NCSBN 18' Exam 2 Flashcards
- The nurse is caring for a client with systemic lupus erythematosis (SLE). The major complication associated with systemic lupus erythematosis is:
❍ A. Nephritis
❍ B. Cardiomegaly
❍ C. Desquamation
❍ D. Meningitis
Answer A is correct.
The major complication of SLE is lupus nephritis, which results in end-stage renal disease. SLE affects the musculoskeletal, integumentary, renal, nervous, and cardiovascular systems, but the major complication is renal involvement; therefore, answers B and D are incorrect. Answer C is incorrect because the SLE pro-
duces a “butterfly” rash, not desquamation.
- A client with benign prostatic hypertrophy has been started on Proscar (finasteride). The nurse’s discharge teaching should include:
❍ A. Telling the client’s wife not to touch the tablets
❍ B. Explaining that the medication should be taken with
meals
❍ C. Telling the client that symptoms will improve in 1–2 weeks
❍ D. Instructing the client to take the medication at bedtime, to prevent nocturia
Answer A is correct.
Finasteride is an androgen inhibitor; therefore, women who are pregnant or who might become pregnant should be told to avoid touching the tablets. Answer B is incorrect because there are no benefits to giving the medication with food. Answer C is incorrect because the medication can take 6 months to a year to be effective. Answer D is not an accurate statement; therefore, it is incorrect.
- A 5-year-old child is hospitalized for correction of congenital hip dysplasia. During the assessment of the child, the nurse can expect to find the presence of:
❍ A. Scarf sign
❍ B. Harlequin sign
❍ C. Cullen’s sign
❍ D. Trendelenburg sign
Answer D is correct.
The nurse can expect to find the presence of Trendelenburg sign. (While bearing weight on the affected hip, the pelvis tilts downward on the unaffected
side instead of tilting upward, as expected with normal stability). Scarf sign is a characteristic of the preterm newborn; therefore, answer A is incorrect. Harlequin sign can be found in normal newborns and indicates transient changes in circulation; therefore, answer B is incorrect. Answer C is incorrect because Cullen’s sign is an indication of intra-abdominal bleeding.
- Which diet is associated with an increased risk of colorectal cancer?
❍ A. Low protein, complex carbohydrates
❍ B. High protein, simple carbohydrates
❍ C. High fat, refined carbohydrates
❍ D. Low carbohydrates, complex proteins
Answer C is correct.
A diet that is high in fat and refined carbohydrates increases the risk of colorectal cancer. High fat content results in an increase in fecal bile acids, which facilitate carcinogenic changes. Refined carbohydrates increase the transit time of food through the gastrointestinal tract and increase the exposure time of the intestinal mucosa to cancer-causing substances. Answers A, B, and D do not relate to the question; therefore, they are incorrect.
- The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:
❍ A. Holding the infant
❍ B. Offering a pacifier
❍ C. Providing a mobile
❍ D. Offering sterile water
Answer B is correct.
The nurse should avoid giving the infant a pacifier or bottle because sucking is not permitted. Holding the infant cradled in the arms, providing a mobile, and offering sterile water using a Breck feeder are permitted; therefore, answers A, C, and D are incorrect.
- The physician has diagnosed a client with cirrhosis characterized by asterixis. If the nurse assesses the client with asterixis, he can expect to find:
❍ A. Irregular movement of the wrist
❍ B. Enlargement of the breasts
❍ C. Dilated veins around the umbilicus
❍ D. Redness of the palmar surfaces
Answer A is correct.
The client with asterixis or “flapping tremors” will have irregular flexion and extension of the wrists when the arms are extended and the wrist is hyperextended with the fingers separated. Asterixis is associated with hepatic encephalopathy. Answers B, C, and D do not relate to asterixis; therefore, they are incorrect.
