Practice Examination Two
Part One
You will have two hours and 30 minutes to complete Part One.
1. Shortly after being admitted to the coronary care unit with an
acute myocardial infarction (MI), a client reports midsternal chest
pain radiating down the left arm. The nurse notices that the client
is restless and slightly diaphoretic, and measures a temperature of
99. 6°F (37.6℃), a heart rate of 102 beats/minute; regular,
slightly labored respirations at 26 breaths/minute; and a blood
pressure of 150/90mmHg. Which nursing diagnosis takes highest
priority?
A. Risk for imbalanced body temperature.
B. Decreased cardiac output.
C. Anxiety.
D. Acute pain.
2. A client with hepatitis C develops liver failure and GI
hemorrhage. The blood products that would most likely bring about
hemostasis in the client are
A. whole blood and albumin.
B. platelets and packed red blood cells.
C. fresh frozen plasma and whole blood.
D. cryoprecipitate and fresh frozen plasma.
3. A client hospitalized with pneumonia has thick, tenacious
secretions. To help liquefy these secretions, the nurse should
A. turn the client every 2 hours.
B. elevate the head of the bed 30 degrees.
C. encourage increased fluid intake.
D. maintain a cool room temperature.
4. The client is to receive an IV infusion of 3000 mL of dextrose
and normal saline solution over 24 hours. The nurse observes that the
rate is 150mL/hour. If the solution runs continuously at this rate,
the infusion will be completed in
A. 12 hours.
B. 20 hours.
C. 24 hours.
D. 50 hours.
5. The nurse is teaching a psychiatric client about her
prescribed drugs, chlorpromazine and benztropine. Why is benztropine
administered?
A. To reduce psychotic symptoms.
B. To reduce extrapyramidal symptoms.
C. To control nausea and vomiting.
D. To relieve anxiety.
6. A female client has just been diagnosed with condylomata
acuminata (genital warts). What information is appropriate to tell
this client?
A. This condition puts her at a higher risk for cervical cancer;
therefore, she should have a Papanicolaou (Pap) test annually.
B. The most common treatment is metronidazole (Flagyl), which
should eradicate the problem within 7 to 10 days.
C. The potential for transmission to her sexual partner will be
eliminated if condoms are used every time they have sexual
intercourse.
D. The human papillomavirus (HPV), which causes condylomata
aeuminata, can't be transmitted during oral sex.
7. The nurse is caring for an elderly client who exhibits signs
of dementia. The most common cause of dementia in an elderly client
is
A. delirium.
B. depression.
C. excessive drug use.
D. Alzheimer's disease.
8. To assess a client's cranial nerve function, the nurse should
A. assess hand grip.
B. assess orientation to person, time, and place.
C. assess arm drifting.
D. assess gag reflex.
9. A client with hypotonic labor dysfunction is receiving
oxytoein augmentation. Her contractions become more frequent and
intense. Dilation progresses to 8 cm, but the fetal head remains at
station +1. The nurse notes a soft bulge just above the symphysis.
Which of the following actions is best?
A. Re-evaluate the fetal presentation.
B. Change the client's position.
C. Offer a narcotic analgesic.
D. Help the client urinate.
10. The nurse is caring for a neonate with congenital clubfoot.
After the final cast has been removed, which member of the health
care team will most likely help the neonate with leg and ankle
exercises and provide his parents with a home exercise regimen?
A. Occupational therapist.
B. Physical therapist.
C. Recreational therapist.
D. Speech therapist.
11. The nurse is administering total parenteral nutrition (TPN)
to a client who underwent surgery for gastric cancer. What is a major
complication of TPN?
A. Hyperglycemia.
B. Extreme hunger.
C. Hypotension.
D. Hypoglycemia.
12. Which one of the following clients is at the greatest risk
for aspiration?
A. A stroke client with dysarthria.
B. An ambulatory client with Alzheimer's disease.
C. A 92-year-old client who needs help with activities of daily
living (ADLs).
D. A client with severe, deforming rheumatoid arthritis.
13. Drugs to treat acute anxiety are prescribed to a client
hospitalized for an acute myocardial infarction. The client is
reluctant to take anti-anxiety drugs. The nurse suspects that the
client is holding the drugs under his tongue and disposing of them
after she has left the room. What should the nurse do first?
A. Report her suspicions to the client's physician.
B. Talk to the client about his attitude toward the medications.
C. Search the client's room for evidence of the medications.
D. Tell the client that his behavior must stop for his own wellbeing.
14. The nurse is providing care for a postoperative client who
has undergone a small bowel resection. The nurse may use an epidural
catheter for which of the following?
A. Antibiotic therapy.
B. Pain management.
C. Blood transfusion.
D. Anticoagulation.
15. The nurse is preparing to remove a previously applied topical
medication from a client. The rationale for removing previously
applied topical medications before applying new medications is to
A. decrease the possibility of absorption on the nurse's skin.
B. allow distribution of medication.
C. prevent soiling of the client's clothes.
D. avoid administering more than the prescribed dose.
16. The nurse is providing home care to a client with failing
vision due to macular degeneration. The nurse is concerned about the
client's safety. Which of the following activities would help to
lessen the client's risk of falling?
A. Arranging pieces of furniture close together so the client can
use them for guidance and support.
B. Encouraging the client to wear a medical identification
bracelet that describes the client’s visual deficit.
C. Installing a flashing light to indicate when the phone or
doorbell is ringing.
D. Installing handrails in hallways, in bathrooms, and on steps.
17. The nurse is caring for a woman with phenylketonuria who
wants to start a family. Which of the following guidelines should the
nurse provide the woman?
A. Follow a low-phenylalanine diet before trying to conceive.
B. A low-phenylalanine diet is necessary only during the first
trimester.
C. Begin a low-phenylalanine diet when pregnancy is confirmed.
D. Dietary restrictions won't be necessary.
18. A high school student is referred to the school nurse for
suspected substance abuse. Following the nurse's assessment and
interventions, what would be the most desirable outcome?
A. The student discusses conflicts over drug use.
B. The student accepts a referral to a substance abuse counselor.
C. The student agrees to inform his parents of the problem.
D. The student reports increased comfort with making choices.
19. A client is taking spironolactone (Aldactone) to control her
hypertension. Her serum potassium level is 6 mEq/L. For this client,
the nurse's priority would be to assess her
A. neuromuscular function.
B. bowel sounds.
C. respiratory rate.
D. electrocardiogram (ECG) results.
20. The nurse is preparing a treatment plan for a client taking
oral corticosteroids to control severe chronic asthma. Which
statement indicates that the client understands his treatment plan?
A. "I should take corticosteroids on an empty stomach. "
B. "I need to take corticosteroids to help build up my immune
system. "
C. "I should stop taking corticosteroids if I haven't had an
asthma attack for 1 week. "
D. "I'll tell my other health care providers that I'm taking a
corticosteroid. "
21. Which finding is considered normal in a neonate during the
first few days after birth?
A. Weight loss of 25%.
B. Birth weight of 2,000 to 2,500 g.
C. Weight loss then return to birth weight.
D. Weight gain of 25%.
22. Which nursing action takes priority when admitting a elient
with right lower lobe pneumonia?
A. Elevating the head of the bed 45 to 90 degrees.
B. Auscultating the chest for adventitious sounds.
C. Obtaining a sputum specimen for culture.
D. Notifying the physician of the client's admission.
23. A 3288. 5g baby boy is born by spontaneous vaginal delivery.
During the initial assessment at 1 hour postpartum, the nurse notices
lanugo, acrocyanosis, mongolian spots, and hemangiomas. Which of
these is an abnormal finding in a neonate?
A. Lanugo.
B. Acroeyanosis.
C. Mongolian spots.
D. Hemangiomas.
24. A woman in her 8th month of pregnancy is having dinner with
her husband at their favorite restaurant. The woman suddenly chokes
on a piece of chicken and appears to lose consciousness. What would
be the best action by a nurse sitting at the next table?
A. Apply abdominal thrust.
B. Apply chest thrust.
C. Begin cardiopulmonary resuscitation (CPR).
D. Reposition the client on her side.
25. Which of the following statements about external otitis is
true?
A. External otitis is eharaeterized by pain when the pinna of the
ear is pulled.
B. External otitis is usually accompanied by a high fever in
children.
C. External otitis is usually related to an upper respiratory
infection.
D. External otitis can be prevented by using cotton-tipped
applicators to clean the ear.
26. The nurse is caring for a client who is in labor. The
physician still isn't present. After the neonate's head is delivered,
which nursing intervention would be most appropriate?
A. Checking for the umbilical cord around the neonate's neck.
B. Placing antibiotic ointment in the neonate's eyes.
C. Turning the neonate's head to the side, to drain secretions.
D. Assessing the neonate for respirations.
27. The nurse is developing a plan to teach a mother how to
reduce her baby's risk of developing otitis media. Which of the
following directions should the nurse include in the teaching plan?
A. Administer antibiotics whenever the baby has a cold.
B. Place the baby in an upright position when giving a bottle.
C. Avoid getting the ears wet while bathing or swimming.
D. Clean the external ear canal daily.
28. The nurse is caring for a client who's hypoglycemic. This
client will have a blood glucose level
A. below 70 mg/dL.
B. between 70 and 120 mg/dL.
C. between 120 and 180 mg/dL.
D. above 180 mg/dL.
29. A client with a neurogenic bladder is beginning bladder
training. Which of the following nursing actions is most important?
A. Set up specific times to empty the bladder.
B. Force fluids.
C. Provide adequate roughage.
D. Encourage the use of an indwelling urinary catheter.
30. A client is admitted for a suspected eating disorder. Which
of the following statements would indicate that the client may be
suffering from anorexia nervosa?
A. "I've gained 3 pounds in the last month. "
B. "I eat loads of spinach and yellow vegetables each day. "
C. "I'm a perfectionist, and I work hard to get A's. "
D. "I binge frequently in the morning and feel fat. "
31. The nurse is caring for a client admitted to the hospital
with a bowel obstruction. The nurse should wear sterile gloves when
A. inserting an indwelling urinary catheter.
B. giving a back rub on intact skin.
C. changing an oxygen system.
D. inserting an IV catheter.
32. The nurse is preparing to discharge a child who has rheumatic
fever. Which of the following medications is prescribed to prevent
recurrence of rheumatic fever?
A. Glucocorticoids.
B. Digoxin.
C. Antibiotics.
D. Anti-inflammatory medications.
33. The nurse is providing care for a pregnant 16-year-old client.
The client says that she's concerned she may gain too much weight and
wants to start dieting. The nurse should respond by saying.
A. "Now isn't a good time to begin dieting because you are eating
for two. "
B. "Let's explore your feelings further. "
C. " Nutrition is important because depriving your baby of
nutrients can cause developmental and growth problems. "
D. "The prenatal vitamins should ensure the baby gets all the
necessary nutrients. "
34. The nurse is assessing a client with possible osteoarthritis.
The most significant risk factor for osteoarthritis is
A. congenital deformity.
B. age.
C. trauma.
D. obesity.
35. A client with heart failure develops pink frothy sputum,
coarse crackles, and restlessness. Which of the following actions
should the nurse take first?
A. Check the client's blood pressure.
B. Place the client in high Fowler's position.
C. Calculate the client's fluid balance.
D. Notify the physician.
36. A 2-month-old neonate with diarrhea and vomiting has been
receiving IV fluids for the past 24 hours. The specific gravity of
the neonate's urine is 1.012. What should the nurse do next?
A. Check the neonate's blood pressure.
B. Check the specific gravity again as soon as possible.
C. Notify the physician.
D. Continue the ordered IV flow rate.
37. A 10-year-old girl visits the clinic for a checkup before
entering school. The child's mother questions the nurse about what to
expect of her daughter's growth and development at this stage. Which
response is most appropriate?
A. "Her physical development will be rapid at this stage, and
rapid development will continue from now on. "
B. "She'll become more independent and won't require parental
supervision. "
C. "Don't anticipate any changes at this stage in her growth and
development. "
D. "Friends will be very important to her, and she'll develop an
interest in the opposite sex. "
38. A 4-year-old girl is admitted to the hospital to rule out
leukemia. Which of the following would be the best room assignment?
A. With a 4-year-old girl who has rheumatoid arthritis.
B. With a 5-year-old boy who is having a tonsillectomy.
C. With a 4-year-old girl who has leukemia.
D. Alone in a private room.
39. A primigravida in labor for 13 hours clenches her fists,
tightens her muscles, and screams during every contraction. Her
reaction to labor seems exaggerated compared to the contraction
pattern recording from the electronic fetal monitor (EFM). What's the
nurse's best response?
A. Explain to the client that the EFM shows mild contractions, so
she should just relax and let the contractions work.
B. Take over as her coach because her husband isn't helping her
properly.
C. Ignore her reactions, realizing that this is her first time in
labor and her reactions will soon match the intensity of contractions
shown on the EFM.
D. Palpate her abdomen to determine the intensity of labor
contractions as they're taking place.
40. The nurse is administering warfarin (Coumadin) to a client
with deep vein thrombophlebitis. Which laboratory value indicates
warfarin is at therapeutic levels?
A. Partial thromboplastin time (PTT)
to 2 times the control.
B. Prothrombin time (PT)
to 2 times the control.
C. International normalized ratio (INR) of 3 to 4.
D. Hematocrit of 32%.
41. 37-year-old teacher is hospitalized with complaints of
weakness, incoordination, dizziness, and loss of balance. The
diagnosis is multiple sclerosis (MS). Which of the following signs
and symptoms, discovered during the history and physical assessment,
is typical of MS?
A. Diplopia, history of increased fatigue, and decreased or
absent deep tendon reflexes.
B. Flexor spasm, clonus, and negative Babinski's reflex.
C. Blurred vision, intention tremor, and urinary hesitancy.
D. Hyperactive abdominal reflexes and history of unsteady gait
and episodic paresthesia in both legs.
42. The nurse is giving instructions to a client who is going
home with a cast on his leg. Which point is most critical?
A. Using crutches properly.
B. Exercising joints above and below the cast, as ordered.
C. Avoiding walking on a leg cast without the physician's
permission.
D. Reporting signs of impaired circulation.
43. A recent immigrant from Vietnam is diagnosed with pulmonary
tuberculosis (TB). Which intervention is most important for the nurse
to implement with this client?
A. Client teaching about the cause of TB.
B. Reviewing the risk factors for TB.
C. Developing a list of people with whom the client has had
contact.
D. Client teaching about the importance of TB testing.
44. The nurse is caring for a client with otosclerosis scheduled
to undergo a stapedectomy. The client asks the nurse when her hearing
will improve. Which response by the nurse is most appropriate?
A. Your hearing may not improve but you'll no longer be bothered
by tinnitus.
B. Your hearing may be dramatically improved right after surgery.
C. You may notice improved hearing within 1 to 2 weeks.
D. Your hearing may improve 3 to 6 weeks after surgery.
45. The nurse teaches a mother how to provide adequate nutrition
for her toddler, who has cerebral palsy. Which of the following
observations indicates that teaching has been effective?
A. The toddler stays neat while eating.
B. The toddler finishes the meal within a specified period of
time.
C. The child lies down to rest after eating.
D. The child eats finger foods by himself.
46. A nurse performs cardiopulmonary resuscitation (CPR) for 1
minute on an infant without calling for assistance. In reassessing
the infant after I minute of CPR, the nurse finds that he still isn't
breathing and that he has no pulse. The nurse should then
A. resume CPR beginning with breaths.
B. declare her efforts futile.
C. resume CPR beginning with chest compressions.
D. call for assistance.
47. Which of the following assessments indicates fetal distress?
A. Fetal scalp pH of 7.14.
B. Fetal heart rate (FHR) of 144 beats/minute.
C. Acceleration of FHR with contractions.
D. Long-term variability.
48. A 38-year-old client is hospitalized with obsessivecompulsive disorder. On admission, she becomes nervous and asks to go
to the bathroom to brush her teeth. Her husband says that she brushes
her teeth at least 25 times per day. The nurse notes that the
client's gums are inflamed and bleeding. What's the best nursing
intervention?
A. Have her stop brushing her teeth until the gums heal.
B. Allow her to continue her routine of daily brushing.
C. Monitor her dental care and set limits on the amount of daily
brushing.
D. Brush her teeth for her.
49. The nurse is caring for a client undergoing IV antibiotic
therapy with gentamicin sulfate. Which of the following interventions
is most important?
A. Infuse the medication quickly to minimize its irritating
effect on the walls of blood vessels.
B. Obtain renal function tests, such as blood urea nitrogen (BUN)
and creatinine levels, throughout the course of therapy.
C. Assess for pulmonary and peripheral edema.
D. Obtain an order for an antiemetic to counteract the common
adverse effect of nausea.
50. A 26-year-old primigravida is in labor. Her cervix is 5 cm
dilated and 75% effaced; the fetus is at 0 station. The client
requests medication to relieve the discomfort of contractions, and
the physician prescribes an epidural regional block. What position
should the nurse help the client to assume when the epidural is
administered?
A. Lithotomy.
B. Supine.
C. Prone.
D. Lateral.
51. A client is receiving chemotherapy for cancer. The nurse
reviews his laboratory report and notes that he has thrombocytopenia.
To which nursing diagnosis should the nurse give the highest priority?
A. Activity intolerance.
B. Impaired tissue integrity.
C. Impaired oral mucous membranes.
D. Ineffective tissue perfusion (cerebral, cardiopulmonary, GI).
52. The nurse is caring for a client who underwent a total hip
replacement. What should the nurse and other caregivers do to prevent
dislocation of the new prosthesis?
A. Keep the affected leg in a position of adduction.
B. Use measures other than turning to prevent pressure ulcers.
C. Prevent internal rotation of the affected leg.
D. Keep the hip flexed by placing pillows under the client's knee.
53. Which of the following nursing interventions would be
included in the care of a client with anorexia nervosa as therapy
progresses?
A. Let the client eat alone to avoid embarrassment.
B. Weigh the client once a week in the same clothing.
C. Monitor the client for self-destructive tendencies.
D. Praise the client for "looking better" and remind the client
that she isn't "too fat. "
54. The nurse is administering sublingual nitroglycerin to a
client with chest pain. The nurse should place the medication
A. in the cheek.
B. on the tip of the tongue.
C. under the tongue.
D. under the lower lid of the eye.
55. A client in her 7th month of pregnancy has been complaining
of back pain and wants to know what can be done to relieve it. Which
of the following responses by the nurse is most effective?
A. "You need to lie down more during the day to get off your feet.
"
B. "Avoid lifting heavy loads, and try using the pelvic tilt
exercise. "
C. "Have others pick things up for you so you don't have to bend
over so much. "
D. "Your back pain will go away after the baby is born. "
56. The nurse is caring for a client who has just had a modified
radical mastectomy with immediate reconstruction. She's in her 30s
and has two young children. Although she's worried about her future,
she seems to be adjusting well to her diagnosis. What should the
nurse do to support her coping?
A. Tell the client's spouse or partner to be supportive while she
recovers.
B. Encourage the client to proceed with the next phase of
treatment.
C. Recommend that the client remain cheerful for the sake of her
children.
D. Refer the client to the American Cancer Society's Reach for
Recovery program or another support program.
57. When inserting a urinary catheter, the nurse can facilitate
the insertion by asking the client to
A. initiate a stream of urine.
B. breathe deeply.
C. turn to the side.
D. hold the labia or shaft of penis.
58. The nurse is providing postprocedure care for a client who
underwent percutaneous
lithotripsy. In this procedure, an ultrasonic probe inserted
through a nephrostomy tube into the renal pelvis generates ultrahigh-frequency sound waves to shatter renal calculi. The nurse should
instruct the client to
A. limit oral fluid intake for 1 to 2 weeks.
B. report the presence of fine, sandlike particles through the
nephrostomy tube.
C. notify the physician about cloudy or foul-smelling urine.
D. report bright pink urine within 24 hours after the procedure.
59. A 4-month-old infant is brought to the pediatrician by his
parents because they' re concerned about his frequent respiratory
infections, poor feeding habits, frequent vomiting, and colic. The
physician notes that the baby has failed to gain expected weight and
recommends that the baby have a sweat test performed to detect
possible cystic fibrosis. To prepare the parents for the test, the
nurse should explain that
A. the baby will need to fast before the test.
B. a sample of blood will be necessary.
C. a low-sodium diet is necessary for 24 hours before the test.
D. a low-intensity, painless electrical current is applied to the
skin.
60. While auscultating heart sounds of a client with heart
failure, the nurse hears an extra heart sound immediately after the
second heart sound (S2). The nurse should document this as
A. a first heart sound (S1).
B. a third heart sound (S3).
C. a fourth heart sound (S4).
D. a murmur.
61. The nurse is teaching family members of a client with
hepatitis A virus (HAV). Family members were exposed to the client
and, therefore, should receive immunoglobulin. The nurse should tell
the family members that immunoglobulin
A. prevents hepatitis infection in all people.
B. provides immunity for life.
C. must be administered within 2 weeks of exposure.
D. should be administered even if the person has anti-HAV
antibodies.
