Exit 8

Question 1

The client presents to the clinic with a serum cholesterol of 275 mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client?

A. Report muscle weakness to the physician.
B. Allow six months for the drug to take effect.
C. Take the medication with fruit juice.
D. Ask the doctor to perform a complete blood count before starting the medication.

Answer 1

A. Report muscle weakness to the physician.

The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyolysis.

Option B: The medication takes effect within 1 month of beginning therapy.
Option C: The medication should be taken with water because fruit juice, particularly grapefruit, can decrease the effectiveness.
Option D: Liver function studies should be checked before beginning the medication, not after the fact, making answer D incorrect.

Question 2

The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:

A. Utilize an infusion pump
B. Check the blood glucose level
C. Place the client in Trendelenburg position
D. Cover the solution with foil

Answer 2

B. Check the blood glucose level

Hyperstat is given IV push for hypertensive crises, but it often causes hyperglycemia. The glucose level will drop rapidly when stopped.

Option A: Diazoxide (Hyperstat) is given by IV push.
Option C: The client should be placed in dorsal recumbent position, not a Trendelenburg position.
Option D: This medication does not have to be covered with foil.

Question 3

The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?

A. Blood pressure of 126/80
B. Blood glucose of 110 mg/dL
C. Heart rate of 60 bpm
D. Respiratory rate of 30 per minute

Answer 3

C. Heart rate of 60 bpm

A heart rate of 60 in the baby should be reported immediately. The dose should be held if the heart rate is below 100 bpm.

Options A, B, and D: The blood glucose, blood pressure, and respirations are within normal limits.

Question 4

The client admitted with angina is given a prescription for nitroglycerin. The client should be instructed to:

A. Replenish his supply every 3 months
B. Take one every 15 minutes if pain occurs
C. Leave the medication in the brown bottle
D. Crush the medication and take with water

Answer 4

C. Leave the medication in the brown bottle

Nitroglycerine should be kept in a brown bottle because of its instability and tendency to become less potent when exposed to air, light, or water.

Options A and B: The supply should be replenished every 6 months, not 3 months, and one tablet should be taken every 5 minutes until pain subsides. If the pain does not subside, the client should report to the emergency room.
Option D: The medication should be taken sublingually and should not be crushed.

Question 5

The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?

A. Macaroni and cheese
B. Shrimp with rice
C. Turkey breast
D. Spaghetti

Answer 5

C. Turkey breast

Turkey contains the least amount of fats and cholesterol.

Options A, B, and D: Liver, eggs, beef, cream sauces, shrimp, cheese, and chocolate should be avoided by the client. The client should bake meat rather than frying to avoid adding fat to the meat during cooking.

Question 6

The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:

A. Feet
B. Neck
C. Hands
D. Sacrum

Answer 6

B. Neck

The jugular veins in the neck should be assessed for distension.

Options A, C, and D: The other parts of the body will be edematous in right-sided congestive heart failure, not left-sided.

Question 7

The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the:

A. Phlebostatic axis
B. PMI
C. Erb’s point
D. Tail of Spence

Answer 7

A. Phlebostatic axis

The phlebostatic axis is located at the fifth intercostal space midaxillary line and is the correct placement of the manometer.

Option B: The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line.
Option C: Erb’s point is the point at which you can hear the valves close simultaneously.
Option D: The Tail of Spence (the upper outer quadrant) is the area where most breast cancers are located and has nothing to do with the placement of a manometer.

Question 8

The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:

A. Question the order
B. Administer the medications
C. Administer separately
D. Contact the pharmacy

Answer 8

B. Administer the medications

Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension.

Options A, C, and D: The order is accurate. There is no need to question the order, administer the medication separately, or contact the pharmacy.

Question 9

The best method of evaluating the amount of peripheral edema is:

A. Weighing the client daily
B. Measuring the extremity
C. Measuring the intake and output
D. Checking for pitting

Answer 9

B. Measuring the extremity

The best indicator of peripheral edema is measuring the extremity. A paper tape measure should be used rather than one of plastic or cloth, and the area should be marked with a pen, providing the most objective assessment.

Option A: Weighing the client will not indicate peripheral edema.
Option C: Measuring the intake and output will not indicate peripheral edema.
Option D: Checking for pitting edema is less reliable than measuring with a paper tape measure.