- The physician has ordered Amoxil (amoxicillin) 500mg capsules for a client with esophageal varices. The nurse can best care for the client’s needs by:
❍ A. Giving the medication as ordered
❍ B. Providing extra water with the medication
❍ C. Giving the medication with an antacid
❍ D. Requesting an alternate form of the medication
Answer D is correct.
The client with esophageal varices might develop spontaneous bleeding from the mechanical irritation caused by taking capsules; therefore, the nurse
should request the medication in an alternative form such as a suspension. Answer A is incorrect because it does not best meet the client’s needs. Answer B is incorrect because it is not the best means of preventing bleeding. Answer C is incorrect because the medications should not be given with milk or antacids.
- A client with an inguinal hernia asks the nurse why he should have surgery when he has had a hernia for years. The nurse understands that surgery is recommended to:
❍ A. Prevent strangulation of the bowel
❍ B. Prevent malabsorptive disorders
❍ C. Decrease secretion of bile salts
❍ D. Increase intestinal motility
Answer A is correct.
Surgical repair of an inguinal hernia is recommended to prevent strangulation of the bowel, which could result in intestinal obstruction and necrosis. Answer B does not relate to an inguinal hernia; therefore, it is incorrect. Bile salts, which are important to the digestion of fats, are produced by the liver, not the intestines; therefore, answer C is incorrect. Repair of the inguinal hernia will prevent swelling and obstruction associated with strangulation, but it will not increase intestinal motility; therefore, answer D is incorrect.
- The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron?
❍ A. Tomatoes
❍ B. Legumes
❍ C. Dried fruits
❍ D. Nuts
Answer A is correct.
Tomatoes are a poor source of iron, although they are an excellent source of vitamin C, which increases iron absorption. Answers B, C, and D are good sources of iron; therefore, they are incorrect.
- A client is admitted with suspected acute pancreatitis. Which lab finding confirms the diagnosis?
❍ A. Blood glucose of 260mg/dL
❍ B. White cell count of 21,000cu/mm
❍ C. Platelet count of 250,000cu/mm
❍ D. Serum amylase level of 600 units/dL
Answer D is correct.
Serum amylase levels greater than 200 units/dL help confirm the diagnosis of acute pancreatitis. Elevations of blood glucose occur with conditions other than acute pancreatitis; therefore, answer A is incorrect. Elevations in WBC are associated with infection and are not specific to acute pancreatitis; therefore, answer B is incorrect. Answer C is within the normal range; therefore, it is incorrect.
- The nurse is teaching a client with Parkinson’s disease ways to prevent curvatures of the spine associated with the disease. To prevent spinal flexion, the nurse should tell the client to:
❍ A. Periodically lie prone without a neck pillow
❍ B. Sleep only in dorsal recumbent position
❍ C. Rest in supine position with his head elevated
❍ D. Sleep on either side, but keep his back straight
Answer A is correct.
Periodically lying in a prone position without a pillow will help prevent the flexion of the spine that occurs with Parkinson’s disease. Answers B and C flex the spine; therefore, they are incorrect. Answer D is not realistic because position changes during sleep; therefore, it is incorrect.
- The physician has ordered Dilantin (phenytoin) 100mg intravenously for a client with generalized tonic clonic seizures. The nurse should administer the medication:
❍ A. Rapidly with an IV push
❍ B. With IV dextrose
❍ C. Slowly over 2–3 minutes
❍ D. Through a small vein
Answer C is correct.
The medication should be administered slowly (no more than 50mg per minute); otherwise, cardiac arrhythmias can occur. Answer A is incorrect because the medication must be given slowly. Dextrose solutions cause the medication to crystallize in the line and the medication should be given through a large vein to prevent “purple glove” syndrome; therefore, answers B and D are incorrect.
- The nurse is planning dietary changes for a client following an episode of acute pancreatitis. Which diet is suitable for the client?
❍ A. Low calorie, low carbohydrate
❍ B. High calorie, low fat
❍ C. High protein, high fat
❍ D. Low protein, high carbohydrate
Answer B is correct.