62. The nurse administers racemic epinephrine to a child. Ten
minutes after administration, the nurse should be alert for
A. respiratory distress.
B. profound tachycardia.
C. signs of improved oxygenation.
D. diminished cyanosis.
63. The nurse provides fluid replacement for a client with burns
on 35% of his body. It has been 12 hours since the burns occurred.
His blood pressure is 85/60 mmHg. His pulse is 124 beats/minute.
Urine output was 25 mL during the past hour. What orders should the
nurse expect to receive from the physician?
A. Maintain IV fluids at the present rate, and continue to
reassess vital signs and urine output hourly.
B. Increase the IV rate, and continue to reassess vital signs and
urine output hourly.
C. Decrease the IV rate, and continue to reassess vital signs and
urine output hourly.
D. Administer a vasoconstrictor, and reassess vital signs and
urine output hourly.
64. The nurse is caring for four clients on a step-down intensive
care unit. The client at the highest risk for developing nosocomial
pneumonia is the one who
A. has a respiratory infection.
B. is intubated and on a ventilator.
C. has pleural chest tubes.
D. is receiving feedings through a jejunostomy tube.
65. The nurse is developing a care plan for a client who's at
risk for ineffective coping due to the effects of chronic illness.
Which factor provides the best evidence that the client is at risk
for difficulty in coping with his illness?
A. Poor sleeping habits.
B. Lack of social support.
C. Adverse drug effects.
D. Presence of panic disorder.
66. A 7-year-old boy is hospitalized with cystic fibrosis. To
help him manage secretions and avoid respiratory distress, the nurse
should
A. perform chest physiotherapy every 4 hours.
B. give pancreatic enzymes as ordered.
C. place the child in an oxygen tent and have oxygen administered
continuously.
D. serve a high-calorie diet.
67. The nurse has a client at 30 weeks' gestation who has tested
positive for the human immunodeficiency virus (HIV). What should the
nurse tell the client when she says that she wants to breast-feed her
neonate?
A. Encourage breas-feeding so that she can get her rest and get
healthier.
B. Encourage breast-feeding because it's healthier for the
neonate.
C. Encourage breast-feeding to facilitate bonding.
D. Discourage breast-feeding because HIV can be transmitted
through breast milk.
68. The nurse-manager of a hospital unit holds monthly staff
meetings. During these meetings, she maintains control over the
meeting and agenda, resists consensus decision making, and uses
discipline and coercion to elicit desired behavior from staff. This
manager uses what type of leadership style?
A. Autocratic.
B. Democratic.
C. Participative.
D. Laissez-faire.
69. The nurse is caring for a client with a fractured hip. The
client is combative and confused, and he's trying to get out of bed.
The nurse should
A. leave the client and get help.
B. obtain a physician's order to restrain the client.
C. read the facility's policy on restraints.
D. order soft restraints from the storeroom.
70. A 56-year-old male has a blood pressure reading of 146/96mmHg.
Upon hearing the reading, he exclaims, "My pressure has never been
this high. Will I need to take medication to reduce it?" Which of the
following responses by the nurse would be best?
A. "Yes. Hypertension is prevalent among males; it's fortunate we
caught this during your routine examination. "
B. "We'll need to reevaluate your blood pressure because your age
places you at high risk for hypertension. "
C. "A single elevated blood pressure doesn't confirm hypertension.
You'll need to have your blood pressure reassessed several times
before a diagnosis can be made. "
D. "You have no need to worry. Your pressure is probably elevated
because you're in the doctor's office. "
71. A family member is caring for a client diagnosed with
Alzheimer's disease. Which of the following is most likely to cause
the caregiver depression and role strain?
A. The caregiver had a close relationship with the client before
diagnosis of the illness.
B. The caregiver has no formal support, such as a visiting nurse
or day care worker.
C. The caregiver understands the full reality of the disease and
its inevitable progression.
D. The caregiver feels unable to control the client and unable to
cope with caregiving.
72. The nurse is caring for a neonate with a myelomeningocele.
The priority nursing care of a neonate with a myelomeningocele is
primarily directed toward
A. ensuring adequate nutrition.
B. preventing infection.
C. promoting neural tube sac drainage.
D. conserving body heat.
73. A 78-year-old client with sensorineural hearing loss is
admitted to a rehabilitation center after hip replacement surgery. A
risk factor for this client would be
A. altered perceptions.
B. toxic levels of pain medication.
C. impaired cognitive function.
D. impaired sense of time.
74. The nurse is developing a teaching plan for a client
diagnosed with diabetes insipidus. The nurse should include
information about which hormone, commonly lacking in clients with
diabetes insipidus?
A. Antidiuretic hormone (ADH).
B. Thyroid-stimulating hormone (TSH).
C. Follicle-stimulating hormone (FSH).
D. Luteinizing hormone (LH).
75. Which procedure or practice is associated with surgical
asepsis?
A. Hand washing.
B. Nasogastrie (NG) tube irrigation.
C. Colostomy irrigation.
D. IV catheter insertion.
76. A client with paranoid type schizophrenia becomes angry and
tells the nurse to leave him alone. The nurse should
A. tell him that she'll leave for now but will return soon.
B. ask him if it's okay if she sits quietly with him.
C. ask him why he wants to be left alone.
D. tell him that she won't let anything happen to him.
77. A 22-year-old client is diagnosed with dependent personality
disorder. Which behavior is most likely evidence of ineffective
individual coping?
A. Inability to make choices and decisions without advice.
B. Showing interest only in solitary activities.
C. Avoiding developing relationships.
D. Recurrent self-destructive behavior with history of depression.
78. The nurse is assigned to care for a postoperative client who
has diabetes mellitus. During the assessment interview, the client
reports that he's impotent and says that he's concerned about its
effect on his marriage. In planning this client's care, the most
appropriate intervention would be to
A. encourage the client to ask questions about personal sexuality.
B. provide time for privacy.
C. provide support for the spouse or significant other.
D. suggest referral to a sex counselor or other appropriate
professional.
79. A client is admitted for detoxification after a cocaine
overdose. The client tells the nurse that he frequently uses cocaine
but that he can control his use if he chooses. Which coping mechanism
is he using?
A. Withdrawal.
B. Logical thinking.
C. Repression.
D. Denial.
80. The physician orders IV fluid volume replacement with
lactated Ringer's solution at a rate of 75 mL/hour. Using an infusion
set that provides 15 gtt/mL, the nurse should calculate the flow rate
to be
A. 10 gtt/min.
B. 12 gtt/min.
C. 19 gtt/min.
D. 75 gtt/min.
81. The nurse is caring for a client who underwent a subtotal
gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube.
The nurse should
A. apply suction to the NG tube every hour.
B. clamp the NG tube if the client complains of nausea.
C. irrigate the NG tube gently with normal saline solution.
D. reposition the NG tube if pulled out.
82. A 35-year-old client is undergoing a brain computed
tomography (CT) scan because of continued migraine headaches. He's
placed in the CT scanner and suddenly begins to complain of
palpitations, sweating, shortness of breath, and shaking. The client
is most likely experiencing
A. an allergic reaction.
B. a myocardial infarction (MI).
C. a panic attack.
D. a hypoglycemic episode.
83. The nurse is caring for a client with adult respiratory
distress syndrome (ARDS). What is the most likely laboratory finding
in the early stages of this disease?
A. Increased carboxyhemoglobin.
B. Decreased partial pressure of arterial oxygen (PaO2).
C. Increased partial pressure of arterial carbon dioxide (PaCO2).
D. Decreased bicarbonate (
).
84. A primigravida client with acquired immunodeficiency syndrome
(AIDS) is in labor at term. In preparing her nursing care plan, the
nurse should include which of the following nursing diagnoses?
A. Risk for fetal or maternal injury related to the crisis of
childbearing.
B. Risk for infection related to suppressed immune status.
C. Risk for deficient fluid volume related to dehydration.
D. Risk for fetal injury related to uteroplacental insufficiency.
85. The nurse is assessing a 71-year-old female client with
ulcerative colitis. Which assessment finding related to the family
will have the greatest impact on the client's rehabilitation after
discharge?
A. The family's ability to take care of the client's special diet
needs.
B. The family's expectation that the client will resume
responsibilities and role-related activities.
C. Emotional support from the family.
D. The family's ability to understand the ups and downs of the
illness.
86. Which client has the highest risk of ovarian cancer?
A. 30-year-old woman taking oral contraceptive pills.
B. 45-year-old woman who has never been pregnant.
C. 40-year-old woman with three children.
D. 36-year-old woman who had her first child at age 22.
87. The nurse is assessing a 15-year-old female who is being
admitted for treatment of anorexia nervosa. Which clinical
manifestation is the nurse most likely to find?
A. Tachycardia.
B. Warm, flushed extremities.
C. Parotid gland tenderness.
D. Coarse hair growth.
88. The nurse is teaching a new group of mental health aides. The
nurse should teach the aides that setting limits is most important
for
A. a depressed client.
B. a manic client.
C. a suicidal client.
D. an anxious client.
89. Every morning a client with type 1 diabetes receives 15 units
of Humulin 70/30. What does this type of insulin contain?
A. 70 units of NPH insulin and 30 units of regular insulin.
B. 70 units of regular insulin and 30 units of NPH insulin.
C. 70% NPH insulin and 30% regular insulin.
D. 70% regular insulin and 30% NPH insulin.
90. The nurse is caring for an elderly female with osteoporosis.
When teaching the client, the nurse should include information about
which major complication?
A. Bone fracture.
B. Loss of estrogen.
C. Negative calcium balance.
D. Dowager’s hump.
91. The employer of a client on the psychiatric unit calls the
nursing station inquiring about the client's progress. The nurse
doesn't know if the client has given consent to allow the staff to
give information out to callers on the phone. Which of the following
would be the nurse's best response?
A. "I'm not permitted to discuss her progress. "
B. "I'll give you the name and telephone number of her physician.
"
C. "I'll have her call you. "
D. "I can't confirm whether your employee is a client here. "
92. The nurse is providing postoperative care for a client
recovering from abdominal surgery. The client is receiving morphine
through a client-controlled analgesia pump. Which finding would
indicate that the client is obtaining adequate pain relief?
A. Awakening several times during the night to redose.
B. Respiratory rate of 10 breaths/minute.
C. Pain rating of 2 or 3 on a scale of 0 to 10.
D. Complaint of itching as an adverse effect of the analgesia.
93. A multigravida in her 34th week of gestation presents in the
emergency department complaining of vaginal bleeding. Which of the
following should be the nurse's first action?
A. Establish IV access.
B. Assess fetal heart rate (FHR) and maternal blood pressure.
C. Prepare the client for a cesarean delivery.
D. Assess maternal heart rate and respiratory rate.
94. A 19-year-old primigravida is admitted to the labor and
delivery unit in labor. She's 2 cm dilated and 50% effaced, and the
fetal head is at 0 station. She's having moderately strong 40-second
contractions every 5 minutes. She seems rather anxious and becomes
very tense during each contraction. When the client asks for pain
relief, what should the nurse do next?
A. Determine the source of her anxiety and institute
interventions to help her relax.
B. Immediately check the physician's order and give her the
analgesic ordered.
C. Inform her that the neonate's head isn't down far enough just
yet but that, as soon as it is, medication will be given.
D. Tell her that her contractions are only moderately strong and
that she should wait until later to take medication.
95. The nurse is admitting a client with a suspected fluid
imbalance. The most sensitive indicator of body fluid balance is
A. daily weight.
B. serum sodium levels.
C. measured intake and output.
D. blood pressure.
96. A client has been prescribed 75 mg of amitriptyline (Elavil)
at bedtime and 15 mg of phenelzine (Nardil) three times per day.
Which nursing action takes priority?
A. Teaching the client about the adverse effects.
B. Calling the physician and questioning the order.
C. Instituting dietary restrictions.
D. Taking baseline vital signs.
97. The nurse is preparing to give a 9-year-old client a
preoperative IM injection. Which size needle should the nurse use?
A. 22G,
.
B. 22G, 1".
C. 20G,
.
D. 20G, 1".
98. A client with type 1 diabetes mellitus is pregnant for the
second time. Her previous pregnancy ended in spontaneous abortion at
18 weeks' gestation. She's now at 22 weeks' gestation. The nurse is
responsible for teaching the client about exercise during her
pregnancy. Which of the following statements indicates that the
client has an appropriate understanding of her exercise needs?
A. "I know I need to walk with a friend or family member. "
B. "I know I need to vary the times of day when I exercise. "
C. "I know I need to exercise before meals. "
D. "I know I need to drink fluids while I walk. "
99. A client at term arrives at the labor room experiencing
contractions every 4 minutes. After a brief assessment, she's
admitted and an electronic fetal monitor is applied. Which of the
following would alert the nurse to an increased potential for fetal
distress?
A. Weight gain of 30 lb (13.6 kg).
B. Maternal age of 32 years.
C. Blood pressure of 146/90 mmHg.
D. Treatment for syphilis at 15 weeks' gestation.
100. The nurse walks into the room of a client who has had
surgery for testicular cancer. The client says that he'll be
undesirable to his wife, and he becomes tearful. He expresses that
he's spoiled a happy, satisfying sex life with his wife, and says
that he thinks it might be best if he would just die. Based on these
signs and symptoms, which nursing diagnosis would be most appropriate
for planning purposes?
A. Situational low self-esteem.
B. Unilateral neglect.
C. Social isolation.
D. Risk for loneliness.
101. The nurse is performing wound care. Which of the following
practices violates surgical asepsis?
A. Holding sterile objects above the waist.
B. Considering a 1" (2.5 cm) edge around the sterile field as
being contaminated.
C. Pouring solution onto a sterile field cloth.
D. Opening the outermost flap of a sterile package away from the
body.
102. The nurse is caring for a client who has hemoconcentration
after fluid loss. Which IV fluids would be the most appropriate fluid
replacement therapy for this client?
A. Distilled water.
B. Dextrose 5% in water (D5W) only.
C. DSW with 40 mEq of potassium chloride.
D. Dextrose 10% in saline.
103. A client has just finished his glucose tolerance test. How
many hours should it take for his blood glucose level to return to
normal?
A. 2 hours.
B. 3 hours.
C. 5 hours.
D. 6 hours.
104. The nurse is providing care to a client with catatonic type
of schizophrenia who exhibits extreme negativism. To help the client
meet his basic needs, the nurse should
A. ask the client which activity he would prefer to do first.
B. negotiate a time when the client will perform activities.
C. tell the client specifically and concisely what needs to be
done.
D. prepare the client ahead of time for the activity.
105. A client who agreed to become an organ donor is pronounced
dead. What is the most important factor in selecting a transplant
recipient?
A. Blood relationship.
B. Sex and size.
C. Compatible blood and tissue types.
D. Need.
106. Which phrase is used to describe the volume of air inspired
and expired with a normal breath?
A. Total lung capacity.
B. Forced vital capacity.
C. Tidal volume.
D. Residual volume.
107. The nurse is teaching a client who receives nitrates for the
relief of chest pain. Which of the following instructions should the
nurse emphasize?
A. Repeat the dose of sublingual nitroglycerin every 15 minutes
for three doses.
B. Store the drug in a cool, well-lit place.
C. Lie down or sit in a chair for 5 to 10 minutes after taking
the drug.
D. Restrict alcohol intake to two drinks per day.
108. A 6-year-old girl has been hospitalized with rheumatic fever
for 4 weeks. Her symptoms have gradually subsided, and she's now
ready for discharge. Which of the following plans for her health care
is most important for her future well-being?
A. Arrange for her to return to school as soon as possible to
promote psychosocial development.
B. Encourage her to engage in unrestricted physical activity to
regain physical strength.
C. Arrange for the administration of prophylactic antibiotics to
prevent a recurrence of rheumatic fever.
D. Maintain seizure precautions, as central nervous system
involvement may persist for several months.
109. A male client with a total hip replacement is progressing
well and expects to be discharged tomorrow. On returning to bed after
ambulating, he complains of severe pain in the surgical wound. Which
action should the nurse take?
A. Assume he's anxious about discharge, and administer pain
medication.
B. Assess the surgical site and affected extremity.
C. Reassure the client that pain is a direct result of increased
activity.
D. Suspect a wound infection, and monitor the client's
temperature and vital signs.
110. A 14-year-old female client in skeletal traction for
treatment of a fractured femur is expected to be hospitalized for
several weeks. When planning care, the nurse should take into account
the client's need to achieve what developmental milestone?
A. Autonomy.
B. Initiative.
C. Industry.
D. Identity.
111. A client with cholecystitis is receiving propantheline
bromide. The client is given this medication because it
A. reduces gastric solution production and hypermobility.
B. slows emptying of the stomach and reduces chyme in the
duodenum.
C. inhibits contraction of the bile duct and gallbladder.
D. decreases bile secretions.
112. The nurse is caring for a client with diabetes mellitus.
When teaching the client about foot care, which instruction should
the nurse provide?
A. Examine feet once per week for redness, blisters, and
abrasions.
B. Apply lotion to dry feet, especially between the toes.
C. Avoid hot-water bottles and heating pads.
D. Dry feet vigorously after each bath.
113. A client's blood glucose level is 45 mg/dL. The nurse should
be alert for which signs and symptoms?
A. Coma, anxiety, confusion, headache, and cool, moist skin.
B. Kussmaul's respirations, dry skin, hypotension, and
bradycardia.
C. Polyuria, polydipsia, hypotension, and hypernatremia.
D. Polyuria, polydipsia, polyphagia, and weight loss.
114. The nurse is assessing a client with possible Cushing's
syndrome. In a client with Cushing's syndrome, the nurse would expect
to find
A. hypotension.
B. thick, coarse skin.
C. deposits of adipose tissue in the trunk and dorsocervical area.
D. weight gain in arms and legs.
115. Which of the following positions is most appropriate for a
neonate with congenital hip dislocation?
A. Semi-Fowler's with both legs flexed.
B. Legs adducted with head elevated.
C. Swaddled in a baby carrier.
D. Prone position with hips abducted.
116. The nurse is caring for a client infected with methicillinresistant Staphylococcus aureus (MRSA). What's the major infection
control measure to reduce MRSA and other nosocomial pathogens in a
health care setting?
A. Using antibacterial soap when bathing clients with MRSA.
B. Conducting culture surveys periodically.
C. Ensuring that personnel wash their hands before and after
contact with every client.
D. Using specific housekeeping practices for environmental
cleaning.
117. A client in her 36th week of pregnancy is admitted to the
hospital with vaginal bleeding. After undergoing an ultrasonic scan,
she's diagnosed with placenta previa. Which assessment finding would
best confirm this diagnosis?
A. A rigid abdomen.
B. A soft, nontender uterus.
C. Painful vaginal bleeding.
D. Hypotension.
118. The nurse is taking the health history of an 85-year-old
client. Which information will be most useful to the nurse for
planning care?
A. General health for the last 10 years.
B. Current health promotion activities.
C. Family history of diseases.
D. Marital status.
119. The nurse-manager has noticed a sharp increase in the
mediation errors with IV antibiotics over the last month. She
discusses the situation with each nurse involved. What other action
should she take?
A. Document it on their evaluation.
B. Ask them to attend inservice training for administration of IV
medications.
C. Report them to the supervisor.
D. Report the incidents to the hospital attorney.
120. The nurse is teaching a client with a history of
atherosclerosis. To decrease the risk of atherosclerosis, the nurse
should encourage the client to
A. avoid focusing on his weight.
B. increase his activity level.
C. follow a regular diet.
D. continue leading a high-stress lifestyle.
121. The nurse is interviewing a 19-year-old female at a clinic.
It's her first visit, and she says that she has been exposed to
herpes by her boyfriend. Initially, with primary genital or type 2
herpes simplex, the nurse would expect the client to have
A. burning or tingling on the vulva, perineum, or vagina.
B. dysuria and urine retention.
C. perineal ulcers and erosions.
D. bilateral inguinal lymphadenopathy.
122. During the assessment of a geriatric client, a nurse would
expect which findings?
A. Eye structure and visual acuity changes.
B. Facial hair decreasing in a female client.
C. Facial hair increasing in a male client.
D. Wounds healing more quickly.
123. The nurse is teaching a client about using vaginal
medications. The nurse should instruct the client to
A. use a tampon after insertion to increase medication absorption.
B. release and pull up on the applicator before removal.
C. never refrigerate suppositories.
D. use only a water-soluble lubricant when inserting a
suppository.
124. The nurse is assessing a neonate. Health history findings
indicate that the mother drank 3 oz (88.7mL) or more of alcohol per
day throughout her pregnancy. Which characteristic should the nurse
expect to find?
A. Prominent nasal bridge.
B. Thick upper lip.
C. Upturned nose.
D. Large for gestational age.
125. An elderly client with Alzheimer's disease begins
supplemental tube feedings through a gastrostomy tube to provide
adequate calorie intake. The nurse should be concerned most with the
potential for
A. hypoglycemia.
B. fluid volume excess.
C. aspiration.
D. constipation.
126. Which of the following nutritional deficiencies may delay
wound healing?