Question 10

A client with vaginal cancer is being treated with a radioactive vaginal implant. The client’s husband asks the nurse if he can spend the night with his wife. The nurse should explain that:

A. Overnight stays by family members is against hospital policy.
B. There is no need for him to stay because staffing is adequate.
C. His wife will rest much better knowing that he is at home.
D. Visitation is limited to 30 minutes when the implant is in place.

Answer 10

D. Visitation is limited to 30 minutes when the implant is in place.

Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important.

Options A, B, and C: These statements are not empathetic and do not address the question; therefore, they are incorrect.

Question 11

The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?

A. Roast beef sandwich, potato chips, pickle spear, iced tea
B. Split pea soup, mashed potatoes, pudding, milk
C. Tomato soup, cheese toast, Jello, coffee
D. Hamburger, baked beans, fruit cup, iced tea

Answer 11

B. Split pea soup, mashed potatoes, pudding, milk

The client with a facial stroke will have difficulty swallowing and chewing, and the foods in answer B provide the least amount of chewing.

Options A, C, and D: The following food items would require more chewing and, thus, are incorrect.

Question 12

The physician has prescribed Novolog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

A. “I will make sure I eat breakfast within 10 minutes of taking my insulin.”
B. “I will need to carry candy or some form of sugar with me all the time.”
C. “I will eat a snack around three o’clock each afternoon.”
D. “I can save my dessert from supper for a bedtime snack.”

Answer 12

A. “I will make sure I eat breakfast within 10 minutes of taking my insulin.”

NovoLog “rapid acting” insulin onsets very quickly, so food should be available within 10–15 minutes of taking the insulin.

Option B does not address a particular type of insulin, so it is incorrect.
Option C: NPH (neutral protamine hagedorn) “intermediate acting” insulin peaks in 8-12 hours, so a snack should be eaten at the expected peak time. It may not be 3 p.m.
Option D: There is no need to save the dessert until bedtime

Question 13

The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first 2 weeks of life because:

A. New parents need time to learn how to hold the baby.
B. The umbilical cord needs time to separate.
C. Newborn skin is easily traumatized by washing.
D. The chance of chilling the baby outweighs the benefits of bathing.

Answer 13

B. The umbilical cord needs time to separate.

The umbilical cord needs time to dry and fall off before putting the infant in the tub.

Options A, C, and D: Although these statements might be important, they are not the primary answer to the question.

Question 14

A client with leukemia is receiving Trimetrexate. After reviewing the client’s chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:

A. Treat iron-deficiency anemia caused by chemotherapeutic agents
B. Create a synergistic effect that shortens treatment time
C. Increase the number of circulating neutrophils
D. Reverse drug toxicity and prevent tissue damage

Answer 14

D. Reverse drug toxicity and prevent tissue damage

Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid derivative.

Options A, B, and C: Leucovorin does not treat iron deficiency, increased neutrophils, or have a synergistic effect.

Question 15

A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:

A. HibTITER
B. Mumps vaccine
C. Hepatitis B vaccine
D. MMR

Answer 15

A. HibTITER

The Haemophilus influenza vaccine is given at 4 months with the polio vaccine.

Options B, C, and D: Mumps, Hepatitis B, and MMR vaccines are given later in life.

Question 16

The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:

A. 30 minutes before meals
B. With each meal
C. In a single dose at bedtime
D. 30 minutes after meals

Answer 16

A. 30 minutes before meals

Proton pump inhibitors reduce the production of acid in the stomach and work best when taken 30 minutes before the first meal of the day.

Question 17

A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?

A. Call security for assistance and prepare to sedate the client.
B. Tell the client to calm down and ask him if he would like to play cards.
C. Tell the client that if he continues his behavior he will be punished.
D. Leave the client alone until he calms down.

Answer 17

A. Call security for assistance and prepare to sedate the client.

If the client is a threat to the staff and other clients, the nurse should call for help and prepare to administer a medication such as Haldol to sedate him.

Option B: Telling the client to calm down will not work.
Option C: Telling the client that if he continues he will be punished is a threat and may further anger him.
Option D: If the client is left alone he might harm himself.