The client recovering from acute pancreatitis needs a diet that is high in calories and low in fat. Answers A, C, and D are incorrect because they can increase the client’s discomfort.
- A client is admitted with a diagnosis of polycythemia vera. The nurse should closely monitor the client for:
❍ A. Increased blood pressure
❍ B. Decreased respirations
❍ C. Increased urinary output
❍ D. Decreased oxygen saturation
Answer A is correct.
The client with polycythemia vera has an abnormal increase in the number of circulating red blood cells that results in increased viscosity of the blood. Increases in blood pressure further tax the overworked heart. Answers B, C, and D do not directly relate to the condition; therefore, they are incorrect.
- A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:
❍ A. Uses an electric blanket at night
❍ B. Dresses in extra layers of clothing
❍ C. Applies a heating pad to her feet
❍ D. Takes a hot bath morning and evening
Answer B is correct.
Dressing in extra layers of clothing will help decrease the feeling of being cold that is experienced by the client with hypothyroidism. Decreased sensation and decreased alertness are common in the client with hypothyroidism. The use of electric blankets and heating pads can result in burns, making answers A and C
incorrect. Answer D is incorrect because the client with hypothyroidism has dry skin, and a hot bath morning and evening would make her condition worse.
- The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17mmHg. The nurse recognizes that:
❍ A. The ICP is elevated and the doctor should be notified.
❍ B. The ICP is normal; therefore, no further action is needed.
❍ C. The ICP is low and the client needs additional IV fluids.
❍ D. The ICP reading is not as reliable as the Glascow coma scale.
Answer A is correct.
An ICP of 17mmHg should be reported to the doctor because it is elevated. (The ICP normally ranges from 4mmHg to 10mmHg, with upper limits of 15mmHg.) Answer B is incorrect because the pressure is not normal. Answer C is incorrect because the pressure is not low. Answer D is incorrect because the ICP read-
ing provides a more reliable measurement than the Glascow coma scale.
- A client has been hospitalized with a diagnosis of laryngeal cancer. Which factor is most significant in the development of laryngeal cancer?
❍ A. A family history of laryngeal cancer
❍ B. Chronic inhalation of noxious fumes
❍ C. Frequent straining of the vocal cords
❍ D. A history of frequent alcohol and tobacco use
Answer D is correct.
A history of frequent alcohol and tobacco use is the most significant factor in the development of cancer of the larynx. Answers A, B, and C are also factors in the development of laryngeal cancer but they are not the most significant; therefore, they are incorrect.
- The nurse is completing an assessment history of a client with pernicious anemia. Which complaint differentiates pernicious anemia from other types of anemia?
❍ A. Difficulty in breathing after exertion
❍ B. Numbness and tingling in the extremities
❍ C. A faster than usual heart rate
❍ D. Feelings of lightheadedness
Answer B is correct.
Numbness and tingling in the extremities is common in the client with pernicious anemia, but not those with other types of anemia. Answers A, C, and D are incorrect because they are symptoms of all types of anemia.
- A client with rheumatoid arthritis is beginning to develop flexion contractures of the knees. The nurse should tell the client to:
❍ A. Lie prone and let her feet hang over the mattress edge
❍ B. Lie supine, with her feet rotated inward
❍ C. Lie on her right side and point her toes downward
❍ D. Lie on her left side and allow her feet to remain in a neutral position
Answer A is correct.
Lying prone and allowing the feet to hang over the end of the mattress will help prevent flexion contractures. The client should be told to do this several times a day. Answers B, C, and D do not help prevent flexion contractures; therefore, they are incorrect.
- The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to:
❍ A. Speak using words that rhyme
❍ B. Repeat words or phrases used by others
❍ C. Include irrelevant details in conversation
❍ D. Make up new words with new meanings
Answer B is correct.
