experiencing pain, he doesn't need education about pain
management.
250. D Fetal immunities are transferred through the placenta, but
the maternal immune system is actually suppressed during pregnancy to
prevent maternal rejection of the fetus, which the mother's body
considers a foreign protein. Thus, the placenta isn't responsible for
the production of maternal antibodies. The placenta produces estrogen
and progesterone, detoxifies some drugs and chemicals, and exchanges
nutrients and electrolytes.
251. D The dorsalis pedis pulse is found on the medial aspect of
the dorsal surface of the foot in line with the big toe.
252. D Memory loss is the primary symptom of dementia. Loss of
short-term memory (retaining new information) is more prominent, but
tong-term memory (recollection of events that occurred in the past)
may also be affected. Psychosis, neurosis, and loss of impulse
control aren't symptoms of dementia.
253. B During the first 48 to 72 hours of fluid resuscitation
therapy, hourly urine output is the most accessible and generally
reliable indicator of adequate fluid replacement. Fluid volume is
also assessed by monitoring mental status, vital signs, peripheral
perfusion, and body weight. Pulmonary artery end-diastolic pressure
(PAEDP) and even central venous pressure (CVP) are preferred guides
to fluid administration, but urine output is best when PAEDP or CVP
are not used. After the first 48 to 72 hours, urine output is a lessreliable guide to fluid needs. The victim enters the diuretic phase
as edema reabsorption occurs, and urine output increases dramatically.
254. B The nitrazine test determines whether the client's
membranes have ruptured. The nurse performs a sterile vaginal
examination, inserts the nitrazine test tape, then assesses the tape
for a color change. If the membranes are ruptured, the tape becomes
bluish, which indicates that the vaginal environment is alkaline. If
the test tape remains yellow or green, the vaginal environment is
acidic, indicating that the membranes aren't ruptured.
255. C Many poisons require immediate attention but do not cause
immediate symptoms.
256. B To determine plans of care for clients who are
noneompliant with medications, the nurse should consult with the
physician. Unless the client presents a danger to himself or others,
medications can't be forced on a client. A dose shouldn't be omitted
without first checking with the physician. Intentionally deceiving or
misleading a client violates the therapeutic relationship.
257. A The typical findings of mild preeclampsia are hypertension,
edema, and proteinuria. Seizures are a sign of eclampsia. Abdominal
pain, blurry vision, and reduced urine output are signs of severe
preeclampsia. The other findings aren't typically found in women with
preeelampsia.
258. D An early indication of hypokalemia is muscle weakness in
the legs. Potassium is essential for proper neuromuscular impulse
transmission. When neuromuscular impulse transmission is impaired, as
in hypokalemia, leg muscles become weak and flabby. If hypokalemia
progresses, respiratory muscles become involved and the client
becomes apneic. Hypokalemia also causes electrocardiogram changes.
959. A The client is instructed to hold the cane on the
uninvolved side, 94" to 26" (61 to 66 era) from the base of the
little toe. This is done to promote a reciprocal gait pattern. The
nurse should instruct the client to hold the cane close to his body
to prevent leaning. The stride length and timing of each step should
be equal. To prevent fails, the nurse stands behind the client as
he's learning to use the cane.
260. B
261. A
262. A
263. B
264. A
265. A An inpatient client usually receives a copy of the Bill of
Rights for psychiatric patients, which includes right to refuse
treatment, right to a written treatment plan, right to
confidentiality and right to personal mail. However, a client in an
inpatient setting cannot select health team members. A client may
apply for disability as a result of a chronic, incapacitating illness;
however, disability is not a patient right, and members of a
psychiatric institution do not decide who should receive it.