Question 18

When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:

A. Check the client for bladder distention
B. Assess the blood pressure for hypotension
C. Determine whether an oxytocic drug was given
D. Check for the expulsion of small clots

Answer 18

A. Check the client for bladder distention

If the fundus is displaced to the side, it might indicate a full bladder. The nurse should check for bladder distention and catheterize if necessary.

Options B, C, and D: These are actions that relate to postpartum hemorrhage.

Question 19

A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client’s symptoms are consistent with a diagnosis of:

A. Pneumonia
B. Reaction to antiviral medication
C. Tuberculosis
D. Superinfection due to low CD4 count

Answer 19

C. Tuberculosis

A low-grade temperature, blood-tinged sputum, fatigue, and night sweats are symptoms consistent with tuberculosis.

Option A: If the answer had said pneumocystis pneumonia, it would have been consistent with the symptoms given in the stem, but just saying pneumonia isn’t specific enough to diagnose the problem.
Options B and D: They are not directly related to the stem.

Question 20

The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client’s history should be reported to the doctor?

A. Diabetes
B. Prinzmetal’s angina
C. Cancer
D. Cluster headaches

Answer 20

B. Prinzmetal’s angina

If the clients with a history of Prinzmetal’s angina. He should not be prescribed triptan preparations because they cause vasoconstriction and coronary spasms.

Options A, C, and D: There is no contraindication for taking triptan drugs in clients with diabetes, cancer, or cluster headaches.

Question 21

The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation.
A positive Kernig’s sign is charted if the nurse notes:

A. Pain on flexion of the hip and knee
B. Nuchal rigidity on flexion of the neck
C. Pain when the head is turned to the left side
D. Dizziness when changing positions

Answer 21

A. Pain on flexion of the hip and knee

Kernig’s sign is positive if pain occurs on flexion of the hip and knee.

Option B: The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest.
Options C and D: These symptoms might be present but are not related to Kernig’s sign.

Question 22

The client with Alzheimer’s disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:

A. Agnosia
B. Apraxia
C. Anomia
D. Aphasia

Answer 22

A. Agnosia

Agnosia is the term used to describe the loss of the ability to recognize what objects are and what they are used for. For an instance, a person with agnosia might try to use a fork instead of a spoon, a shoe instead of a cup or a knife instead of a pencil etc. With regard to people, this might involve failing to recognize who people are, not due to memory loss but rather as a result of the brain not working out the identity of a person on the basis of the information supplied by the eyes.

Option B: Apraxia is the term used to describe the failure to carry out voluntary and purposeful movements notwithstanding the fact that muscular power, sensibility, and coordination are intact. In everyday terms, this might involve the inability to tie shoelaces, turn a tap on, fasten buttons or switch on a radio.

Options C and D: Aphasia is the term used to describe a difficulty or loss of the ability to speak or understand spoken, written or sign language as a result of damage to the corresponding nervous center. This can become apparent in a number of ways. It might involve exchanging a word which is linked by meaning (e.g. time instead of clock), using the wrong word but one which sounds alike (e.g. boat instead of coat) or using a totally different word with no apparent connection. When accompanied by echolalia (the involuntary repetition of words or phrases spoken by another person) and the constant repetition of a word or phrase, the result can be a form of speech which is difficult for others to understand or a kind of jargon. Anomia is a form of aphasia in which the patient is unable to recall the names of everyday objects.

Question 23

The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:

A. Chronic fatigue syndrome
B. Normal aging
C. Sundowning
D. Delusions

Answer 23

C. Sundowning

Increased confusion at night is known as a sundowning syndrome. This increased confusion occurs when the sun begins to set and continues during the night.

Option A: Fatigue is not necessarily present.
Option B: Increased confusion at night is not part of normal aging.
Option D: A delusion is a firm, fixed belief.

Question 24

The client with confusion says to the nurse, “I haven’t had anything to eat all day long. When are they going to bring breakfast?” The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?

A. “You know you had breakfast 30 minutes ago.”
B. “I am so sorry that they didn’t get you breakfast. I’ll report it to the charge nurse.”
C. “I’ll get you some juice and toast. Would you like something else?”
D. “You will have to wait a while; lunch will be here in a little while.”

Answer 24

C. “I’ll get you some juice and toast. Would you like something else?”

The client who is confused might forget that he ate earlier. Don’t argue with the client. Simply get him something to eat that will satisfy him until lunch.