A. Lack of thiamine.
B. Lack of vitamin C.
C. Lack of folate.
D. Lack of vitamin A.
127. A 24-year-old client on the labor unit is being coached in
the Lamaze method by her husband. On assessment, the nurse finds the
client to be 5 cm dilated, 90% effaced, at +1 station with
contractions coming every 2 to 3 minutes and lasting 35 to 40 seconds.
The client has asked for pain relief. What's the nurse's best action?
A. Check maternal blood pressure and pulse and fetal heart rate
in response to contractions.
B. Realize that it’s too early to give pain medication, and
encourage the husband to continue with the Lamaze coaching.
C. Arrange for a sonogram to determine fetal position.
D. Perform a vaginal examination to determine dilation,
effacement, and station.
128. While evaluating the needs of a client during the second
trimester, the nurse can anticipate which of the following?
A. Feelings of disbelief and ambivalence.
B. Feelings of clumsiness and "ugliness".
C. Increasing introspection but a general sense of well-being.
D. Anxiety about the labor and delivery experience.
129. The nurse is interviewing the mother of a 7-year-old child.
Which of the following symptoms reported by the mother would most
lead the nurse to suspect that the child has type 1 diabetes?
A. Recent bed wetting.
B. Poor appetite.
C. Weight gain.
D. Boundless energy.
130. A 15-year-old primigravida gave birth 2 days ago. She tells
the nurse that having her own little baby will be wonderful. Which
nursing response would best evaluate the accuracy of the client's
expectations?
A. "Tell me what your day will be like after you take your baby
home. "
B. "Will anyone be available to help you at home with the baby?"
C. "Have you had any experience taking care of babies?"
D. "What are you planning to do with your baby when you return to
school?"
131. The nurse is teaching parents how to reduce the spread of
impetigo. The nurse should encourage parents to
A. teach children to cover mouths and noses when they sneeze.
B. have their children immunized against impetigo.
C. teach children the importance of proper hand washing.
D. isolate the child with impetigo from other members of the
family.
132. The nurse is assessing a client who gave birth yesterday.
Where should the nurse expect to find the top of the client's fundus?
A. One fingerbreadth above the umbilicus.
B. One fingerbreadth below the umbilicus.
C. At the level of the umbilicus.
D. Below the symphysis pubis.
133. When reporting to the surgeon that a chest tube is
malfunctioning, the nurse is ordered to reposition the tube and
obtain a chest radiograph. The nurse should
A. inform the surgeon this isn't within her scope of practice.
B. report the surgeon to the Ethics Committee.
C. report the surgeon to the nursing supervisor.
D. follow the order as requested by the surgeon.
134. The nurse suspects that a 68-year-old client has digoxin
toxicity. The nurse should assess for
A. hearing loss.
B. vision changes.
C. decreased urine output.
D. gait instability.
135. A child with rheumatic fever complains of painful joints.
What nonpharmacologic measures should the nurse use to reduce the
child's pain?
A. Performing gentle passive range-of-motion (ROM) exercises.
B. Gently massaging the painful joints.
C. Using a bed cradle to keep linens off the joints.
D. Encouraging position changes in bed every 2 hours.
136. A client is in the first postoperative day after a total
laryngectomy and radical neck dissection. Which of the following is a
priority goal?
A. Communicate by use of esophageal speech.
B. Improve body image and self-esteem.
C. Attain optimal levels of nutrition.
D. Maintain a patent airway.
137. The nurse is caring for a client who is suicidal. When
accompanying the client to the bathroom, the nurse should
A. give him privacy in the bathroom.
B. allow him to shave.
C. open the window and allow him to get some fresh air.
D. observe him.
138. A client with coronary artery disease reports intermittent
chest pain that occurs with exertion. The physician prescribes
sublingual nitroglycerin. When teaching the client about
nitroglycerin administration, the nurse should include which
instruction?
A. "Be careful after taking nitroglycerin because it may cause
dizziness. "
B. "Make sure you replace your nitroglycerin tablets every 6
months to ensure potency. "
C. "A burning sensation after taking nitroglycerin indicates
medication potency. "
D. "When you experience chest pain, take one tablet every 30
minutes until the pain is relieved. "
139. In planning a presentation that advocates a decrease in the
client-to-nurse ratio from 8:1 to 6:1, a nurse should emphasize its
effect on
A. institutional resources.
B. standards of practice.
C. client-care quality.
D. nursing recruitment.
140. The nurse is performing a painless, noninvasive procedure to
measure arterial oxygen saturation (SaO2). What procedure is it?
A. Incentive spirometry.
B. Arterial blood gas (ABG) measurement.
C. Peak flow measurement.
D. Pulse oximetry.
141. A nurse in the nursery is preparing to perform
phenylketonuria (PKU) testing. Which neonate is ready for the nurse
to test?
A. A 3-day-old neonate who has been fed IV since birth.
B. A 2-day-old neonate who has been breast-fed.
C. A 1-day-old neonate receiving formula.
D. A breast-fed neonate being discharged within 24 hours of birth.
142. A 72-year-old client seeks help for chronic constipation.
This is a common problem for elderly clients due to several factors
related to aging. Which of the following is one such factor?
A. Increased intestinal motility.
B. Decreased abdominal strength.
C. Increased intestinal bacteria.
D. Decreased production of hydrochloric acid.
143. When prioritizing a client's care plan based on Maslow's
hierarchy of needs, the nurse's first priority would be
A. allowing the family to see a newly admitted client.
B. ambulating the client in the hallway.
C. administering pain medication.
D. placing wrist restraints on the client.
144. The nurse is providing care for an immobilized client. For
this client, the most appropriate and most effective nursing
intervention would be
A. getting the client out of bed and into a chair for 30 minutes,
twice daily.
B. avoiding repositioning the client if he's comfortable.
C. repositioning the client on alternate sides at least every 2
hours.
D. positioning the client with the greatest pressure at the bony
prominence.
145. A 34-year-old client at 32 weeks' gestation tells the nurse
that her baby will be sick because she saw a dead dog on the road
yesterday. What's the best response by the nurse?
A. "Your baby will be fine. That's just superstition. "
B. "Don't worry. We'll make sure your baby is okay. "
C. "I can see that you are concerned. Let's talk about what's
bothering you. "
D. "Perhaps so. Your baby should be seen by a physician as soon
as it's born. "
146. A client with acute respiratory failure is intubated and
placed on mechanical ventilation. Which intervention is most
appropriate when suctioning the client?
A. Insert the suction catheter while applying suction.
B. Apply suction until all the secretions have been removed.
C. Use the same catheter to first suction the mouth, then the
endotraeheal tube.
D. Preoxygenate with 100% oxygen before suctioning.
147. The nurse is caring for a
-year-old male client with
tetralogy of Fallot. Which assessment findings should the nurse
expect?
A. Aortic stenosis, atrial septal defect, overriding aorta, left
ventricular hypertrophy.
B. Pulmonary artery stenosis, intraventricular septal defect,
overriding aorta, right ventricular hypertrophy.
C. Pulmonary artery stenosis, patent ductus arteriosus,
overriding aorta, right ventricular hypertrophy.
D. Transposition of the great vessels, intraventricular septal
defect, right ventricular hypertrophy, patent ductus arteriosus.
148. A client is to have a cesarean delivery because of
continuous vaginal bleeding and an abnormal fetal heart rate tracing.
Which of the following would be the best preoperative medication for
this client?
A. Meperidine (Demerol).
B. Oxytocin (Pitocin).
C. Promethazine (Phenergan).
D. Glycopyrrolate (Robinul).
149. The nurse is caring for a client admitted to the emergency
department after a motor vehicle accident. Under the law, the nurse
must obtain informed consent before treatment unless
A. the client is mentally ill.
B. the client refuses to give informed consent.
C. the client is in an emergency situation.
D. the client asks the nurse to give substituted consent.
150. A 16-year-old student has been admitted to your psychiatric
unit after fainting in physical education class. She has a diagnosis
of anorexia nervosa, weighs 88 lb (40 kg), and is 5'4" (1.6 m) tall.
She has been weighing herself several times per day at home and has
lost 30 lb (13.5 kg) in the past 3 months. Which nursing diagnosis
would be most appropriate for the client?
A. Disturbed thought processes.
B. Impaired adjustment.
C. Imbalanced nutrition. Less than body requirements.
D. Ineffective sexuality patterns.
Part Two
You will have one hour and 50 minutes to complete Part Two.
151. The mother of a hospitalized 3-year-old girl expresses
concern because her daughter is wetting the bed. What should the
nurse tell her?
A. "It's common for a child to exhibit regressive behavior when
anxious or stressed. "
B. "Your child is probably angry about being hospitalized. This
is her way of acting out. "
C. "Don't worry. It's common for a 3-year-olcl child to not be
fully toilet-trained. "
D. "The nurses probably haven't been answering the call light
soon enough. They will try to respond more quickly. "
152. The nurse is teaching breast self-examination (BSE) to a
college student. The nurse knows that the client understands the best
time to examine her breasts when she says:
A. "I'll examine my breasts 1 week after my period starts. "
B. "I'll perform a BSE just before my period starts. "
C. "I must examine my breasts the same time each day. "
D. "Every time I shower I'll do a breast examination. "
153. The physician inserts a chest tube into a client to treat a
pneumothorax. The tube is connected to water-seal drainage. The nurse
can prevent chest tube air leaks by
A. keeping the chest drainage system below the level of the chest.
B. keeping the head of the bed slightly elevated.
C. checking and taping all connections.
D. checking patency of the chest tube.
154. A client on an inpatient psychiatric unit at a community
mental health center is pacing the hallway and appears agitated. When
the nurse approaches him, he says loudly, "Leave me alone. " What's
the nurse's best approach?
A. Say nothing and pace with the client.
B. Say "You sound upset. I'd like to help. "
C. Say "okay" and walk away.
D. Summon help in case the client becomes aggressive.
155. An 8-month-old boy is admitted to the pediatric unit
following a fall from his high chair. The child is awake, alert, and
crying. The nurse should know that a brain injury is more severe in
children because of
A. increased myelination.
B. intracranial hypotension.
C. cerebral hyperemia.
D. a slightly thicker cranium.
156. A hospitalized client taking 30 mg of tranylcypromine
(Parnate) twice per day complains of a stiff neck and headache. Which
action would be best for the nurse to take?
A. Note the complaints as usual adverse effects.
B. Withhold the next dose of medication.
C. Administer an analgesic, as needed and as prescribed.
D. Help the client relax.
157. A client is admitted to the labor and delivery unit in
active labor. She has had no prenatal care but appears to be between
32 and 35 weeks' gestation. History reveals that she's gravida 5,
para 1, abortus 3. She tells the nurse she thinks her friend gave her
a cigarette containing crack cocaine. What should the nurse do next?
A. Move the precipitant delivery cart to the labor room, and
notify the neonatologist on call.
B. Teach the mother controlled breathing techniques.
C. Call a family member to come to the hospital.
D. Call the friend who gave the client the cigarette and find out
exactly what the drug was.
158. A person's psychosocial needs during the dying process of a
relative may include
A. flexible visitation, participation in client care, and rest
breaks.
B. flexible visitation, denial of imminent death, and rest breaks.
C. limited visitation, participation in client care, and rest
breaks.
D. short, frequent, limited periods of visitation; participation
in client care; and rest breaks.
159. The nurse is providing care for a client who underwent
mitral valve replacement. The best example of a measurable client
outcome goal is to
A. change his own dressing.
B. walk in the hallway.
C. walk from his room to the end of the hall and back before
discharge.
D. eat a special diet.
160. A neonate of a client with type 1 diabetes mellitus is at
high risk for hypoglycemia. An initial sign the nurse should
recognize as indicating hypoglycemia in a neonate is
A. peripheral acrocyanosis.
B. bradycardia.
C. lethargy.
D. jaundice.
161. A client with antisocial personality disorder refuses to
take a shower for 3 days. Which response by the nurse is best?
A. "It's policy here for all clients to bathe daily. "
B. "It's time for your shower. I'll help you with it. "
C. "Don't worry about your shower until tomorrow. "
D. "Do you want people to make fun of you?"
162. The mother of a 1B-year-old girl calls the emergency
department, suspecting her daughter's abdominal pain may be
appendicitis. In addition to pain, her daughter has a fever of 100°F
(37.8℃) and has vomited twice. What should the nurse tell the mother?
A. Give the daughter a laxative to rule out the possibility that
constipation is causing the pain.
B. Gently press on the left lower quadrant of her daughter's
abdomen to test for rebound tenderness.
C. It's most likely the flu because her daughter is too young to
have appendicitis.
D. Immediately bring her daughter into the emergency department
before the appendix has a chance to rupture.
163. While monitoring a client for the development of
disseminated intravascular coagulation (DIC), the nurse should take
note of what assessment parameters?
A. Platelet count, prothrombin time (PT), and partial
thromboplastin time (PTT).
B. Platelet count, blood glucose levels, and white blood cell
(WBC) count.
C. Thrombin time, calcium levels, and potassium levels.
D. Fibrinogen level, WBC count, and platelet count.
164. A client is 22 weeks pregnant with her first child. Her
weight gain is normal, but she complains of constipation. What’s the
most effective recommendation the nurse can make?
A. "Take a mild laxative daily. "
B. "Increase intake of fluids and high-fiber foods. "
C. "Relax when trying to move the bowels. "
D. "Start a strenuous exercise program. "
165. The nurse is speaking to grieving parents after a sudden
infant death syndrome (SIDS) death. What should the nurse emphasize
to the parents?
A. The death couldn't have been prevented and isn't the parents'
fault.
B. The parents must allow an autopsy to confirm the diagnosis.
C. The parents are still young and can have more children.
D. The parents should place other infants on their backs to sleep.
166. A client in the manic phase of bipolar disorder constantly
belittles other clients and demands special favors from the nurses.
Which nursing intervention would be most appropriate for this client?
A. Ask other clients and staff members to ignore the client's
behavior.
B. Set limits with consequences for belittling or demanding
behavior.
C. Offer the client an antianxiety drug when belittling or
demanding behavior occurs.
D. Offer the client a variety of stimulating activities to
distract him from belittling or making demands of others.
167. The nurse should anticipate which psychological reactions
during the second trimester of pregnancy?
A. Self-centeredness and concentration on the behavior and
appearance of children.
B. Extroversion and emotional lability.
C. Ambivalence and uncertainty.
D. Dismay over body image and readiness for the end of pregnancy.
168. A client has severe pruritus from hepatitis B. Which of the
following nursing measures would best enhance the client's comfort?
A. Use hot water to increase vasodilation.
B. Use cold water to decrease itching sensation.
C. Give tepid water baths.
D. Avoid lotions and creams.
169. The nurse is caring for a client in the manic phase of
bipolar disorder who is ready for discharge from the psychiatric unit.
As the nurse begins to terminate the nurse-client relationship, which
client response is most appropriate?
A. Expressing feelings of anxiety.
B. Displaying anger, shouting, and banging the table.
C. Withdrawing from the nurse in silence.
D. Rationalizing the termination, saying that everything comes to
an end.
170. The nurse is caring for a client with a fractured left femur.
What signs indicate potential fat emboli?
A. Increased partial pressure of arterial oxygen (PaO2), reduced
sensation in left leg or foot.
B. Left leg pain, dyspnea.
C. Bradycardia, skin bruises.
D. Cyanosis, decreased PaO2.
171. The nurse is assessing a pregnant woman in the clinic. In
the course of the assessment, the nurse learns that this woman smokes
one pack of cigarettes per day. The first step the nurse should take
to help the woman stop smoking is to
A. assess the client's readiness to stop.
B. suggest that the client reduce the daily number of cigarettes
smoked by one-half.
C. provide the client with the telephone number of a formal
smoking cessation program.
D. help the client develop a plan to stop.
172. A client on an inpatient psychiatric unit at a community
mental health center is pacing up and down the hallway. The client
has a history of aggression. Which response by the nurse would be
best when approaching the client?
A. "If you can't relax, you could go to your room. "
B. "Would you like your antianxiety medication now?"
C. "You're pacing. What's going on?"
D. "Let's go play a game of pool. "
173. A female client is discharged from the hospital after having
an episode of heart failure. She's prescribed daily oral doses of
digoxin (Lanoxin) and furosemide (Lasix). Two days later, she tells
her community health nurse that she feels weak and frequently feels
her heart "flutter. " What action should the nurse take?
A. Tell the client to rest more often.
B. Tell the client to stop taking the digoxin, and call the
physiciarn.
C. Call the physician, report the symptoms, and request to draw a
blood sample to determine the client's potassium level.
D. Tell the client to avoid foods that contain caffeine.
174. A 23-year-old primigravida client has a normal vaginal
delivery. The next day, the nurse assesses the client's lochia for
color, amount, and the presence of clots. Which of the following best
describes lochia on the first postpartum day?
A. Dark red (loehia rubra), large amount, with many clots.
B. Pink (lochia serosa), moderate amount, no clots.
C. White (lochia alba), scant amount, no clots.
D. Dark red (lochia rubra), moderate amount, with a few small
clots.
175. A pregnant client is taking folic acid. During prenatal
teaching, which of the following foods would the nurse recommend as
high in folic acid?
A. Egg yolks.
B. Fruit.
C. Bread.
D. Milk.
176. A psychiatric client who was voluntarily admitted now wishes
to be discharged from the hospital, against medical advice. What's
the most important assessment the nurse should make of the client?
A. Ability to care for himself.
B. Degree of danger to self and others.
C. Level of psychosis.
D. Intended compliance with aftercare.
177. The nurse is providing care for a pregnant client with
gestational diabetes. The client asks the nurse if her gestational
diabetes will affect her delivery. The nurse should know that
A. the delivery may need to be induced early.
B. the delivery must be by cesarean.
C. the mother will carry to term safely.
D. it's too early to tell.
178. A registered nurse who usually works on a medical-surgical
unit is told to report to the cardiac care unit (CCU) for the day
because the CCU is short staffed and needs additional help to care
for the clients. The nurse has never worked in the CCU. Which of the
following responses is the most appropriate nursing action?
A. Call the hospital lawyer.
B. Report to the CCU and identify tasks that she feels she can
safely perform.
C. Speak to the nursing supervisor.
D. Refuse to go to the CCU.
179. A 58-year-old client on a mental health unit has lost
control, despite having been properly medicated, and is threatening
to harm himself and others. He has been placed in four- point
restraints. Which nursing measure should be taken next?
A. Release one restraint every 15 minutes.
B. Have a staff member stay with the client at all times.
C. Leave the client alone to reduce his sensory stimulation and
allow him to regain control.
D. Restrict fluids until the restraint period is over.
180. A nurse is reviewing prenatal care with a client. Which of
the following statements by the client best expresses adequate
understanding of nutritional needs during pregnancy?
A. "I expect to gain a few pounds each month at first. Then I'll
really get big and put on 20 pounds or so. "
B. "I guess I will get big and gain 20 to 30 pounds and look
pregnant."
C. "Because I have to eat for two, I should eat whatever I want
whenever I feel hungry. "
D. "I will need to eat more so that I will gain about 25 pounds,
but I want to make sure I don't fill up with junk food. "
181. A nurse needs assistance transferring an elderly, confused
client to bed. The nurse leaves the client to find someone to assist
her with the transfer. While the nurse is gone, the client falls and
hurts herself. The nurse is at fault because she hasn't
A. properly educated this client about safety measures.
B. restrained the client.
C. documented that she left the client.
D. arranged for continual care of the client.
182. The nurse is assessing a client diagnosed with appendicitis.
Which of the following signs or symptoms should the nurse expect to
find?
A. Rigid abdomen, Levine's sign, pain relief leaning forward.
B. Rebound tenderness, McBurney's sign, low-grade fever.
C. Right lower quadrant pain, Chvostek's sign, muscle guarding.
D. Periumbilical pain, Trousseau's sign, pain relief with
pressure.
183. The nurse is caring for a 45-year-old male client admitted
with a retinal detachment in his left eye. What symptoms would the
nurse expect to find during assessment?
A. Flashing lights in the visual field.
B. Sudden eye pain.
C. Loss of color vision.
D. Colored halos around lights.
184. Two family members are arguing in a child's room. They start
to hit each other and the child is crying. What's the most
appropriate nursing action?
A. Call security to come and intervene.
B. Remove the child from the room.
C. Ask one of the family members to leave the room.
D. Try to reason with both family members.
185. A child is sent to the school nurse because, according to
his teacher, he's constantly scratching his head. When the nurse
assesses his hair and scalp, she finds evidence of lice. What did she
probably see?
A. Flaking of the scalp with pink, irritated skin exposed.
B. Small white spots that adhere to the hair shaft, close to the
scalp.
C. Scaly, circumscribed patches on the scalp, with mild alopecia
in these areas.
D. Multiple tiny pustules on the scalp with no abnormal findings
on the hair shafts.
186. The nurse is working in a support group for clients with
acquired immunodeficiency syndrome (AIDS). Which point is most
important for the nurse to stress?
A. Avoiding the use of recreational drugs and alcohol.
B. Refraining from telling anyone about the diagnosis.
C. Following safer-sex practices.
D. Telling potential sex partners about the diagnosis, as
required by law.