The client with echolalia will repeat words or phrases used by others. Answer A is incorrect because it refers to clang association. Answer C is incorrect because it refers to circumstantiality. Answer D is incorrect because it refers to neologisms.
- The mother of a 1-year-old with sickle cell anemia wants to know why the condition didn’t show up in the nursery. The nurse’s response is based on the knowledge that:
❍ A. There is no test to measure abnormal hemoglobin in newborns.
❍ B. Infants do not have insensible fluid loss before a year of age.
❍ C. Infants rarely have infections that would cause them to have a sickling crises.
❍ D. The presence of fetal hemoglobin protects the infant.
Answer D is correct.
The presence of fetal hemoglobin until about 6 months of age protects affected infants from episodes of sickling. Answer A is incorrect because it is an untrue statement. Answer B is incorrect because infants do have insensible fluid loss. Answer C is incorrect because respiratory infections such as bronchiolitis and otitis media can cause fever and dehydration, which cause sickle cell crisis.
- Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?
❍ A. Brushing the teeth
❍ B. Drinking a glass of juice
❍ C. Holding a cup of coffee
❍ D. Brushing the hair
Answer C is correct.
The warmth from holding a cup of coffee or hot chocolate helps to relieve the pain and stiffness in the hands of the client with rheumatoid arthritis. Answers A, B, and D do not relieve the symptoms of rheumatoid arthritis; therefore, they are incorrect.
- A client with B negative blood requires a blood transfusion during surgery. If no B negative blood is available, the client should be transfused with:
❍ A. A positive blood
❍ B. B positive blood
❍ C. O negative blood
❍ D. AB negative blood
Answer C is correct.
If the client’s own blood type and Rh are not available, the safest transfusion is O negative blood. Answers A, B, and D are incorrect because they can cause reactions that can prove fatal to the client.
- The nurse notes that a post-operative client’s respirations have dropped from 14 to 6 breaths per minute. The nurse administers Narcan (naloxone) per standing order. Following administration of the medication, the nurse should assess the client for:
❍ A. Pupillary changes
❍ B. Projectile vomiting
❍ C. Wheezing respirations
❍ D. Sudden, intense pain
Answer D is correct.
Narcan is a narcotic antagonist that blocks the effects of the client’s pain medication; therefore, the client will experience sudden, intense pain. Answers A, B, and C do not relate to the client’s condition and the administration of Narcan; therefore, they are incorrect.
- A newborn weighed 7 pounds at birth. At 6 months of age, the infant could be expected to weigh:
❍ A. 14 pounds
❍ B. 18 pounds
❍ C. 25 pounds
❍ D. 30 pounds
Answer A is correct.
The infant’s birth weight should double by 6 months of age. Answers B, C, and D are incorrect because they are greater than the expected weight gain by 6 months of age.
- A client with nontropical sprue has an exacerbation of symptoms. Which meal selection is responsible for the recurrence of the client’s symptoms?
❍ A. Tossed salad with oil and vinegar dressing
❍ B. Baked potato with sour cream and chives
❍ C. Cream of tomato soup and crackers
❍ D. Mixed fruit and yogurt
Answer C is correct.
The symptoms of nontropical sprue as well as those of celiac are caused by the ingestion of gluten, found in wheat, oats, barley, and rye. Creamed soup and crackers as well as some cold cuts contain gluten. Answers A, B, and D do not contain gluten; therefore, they are incorrect.
- A client with congestive heart failure has been receiving digoxia (Laxoxin). Which finding indicates that the medication is having a desired effect?
❍ A. Increased urinary output
❍ B. Stabilized weight
❍ C. Improved appetite
❍ D. Increased pedal edema
Answer A is correct.
Lanoxin slows and strengthens the contraction of the heart. An increase in urinary output shows that the medication is having a desired effect by eliminating excess fluid from the body. Answer B is incorrect because the weight would decrease. Answer C is not related to the medication; therefore, it is incorrect.
Answer D is incorrect because pedal edema would decrease, not increase.