Options A and D are incorrect because the nurse is dismissing the client.
Option B is validating the delusion.

Question 25

The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer’s disease. Which side effect is most often associated with this drug?

A. Urinary incontinence
B. Headaches
C. Confusion
D. Nausea

Answer 25

D. Nausea

Nausea and gastrointestinal upset are very common in clients taking acetylcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity, dizziness, unsteadiness, and clumsiness.

Options A, B, and C: The client might already be experiencing urinary incontinence or headaches, but they are not necessarily associated, and the client with Alzheimer’s disease is already confused.

Question 26

A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?

A. Document the finding
B. Report the finding to the doctor
C. Prepare the client for a C-section
D. Continue primary care as prescribed

Answer 26

B. Report the finding to the doctor

Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions.

Option A: It is not enough to document the finding.
Option C: The physician must make the decision to perform a C-section.
Option D: It is not enough to continue primary care as prescribed.

Question 27

A client with a diagnosis of HPV is at risk for which of the following?

A. Hodgkin’s lymphoma
B. Cervical cancer
C. Multiple myeloma
D. Ovarian cancer

Answer 27

B. Cervical cancer

The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned in answers A, C, and D, so those are incorrect.

Question 28

During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:

A. Syphilis
B. Herpes
C. Gonorrhea
D. Condylomata

Answer 28

B. Herpes

A lesion that is painful is most likely a herpetic lesion.

Option A: A chancre lesion associated with syphilis is not painful.
Option C: Gonorrhea does not present as a lesion but is exhibited by a yellow discharge.
Option D: Condylomata lesions are painless warts, so answer D is incorrect.

Question 29

A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:

A. Venereal Disease Research Lab (VDRL)
B. Rapid plasma reagin (RPR)
C. Florescent treponemal antibody (FTA)
D. Thayer-Martin culture (TMC)

Answer 29

C. Florescent treponemal antibody (FTA)

Fluorescent treponemal antibody (FTA) is the test for treponema pallidum.

Options A and B: VDRL and RPR are screening tests done for syphilis.
Option D: The Thayer-Martin culture is done for gonorrhea.

Question 30

A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?

A. Elevated blood glucose
B. Elevated platelet count
C. Elevated creatinine clearance
D. Elevated hepatic enzymes

Answer 30

D. Elevated hepatic enzymes

The criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet count.

HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) syndrome is a life-threatening pregnancy complication usually considered to be a variant of preeclampsia. Both conditions usually occur during the later stages of pregnancy, or soon after childbirth

Option A: An elevated blood glucose level is not associated with HELLP.
Option B: Platelets are decreased, not elevated, in HELLP syndrome.
Option C: The creatinine levels are elevated in renal disease and are not associated with HELLP syndrome.

Question 31

The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?

A. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
B. The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow.
C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.

Answer 31

A. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.

Option B elicits the triceps reflex.
Option C elicits the patellar reflex.
Option D elicits the radial nerve.

Question 32

A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor’s order should the nurse question?

A. Magnesium sulfate 4gm (25%) IV
B. Brethine 10 mcg IV
C. Stadol 1 mg IV push every 4 hours as needed prn for pain
D. Ancef 2gm IVPB every 6 hours

Answer 32

B: Brethine 10 mcg IV

Brethine is used cautiously because it raises the blood glucose levels.

Options A, C, and D: Magnesium sulfate, Stadol, and Ancef are all medications that are commonly used in the diabetic client.

Question 33

A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse’s assessment of this data is:

A. The infant is at low risk for congenital anomalies.
B. The infant is at high risk for intrauterine growth retardation.
C. The infant is at high risk for respiratory distress syndrome.
D. The infant is at high risk for birth trauma.

Answer 33

C: The infant is at high risk for respiratory distress syndrome.

When the L/S ratio reaches 2:1, the lungs are considered to be mature. The current ratio indicates the infant is at high risk for respiratory distress syndrome.

Option A: The L/S ratio does not indicate congenital anomalies.
Option B: The infant is not at risk for intrauterine growth retardation.
Option D: The infant will most likely be small for gestational age and will not be at risk for birth trauma.

Question 34

Which observation in the newborn of a diabetic mother would require immediate nursing intervention?