187. The major goal of therapy in crisis intervention is to
A. withdraw from the stress.
B. resolve the immediate problem.
C. decrease anxiety.
D. provide documentation of events.
188. During a routine follow-up examination, the nurse updates
the client's medication history. The client currently receives
prednisone therapy. Concomitant use of an agent from which of the
following classes could increase the risk of peptic ulcer disease?
A. Antidiabetic agents, administered orally.
B. Nonsteroidal anti-inflammatory drugs (NSAIDs).
C. Beta-adrenergic blockers.
D. Contraceptive agents, administered orally.
189. The nurse is teaching a group of women to perform breast
self-examination. The nurse should explain that the purpose of
performing the examination is to discover
A. cancerous lumps.
B. areas of thickness or fullness.
C. changes from previous self-examinations.
D. fibrocystic masses.
190. A mother brings her 15-month-old male child to the
ambulatory care clinic for well-child care. He's crying and pulling
at his left ear, which appears erythematous. Which of the following
actions should the nurse take first?
A. Ask the mother to leave the room because her anxiety is
increasing the child's distress.
B. Examine the ear with the child supine because this aids
visualization of the tympanic membrane.
C. Examine the affected ear last in order to minimize distress
early in the examination.
D. Examine the left ear first in order to assess what may be
physically wrong with the child.
191. A gravida 2, para 1 with pregnancy-induced hypertension is
receiving magnesium sulfate IV, 2g/hour via infusion pump. In
assessing the client, the nurse notes a decrease in respirations from
16 to 12 breaths/minute and slightly pink-tinged urine (output is
25mL/hour). The client still complains of feeling sleepy. The nurse's
action should include
A. checking the most recent serum level of magnesium sulfate and
notifying the physician of the results.
B. turning the client on her left side and taking vital signs
again.
C. flushing the client's indwelling urinary catheter with sterile
normal saline solution to see if it's draining properly.
D. instructing the client to turn, cough, and deep breathe every
30 minutes.
192. A client has a boggy uterus during stage IV of her delivery.
Four hours postpartum, the nurse is preparing to administer
methylergonovine maleate (Methergine) 0.2mg PO as prescribed every 6
hours. The client's vital signs are; temperature, 100.4°F (38℃);
pulse, 60 beats/minute; respirations, 14 breaths/minute; blood
pressure, 140/90mmHg. Which is the most appropriate intervention?
A. Immediately administer the drug.
B. Administer the drug and call the physician.
C. Administer the drug and recheek vital signs.
D. Don't administer the drug.
193. The nurse is planning care for a female client diagnosed
with acute hepatitis A virus (HAV). What's the primary mode of
transmission for HAV?
A. Fecal contamination and oral ingestion.
B. Exposure to contaminated blood.
C. Sexual activity with an infected partner.
D. Sharing a contaminated needle or syringe.
194. Immediately after a 1-year-old client returns from a cardiac
catheterization, the nurse notes that the pulse distal to the
catheter insertion site is weak. The nurse should take which of the
following actions?
A. Remove the pressure bandage from the insertion site.
B. Perform passive exercises on the affected extremity.
C. Notify the physician of the assessment.
D. Record the data on the nursing notes and continue to evaluate.
195. A child with type 1 diabetes mellitus develops diabetic
ketoacidosis and receives a continuous insulin infusion. Which
condition represents the greatest risk for this child?
A. Hypercalcemia.
B. Hyperphosphatemia.
C. Hypokalemia.
D. Hypernatremia.
196. The nurse is teaching a female client with osteoporosis
about her prescribed diet. Which of the following foods is the best
source of calcium?
A. 1 cup of low-fat yogurt.
B. 1 cup of skim milk.
C. 1 oz of cheddar cheese.
D. 1 cup of ice cream.
197. A client received burns to his entire back and left arm.
Using the Rule of Nines, the nurse can calculate that he has
sustained burns on what percentage of his body?
A. 9%.
B. 18%.
C. 27%.
D. 36%.
198. Which intervention has the highest priority when providing
skin care to a bedridden client?
A. Changing the bed linens frequently for an incontinent client.
B. Keeping the skin clean and dry without using harsh soaps.
C. Gently massaging the skin around the pressure areas.
D. Rubbing moisturizing lotion over the pressure areas.
199. Which intervention will best help to prevent a client from
falling?
A. Monitor the client regularly or continually if his condition
warrants it.
B. Keep the bed at a level where the nurse can easily provide
care.
C. Make sure the side rails of the client's bed are down.
D. Restrain the client to prevent him from getting out of bed and
falling.
200. The nurse is teaching a client who has been prescribed
allopurinol for the treatment of gout. Which instruction would the
nurse give to the client?
A. Increase alcohol intake while taking the drug.
B. Avoid foods that are rich in purine.
C. Take aspirin for pain.
D. Take the drug between meals to promote absorption.
201. A child, age 3, is brought to the emergency department in
respiratory distress caused by acute epiglottiditis. Which clinical
manifestations should the nurse expect to assess?
A. Severe sore throat, drooling, leaning forward to breathe.
B. Low-grade fever, stridor, barking cough.
C. Pulmonary congestion, productive cough, fever.
D. Sore throat, fever, general malaise.
202. Several children in a kindergarten class have been treated
for pinworm. To prevent the spread of pinworm, the school nurse meets
with the parents and explains that they should
A. tell the children not to bite their fingernails.
B. not let children share hairbrushes.
C. tell the children to cover their mouths and noses when they
cough or sneeze.
D. have their children immunized.
203. The nurse is caring for a client with cholelithiasis. Which
sign indicates obstructive jaundice?
A. Straw-colored urine.
B. Reduced hematocrit.
C. Clay-colored stools.
D. Elevated urobilinogen in the urine.
204. The nurse is planning care for a client after a tracheostomy.
One of the client's goals is to overcome verbal communication
impairment. Which of the following interventions should the nurse
include in the care plan?
A. Make an effort to read the client's lips to foster
communication.
B. Encourage the client's communication attempts by allowing him
time to select or write words.
C. Answer questions for the client to reduce his frustration.
D. Avoid using a tracheostomy plug because it blocks the airway.
205. The nurse is developing a teaching plan for a client
diagnosed with osteoarthritis. To minimize injury to the
osteoarthritic client, the nurse should instruct the client to
A. install safety devices in his home.
B. wear comfortable shoes.
C. get help when lifting objects.
D. wear protective devices when exercising.
206. While admitting a client with pneumonia, the nurse notes
multiple bruises in various stages of healing. The client has
Alzheimer's disease and a history of multiple fractures. Legally, the
most important action for the nurse to take is to
A. document findings thoroughly.
B. question the client about the bruising.
C. inform appropriate local authorities.
D. tell the client's physician.
207. The nurse is developing a teaching plan for a client with
diabetes mellitus. A client with diabetes mellitus should
A. use commercial preparations to remove corns.
B. cut toenails by rounding edges.
C. wash and inspect feet daily.
D. walk barefoot at least once each day.
208. The nurse is caring for an 85-year-old client. For which
important factor directly influencing this client's mental health
should the nurse be most aware?
A. The client's attitude toward life circumstances.
B. The client's age, education level, social status, and economic
level.
C. The number of children and grandchildren in the family and the
client's relationship with them.
D. Grief issues related to loss, role changes, and physical
stamina.
209. A mother brings her 5-month-old female child to the
pediatric clinic. The child has had recurrent middle-ear infections
since she was 3 months old. Which of the following areas is most
important to assess?
A. How well the client eats.
B. The client's weight gain since her last visit.
C. Whether the client received all of her prescribed antibiotic
at the time of the last infection.
D. The client's temperature.
210. The nurse provides care for a client with chronic
obstructive pulmonary disease (COPD). Administering high doses of
oxygen may produce what result?
A. Increased respiratory drive.
B. Diminished respiratory drive.
C. A mismatch between ventilation and perfusion.
D. A profound decrease in partial pressure of arterial carbon
dioxide (PaCO2).
211. A nurse instructs a prenatal class about the importance of
doing Kegel exercises frequently. Kegel exercises help to
A. promote better breathing by strengthening the diaphragm muscle.
B. maintain good perineal muscle tone by tightening the
pubococcygeus muscle.
C. minimize leg cramps by strengthening the calf muscles.
D. prepare the mother for pushing by strengthening the abdominal
muscles.
212. The nurse is caring for a bedridden, elderly adult. To
prevent pressure ulcers, which intervention should the nurse include
in the care plan?
A. Turn and reposition the client a minimum of every 8 hours.
B. Vigorously massage lotion into bony prominences.
C. Post a turning schedule at the client's bedside.
D. Slide the client, rather than lift, when turning.
213. Hyperthyroidism is caused by increased levels of thyroxine
in blood plasma. A client with this endocrine dysfunction would
experience
A. heat intolerance and systolic hypertension.
B. weight gain and heat intolerance.
C. diastolic hypertension and widened pulse pressure.
D. anorexia and hyperexcitability.
214. The nurse is delivering the client's 10 AM medications. The
client is away from his room for a diagnostic study. Which action is
the most appropriate for the nurse to take?
A. Leave the medications on the client's bedside table.
B. Ask the client's roommate to keep the medications for the
client until he returns.
C. Lock the medications in the medicine preparation area until
the client returns.
D. Have the client skip that dose of medication.
215. The nurse is providing preoperative care to a client
scheduled for an appendectomy. Which statement regarding pain control
is most appropriate?
A. "There's no need to ask for pain medication, you'll receive it
on a schedule. "
B. "Take your pain medication after walking so that you won't
feel dizzy. "
C. "Take your pain medication before your pain becomes intense. "
D. "Use as little pain medication as possible to avoid addiction.
"
216. The nurse is developing a care plan for a client in her 34th
week of gestation who is experiencing premature labor. What
nonpharmacologic intervention should the plan include to halt
premature labor?
A. Encouraging ambulation.
B. Serving a nutritious diet.
C. Promoting adequate hydration.
D. Performing nipple stimulation.
217. The nurse is giving home care instructions to a client who
just had a cataract removed and an intraocular lens implanted. What
should the nurse tell the client?
A. Don't sleep on the operated side.
B. Wear the eye shield continuously for 2 weeks.
C. Aspirin may be taken for mild pain.
D. Straining during bowel movements is allowed.
218. The nurse is caring for a comatose client who has suffered a
closed head injury. What intervention should the nurse implement to
prevent increases in intracranial pressure (ICP) ?
A. Suction the airway every hour and as needed.
B. Elevate the head of the bed 15 to 30 degrees.
C. Turn the client and change his position every 2 hours.
D. Maintain a well-lit room.
219. The nurse is caring for a client who has had an above-theknee amputation. The client refuses to look at the stump. When the
nurse attempts to speak with the client about his surgery, he tells
the nurse that he doesn't wish to discuss it. The client also refuses
to have his family visit. The nursing diagnosis that best describes
the client's problem is
A. hopelessness.
B. powerlessness.
C. disturbed body image.
D. fear.
220. The nurse is caring for a client who underwent a lumbar
laminectomy 2 days ago. Which of the following findings should the
nurse consider abnormal?
A. More back pain than the first postoperative day.
B. Paresthesia in the dermatomes near the wounds.
C. Urinary retention or incontinence.
D. Temperature of 99.2°F(37.3℃).
221. A 54-year-old female was found unconscious on the floor of
her bathroom with self- inflicted wrist lacerations. An ambulance was
called and the client was taken to the emergency department. When she
was stable, the client was transferred to the inpatient psychiatric
unit for observation and treatment with antidepressants. Now that the
client is feeling better, which nursing intervention is most
appropriate?
A. Observing for extrapyramidal symptoms.
B. Beginning a therapeutic relationship.
C. Canceling any no-suicide contracts.
D. Continuing suicide precautions.
222. A local elementary school has requested scoliosis screening
for its students from the hospital's community outreach program. The
school should be informed that
A. these students are too young to screen; instead, older
students should be screened.
B. these students are too old to screen and will no longer
benefit from screening for scoliosis.
C. scoliosis screening requires sophisticated equipment and can't
be done in school.
D. this is an appropriate request and arrangements will be made
as soon as possible.
223. The child with rheumatic fever must have his heart rate
measured while awake and while sleeping. Why are two readings
necessary?
A. To obtain a heart rate that isn't affected by medication.
B. To eliminate interference from the jerky movements of chorea.
C. To ensure that the child can't consciously raise or lower the
heart rate.
D. To compensate for the effects of activity on the heart rate.
224. The nurse is planning care for a client admitted to the
psychiatric unit with a diagnosis of paranoid schizophrenia. Which
nursing diagnosis should receive the highest priority?
A. Risk for self- or other-directed violence.
B. Imbalanced nutrition.
C. Ineffective coping.
D. Impaired verbal communication.
225. During afternoon rounds, the nurse finds a male client using
a pencil to scratch inside his knee-to-toe cast. The client is
complaining of severe itching in the ankle area. Which action should
the nurse take?
A. Allow him to continue to scratch inside the cast with a pencil.
B. Give him a sterile metal object to use for scratching instead
of the pencil.
C. Encourage him to avoid scratching, and obtain an order for
diphenhydramine (Benadryl) if severe itching persists.
D. Obtain an order for a sedative, such as diazepam (Valium), to
prevent him from scratching.
226. Conjunctivitis may be caused by bacteria, viruses, allergens,
or irritants. What signs and symptoms differentiate bacterial
conjunctivitis from other types?
A. Subacute onset, severe pain, and preauricular adenopathy.
B. Recurrent onset, no pain, and clear discharge.
C. Acute onset, moderate pain, and purulent discharge.
D. Acute onset, mild pain, and clear discharge.
227. The nurse is caring for a client who recently underwent a
tracheostomy. The first priority when caring for a client with a
tracheostomy is
A. helping him communicate.
B. keeping his airway patent.
C. encouraging him to perform activities of daily living.
D. preventing him from developing an infection.
228. A 32-year-old client is admitted to the unit. She states,
"I'm a well-known, wealthy designer," and begins to order the nurses
to prepare her bath while she orders her tray and telephones her
colleagues. Her husband states that she's too busy to eat and sleep
and is losing weight. Her admitting diagnosis is bipolar disorder,
manic phase. For which of the following events should the nurse plan?
A. Erratic and unpredictable behavior if challenged.
B. Boredom and the need for minute-to-minute activities.
C. Rapid mood changes from elation to depression.
D. One-to-one treatment to occupy the client's time.
229. A client who has sustained a head injury is to receive
mannitol (Osmitrol) by IV push. In evaluating the effectiveness of
the drug, the nurse should expect to find
A. increased lung expansion.
B. decreased cerebral edema.
C. decreased cardiac workload.
D. increased cerebral circulation.
230. For a client with bulimia, which assessment is least
important in the care plan?
A. Observe the client after eating for 1 hour.
B. Note the client's intake.
C. Note changes in appetite.
D. Note changes in respiratory rate.
231. The parents of a 4-year-old with sickle cell anemia tell the
nurse that they would like to have other children, but they're
concerned about passing sickle cell anemia on to them. Which health
care team member would be the most appropriate person for the nurse
to refer them to?
A. Clergy.
B. Social worker.
C. Certified nurse midwife.
D. Genetic counselor.
232. A 69-year-old client asks the nurse what the difference is
between osteoarthritis (OA) and rheumatoid arthritis (RA). Which
response is correct?
A. OA is a noninflammatory joint disease. RA is characterized by
inflamed, swollen joints.
B. OA and RA are very similar. OA affects the smaller joints, and
RA affects the larger, weight-bearing joints.
C. OA affects joints on both sides of the body. RA is usually
unilateral.
D. OA is more common in women. RA is more common in men.
233. The nurse is developing a teaching plan for a client with
genital herpes. She should include information about
A. acyclovir (Zovirax).
B. penicillin.
C. doxycycline.
D. tetracycline.
234. A 28-year-old accountant is admitted to the neurologic unit
after a sudden onset of blindness the day before an important project
is due for her boss. After preliminary evaluation and testing yields
no positive findings, the physician's initial reaction is that the
client may be demonstrating which defense mechanism?
A. Repression.
B. Transference.
C. Reaction formation.
D. Conversion.
235. A 21-year-old primigravida has an emergency cesarean
delivery under general anesthesia because of unanticipated fetal
distress. One postoperative intervention is to assist her to turn
every 2 hours. Which of the following conditions is this intervention
intended to prevent?
A. Pressure ulcers.
B. Muscular stiffness.
C. Respiratory complications.
D. Venous stasis.
236. A female client is being treated for genital herpes. The
client should receive teaching on the
A. prevention of outbreaks of lesions.
B. need to abstain from sexual contact.
C. need to keep the perineal area moist.
D. need to wear tight-fitting nylon underwear.
237. 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 her blood
glucose levels, so she has started insulin therapy. The nurse should
consider the teaching effective when the client says
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. "
238. The physician prescribes a monoamine oxidase (MAO) inhibitor
for a client. Which of the following nursing diagnostic categories
would be most appropriate to focus on during client teaching?
A. Risk for injury.
B. Disturbed thought processes.
C. Deficient fluid volume.
D. Disturbed sleep pattern.
239. A 13-year-old visits the school nurse because he's
experiencing back pain, fatigue, and dyspnea. The nurse suspects that
the child may have scoliosis. The nurse should first
A. send the child home to recover.
B. inspect the child for uneven shoulder height or uneven hip
height.
C. arrange for the child to have spinal X-rays as soon as
possible.
D. ask the child's parent to take him to a physician immediately.
240. The nurse in the emergency department is assessing a 64year-old client experiencing substernal chest pain. The client's
electrocardiogram shows evidence of myocardial ischemia. Which
statement should indicate to the nurse that the client may be a
candidate for thrombolytic therapy?
A. "I have had chest pain for 2 days. "
B. "My chest pain started 3 hours ago. "
C. "My chest pain stops when I take a nitroglycerin pill. "
D. "I have had chest pain on and off all week. "
241. A 28-year-old single female arrives at a mental health
clinic complaining of depression. She states that she has been
feeling numb and empty most of the time and has little energy to
perform her usual activities. She has experienced these difficulties
since the death of her best friend 6 months ago. Which of the
following is the nurse's best response?
A. Tell the client that the physician will prescribe an
antidepressant and she will feel better.
B. Encourage the client to get on with her life and stop feeling
sorry for herself.
C. Advise the client that it isn't unusual for grieving and loss
to continue for quite some time.
D. Suggest that the client return in 3 months if the feelings
persist.
242. The nurse is caring for a client who is on ritodrine therapy
to halt premature labor. What condition indicates an adverse reaction
to ritodrine therapy?
A. Hypoglycemia.
B. Crackles.
C. Bradycardia.
D. Hyperkalemia.
243. A 2-year-old client returns from surgery after a bowel
resection as a result of Hirschsprung’s disease. A temporary
colostomy is in place. Which immediate postoperative nursing
intervention takes priority?
A. Changing the surgical dressing.
B. Suctioning the nasopharynx frequently to remove secretions.
C. Irrigating the colostomy with 100 ml of normal saline solution.
D. Auscultating lung sounds.
244. While making rounds in a senior citizens' housing complex,
the visiting nurse discovers one of her clients sobbing in her
darkened apartment. On questioning the client, an 85- year-old widow,
the nurse learns that her pet cat of 15 years had been put to sleep
the day before. What's the nurse's best response?
A. "It shouldn't be hard to find another cat. You'll feel better
once you have another pet. "
B. "It was only a cat. Why are you allowing yourself to be so
upset? It would be different if it were a person. "
C. "I'm so sorry that your pet had to be put to sleep. I know how
important your cat was to you. "
D. "It's probably best for the cat because it was so old and ill.
"
245. The nurse is caring for a 10-year-old child with rheumatic
fever. While obtaining the child's health history from the mother,
the nurse should ask if the child recently had which illness?
A. Strep throat.
B. Influenza.
C. Chickenpox.
D. Mononucleosis.
246. The nurse is teaching a group of patient-care attendants
about infection-control measures. The nurse tells the group that the
first line of intervention for preventing the spread of infection is
A. wearing gloves.
B. administering antibiotics.
C. washing hands.
D. assigning private rooms for clients.
247. A woman in labor shouts to the nurse, "My baby is coming
right now! I feel like I have to push!" An immediate nursing
assessment reveals that the head of the fetus is crowning. After
asking another staff member to notify the physician and setting up
for delivery, which nursing intervention is most appropriate?
A. Gently pulling at the neonate's head as it's delivered.
B. Holding the neonate's head back until the physician arrives.
C. Applying gentle pressure to the neonate's head as it's
delivered.
D. Placing the mother in a Trendelenburg position until the
physician arrives.
248. What is the normal pH range for arterial blood?
A. 7.00 to 7.49.
B. 7.35 to 7.45.
C. 7.50 to 7.60.
D. 7.55 to 7.65.
249. The nurse is providing breast cancer education at a
community facility. The American Cancer Society recommends that women
get mammograms
A. yearly after age 40.
B. after the birth of the first child and every 2 years
thereafter.
C. after the first menstrual period and annually thereafter.
D. every 3 years between ages 20 and 40 and annually thereafter.
250. A 2-week postpartum client inquires about alcohol use during
lactation. She tells the nurse she has heard that a small glass of
wine or beer before nursing will increase her milk supply and be good
for the baby. What's the nurse's best response?