A. Crying
B. Wakefulness
C. Jitteriness
D. Yawning

Answer 34

C: Jitteriness

Jitteriness is a sign of seizure in the neonate.

Options A, B, and D: Crying, wakefulness, and yawning are expected in the newborn.

Question 35

The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:

A. Decreased urinary output
B. Hypersomnolence
C. Absence of knee jerk reflex
D. Decreased respiratory rate

Answer 35

B: Hypersomnolence

The client is expected to become sleepy, have hot flashes, and be lethargic.

Options A, C, and D: A decreasing urinary output, absence of the knee-jerk reflex, and decreased respirations indicate a magnesium sulfate toxicity.

Question 36

The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:

A. Place her in Trendelenburg position
B. Decrease the rate of IV infusion
C. Administer oxygen per nasal cannula
D. Increase the rate of the IV infusion

Answer 36

D: Increase the rate of the IV infusion

If the client experiences hypotension after an injection of epidural anesthetic, the nurse should turn her to the left side, apply oxygen by mask, and speed the IV infusion. If the blood pressure does not return to normal, the physician should be contacted. Epinephrine should be kept for emergency administration.

Option A: Placing the client in Trendelenburg position (head down) will allow the anesthesia to move up above the respiratory center, thereby decreasing the diaphragm’s ability to move up and down and ventilate the client.
Option B: The IV rate should be increased, not decreased.
Option C: the oxygen should be applied by mask, not cannula.

Question 37

A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?

A. Alteration in nutrition
B. Alteration in bowel elimination
C. Alteration in skin integrity
D. Ineffective individual coping

Answer 37

A. Alteration in nutrition

Cancer of the pancreas frequently leads to severe nausea and vomiting and altered nutrition.

Options B, C, and D: The other problems are of lesser concern.

Question 38

The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?

A. Inspection of the abdomen for enlargement
B. Bimanual palpation for hepatomegaly
C. Daily measurement of abdominal girth
D. Assessment for a fluid wave

Answer 38

C. Daily measurement of abdominal girth

Measuring with a paper tape measure and marking the area that is measured is the most objective method of estimating ascites.

Options A and D: Inspecting and checking for fluid waves are more subjective.
Option B: Palpation of the liver will not determine the amount of ascites.

Question 39

The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis?

A. Alteration in cerebral tissue perfusion
B. Fluid volume deficit
C. Ineffective airway clearance
D. Alteration in sensory perception

Answer 39

B. Fluid volume deficit

The vital signs indicate hypovolemic shock.
Options A, C, and D: They do not indicate cerebral tissue perfusion, airway clearance, or sensory perception alterations.

Question 40

The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:

A. Likes to play football
B. Drinks several carbonated drinks per day
C. Has two sisters with sickle cell trait
D. Is taking acetaminophen to control pain

Answer 40

A. Likes to play football

The client with osteogenesis imperfecta is at risk for pathological fractures and is likely to experience these fractures if he participates in contact sports. The client might experience symptoms of hypoxia if he becomes dehydrated or deoxygenated; extreme exercise, especially in warm weather, can exacerbate the condition.

Options B, C, and D are not factors for concern.

Question 41

The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?

A. Allow the client to keep the fruit
B. Place the fruit next to the bed for easy access by the client
C. Offer to wash the fruit for the client
D. Tell the family members to take the fruit home

Answer 41

D. Tell the family members to take the fruit home

The client with neutropenia should not have fresh fruit because it should be peeled and/or cooked before eating. He should also not eat foods grown on or in the ground or eat from the salad bar. The nurse should remove potted or cut flowers from the room as well. Any source of bacteria should be eliminated, if possible.

Options A, B, and C will not help prevent bacterial invasions.

Question 42

The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40 systolic. The initial nurse’s action should be to:

A. Place the client in Trendelenburg position
B. Increase the infusion of Dextrose in normal saline
C. Administer atropine intravenously
D. Move the emergency cart to the bedside

Answer 42

B. Increase the infusion of Dextrose in normal saline

Option A: In clients who have not had surgery to the face or neck, however, in this situation, this could further interfere with the airway. Increasing the infusion and placing the client in supine position would be better.
Option C: Administration of atropine IV is not necessary at this time and could cause hyponatremia and further hypotension.
Option D: Moving the emergency cart at the bedside is not necessary at this time.

Question 43

The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?

A. Order a chest x-ray
B. Reinsert the tube
C. Cover the insertion site with a Vaseline gauze
D. Call the doctor

Answer 43

C. Cover the insertion site with a Vaseline gauze

If the client pulls the chest tube out of the chest, the nurse first action should be to cover the insertion site with an occlusive dressing. Afterward, the nurse should call the doctor, who will order a chest x-ray and possibly reinsert the tube.

Options A, B, and D are not the first action to be taken.

Question 44

A client being treated with sodium warfarin has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?

A. Assess for signs of abnormal bleeding
B. Anticipate an increase in the Coumadin dosage
C. Instruct the client regarding the drug therapy
D. Increase the frequency of neurological assessments

Answer 44

A. Assess for signs of abnormal bleeding

The normal Protime is 12–20 seconds. A Protime of 120 seconds indicates an extremely prolonged Protime and can result in a spontaneous bleeding episode.

Options B, C, and D may be needed at a later time but are not the most important actions to take first.

Question 45

Which selection would provide the most calcium for the client who is 4 months pregnant?

A. A granola bar
B. A bran muffin
C. A cup of yogurt
D. A glass of fruit juice

Answer 45

C. A cup of yogurt

The food with the most calcium is the yogurt.

Options A, B, and D are good choices, but not as good as the yogurt, which has approximately 400 mg of calcium.

Question 46

The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of the possible side effects of magnesium sulfate?

A. The nurse places a sign over the bed not to check blood pressure in the right arm.
B. The nurse places a padded tongue blade at the bedside.
C. The nurse inserts a Foley catheter.
D. The nurse darkens the room.

Answer 46

C. The nurse inserts a Foley catheter

The client receiving magnesium sulfate should have a Foley catheter in place, and hourly intake and output should be checked.

Option A: There is no need to refrain from checking the blood pressure in the right arm.
Option B: A padded tongue blade should be kept in the room at the bedside, just in case of a seizure, but this is not related to the magnesium sulfate infusion.
Option D: Darkening the room is unnecessary.

Question 47

A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The physician has written an order to transfuse 2 units of whole blood. When discussing the treatment, the child’s mother tells the nurse that she does not believe in having blood transfusions and that she will not allow her child to have the treatment. What nursing action is most appropriate?

A. Ask the mother to leave while the blood transfusion is in progress
B. Encourage the mother to reconsider
C. Explain the consequences without treatment
D. Notify the physician of the mother’s refusal

Answer 47

D. Notify the physician of the mother’s refusal

If the client’s mother refuses the blood transfusion, the doctor should be notified. Because the client is a minor, the court might order treatment.

Options A, B, and C are incorrect because it is not the primary responsibility for the nurse to encourage the mother to consent or explain the consequences.

Question 48

A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?

A. Hypovolemia
B. Laryngeal edema
C. Hypernatremia
D. Hyperkalemia

Answer 48

B. Laryngeal edema

The nurse should be most concerned with laryngeal edema because of the area of the burn.

Options A, C, and D: The next priority after laryngeal edema should be hypovolemia, as well as hyponatremia and hypokalemia, but these answers are not of primary concern so are incorrect.

Question 49

The nurse is evaluating nutritional outcomes for a client with anorexia nervosa. Which data best indicates that the plan of care is effective?

A. The client selects a balanced diet from the menu.
B. The client’s hemoglobin and hematocrit improve.
C. The client’s tissue turgor improves.
D. The client gains weight.

Answer 49

D. The client gains weight

The client with anorexia shows the most improvement by weight gain.

Option A: Selecting a balanced diet does little good if the client will not eat.
Option B: The hematocrit might improve by several means, such as blood transfusion, but that does not indicate improvement in the anorexic condition.
Option C: The tissue turgor indicates fluid stasis, not an improvement of anorexia.

Question 50

The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?

A. Pain beneath the cast
B. Warm toes
C. Pedal pulses weak and rapid
D. Paresthesia of the toes

Answer 50

D. Paresthesia of the toes

Paresthesia is not normal and might indicate compartment syndrome.

Option A: At this time, pain beneath the cast is normal.
Options B and C: The client’s toes should be warm to the touch, and pulses should be present.