A. "It's true that a little alcohol before breast-feeding will
help your milk supply because it will help you relax. "
B. "Research has shown that it actually decreases the amount of
milk the baby will get, perhaps because it affects the taste of your
milk. "
C. "A little alcohol will help you to relax and the small amount
that will pass through the milk may just help the baby relax. "
D. "You shouldn't even consider drinking alcohol while you are
nursing a baby. "
251. The nurse is about to administer a medication to a client
with whom the nurse is unfamiliar. To verify the client's identity,
the nurse should
A. ask the client his name.
B. check the name posted outside the client's room.
C. ask a family member the identity of the client.
D. check the client's identification bracelet.
252. The nurse is caring for a neonate with congenital clubfoot.
The child has a cast to correct the defect. Before discharge, what
should the nurse tell the parents?
A. "The cast will be removed in 6 weeks. "
B. "A new cast is needed every 1 to 2 weeks. "
C. "A short leg cast is applied when the baby is ready to walk. "
D. "The cast will be removed when the baby begins to crawl. "
253. An 8-year-old child enters a health care facility. During
assessment, the nurse discovers that the child is experiencing the
anxiety of separation from his parents. The nurse makes the nursing
diagnosis of Fear related to separation from familiar environment and
family. Which nursing intervention is most likely to help the child
cope with fear and separation?
A. Ask the parents not to visit the child until he has adjusted
to the new environment.
B. Ask the physician to explain to the child why he needs to stay
in the health care facility.
C. Explain to the child that he must act like an adult while he's
in the facility.
D. Have the parents stay with the child and participate in his
care.
254. A mother complains to the nurse that her 4-year-old son
often lies. What's the nurse's best response?
A. Let the child know that he'll be punished for lying.
B. Ask him why he isn't telling the truth.
C. It's probably due to his vivid imagination and creativity.
D. Acknowledge him by saying, "That's a pretend story. "
255. A first-time mother-to-be is in the labor room, her husband
at her bedside. The client states that her contractions began 6 hours
ago. Which of the following assessment findings would confirm that
the client is in true labor?
A. Discomfort located chiefly in the abdomen.
B. Constant intensity of contractions.
C. Contractions occurring every 10 to 15 minutes and lasting 20
to 30 seconds.
D. Cervix that is 100% effaced and 2 cm dilated.
256. The nurse is planning care for a 10-year-old child in the
acute phase of rheumatic fever. Which activity would be most
appropriate for the nurse to schedule in the care plan?
A. Playing ping-pong.
B. Reading books.
C. Climbing on play equipment in the playroom.
D. Unrestricted ambulation.
257. What laboratory finding is the primary diagnostic indicator
for pancreatitis?
A. Elevated blood urea nitrogen (BUN).
B. Elevated serum lipase.
C. Elevated aspartate aminotransferase (AST).
D. Increased lactate dehydrogenase (LD).
258. When caring for a client with the nursing diagnosis Impaired
swallowing related to neuromuscular impairment, the nurse should
A. position the client in a supine position.
B. elevate the head of the bed 90 degrees during meals.
C. encourage the client to remove dentures.
D. encourage thin liquids for dietary intake.
259. A client with bicuspid aortic valve has severe stenosis and
is scheduled for valve replacement. While teaching the client about
his condition and upcoming surgery, the nurse shows him a heart
illustration. Which valve will be replaced?
A. A
B. B
C. C
D. D
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.
A client is diagnosed with gout. Which foods should the nurse
instruct the client to avoid?
260. (Select A or B. ) Green leafy vegetables.
261. (Select A or B. ) Liver.
262. (Select A or B. ) Chocolate.
263. (Select A or B. ) Sardines.
264. (Select A or B. ) Cod.
265. (Select A or B. ) Eggs.
Answers and Rationales
1. D The nursing diagnosis of Acute pain takes highest priority
because pain increases the client's pulse and blood pressure. During
an acute phase of an MI, low-grade fever is an expected result of the
body's response to the myocardial tissue necrosis. This makes Risk
for imbalanced body temperature an incorrect answer. The client's
blood pressure and heart rate don't suggest a nursing diagnosis of
Decreased cardiac output. Anxiety could be an appropriate nursing
diagnosis but it may be corrected by addressing the priority concernpain.
2. D The liver is vital in the synthesis of clotting factors, so
when it's diseased or dysfunctional, as in hepatitis C, bleeding
occurs. Treatment consists of administering blood products that aid
clotting. These include fresh frozen plasma containing fibrinogen and
cryoprecipitate, which have most of the clotting factors. Although
administering whole blood, albumin, and packed cells will contribute
to hemostasis, those products aren't specifically used to treat
hemostasis. Platelets are helpful, but the best answer is
cryoprecipitate and fresh frozen plasma.
3. C Increasing the client's intake of oral or IV fluids helps
liquefy thick, tenacious secretions and ensures adequate hydration.
Turning the client every 2 hours would decrease pooling of secretions
but wouldn't liquefy them. Elevating the head of the bed would reduce
pressure on the diaphragm and ease breathing but wouldn't liquefy
secretions. Maintaining a cool room temperature would increase the
client's comfort but wouldn't liquefy secretions.
4. B The total amount to be given, 3,000mL, divided by the hourly
rate, 150mL/hour, equals the length of the infusion or, in this case,
20 hours.
5. B Benztropine is an anticholinergic medication, administered
to reduce the extrapyramidal adverse effects of chlorpromazine and
other antipsyehotic medications. Benztropine doesn't reduce psychotic
symptoms, relieve anxiety, or control nausea and vomiting.
6. A Women with condylomata acuminata are at risk for cancer of
the cervix and vulva. Yearly Pap tests are important for early
detection. Because condylomata acuminata is a virus, there's no
permanent cure. Because condylomata acuminata can occur on the vulva,
a condom won't protect sexual partners. HPV can be transmitted to
other parts of the body, such as the mouth, oropharynx, and larynx.
7. D Alzheimer's disease is the most common cause of dementia in
the elderly. Approximately 10% of people over age 65 have Alzheimer's
disease; about 50% of people over age 85 have the disease. Delirium,
or acute confusion, is caused by an underlying disease and isn't
itself a cause of dementia. Depression is common in the elderly but,
in many cases, manifests itself in apathy, self-deprecation, or
inertia--not dementia. Excessive drug use, commonly stemming from the
client seeing multiple physicians who are unaware of drugs that other
physicians have prescribed, can cause dementia. Although it's a
problem among the elderly, it isn't as common as Alzheimer's disease.
8. D The gag reflex is governed by the glossopharyngeal nerve,
one of the cranial nerves. Hand grip and arm drifting are part of
motor function assessment. Orientation is an assessment parameter
related to a mental status examination.
9. D Assessment data indicate a full bladder that may impede
fetal descent. The other options are inappropriate because they don't
address the assessment findings.
10. B After the final cast has been removed, foot and ankle
exercises may be necessary to improve range of motion. A physical
therapist should work with the child. A physical therapist is trained
to help clients restore function and mobility, which will prevent
further disability. An occupational therapist, who helps the
chronically ill or disabled perform activities of daily living and
adapt to limitations, isn't necessary at this time. A recreational
therapist, who uses games and group activities to redirect
maladaptive energy into appropriate behavior, also isn't required. A
speech therapist isn't necessary; clubfoot isn't accompanied by
speech problems.
11. A The solution, used as a base for most TPN, consists of a
high dextrose concentration and may raise blood glucose levels
significantly, resulting in hyperglycemia. Fluid overload may cause
hypertension, not hypotension. Extreme hunger occurs with
hypoglycemia.
12. A The muscles that become paralyzed in dysarthria are the
same ones used for swallowing. This increases the client's risk of
aspiration. Clients with Alzheimer's disease that are still
ambulatory probably don't have the voluntary muscle problems that
occur later in the disease. Clients that need help with ADLs or have
severe arthritis shouldn't have difficulty swallowing unless it
exists secondary to another problem.
13. B Before reporting these concerns to the physician, the nurse
should discuss the perceived problem about the medications with the
client. The nurse will then have more information about the client's
attitude toward anti-anxiety medications when she informs the
physician of her suspicions. Searching the client's room for the
medications is a violation of the client's right to privacy. The
nurse and the physician can talk to the client about the benefits of
taking the medication prescribed; however, the client has the right
to refuse the medication.
14. B Administration of pain medication through an epidural
catheter is recommended if severe pain is anticipated or if the pain
doesn't respond to less invasive measures. Epidural catheters can
also be used for the administration of regional anesthesia. Epidural
catheters may not be used for antibiotic therapy, blood transfusion,
or anticoagulation.
15. D The nurse should remove previously applied topical
medications before applying new medications to prevent accumulation
of medication that exceeds the prescribed dose. Wearing gloves will
decrease the possibility of absorption on the nurse's skin. Spreading
topical medications evenly will allow for distribution of medication.
Placing a dressing, if allowable, over the medication will prevent
soiling of client's clothes.
16. D Handrails help to guide the client in his environment as
well as provide physical support to enhance stability. Close
arrangement of furniture provides dangerous obstacles that could
precipitate falls and sharp, hard objects upon which to fall. A
medical identification bracelet provides no protection in the event
of a fall. Blinking lights that indicate a ringing doorbell or phone
are useful for the hearing impaired.
17. A A woman with phenylketonuria should begin a lowphenylalanine diet before she tries to conceive. This will reduce the
risk of giving birth to a baby with microcephaly, mental retardation,
and low birth weight. The low-phenylalanine diet must be continued
throughout pregnancy and during breast-feeding. Starting a lowphenylalanine diet after conception increases the risk of physical
and mental disabilities to the fetus.
18. B All of the outcomes stated are desirable; however, the best
outcome is that the student would agree to seek the assistance of a
professional substance abuse counselor.
19. D Although changes in all these findings are seen in
hyperkalemia, ECG changes can indicate potentially lethal arrhythmias
such as ventricular fibrillation. It wouldn't be appropriate to
assess the client's neuromuscular function, bowel sounds, or
respiratory rate for effects of hyperkalemia.
20. D The client's other health care providers need to know that
the client is taking a corticosteroid because these drugs can
suppress inflammatory and immune responses. To reduce GI symptoms,
clients should take eorticosteroids with food or milk, never on an
empty stomach. Corticosteroids suppress, rather than build up, the
immune system. Clients should never take corticosteroids without
consulting with a physician. To prevent an adrenal crisis,
corticosteroid use must be discontinued by gradually reducing drug
dosage, especially when the client has been on long-term
corticosteroid therapy.
21. C Babies lose approximately 10% of their birth weight during
the first 3 or 4 days, due to the loss of excess extracellular fluids
and meconium as well as limited oral intake, until breast-feeding is
established. Return to birth weight should occur within 10 days after
birth. Normal birth weights range from 2,700 to 4,000g.
22. A Clients with pneumonia breathe easier in Fowler's or semiFowler’s position because gravity facilitates diaphragmatic movement.
The other nursing actions are important but don't take first priority.
23. D Hemangiomas are vascular tumors considered deviations from
the norm. The other options are normal neonatal findings.
24. B Because it prevents fetal injury, a chest thrust is the
best way to force air through the throat and dislodge the obstruction.
Abdominal thrust might cause fetal injury. CPR and repositioning the
client on her side won't help dislodge the obstruction.
25. A External otitis is an infection of the external ear. Pain
can be elicited when the pinna of the ear is pulled. Fever and
accompanying upper respiratory infection occur more commonly in
conjunction with otitis media (infection of the middle ear). Cottontipped applicators can actually cause external otitis so their use
should be avoided.
26. A After the neonate's head is delivered, the nurse should
check for the cord around the neonate's neck. If the cord is around
the neck, it should be gently lifted over the neonate's head.
Antibiotic ointment, to prevent gonorrheal conjunctivitis, is
administered to the neonate after birth, not during delivery of the
head. The neonate’s head isn't turned during delivery. After
delivery, the neonate is held with his head lowered to help with
drainage of secretions. If a bulb syringe is available, it can be
used to gently suction the neonate's mouth. Assessing the neonate's
respiratory status should be done immediately after delivery.
27. B Feeding a baby in an upright position reduces the pooling
of formula in the nasopharynx. Formula provides a good medium for the
growth of bacteria, which can travel easily through the short,
horizontal eustachian tubes. The other interventions don't reduce the
risk of a baby developing otitis media.
28. A A blood glucose level below 70mg/dL is considered
hypoglycemic. A normal blood glucose level is between 70 and 120mg/dL.
Above 120mg/dL indicates hyperglycemia.
29. A Clients are taught to write down their voiding pattern and
to empty the bladder at the same times each day. Forcing fluids (more
than 2 L/day) increases urine production and complicates the initial
bladder-training process. Roughage is unnecessary for bladder
training. An indwelling urinary catheter is used only when other
methods of control don't work.
30. C Typically, the anorexic client works hard to achieve
perfection and loses the ability to accept help. Option A refers to
weight gain, which may indicate bulimia. Option B is atypical of
anorexic clients, who have an intense fear of becoming obese and
compulsively resist any attempts at eating. Binge eating (option D)
is characteristic of bulimia (although bulimics tend to binge more
frequently in the evening, and "feeling fat" is characteristic of
anorexia).
31. A Inserting an indwelling urinary catheter is the only
sterile procedure listed here. Gloves aren't necessary when giving a
back rub on intact skin or when changing an oxygen system. Nonsterile
gloves would be worn when inserting an IV catheter.
32. C Because the child with rheumatic fever is at risk for a
recurrence, especially if the condition is complicated by carditis,
long-term antibiotic therapy is necessary into adulthood, maybe even
for life. Digoxin may be prescribed to treat heart failure, but it
doesn't prevent the recurrence of rheumatic fever. Corticosteroids
and anti-inflammatory medications reduce inflammation in rheumatic
fever but won't prevent a recurrence.
33. C Depriving the developing fetus of nutrients can cause
serious problems, and the nurse should discuss this with the client.
The client isn't eating for two; this is a misconception. Exploring
feelings helps the client understand her concerns, but she needs to
be aware of the risks at this time. The vitamins are supplements and
don't contain everything a mother or neonate needs; they work in
congruence with a balanced diet.
34. B Age is the most significant risk factor for developing
osteoarthritis. Development of primary osteoarthritis is influenced
by genetic, metabolic, mechanical, and chemical factors. Secondary
osteoarthritis usually has identifiable precipitating events such as
trauma.
35. B Proper positioning can help reduce venous return to the
heart. High Fowler's position also decreases lung congestion.
Checking the client's blood pressure is important but doesn't take
top priority. Calculating the client's fluid balance wouldn't be an
immediate priority in an emergency. Notifying the physician should be
done after the client has been repositioned and assessed.
36. D The neonate's urine specific gravity is within normal
limits, indicating that he's being adequately hydrated. The other
options aren't necessary.
37. D Friends become very important at this age. Children usually
begin having an interest in the opposite sex around this age,
although they aren't always willing to admit it. Her physical
development towards maturity continues, but it isn't as rapid at this
stage as in previous years. Although independence increases at this
stage, children continue to need parental supervision. Growth and
development slow down, but gradual changes continue to occur.
38. D Avoiding exposure to infection requires a private room.
39. D Internal and external fetal monitors are helpful in
assessing the duration and frequency of contractions, but the
external monitor doesn't accurately portray the intensity of the
contraction. The labor room nurse must evaluate this by palpation.
Taking over as her coach, ignoring her reactions, and telling her to
relax fail to recognize the need for palpation.
40. B Warfarin is at therapeutic levels when the client's PT is
to 2 times the control. Higher values indicate increased risk of
bleeding and hemorrhage; whereas lower values indicate increased risk
of blood clot formation. Heparin--not warfarin--prolongs PTT. The INR
may also be used to determine if warfarin is at a therapeutic level.
An INR of 2 to 3 is considered therapeutic. Hematocrit doesn't
provide information on the effectiveness of warfarin; however, a
falling hematocrit in a client taking warfarin may be a sign of
hemorrhage.
41. C Optic neuritis, leading to blurred vision, is a common
early sign of MS, as is intention tremor (tremor when performing an
activity). Nerve damage can cause urinary hesitancy. In MS, deep
tendon reflexes are increased or hyperactive. A positive Babinski's
reflex is found in MS. Abdominal reflexes are absent with MS.
42. D Although all of these interventions are important,
reporting signs of impaired circulation is the most critical. Signs
of impaired circulation must be reported to the physician immediately
to prevent permanent damage. The other options reflect more longterm concerns. The client should learn to use his crutches properly
to avoid nerve damage. The client may exercise above and below the
cast, as the physician orders. The client should be told not to walk
on the cast without the physician's permission.
43. C To lessen the spread of TB, everyone who had contact with
the client must undergo a chest X-ray and TB skin test. Testing will
help to determine if the client infected anyone else. The remaining
options are important areas to address when educating high- risk
populations about TB before its development.
44. D After stapedectomy, it can take as long as 6 weeks for
hearing to improve. The client may not notice any improvement in the
first 2 weeks after surgery. After surgery, hearing may initially
worsen because of swelling and fluid accumulation in the ear.
Tinnitus may not resolve.
45. D The child with cerebral palsy should be encouraged to be as
independent as possible. Finger foods allow the toddler to feed
himself. Because spasticity affects coordinated chewing and
swallowing as well as the ability to bring food to the mouth, it's
difficult for the child with cerebral palsy to eat neatly.
Independence in eating should take precedence over neatness. The
child with cerebral palsy may require more time to bring food to the
mouth; thus, chewing and swallowing shouldn't be rushed to finish a
meal by a specified time. The child with cerebral palsy may vomit
after eating, due to a hyperactive gag reflex. Therefore, the child
should remain in an upright position after eating to prevent
aspiration and choking.
46. D After 1 minute of CPR, the nurse should call for assistance
and then resume efforts. CPR shouldn't be stopped after it has been
started unless the nurse is too exhausted to continue. A cycle
usually ends with breaths, so the next beginning cycle after pulse
check and summoning help would begin with chest compressions.
47. A A scalp pH of less than 7.25 indicates acidosis and fetal
hypoxia. The other options are normal responses of a healthy fetus to
labor.
48. C This allows the behavior that reduces anxiety for the
client, but it sets limits as a first step in modifying the behavior.
Having her stop brushing her teeth until her gums heal may leave the
client unable to manage anxiety. Allowing her to continue her routine
of daily brushing does nothing to change the behavior. Brushing her
teeth for her treats the client like a toddler.
49. B Gentamicin sulfate is toxic to the kidneys. Monitoring BUN
and creatinine levels during the course of therapy can identify
nephrotoxicity before severe damage occurs. Be aware that gentamicin
sulfate is also toxic to ears. Assessing for tinnitus, dizziness,
vertigo, and hearing loss can prevent damage from ototoxicity.
Gentamicin sulfate should be infused slowly. Nausea isn't an adverse
effect of IV gentamicin sulfate. Pulmonary and peripheral edema
aren't common adverse effects.
50. D The client is placed on her left side, with shoulders
parallel and legs slightly flexed. The epidural space, the potential
space between the dura mater and the ligamentum flavum, is readily
accessed with the client on her side. None of the other positions
allows proper access to the epidural space.
51. D These are all appropriate nursing diagnoses for the client
with thrombocytopenia (reduced platelet count). However, the risk of
cerebral and GI hemorrhage and hypotension pose the greatest risk to
the client's physiological integrity.
52. C External rotation and abduction of the hip helps to prevent
dislocation of a new hip joint. Internal rotation and adduction
should be avoided. Postoperative total hip replacement clients may be
turned onto the unaffected side. While the hip may be flexed slightly,
it shouldn't exceed 90 degrees and maintenance of flexion isn't
necessary.
53. C Self-starvation is life-threatening; the client should be
monitored for self- destructive tendencies. The nurse must stay with
the client during meals to ensure that food is being eaten. The
client should be weighed three times daily in light clothing to
ensure accuracy. Praising the client for looking better could signal
a power struggle with the client and the nurse's unconscious means of
exerting control.
54. C Sublingual medication should be placed under the tongue.
Buccal medication should be placed in the cheek. Eyedrops should be
instilled in the lower lid in the conjunctival sac. Oral medications
should be placed on the tongue and swallowed.
55. B The pelvic tilt exercise, which can be done standing as
well as lying down, can greatly relieve back discomfort. As the
pregnancy progresses into the last trimester, women typically develop
a "swayback" curvature of the spine to counterbalance the enlarging
fetus. Tilting of the pelvis aligns the spine, decreasing pressure
and back discomfort. Lying down more during the day may not be
possible or convenient for some clients. Also, the supine position
may not be comfortable for some clients and may cause vena cava
syndrome (dizziness on rising and decreased circulation to the fetus).
Avoiding bending over as much may not be realistic for the client's
circumstances, nor does it address back pain as effectively as the
pelvic tilt. The last response doesn't help to relieve the client's
discomfort.
56. D The client isn't withdrawn or showing other signs of
anxiety or depression. Therefore, the nurse can probably safely
approach her about talking with others who have had similar
experiences, either through Reach for Recovery or another formal
support group. The nurse may educate the client's spouse or partner
to listen for concerns, but the nurse shouldn't tell the client's
spouse what to do. The client must consult with her physician and
make her own decisions about further treatment. The client needs to
express her sadness, frustration, and fear. She can't be expected to
be cheerful at all times.
57. B When inserting a urinary catheter, facilitate insertion by
asking the client to breathe deeply. Doing this will relax the
urinary sphincter. Initiating a stream of urine isn't recommended
during catheter insertion. Turning to the side or holding the labia
or penis won't ease insertion, and doing so may contaminate the
sterile field.
58. C The client should report the presence of foul smelling or
cloudy urine. Unless contraindicated, the client should be instructed
to drink large quantities of fluid each day to flush the kidneys.
Sandlike debris is normal due to residual stone products. Hematuria
is common after lithotripsy.
59. D Because cystic fibrosis clients have elevated levels of
sodium and chloride in their sweat, a sweat test is performed to
confirm this disorder. After pilocarpine (a cholinergic medication
that induces sweating) is applied to a gauze pad and placed on the
arm, a low- intensity, painless electrical current is applied for
several minutes. The arm is then washed off, and a filter paper is
placed over the site with forceps to collect the sweat. Elevated
levels of sodium and chloride are diagnostic of cystic fibrosis. No
fasting is necessary before this test and no blood sample is required.
A low-sodium diet isn't required before the test.
60. B An S3 is heard following an S2, which commonly occurs in
clients experiencing heart failure and results from increased filling
pressures. An S1 is a normal heart sound made by the closing of the
mitral and tricuspid valves. An S4 is heard before an S1 and is caused
by resistance to ventrieular filling. A murmur is heard when there's
turbulent blood flow across the valves.
61. C If immunoglobulin is administered within 2 weeks of
exposure it usually prevents HAV. If family members do contract HAV,
the course of the disease may be reduced to a subclinical infection
after receiving immunoglobulin. Immunoglobulin provides passive
immunity for 6 to 8 weeks only--not for life. If a person with antiHAV antibodies is exposed to HAV, it isn't necessary to administer
immunoglobulin.
62. A A rebound effect from racemic epinephrine can occur up to 4
hours after treatment with signs of respiratory distress (tachypnea,
restlessness, cyanosis). Tachycardia may initially follow treatment
with racemic epinephrine as well as improvement in client status
(improved oxygenation and improved color).
63. B During the first 24 hours after a burn, interstitial and
intracellular fluid shifts occur and intravascular fluid volume
decreases. Hypovolemia calls for fluid replacement therapy to
maintain vital organ perfusion. Keeping IV fluids at the current rate
wouldn't correct the client's fluid deficit. A vasoconstrictor would
be inappropriate because it doesn't correct fluid volume deficits.
64. B When clients are on mechanical ventilation, the artificial
airway impairs the gag and cough reflexes that help keep organisms
out of the lower respiratory tract. The artifical airway also
prevents the upper respiratory system from humidifying and heating
air to enhance mucociliary clearance. Manipulations of the artificial
airway sometimes allow secretions into the lower airways. With
standard procedures the other choices wouldn't be at high risk.
65. B Lack of social support most directly indicates that the
client is at risk for ineffective coping related to the effects of
chronic illness. Sleeping habits and adverse drug effects are
physiological responses to illness but don't indicate difficulty
coping. Presence of a panic disorder is a problem unrelated to
another chronic illness.
66. A Chest physiotherapy aids in loosening secretions in the
entire respiratory tract. Pancreatic enzymes aid in the absorption of
necessary nutrients--not in managing secretions. Oxygen therapy
doesn't aid in loosening secretions and can cause carbon dioxide
retention and respiratory distress in children with cystic fibrosis.
A high-calorie diet is appropriate but doesn't facilitate respiratory
effort.
67. D Transmission of HIV can occur through breast milk, so
breast-feeding should be discouraged in this case.
68. A Autocratic leaders obtain power with a group by maintaining
control over the group. Democratic leaders share power by allowing
consensus decision making and distribution of power. Participative
leadership is another term for democratic leadership. Laissez-faire
leaders maintain no control over the group; decision making is
unstructured and commonly performed by an unofficial leader of the
group.
69. B It's mandatory in most settings to have a physician's order
before restraining a client. A client should never be left alone
while the nurse summons assistance. All staff members require annual
instruction on the use of restraints, and the nurse should be
familiar with the facility's policy.
70. C Hypertension is confirmed by two or more readings with
systolic pressure of at least 140mmHg and diastolic pressure of at
least 90mmHg. Option A is premature. Option B isn't as specific as
option C and also is insensitive to the client's anxiety. Option D
gives false reassurance; the client does need to have his blood
pressure reevaluated.
71. D The caregiver who feels unable to control the client's
behavior and unable to cope with the responsibility of caregiving is
at the greatest risk for depression and role strain. A close
relationship with the client who has Alzheimer's disease doesn't
place the caregiver at greater risk for role strain and depression.
Absence of formal support may cause role strain and depression, but
the effect may be mitigated by the caregiver's coping mechanisms and
skills. A deeper understanding of the disease is unlikely to increase
role strain or depression.
72. B The nurse needs to provide special care to the neural tube
sac to prevent infection. Allowing the sac to dry could result in
cracks that allow microorganisms to enter. Pressure on the sac could
cause it to rupture, creating a portal of entry for microorganisms.
Administering antibiotics and keeping the sac free from urine and
stool are other measures to prevent infection. Adequate nutrition is
a concern for all neonates, including those with a myelomeningocele.
Like all neonates, the neonate with a myelomeningocele must be kept
warm, but care must be taken to avoid drying out the neural tube sac
with a radiant heater or exerting pressure using a sheet or blanket
over the sac.
73. A This client may be at risk for altered perceptions related
to an unfamiliar environment. Nothing in this case relates to pain or
medication for pain. Also, no information is given regarding the
client's cognitive function. Impaired sense of time would be included
in altered perceptions.
74. A ADH is the hormone lacking in diabetes insipidus. The
client's TSH, FSH, and LH levels won't be affected.
75. D Caregivers must use surgical asepsis when performing any
procedure in which skin integrity is broken or a sterile body cavity
is entered. Because it disrupts skin integrity and involves entry
into a sterile cavity (a vein), inserting an IV catheter requires
surgical asepsis. The other options require the use of clean
technique to prevent the spread of infection. Hand washing cleans the
hands; it doesn't sterilize them. The GI tract isn't sterile;
therefore, irrigating an NG tube or a colostomy requires only clean
technique.
76. A If the client tells the nurse to leave, the nurse should
leave but let the client know that she'll return so that he doesn't
feel abandoned. Not heeding the client's request can agitate him
further. Also, challenging the client isn't therapeutic and may
increase his anger. False reassurance isn't warranted in this
situation.
77. A Individuals with dependent personality disorder typically
show indecisiveness, submissiveness, and clinging behaviors so that
others will make decisions for them. These clients feel helpless and
uncomfortable when alone and don't show interest in solitary
activities. They also pursue relationships in order to have someone
to take care of them. Although clients with dependent personality
disorder may become depressed and suicidal if their needs aren't met,
this isn't a typical response.
78. D The nurse should refer this client to a sex counselor or
other professional. Making appropriate referrals is a valid part of
planning the client's care. The nurse doesn't normally provide sex
counseling.
79. D Denial is an unconscious defense mechanism in which
emotional conflict and anxiety is avoided by refusing to acknowledge
feelings, desires, impulses, or external facts that are consciously
intolerable. Withdrawal is a common response to stress, characterized
by apathy. Logical thinking is the ability to think rationally and
make responsible decisions, which would lead the client to admitting
the problem and seeking help. Repression is suppressing past events
from the consciousness because of guilty association.
80. C The equation used to calculate the flow rate is:
drops/minute= volume (in milliliters)×drip factor
(drops/milliliter)/time (in minutes). So, the calculation is: 75mL
×15gtt/mL/60 minutes=18.75 gtt/minute=19 gtt/minute.
81. C The nurse can gently irrigate the tube but must take care
not to reposition it. Repositioning can cause bleeding. Suction
should be applied continuously--not every hour. The NG tube shouldn't
be clamped postoperatively because secretions and gas will accumulate,
stressing the suture line.
82. C Considering the circumstances surrounding these symptoms,
they most probably signal a panic attack, which is a period of
intense fear or discomfort that develops abruptly, and peaks in 10
minutes. An allergic reaction would have a precipitating cause and
may also include a cutaneous reaction or edema. An MI would involve
chest pain or cardiac compromise. Hypoglycemia rarely includes
shortness of breath but would need to be differentiated by obtaining
the client's blood glucose level.
83. B Decreased PaO2 indicates hypoxemia, which is a universal
finding in ARDS. The PaO2 level is low early in the disease due to
hyperventilation and then elevates later in the disease due to
fatigue and worsening clinical status. The
level may be low in
ARDS and is related to reduced tissue oxygenation. The
carboxyhemoglobin level will be increased in a client with an
inhalation injury, which commonly progresses into ARDS. This isn't a
common cause of ARDS.
84. B Infection at any time is a problem for the client with AIDS
because the immune system is depressed. Invasive procedures, which
always increase the risk of infection, are numerous during labor and
delivery. Clients with AIDS usually die from opportunistic diseases,
not childbirth itself. Deficient fluid volume isn't a major concern
to the nurse at this time. The fetus may acquire AIDS in utero, but
it isn't currently believed that AIDS directly affects the placenta
or oxygen transfer to the fetus.
85. C Emotional support from the family is the main need. A
special diet doesn't focus on emotional needs. Role expectations
don't address the main issue, but emotional support while the client
is fulfilling these roles is important. The family's ability to
understand the ups and downs of the illness will help them but not
the client.
86. B The incidence of ovarian cancer increases in women who have
never been pregnant, are infertile, or have menstrual irregularities
and after menopause. Other risk factors include a personal or family
history of ovarian, breast, bowel, or endometrial cancer. The risk of
ovarian cancer is reduced in women who have taken oral contraceptives,
have had multiple births, or have had a first child at a young age.
87. 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.
88. B Setting limits for unacceptable behavior is most important
in a manic client. Typically, depressed, anxious, or suicidal clients
don't physically or mentally test the limits of the caregiver.
89. C Humulin 70/30 insulin is a combination of 70% NPH insulin
and 30% regular insulin.
90. A Bone fracture is a major complication of osteoporosis that
results when loss of calcium and phosphate increases the fragility of
bones. Estrogen deficiencies result from menopause--not osteoporosis.
Calcium and vitamin D supplements may be used to support normal bone
metabolism, but a negative calcium balance isn't a complication of
osteoporosis. Dowager's hump results from bone fractures. It develops
when repeated vertebral fractures increase spinal curvature.
91. D The nurse's release of information to the client's employer
without the client's consent is a breach of confidentiality. The
stigma associated with psychiatric illness may affect the client's
employment; therefore, it's better to maintain confidentiality and
refrain from disclosing any information about the client, including
whether she's a client in the hospital.
92. C A rating of 2 or 3 on a scale of 0 to 10 is considered mild
pain, which is to be expected after abdominal surgery. Redosing
during the night, which disrupts sleep, is a disadvantage of this
method and doesn't indicate adequate or inadequate pain relief. A
depressed respiratory rate of 10 breaths/minute is an adverse effect
of an opiate analgesic rather than indication of comfort. Itching is
a common adverse effect and bears no relationship to pain relief.
93. B FHR and maternal blood pressure will provide important data
on the conditions of mother and fetus. An IV should be started after
the maternal-fetal dyad is assessed. Preparing the client for a
cesarean delivery before determining the cause of the vaginal
bleeding would be premature. Maternal heart rate and respiratory rate
aren't the best indicators of maternal health status and provide no
information about fetal health.
94. A Decreasing anxiety can break the fear-tension-pain cycle.
Analgesics given too early can prolong labor. Informing the client
that the neonate's head isn't down far enough and telling her that
her contractions are only moderately strong aren't helpful or
encouraging; she obviously needs immediate attention of some kind.
95. A Daily weight shows trends and can assist medical management
by indicating if interventions and medications are effective.
Laboratory data are objective data that indicate whether electrolyte
levels are within normal limits for the client with fluid balance
problems. However, if a client is dehydrated, some laboratory data
can show false elevations. Intake and output is extremely important,
but matching the two is difficult because fluid is also lost through
breathing, perspiration, stool, and surgical tubes. Vital signs may
or may not be helpful because heart rate and blood pressure can be
elevated by either depletion or excess of fluids in some situations.
96. B Administering amitriptyline (a tricyclic antidepressant)
and phenelzine (a monoamine oxidase [MAO] inhibitor) together could
cause hypertension, tachycardia, or a potentially fatal reaction; the
nurse should call the physician to check the order. The other options
are important nursing actions, but they don't take priority over
calling the physician.
97. B The nurse should first evaluate the muscle mass and amount
of subcutaneous fat and then select the correct size needle. Without
more information, the nurse would select the 22G, 1" needle,
appropriate for an average-sized school-age child. The 20G, 1" needle
would be unnecessarily large. The 22G,
needle would be too long.
The 20G,
needle would be too long and unnecessarily large.
98. A A client with type 1 diabetes mellitus may become
hypoglycemic while exercising. Someone must accompany her for her
safety. She should exercise at the same time each day. She needs to
exercise after meals, when blood sugar is high. Fluids aren't
necessary, but the client needs to bring a simple carbohydrate with
her to treat hypoglycemia.
99. C Blood pressure of 146/90mmHg indicates pregnancy-induced
hypertension (PIH). Over time, PIH reduces blood flow to the placenta;
it can cause intrauterine growth retardation and other problems that
make the fetus less able to tolerate the stress of labor. A weight
gain of 30 lb is within the expected parameters for a healthy
pregnancy. A woman over age 30 doesn't have a greater risk of
complications if her general condition is healthy before pregnancy.
Syphilis that has been treated doesn't pose an additional risk.
100. A The signs and symptoms stated in this case are typical of
a client with situational low self-esteem. The diagnosis of
unilateral neglect occurs in neurologic illness or trauma when the
client shows a lack of awareness of a body part. This client is at
risk for social isolation and loneliness, but there's no indication
in the case study that these diagnoses are present.
101. C Pouring solution onto a sterile field cloth violates
surgical asepsis because moisture penetrating the cloth can carry
microorganisms to the sterile field via capillary action. The other
options are practices that help ensure surgical asepsis.
102. B Increasing fluid volume and urine output is the main
consideration when fluid replacement therapy is indicated. Therefore,
DSW and a hypotonic solution would be indicated. Distilled water is
never given for IV replacement therapy, even though it's a hypotonic
solution. Potassium chloride is added when adequate output is
established, depending on the extent of hypokalemia determined by
laboratory electrolyte studies. Dextrose 10% in saline is a
hypertonic solution that increases the degree of osmotic pressure and
would increase intracellular dehydration; therefore, it's
contraindicated.
103. B The blood glucose level should return to normal within 3
hours. Some hypoglycemia (a less than normal amount of glucose in the
blood) within this time can be expected without causing problems.
104. C The client needs to be informed of the activity and when
it will be done. Giving the client choices isn't desirable because he
can he manipulative or refuse to do anything. Negotiating and
preparing the client ahead of time also isn't therapeutic with this
type of client because he may not want to perform the activity.
105. C The donor and recipient must have compatible blood and
tissue types. They should be fairly close in size and age. When a
living donor is considered, it's preferable to have a relative donate
the organ. Need is important, but it can't be the critical factor if
a compatible donor isn't available.
106. C Tidal volume refers to the volume of air inspired and
expired with a normal breath. Total lung capacity is the maximal
amount of air the lungs and respiratory passages can hold after a
forced inspiration. Forced vital capacity is vital capacity performed
with a maximally forced expiration. Residual volume is the maximal
amount of air left in the lung after a maximal expiration.
107. C Nitrates act primarily to relax coronary smooth muscle and
produce vasodilation. They can cause hypotension, which makes the
client very dizzy and weak. Nitrates are taken at the first sign of
chest pain and before activities that might induce chest pain.
Sublingual nitroglycerin is taken every 5 minutes for three doses. If
the pain persists, the client should seek medical assistance
immediately. Nitrates must be stored in a dark place in a closed
container. Sunlight causes the medication to lose its effectiveness.
Alcohol is prohibited because nitrates may enhance the effects of
alcohol.
108. C Children who have had rheumatic fever are more susceptible
to contract it again. Prophylactic antibiotics are typically
maintained for at least 5 years. Psychosocial development can be
promoted even before a return to school is appropriate. Physical
activity should be limited until cardiac status is normal. Choreic
movements aren't permanent and aren't seizures.
109. B Worsening pain after a total hip replacement may indicate
dislocation of the prosthesis. Assessment of pain should include
evaluation of the wound and the affected extremity. Assuming he's
anxious about discharge and administering pain medication don't
address the cause of the pain. Sudden severe pain isn't normal after
hip replacement. Wound infections are usually distinguished by
purulent drainage.
110. D According to Erickson's theory of personal development,
the adolescent is in the stage of identity versus role confusion.
During this stage, the body is changing as secondary sex
characteristics emerge. The adolescent is trying to develop a sense
of identity, and peer groups take on more importance. When an
adolescent is hospitalized, she's separated from her peer group and
her body image may be altered. Toddlers are in the developmental
stage of autonomy versus shame and doubt. Preschool children are in
the stage of initiative versus guilt. School-age children are in the
stage of industry versus inferiority.
111. C Propantheline bromide is classified as a GI
anticholinergic; the medication inhibits muscarinic actions of
acetylcholine at postganglionic parasympathetic neuroeffector sites.
For gallbladder disease, propantheline has an antispasmodic effect on
the bile duct and gallbladder. Although the medication reduces
production of gastric solutions and also reduces hypermobility, it
isn't the main reason for the medication. The drug doesn't slow
emptying of the stomach or reduce chyme in the duodenum.
112. C Hot-water bottles and heating pads should never be used to
warm cold feet. Because many clients with diabetes mellitus have
neuropathy and can't feel temperature changes, serious injuries or
burns may occur. Socks should be worn for warmth. Feet should be
examined each day for cuts, blisters, swelling, redness, tenderness,
and abrasions. Lotion should be applied to dry feet but never between
the toes. After a bath, the client should gently--not vigorously--pat
feet dry to avoid injury.
113. A Signs and symptoms of hypoglycemia include anxiety,
restlessness, headache, irritability, confusion, diaphoresis, cool
skin, tremors, coma, and seizures. Kussmaul's respirations, dry skin,
hypotension, and bradycardia are signs of diabetic ketoacidosis.
Excessive thirst, hunger, hypotension, and hypernatremia are symptoms
of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight
loss are classic signs and symptoms of diabetes mellitus.
114. C Because of changes in fat distribution, adipose tissue
accumulates in the trunk, face (moon face), and dorsocervical areas
(buffalo hump). Hypertension is caused by fluid retention. Skin
becomes thin and bruises easily because of a loss of collagen. Muscle
wasting causes muscle atrophy and thin extremities.
115. D Abduction places the femoral head into the acetabulum for
correct alignment. Placing the client in semi-Fowler’s position with
both legs flexed or with his legs adducted and his head elevated
won't help correct the problem. Swaddling the client in a baby
carrier would worsen the dislocation.
116. C Hand washing is the major infection control measure to
reduce the risk of transmission of MRSA and other nosocomial
pathogens. No convincing evidence exists to support that bathing
clients with antibacterial soap is effective. Culture surveys can
help establish the true prevalence of MRSA in a facility but is used
only to help implement where and when infection-control measures need
to be implemented. Because contaminated environmental surfaces aren't
an important reservoir for MRSA, specific housekeeping practices
aren't warranted.
117. B A soft, relaxed, nontender uterus accompanied by vaginal
bleeding indicates placenta previa. A rigid abdomen indicates
abruptio placentae, in which a normally implanted placenta in the
upper uterine segment prematurely separates from its implantation
site. In placenta previa, the placenta isn't normally implanted, and
the client shouldn't feel pain when it begins to break away.
Hypotension may indicate many conditions other than placenta previa.
Also, bleeding with placenta previa may not be severe enough to cause
hypotension.
118. B Recognizing an individual's positive health measures is
very useful. General health in the previous 10 years is important;
however, the current activities of an 85-year-old client are most
significant in planning care. Family history of disease for a client
in later years is of minor significance. Marital status information
may be important for discharge planning but isn't as significant for
addressing the immediate medical problem.
119. B Identification of causes of medication errors requires inservice education to inform the staff of strategies to decrease these
errors. Errors are frequently the result of systemic problems that
can be identified and rectified through problem-solving techniques
and changes in procedures. Documenting or reporting the situation
wouldn't directly assist the nurses in eliminating errors. Reporting
the incidents to the hospital attorney isn't necessary.
120. B The client should be encouraged to increase his activity
level. Maintaining an ideal weight; following a low-cholesterol, lowsodium diet; and avoiding stress are all important factors in
decreasing the risk of atherosclerosis.
121. A Burning and tingling genital discomfort is the most common
initial finding. This symptom will advance to vesicular lesions
rupturing into ulcerations, which then dry into a crusty erosion. The
client may also experience fever, headache, malaise, myalgia,
regional lymphadenopathy, and dysuria.
122. A Multiple structural changes occur in the eyes of aging
clients. Vision is often diminished, particularly night vision.
Healing is slowed from nitrogen loss. Women have increased facial
hair, while men have decreased facial hair.
123. D The nurse should instruct the client to use only a watersoluble lubricant when inserting a suppository. Tampons shouldn't be
used because the tampon will absorb some medication, making the
medication less effective. When removing the applicator, the client
should keep the plunger depressed. Suppositories may be refrigerated
to keep their form.
124. C Neonates born with fetal alcohol syndrome have upturned
noses, flattened nasal bridges, and a thin upper lip. They may also
be small for gestational age.
125. C Of the choices listed, aspiration is the most serious
potential complication of tube feedings. Dehydration--not fluid
volume excess--is a concern because of decreased free water intake.
Hyperglycemia, not hypoglycemia, is a complication secondary to
carbohydrate load of enterat feeding solutions. Constipation is a
problem, but it usually isn't a serious one. The client would most
likely experience diarrhea.
126. B Vitamins C, B6, and B12 are necessary for collagen
synthesis that takes place during wound healing. Folate enables
oxygen transport. Vitamin A is needed for reversal of effects of the
glucocorticoids. Thiamine is required for carbohydrate metabolism.
127. A Before administering medication to a client in labor, the
nurse must assess the client and fetus. Pain medication can be given
when the client is in active labor. A sonogram is inappropriate for a
client in labor. The vaginal examination had just been performed and
therefore isn't necessary at this time.
128. C Women generally feel best during the second trimester.
Most enjoy a rather tranquil few months when they experience
quickening and begin to "show" without the heaviness and awkwardness
of the third trimester. Feelings of disbelief and ambivalence are
more common in the first trimester; feelings of clumsiness and
"ugliness" and anxiety about the labor and delivery experience are
more common in the third trimester.
129. A Polyuria is a hallmark sign of type 1 diabetes mellitus.
Parents often notice this symptom as bed wetting in a child
previously toilet trained. Polyphagia is also a hallmark sign of type
1 diabetes mellitus. A parent is likely to report that a child eats
excessively but seems to be losing weight. The child with type 1
diabetes mellitus may also complain of fatigue.
130. A Teenage lifestyles and support systems can vary immensely.
This open-ended question will best help the health team gather data
about the teen mother's feelings and expectations. The other options
aren't open-ended and don't clearly ask the client about her
expectations.
131. C The spread of childhood infections, including impetigo,
can be reduced when children are taught proper hand-washing technique.
Because impetigo is spread through direct contact, covering the mouth
and nose when sneezing won't prevent its spread. Currently, there's
no vaccine to prevent a child from contracting impetigo. Isolating
the child with impetigo is unnecessary.
132. B After a client gives birth, the height of her fundus
should decrease about one fingerbreadth (about 1 cm) each day.
Immediately after birth, the fundus may be above the umbilicus. At 6
to 12 hours after birth, it should be at the level of the umbilicus.
By the end of the first postpartum day, the fundus should be one
fingerbreadth below the umbilicus. After 10 days, it should be below
the symphysis pubis.
133. A Initially, the nurse needs to inform the surgeon that the
task is outside the scope of nursing practice. If the surgeon still
requests the activity, the nurse should refuse to perform the task
and should follow the chain of communication for reporting unsafe
practice according to the hospital's policy. The nurse must not
comply with any order that goes beyond the scope of nursing practice.
134. B Vision changes, such as halos around objects, are signs of
digoxin toxicity. Hearing loss can be detected through hearing
assessment; however, it isn't a common sign of digoxin toxicity.
Intake and output aren't affected unless there's nephrotoxicity, but
that situation is uncommon. Gait changes are also uncommon.
135. C In rheumatic fever, the joints may be so painful that even
the weight of the bed linens can cause pain. A bed cradle lifts the
weight of the linens off the child, reducing pain. Pain may be
increased when the affected joint is moved; therefore, passive ROM
exercises aren't recommended. Pain isn't likely to be relieved by
massaging the joints. The child should be encouraged to change
positions at least every 2 hours, to reduce the risk of skin
breakdown, but this is unlikely to relieve joint pain.
136. D Although all of these options are appropriate
postoperative goals, maintaining a patent airway takes priority,
especially on the first postoperative day. A laryngectomy tube is
most likely to be in place, and suctioning is commonly needed to
clear secretions. Edema and hematoma formation at the surgical site
also can increase the risk of a blocked airway. Communicating by use
of esophageal speech and attaining optimal level of nutrition are
important hut wouldn't take priority on the first postoperative day.
Improving body image is a long-term goal.
137. D The nurse has a responsibility to observe continuously the
acutely suicidal client--not provide privacy. The nurse should watch
for clues, such as communicating suicidal thoughts, threats, and
messages; hoarding medications; and talking about death. By
accompanying the client to the bathroom, the nurse will naturally
prevent hanging or other injury. The nurse will check the client's
area and fix dangerous conditions, such as exposed pipes and windows
without safety glass. The nurse will also remove potentially
dangerous objects, such as belts, razors, suspenders, glass, and
knives.
138. A Clients should use caution when taking nitroglycerin
because it commonly causes orthostatic hypotension and dizziness. The
client should rise slowly and lie down at the first sign of dizziness.
To ensure potency, store nitroglycerin in a tightly closed container
in a cool, dark place and replace the tablets every 3 months. Many
brands of nitroglycerin no longer cause a burning sensation. The
client should take a sublingual nitroglycerin tablet at the onset of
chest pain and repeat the dose every 5 to 10 minutes, for up to 3
doses. If this doesn't relieve chest pain, the client should seek
immediate medical attention.
139. C Client-care quality should always be the first
consideration when proposing a change in care provision.
Institutional resources, standards of practice, and nursing
recruitment will all influence the decision but none as much as
client-care quality should.
140. D Pulse oximetry is a noninvasive procedure in which a small
sensor is positioned over a pulsating vascular bed. It can be used
during transport and causes the client no discomfort. An incentive
spirometer is used to assist the client with deep breathing after
surgery. ABG measurement can measure SaO2, but this is an invasive
procedure that can be painful. Some clients with asthma use peak flow
meters to measure levels of expired air.
141. B To test for PKU, a neonate must have had a sufficient
intake of phenylalanine through the ingestion of either formula or
breast milk for at least 2 days. A neonate who has been receiving IV
fluids and hasn't yet received breast milk or formula isn't ready to
be tested for PKU. A neonate who is discharged within 24 hours of
delivery will need to see the physician for PKU testing after
receiving formula or breast milk for 48 hours.
142. B Decreased abdominal strength, muscle tone of the
intestinal wall, and motility all contribute to chronic constipation
in the elderly. A decrease in hydrochloric acid causes a decrease in
absorption of iron, and an increase in intestinal bacteria actually
causes diarrhea.
143. C In Maslow's hierarchy of needs, pain relief is on the
first layer. Activity is on the second layer. Safety is on the third
layer. Love and belonging are on the fourth layer.
144. C Changing the client's position frequently allows for
increased circulation and helps to prevent skin breakdown. The
immobilized client receives minimal benefit from sitting upright in a
chair for 30 minutes, twice daily. The client shouldn't be left in
one position for longer than 2 hours. The greatest pressure shouldn't
be placed on bony prominences because these areas can break down from
increased pressure.
145. C Some cultures hold that if a pregnant woman looks upon a
dead animal, the fetus is exposed to the realm of the dead and may
later become ill as a baby. The nurse’s response is sensitive to the
mother's beliefs and eases the way for the mother to begin to talk
about her concern. Option A discounts the mother's beliefs. Option B
dismisses the mother's concerns and offers false reassurance. Option
D carries empathy over into false validation and overreaction, yet it
fails to set up any dialogue with the client.
146. D Preoxygenate the client with 100% oxygen before suctioning
to prevent the hypoxia that occurs when the client is disconnected
from the oxygen source and oxygen is removed from the airway during
suctioning. To avoid hypoxia and trauma to the trachea, suction
shouldn't be applied when inserting the catheter. To prevent hypoxia,
never suction longer than 15 seconds. A suction catheter that has
been used to suction the mouth should be considered contaminated and
shouldn't be used to suction the endotracheal tube.
147. B Tetralogy of Fallot consists of four congenital anomalies,
pulmonary artery stenosis, intraventricular septal defect, overriding
aorta, and right ventricular hypertrophy. The other combinations of
defects aren't characteristic of tetralogy of Fallot.
148. D Glycopyrrolate is a parasympatholytic that will decrease
the risk of aspiration. Meperidine and promethazine can cause central
nervous system and respiratory depression in neonates. Oxytocin
precipitates labor.
149. C The law doesn't require informed consent in an emergency
situation when the client is unable to give consent and no next of
kin is present. A mentally competent client may refuse or revoke
consent at any time. Even though a client who is declared mentally
incompetent can't give informed consent, mental illness doesn't by
itself indicate that the client is incompetent to give informed
consent. Although the nurse may act as a client advocate, the nurse
can never give substituted consent.
150. C Addressing the client's urgent physical needs is most
important. The other diagnoses are possible with anorexia nervosa,
but no data in the case study directly support them.
151. A Young children commonly demonstrate regressive behavior
when anxious, under stress, or in a strange environment. Although the
child could be deliberately wetting the bed out of anger, her
behavior is most likely not under voluntary control. It's appropriate
to expect a 3-year-old child to be toilet-trained, but it isn't
appropriate to expect that child to be able to utilize a call light
to summon the nurse.
152. A The breasts are least tender and have fewer nodules 1 week
after menstruation starts. Before the onset of menstruation, breasts
may be most tender and nodular. Examining the breasts every day or
after every shower is excessive and unnecessary.
153. C Air leaks commonly occur if the system isn't secure.
Checking all connections and taping will prevent air leaks. The chest
drainage system is kept lower to promote drainage--not to prevent air
leaks. The head of the bed may be elevated to promote drainage. Chest
tubes that aren't patent may lead to tension pneumothorax but
wouldn't cause an air leak.
154. B This demonstrates the nurse's concern and encourages the
client to discuss feelings. Given the likelihood of an increase in
anxiety level, the client shouldn't be left alone. Summoning help may
escalate the client's anxiety. Saying nothing and pacing with the
client acknowledge the client's emotional state.
155. C Cerebral hyperemia (excess blood in the brain) causes an
initial increase in intracranial pressure in the head of an injured
child. The brain is less myelinated in a child and more easily
injured than an adult brain. Intracranial hypertension--not
hypotension-- places the child at greater risk for secondary brain
injury. A child's cranium is thinner and more pliable, causing the
child to receive a more severe injury.
156. B A stiff neck and headache may be prodromal symptoms of
hypertensive crisis. Rather than dismiss the symptoms, the nurse
should continue to assess them and consult the physician.
Administering an analgesic and helping the client relax would be
appropriate measures for a tension headache.
157. A Cocaine causes increased uterine contractility, preterm
labor, and illness in babies born to addicted mothers. This client is
in active labor, has a questionable history, and an undetermined
length of gestation. The nurse should anticipate a quick delivery and
a small, sick neonate. This client isn't in a teachable frame of mind
or situation. Calling a family member isn't a priority when a highrisk birth is imminent. The client's friend may be impossible to
locate and may not know exactly what was in the cigarette.
158. A A person's psychosocial needs during the dying process of
a relative may include flexible visitation, participation in client
care, and rest breaks. Denial of death may be a response to the
situation but isn't classified as a need. Visitation should
accommodate wishes of the family member as long as client care isn't
compromised.
159. C Walking from his room to the end of the hall and back
before discharge is a specific, measurable, attainable, timed goal.
It's also a client-oriented outcome goal. Having the client change
his own dressing is incomplete and not as significant. Just walking
in the hall isn't measurable. The need for a special diet isn't
evident in this case.
160. C Lethargy in the neonate may be seen with hypoglycemia
because of a lack of glucose in the nerve cells. Peripheral
acrocyanosis is normal in the neonate because of immature capillary
function. Tachycardia, not bradycardia, is seen with hypoglycemia.
Jaundice isn't a sign of hypoglycemia.
161. B This response offers support and sets limits. Option A
doesn't offer support. Option C allows the client to continue to
break rules. Option D offers neither support nor respect.
162. D Abdominal pain, low-grade fever, and vomiting are cardinal
signs of appendicitis. Administration of a laxative during
appendicitis is dangerous because it may cause the appendix to
rupture. Rebound tenderness is also a symptom but would be found in
the right lower quadrant.
163. A The diagnosis of DIC is based on the results of laboratory
studies of PT, platelet count, thrombin time, PTT, and fibrinogen
level as well as client history and other assessment factors. Blood
glucose levels, WBC count, calcium levels, and potassium levels
aren't used to confirm a diagnosis of DIC.
164. B Increased fluids and fiber will soften the stool, making
it easier to pass without medication use. Taking a laxative makes the
client rely on medication. Relaxing during bowel movements is
important but doesn't address the problem as effectively as
increasing fluids and fiber. Starting a strenuous exercise program is
discouraged during pregnancy unless the client is already accustomed
to it. Mild exercise is safe, however, and may increase peristalsis
and enhance stool passage.
165. A The nurse can best help the parents by countering the
false belief that the death is their fault or that they could have
prevented it. Informing the parents that an autopsy needs to be
performed is a secondary concern. Stressing that they're still young
and can have more children minimizes their feelings of grief.
Instructing the parents to place other infants on their backs to
sleep implies that the parents did something to cause the death.
166. B To protect others from a client who exhibits belittling
and demanding behaviors, the nurse may need to set limits with
consequences for noncompliance. Asking others to ignore the client is
likely to increase those behaviors. Offering the client an
antianxiety drug or stimulating activities provides no motivation for
the client to change problematic behaviors.
167. A Women during the second trimester are somewhat
narcissistic; at the same time, they're commonly fascinated by
children. Extroversion is a personality trait not specific to
pregnancy; emotional lability may be present in every trimester.
Ambivalence and uncertainty are characteristic of the first trimester.
Dismay over body image and readiness for pregnancy to be over are
characteristic of the third trimester.
168. C Measures to treat pruritus include tepid sponge baths and
the use of emollient creams and lotions. Hot water should be avoided
because capillary dilation may increase pruritus. Warm water is
preferred to cold. The use of emollient creams and lotions on dry
skin is recommended.
169. A Anxiety is a normal reaction to the termination of the
nurse-client relationship. The nurse should help the client explore
his feelings about the end of the therapeutic relationship. While
anger about the termination may be a healthy response, banging the
table, shouting, and other forms of acting out aren't appropriate
behavior. Withdrawal isn't a healthy response to the termination of a
relationship. By rationalizing the termination, the client avoids
expressing his feelings and emotions.
170. D Fat emboli may occur with fractures of the long bones and
pelvis and may be fatal. Clinical manifestations include cyanosis,
dyspnea, tachycardia, chest pain, tachypnea, apprehension,
restlessness, confusion, petechiae, and decreased PaO2. Increased
PaO2,reduced sensation in left leg or foot, pain in the affected
extremity, skin bruises, and bradycardia aren't associated with fat
emboli.
171. A Before planning any intervention with a client who smokes,
it's essential to determine whether the client is willing or ready to
stop smoking. Commonly, a pregnant woman will agree to stop smoking
for the duration of the pregnancy. This gives the nurse an
opportunity to work with her over time to help with permanent smoking
cessation.
172. C This response acknowledges the client's behavior and
explores his feelings. Options A and B assume that the client is
anxious, which may be a projection on the nurse's part, considering
the client's history of aggression. Option D ignores what might be
going on with the client.
173. C Furosemide is a potassium-wasting diuretic. A low
potassium level may cause weakness and palpitations. Telling the
client to rest more often won't help the client if she's hypokalemic.
Digoxin isn't causing the client's symptoms, so she doesn't need to
stop taking it. The client should probably avoid caffeine, but this
wouldn't resolve potassium depletion.
174. D Lochia rubra is usually seen during the first 1 to 3 days.
It should be moderate in amount and may include some small clots.
Four to eight perineal pads are used daily on average. Heavy bleeding
could be from uterine atony or retained placental fragments and
therefore requires further investigation. Lochia serosa follows
lochia rubra and lasts to about the 10th postpartum day. Lochia alba
is seen from approximately the 11th to the 21st postpartum day.
175. A Egg yolks, nuts, seeds, and liver are all high in folic
acid. The other options aren't good sources of folic acid.
176. B A voluntary client who poses a danger to himself or others
may be denied permission to leave the hospital. The other options are
important assessments, but the client's danger to himself or others
takes priority.
177. A Early induction or early cesarean delivery are
possibilities if the mother has diabetes and euglycemia that hasn't
been maintained during pregnancy. Cesarean delivery isn't always
necessary.
178. B When the nurse is placed in this situation, the most
appropriate action is to set priorities and identify potential areas
of harm to the client. Reassignment to another nursing area is an
acceptable legal practice used by hospitals to meet their staffing
needs. A nurse can't legally refuse to be reassigned unless there's a
specific clause in her union contract.
179. B A client such as this one needs sensory stimulation and
should never be left alone (although the nurse should maintain the
client's privacy). Restraints should be removed for 5 minutes at
least every 2 hours. A client in restraints should have someone with
him at all times. Fluids are offered, and the client is given food at
mealtimes.
180. D This statement shows an understanding of nutritional needs
during pregnancy. Option A accurately portrays weight gain but
doesn't express an understanding of nutritional needs. Option B
doesn't show an understanding of either nutritional needs or how and
when the weight gain will occur. Option C is a common rationalization
that can result in excessive weight gain.
181. D By leaving the client, the nurse is at fault for
abandonment. The better course of action is to turn on the call bell
or elicit help on the way to the client's room. Educating the client
about safety measures doesn't alleviate the nurse from responsibility
for ensuring the client's safety. The nurse can't restrain the client
without a physician's order and restraints won't ensure the client's
safety. Documenting that she left the client doesn't excuse the nurse
from her responsibility for ensuring the client's safety.
182. B Rebound tenderness, McBurney's sign (pain midway between
umbilicus and right iliac crest), and a low-grade fever are all signs
of appendicitis. Other clinical findings include a rigid abdomen, a
preference to lie still with right leg flexed, right lower quadrant
pain, muscle guarding, periumbilical pain, anorexia, nausea, and
vomiting. The other findings aren't signs of appendicitis.
183. A Flashing lights in the visual field are a common symptom
of retinal detachment. Clients may also report spots or floaters or
the sensation of a curtain being pulled across the eye. Retinal
detachment isn't associated with eye pain, loss of color vision, or
colored halos around lights.
184. B The first action would be to protect the child by removing
him from the room. Calling security is necessary but only after
ensuring the safety of the child. Asking one of the family members to
leave the room or reasoning with them would be ineffective at this
point and may even escalate the situation.
185. B The small white spots that adhere to the hair shafts are
the eggs, or nits, of lice. These are easy to see and can't be
brushed off like dandruff. Flaking of the scalp may indicate dandruff
or a dry scalp. Scaly patches and pustules, due to the scratching,
may accompany a lice infestation, but nits would also be found on the
hair shafts.
186. C It's essential that AIDS clients follow safer-sex
practices to prevent transmission of the human immunodeficiency virus.
Although it's helpful if AIDS clients avoid using recreational drugs
and alcohol, for purposes of avoiding transmission it's more
important that IV drug users use clean needles and dispose of used
needles. Whether the AIDS client chooses to tell anyone about an AIDS
diagnosis is the client's decision; there's no legal obligation to do
so.
187. B During a period of crisis, the major goal is to resolve
the immediate problem with hopes of getting the individual to the
level of functioning that existed before the crisis. Withdrawing from
stress doesn't address the immediate problem and isn't therapeutic.
Anxiety will decrease after the immediate problem is resolved.
Providing support and safety are necessary interventions while
working toward accomplishing the goal. Documentation is necessary for
maintaining accurate records of treatment.
188. B Concomitant use of NSAIDs may increase the risk of a
peptic ulcer; therefore, they should be administered 2 hours before
or 2 hours after prednisone. Oral antidiabetic agents, betaadrenergic blockers, and oral contraceptive agents don't increase the
risk of peptic ulcer disease when administered with prednisone.
189. C Women are instructed to examine themselves to discover
changes that have occurred in the breast. Only a physician can
diagnose lumps that are cancerous, areas of thickness or fullness
that signal the presence of a malignancy, or masses that are
fibrocystic as opposed to malignant.
190. C The suggested sequence of a well-child exam changes when
the child is in pain. In this case, it's preferable to examine the
affected area last in order to minimize distress early in the
examination and to focus on normal, healthy body parts. Parental
presence is almost always conducive to a child's cooperation and
sense of security. Examination of the ear in an upright position is
preferable, especially in a crying child; it's less frightening for
the child and decreases the bulging of the tympanic membrane from
crying.
191. A Urine that is scant (less than 30 mL/hour) and tinged with
blood indicates potential renal damage and must be reported to the
physician. Turning the client on her left side and taking vital signs
increases blood perfusion to the uterus. Flushing the client's
indwelling urinary catheter is unnecessarily invasive and doesn't
address the blood-tinged urine. Instructing the client to turn, cough,
and deep breathe every 30 minutes has nothing to do with the client's
symptoms.
192. D Methylergonovine maleate, a vasoconstrictor, can cause
hypertension. It shouldn't be administered to a hypertensive client.
193. A HAV is predominantly transmitted by the ingestion of
fecally contaminated food. Transmission is more likely to occur with
poor hygiene, crowded conditions, and poor sanitation. Hepatitis B
and C may be transmitted through exposure to contaminated blood and
blood products. Sexual activity with an infected partner and sharing
contaminated needles or syringes may also transmit hepatitides B and
C.
194. D The pulse distal to the insertion site may be weak for a
few hours but should gradually increase in strength. The pressure
dressing shouldn't be removed because of the risk of hemorrhage.
Passive exercises on the affected extremity wouldn't be performed
after a cardiac catheterization. The physician doesn't need to be
notified at this time but should be notified if the weak pulse
continues for longer than 2 hours.
195. C Insulin administration causes glucose and potassium to
move into the cells, causing hypokalemia. Calcium levels aren't
directly affected by insulin administration. Hypophosphatemia, not
hyperphosphatemia, may occur with insulin administration because
phosphorus also enters the cells with insulin and potassium. Sodium
levels aren't directly affected by insulin administration.
196. A One cup of low-fat yogurt contains 415 mg of calcium. One
cup of skim milk has 302 mg of calcium. One ounce of cheddar cheese
has 20 mg of calcium. One cup of ice cream has 176 mg of calcium.
197. C According to the Rule of Nines, the posterior trunk,
anterior trunk, and legs each make up 18% of the total body surface.
The head, neck, and arms each make up 9% of the total body surface,
and the perineum makes up 1%. In this case, the client received burns
to his back (18%) and one arm (9%), totaling 27% of his body.
198. B Keeping the skin clean is always the highest priority. The
other measures are also important but only after the skin is cleaned.
Rub around, not directly over, pressure areas to avoid skin breakdown.
199. A Monitoring the client regularly, especially if the client
is elderly or confused, will help to prevent falls. The bed should be
kept in its lowest position unless a member of the health care team
is present and providing care. Side rails may be used judiciously to
prevent the client from falling out of bed, but the client can crawl
over side-rails. The nurse should refer to facility policy for
information about side-rails. Restraints are used with a physician's
order and only after other means have failed.
200. B Clients with gout should avoid foods high in purine.
Alcohol should be avoided because it increases the uric acid level.
Aspirin interferes with the action of allopurinol; therefore,
salicylates should be avoided. Allopurinol may irritate the gastric
lining and should be taken with food or milk.
201. A A child with acute epiglottiditis appears acutely ill, and
clinical manifestations may include drooling (because of difficulty
swallowing), severe sore throat, hoarseness, leaning forward with the
neck hyperextended, high fever, and severe inspiratory stridor. A
low-grade fever, stridor, and barking cough that worsens at night are
suggestive of croup. Pulmonary congestion, productive cough, and
fever along with nasal flaring, retractions, chest pain, dyspnea,
decreased breath sounds, and crackles are indicative of pneumococcal
pneumonia. A sore throat, fever, and general malaise point to viral
pharyngitis.
202. A Pinworms come out of the intestine through the anus at
night to lay eggs, causing perianal itching. The child wakes up and
may begin scratching. Eggs under the fingernails are carried to the
mouth if the child chews on his nails, and the pinworm's life cycle
continues. In addition to teaching children not to bite their
fingernails, parents should keep the nails short and encourage hand
washing before food preparation and eating. Sharing hairbrushes
contributes to the spread of head lice, not pinworms. Although
covering the mouth and nose are hygienic practices to reduce the
spread of infections from respiratory droplets, doing so doesn't
affect the spread of pinworms. There are no immunizations to protect
against pinworms.
203. C Obstructive jaundice develops when a stone obstructs the
flow of bile in the common bile duct. When the flow of bile to the
duodenum is blocked, the lack of bile pigments results in a claycolored stool. In obstructive jaundice, urine tends to be dark amber
(not straw-colored), as a result of soluble bilirubin in the urine.
Hematocrit isn't affected by obstructive jaundice. Because
obstructive jaundice prevents bilirubin from reaching the intestine
(where it's converted to urobilinogen), the urine contains no
urobilinogen.
204. B The nurse should allow ample time for the client to
respond and shouldn't speak for him. She should use as many aids as
possible to assist the client with communicating and encourage the
client when he attempts to communicate. When the client is ready, the
nurse can use a tracheostomy plug to facilitate speech. The other
options are inappropriate.
205. A Most accidents occur in the home and safety devices are
the most important element in minimizing injury. Shoes should be
supportive and not too worn. The client needs to use proper body
mechanics when stooping or picking up objects. Protective devices
aren't usually necessary for the client to perform exercises.
206. C This client may be experiencing elder abuse based on her
history and symptoms. Authorities to be notified may include local
social service or law enforcement agencies. The nurse should also
document findings and include illustrations to support the assessment.
The client with Alzheimer's disease may not be able to accurately
inform the nurse about what happened. Reporting findings to the
physician may not be sufficient for fulfilling the nurse's legal
responsibility.
207. C Diabetic clients should wash their feet daily to allow for
daily inspection of the feet. The client should wear nonconstrictive
shoes. Corns should be treated by a podiatrist, not with commercial
preparations. Nails should be filed straight across. Clients with
diabetes mellitus should never walk barefoot.
208. A Elderly clients are in the psychosocial stage of
continuation of ego integrity and acceptance. The client's attitude
toward life circumstances would, therefore, be the most comprehensive.
The other choices are valid and important, but option A encompasses
all the other answers.
209. C If the client isn't receiving her full course of
antibiotic therapy, her ear infections will recur; permanent hearing
loss or systemic infection may result. Parents may not understand
this and may discontinue treatment when the neonate seems better. The
other options are important aspects to assess, but none is as
critical as ensuring full compliance with antibiotic therapy.
210. B A client with COPD who has had an elevated PaCO2 level for
a prolonged time no longer depends on changes in carbon dioxide level
to regulate the respiratory drive. The client with COPD depends on
hypoxia or lower partial pressure of arterial oxygen level changes to
regulate respirations. If high levels of oxygen are administered, the
client will lose his hypoxic respiratory drive, causing respirations
to decrease or even stop. As the respirations decrease, the PaCO2
levels elevate. COPD leads to a mismatch between ventilation and
perfusion. The alveoli enlarge and overdistend, decreasing the
surface area of alveoli to capillary ratio. Increasing the oxygen
level won't increase the ventilation-perfusion mismatch.
211. B Kegel exercises are performed by alternately tightening
and releasing perineal muscles to strengthen the pubococcygeus muscle
and increase its elasticity. The pubococcygeus muscle supports
internal organs, such as the uterus and bladder. Kegel exercises
don't affect breathing or muscles of the diaphragm, leg, or abdomen.
212. C A turning schedule with a signing sheet will help ensure
that the client gets turned and, thus, help prevent pressure ulcers.
Turning should occur every 1 to 2 hours--not every 8 hours--for
clients who are in bed for prolonged periods. The nurse should apply
lotion to keep the skin moist but should avoid vigorous massage,
which could damage capillaries. When moving the client, the nurse
should lift rather than slide the client to avoid shearing.
213. A An increased metabolic rate in hyperthyroidism because of
excess serum thyroxine leads to systolic hypertension and heat
intolerance. Weight loss--not gain occurs due to the increased
metabolic rate. Diastolic blood pressure decreases because of
decreased peripheral resistance. Heat intolerance and widened pulse
pressure do occur, but the other answers are incorrect. Clients with
hyperthyroidism experience an increase in appetite--not anorexia.
214. C Whenever a client isn't immediately available to take the
medication, the nurse must put the medicine in a secured area. The
nurse should never leave drugs unattended in a client's room or in
the care of a roommate. The nurse also shouldn't omit doses of
medication without an order from the physician.
215. C When an analgesic is taken before pain becomes severe,
less medication is required to control the pain, thus minimizing the
risk of adverse effects. Clients shouldn't be told to wait for the
nurse to ask about pain or offer an analgesic. Pain medication should
be taken before walking or other activities that are expected to
cause pain. The client shouldn't be discouraged from using pain
medication because of possible addiction. A client with no history of
substance abuse has a very minimal risk of addiction when using pain
medication for postoperative pain relief.
216. C Providing adequate hydration to the woman in premature
labor may help halt contractions. The client should be placed on bed
rest so that the fetus exerts less pressure on the cervix. A
nutritious diet is important in pregnancy, but it won't halt
premature labor. Nipple stimulation activates the release of oxytocin,
which promotes uterine contractions.
217. A Postoperative cataract clients should avoid sleeping on
the operated side as well as lifting heavy objects or straining, all
of which could cause bleeding in the eye. Aspirin, due to its
anticoagulant properties, should be avoided for the same reason. An
eye shield is worn continuously for the first 24 hours
postoperatively. Straining during a bowel movement should be avoided
because it increases intraocular pressure.
218. B To facilitate venous drainage and avoid jugular
compression, the nurse should elevate the head of the bed 15 to 30
degrees. Clients with increased ICP poorly tolerate suctioning and
shouldn't be suctioned on a regular basis. Turning from side to side
increases the risk of jugular compression and rises in ICP, so
turning and changing positions should be avoided. The room should be
kept quiet and dimly lit.
219. C Disturbed body image is a negative perception of self that
makes healthful functioning more difficult. The defining
characteristics for this nursing diagnosis include undergoing a
change in body structure or function, hiding or overexposing a body
part, not looking at a body part, and responding verbally or
nonverbally to the actual or perceived change in structure or
function. This client may have any of the other diagnoses, but the
signs and symptoms described in the case most closely match the
defining characteristics disturbed body image.
220. C Urinary retention or incontinence may indicate cauda
equina syndrome, which requires immediate surgery. An increase in
pain on the second postoperative day is common because the longacting local anesthetic, which may have been injected during surgery,
will wear off. While paresthesia is common after surgery, progressive
weakness or paralysis may indicate spinal nerve compression. A mild
fever is also common after surgery but is considered significant only
if it reaches 101°F(38.3℃).
221. D As antidepressants begin to take effect and the client
feels better, she may have the energy to initiate and complete
another suicide attempt. As the client's energy level increases, the
nurse must continue to be vigilant to the risk of suicide.
Extrapyramidal symptoms may occur with antipsychotics and aren't
adverse effects of antidepressants. A therapeutic relationship should
be initiated upon admission to the psychiatric unit, after suicide
precautions have been instituted. It's through this relationship that
the client develops feelings of self-worth and trust and problemsolving takes place. In a no-suicide contract, the client states
verbally or in writing that she won't attempt suicide and will seek
out staff if she has suicidal thoughts. When the time period for a
contract has expired, a new contract should be obtained from the
client.
222. D Screening for scoliosis should begin at age 10 and be
performed yearly until at least age 16. Screening for scoliosis
involves inspection of the spine and use of a scoliometer, both of
which can be done in a school setting.
223. D Tachycardia may be a sign of heart failure. Mild
tachycardia is more easily detected during sleep than during the day
when activity can cause an increase in heart rate. Medications given
for rheumatic fever and rheumatic heart disease, such as digoxin,
exert their influence day and night. Chorea, a symptom of rheumatic
fever, is the loss of voluntary muscle control. However, it doesn't
affect pulse because the child would be sitting quietly and not
involved in purposeful movement. A ten-year-old child is unlikely to
be able to consciously raise or lower his heart rate.
224. A Because of such factors as suspiciousness, anxiety, and
hallucinations, the client with paranoid schizophrenia is at risk for
violence toward himself or others. The other options are also
appropriate nursing diagnoses but should be addressed after the
safety of the client and those around him is established.
225. C Most clients can be discouraged from scratching if given a
mild antihistamine, such as diphenhydramine, to relieve itching.
Clients shouldn't scratch inside casts because of the risk of skin
breakdown and potential damage to the cast. Sedatives aren't usually
indicated for itching.
226. C Bacterial conjunctivitis has an acute onset, moderate pain,
preauricular adenopathy, and a copious and purulent discharge. Viral
conjunctivitis has an acute or subacute onset, mild to moderate pain,
preauricular adenopathy, and moderate and seropurulent discharge.
Allergic conjunctivitis has a recurrent onset, no pain, no
preauricular adenopathy, and moderate and clear discharge. Irritant
conjunctivitis has an acute onset, mild pain or no pain, rare
preauricular adenopathy, and minimal and clear discharge.
227. B Maintaining a patent airway is the most basic and most
critical human need. All other interventions are important to the
client's well-being, but they aren't as important as having
sufficient oxygen to breathe.
228. A Bipolar clients are often unpredictable and exhibit angry
outbursts. The unit itself, with its regularly scheduled activities,
may provide too much stimulation for the manic client. The course of
illness wouldn't be expected to move rapidly through the manicdepressive-manic cycle, although the client should be observed for
signs of depression.
229. B Mannitol, an osmotic diuretic, is used to decrease
cerebral edema in clients with head injuries. Increased lung
expansion, decreased cardiac workload, and increased cerebral
circulation aren't effects of mannitol.
230. D Respiratory rate usually isn't affected by bulimia.
Observing the client after eating for 1 hour is important because
it's the time that she's likely to vomit. Noting the client's intake
and changes in her appetite are important factors to monitor in
butimia or any other eating disorder.
231. D A genetic counselor can educate the couple about an
inherited disorder, screening tests that can be done, and treatments
and can provide emotional support. Clergy are available to provide
spiritual support. A social worker can provide emotional support and
help with referrals for financial problems. A nurse midwife cares for
women during pregnancy and birth.
232. A OA is a degenerative arthritis, characterized by the loss
of cartilage on the articular surfaces of weight-bearing joints with
spur development. RA is characterized by inflammation of synovial
membranes and surrounding structures. OA may occur in one hip or knee
and not the other, whereas RA commonly affects the same joints
bilaterally. RA is more common in women, while OA affects both sexes
equally.
233. A Acyclovir reduces symptoms of herpes and also reduces
viral shedding and healing time. Doxycycline and tetracycline are
used to treat Lyme disease. Penicillin is used to treat syphilis.
234. D A person can convert unbearable feelings into a physical
symptom with no organic cause. This defense mechanism usually
manifests itself near the time of a traumatic or conflict-producing
event. The symptom commonly provides attention or a means of escaping
the conflict. Repression is a defense mechanism in which a person
unconsciously keeps unwanted feelings from entering awareness.
Transference involves the projection of feelings, thoughts, and
wishes (positive or negative) onto someone, usually a therapist, who
represents a figure from the person's past. Reaction formation is a
means of alleviating unresolved conflicts between feelings or
impulses by reinforcing one feeling and repressing another, thereby
disguising the true feelings from the self.
235. C General anesthesia and postoperative pain may lead to
immobility, which predisposes to respiratory complications
postoperatively. Changing positions, along with coughing and deep
breathing, is done to prevent respiratory complications. It's
unlikely that an otherwise healthy young woman would develop pressure
ulcers during a brief postoperative period. Muscular stiffness would,
of course, be decreased with frequent turning, but this isn't the
most important rationale for turning. Turning may decrease venous
stasis, but a more effective intervention to decrease venous stasis
in the early postoperative period would be leg exercises.
236. B The client with genital herpes should be instructed to
avoid sexual intercourse until lesions completely heal. When the
client is diagnosed with genital herpes, outbreaks may occur at any
time. The perineal area should be kept dry. Clients should wear
loose-fitting cotton underwear to promote drying of the lesions.
237. 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.
238. A Because an MAO inhibitor can cause hypotension, the client
must be given precautions related to driving. Disturbed thought
processes and disturbed sleep pattern are possible but not likely,
and they have lower priority than client safety. Excessive fluid
volume is more likely than a deficit.
239. B Before deciding on any specific intervention, the school
nurse should perform a basic assessment for scoliosis, including
inspecting for uneven shoulder or hip height. The nurse will then
have more specific information to give to the parent. The parent
bears responsibility for seeking further medical care for the child.
240. B Because it takes 4 to 6 hours for myocardial cells to die,
thrombolytic therapy should be given within 6 hours of the onset of
chest pain to achieve the best results in an acute myocardial
infarction. The client who has waited 2 days to be treated for chest
pain won't benefit from thrombolytic therapy. Chest pain that's
relieved by nitroglycerin is most likely due to angina and not an
indication for thrombolytic therapy. Chest pain for 1 week is also
beyond the 6-hour time limit.
241. C This provides the client with validation and support for
her feelings. The other options neither validate the client's
bereavement nor allow her to resolve them.
242. B Use of ritodrine can lead to pulmonary edema. Therefore,
the nurse should assess for crackles and dyspnea. Blood glucose
levels may temporarily rise, not fall, with ritodrine. Ritodrine may
cause tachycardia, not bradycardia. Ritodrine may also cause
hypokalemia, not hyperkalemia.
243. D Immediately after surgery, the priority nursing
intervention is assessing pulmonary function. The surgical dressing
shouldn't require changing right away. Suctioning should be performed
only if the client can't maintain a patent airway. Colostomy
irrigation isn't warranted.
244. C This offers support and empathy and enhances the grieving
process. The other options don't address the client's need for
support and grieving.
245. A Rheumatic fever typically follows an infection with group
A beta-hemolytic streptococcus, as in strep throat, impetigo, scarlet
fever, or pharyngitis. Influenza, chickenpox, and mononucleosis are
caused by viruses and don't lead to rheumatic fever.
246. C Hand washing is the first line of intervention for
preventing the spread of infection. Antibiotics should be initiated
when an organism is identified. Wearing gloves and assigning private
rooms for clients can also decrease the spread of infection and
should be implemented according to standard precautions.
247. C Gentle pressure applied to the neonate’s head as it's
delivered prevents rapid expulsion, which can cause brain damage to
the neonate and perineal tearing in the mother. Never pull at the
neonate's head or hold the head back. Placing the mother in the
Trendelenburg position won't halt labor and may cause respiratory
difficulties.
248. B A pH less than 7.35 is indicative of acidosis; a pH above
7.45 indicates alkalosis.
249. A The American Cancer Society recommends a mammogram yearly
for women over age 40. The other statements are incorrect. It's
recommended that women between ages 20 and 40 have a professional
breast examination (not a mammogram) every 3 years.
250. B According to several recent studies, breast-fed babies
consume less milk on days when their mothers drink alcohol. In light
of the recent studies and the incidence of alcohol-related problems
in our society, encouraging alcohol use by breast-feeding mothers is
unwise. This judgmental response negates the responsible behavior
that the client demonstrated by asking a nurse for advice.
251. D To verify the client's identity, check the identification
bracelet. If confused, the client may give an inaccurate answer. The
name posted outside the door may be inaccurate or another client may
have wandered into the wrong room. A family member with whom the
nurse is unfamiliar isn't a reliable source.
252. B Because a neonate grows so quickly, the cast may need to
be changed as often as every 1 to 2 weeks. A cast for congenital
clubfoot isn't left on for 6 weeks because of the rapid rate of the
infant's growth. By the time a baby is crawling or ready to walk, the
final cast has long since been removed. After the cast is permanently
removed, the baby may wear a Denis Browne splint until he is 1 year
old.
253. D Allowing the parents to stay and participate in the
child's care can provide support to the parents and the child. The
other interventions won't address the client's diagnosis and may
exacerbate the problem.
254. D It's important to acknowledge the child's imagination,
while also letting him know in a nice way that what he has said isn't
real. Punishment isn't appropriate for a 4-year-old child using his
imagination, and accusing him of lying is a negative reinforcement.
The child isn't truly lying in the adult sense. Imagination and
creativity need to be acknowledged.
255. D In true labor, the cervix becomes effaced and dilated. In
false labor, contractions are located chiefly in the abdomen, the
intensity of contractions remains the same, and the interval between
contractions remains long.
256. B During the acute phase of rheumatic fever, the child
should be placed on bed rest to reduce the heart's workload and
prevent heart failure. An appropriate activity for this child would
he reading books. The other activities are too strenuous during the
acute phase.
257. B Elevation of serum lipase is the most reliable indicator
of pancreatitis because this enzyme is produced solely by the
pancreas. A client's BUN is typically elevated in relation to renal
dysfunction; the AST, in relation to liver dysfunction; and LD, in
relation to damaged cardiac muscle.
958. B The head of the bed must be elevated while the client is
eating. The client should be placed in a recumbent position--not a
supine position--when lying down to reduce the risk of aspiration.
Encourage the client to wear properly fitted dentures to enhance his
chewing ability. Thickened liquids, not thin liquids, decrease
aspiration risk.
259. A The aortic valve is located between the left ventricle and
the aorta. It's one of the semilunar valves and normally has three
cusps.
260. B
261. A
262. B
263. A
264. A
265. B Clients with gout should avoid foods that are high in
purines, such as liver, cod, and sardines. They should also avoid
anchovies, kidneys, sweet-breads, lentils, and alcoholic beverages-especially beer and wine. Green leafy vegetables, chocolate and eggs
aren't high in purines.