- Which play activity is best suited to the gross motor skills of the toddler?
❍ A. Coloring book and crayons
❍ B. Ball
❍ C. Building cubes
❍ D. Swing set
Answer B is correct.
The toddler has gross motor skills suited to playing with a ball, which can be kicked forward or thrown overhand. Answers A and C are incorrect because they require fine motor skills. Answer D is incorrect because the toddler lacks gross motor skills for play on the swing set.
- A client in labor admits to using alcohol throughout the pregnancy. The most recent use was the day before. Based on the client’s history, the nurse should give priority to assessing the newborn for:
❍ A. Respiratory depression
❍ B. Wide-set eyes
❍ C. Jitteriness
❍ D. Low-set ears
Answer C is correct.
Jitteriness and irritability are signs of alcohol withdrawal in the newborn. Answer A is incorrect because it would be associated with use more recent than 1 day ago. Answers B and D are characteristics of a newborn with fetal alcohol syndrome, but they are not a priority at this time; therefore, they are incorrect.
- The physician has ordered Basalgel (aluminum carbonate gel) for a client with recurrent indigestion. The nurse should teach the client common side effects of the medication, which include:
❍ A. Constipation
❍ B. Urinary retention
❍ C. Diarrhea
❍ D. Confusion
Answer A is correct.
Antacids containing aluminum tend to cause constipation. Answers B, C, and D are not common side effects of the medication.
- A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is:
❍ A. Loss of sensation in the lower extremities
❍ B. Back pain that lessens when standing
❍ C. Decreased urinary output
❍ D. Pulsations in the periumbilical area
Answer D is correct.
The client with an abdominal aortic aneurysm frequently complains of pulsations or feeling the heart beat in the abdomen. Answers A and C are incorrect because they are not associated with abdominal aortic aneurysm. Answer B is incorrect because back pain is not affected by changes in position.
- The nurse is caring for a client hospitalized with nephotic syndrome. Based on the client’s treatment, the nurse should:
❍ A. Limit the number of visitors
❍ B. Provide a low-protein diet
❍ C. Discuss the possibility of dialysis
❍ D. Offer the client additional fluids
Answer A is correct.
The client with nephotic syndrome will be treated with immunosuppressive drugs. Limiting visitors will decrease the chance of infection. Answer B is incorrect because the client needs additional protein. Answer C is incorrect because dialysis is not indicated for the client with nephrotic syndrome. Answer D is incorrect because additional fluids are not needed until the client begins diuresis.
- A client is admitted with acute adrenal crisis. During the intake assessment, the nurse can expect to find that the client has:
❍ A. Low blood pressure
❍ B. A slow, regular pulse
❍ C. Warm, flushed skin
❍ D. Increased urination
Answer A is correct.
The client with acute adrenal crisis has symptoms of hypovolemia and shock; therefore, the blood pressure would be low. Answer B is incorrect because the pulse would be rapid and irregular. Answer C is incorrect because the skin would be cool and pale. Answer D is incorrect because the urinary output would be decreased.
- A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A
lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
❍ A. Periorbital edema
❍ B. Tenseness of the anterior fontanel
❍ C. Positive Babinski reflex
❍ D. Negative scarf sign
Answer B is correct.
Tenseness of the anterior fontanel indicates an increase in intracranial pressure. Answer A is incorrect because periorbital edema is not associated with meningitis. Answer C is incorrect because a positive Babinski reflex is normal in the infant. Answer D is incorrect because it relates to the preterm infant, not the infant with meningitis.
- A client with AIDS is admitted with a diagnosis of pneumocystis carinii pneumonia. Shortly after his admission, he becomes confused and disoriented. He attempts to pull out his IV and refuses to wear an O2 mask. Based upon his mental status, the priority nursing diagnosis is:
❍ A. Social isolation
❍ B. Risk for injury
❍ C. Ineffective coping
❍ D. Anxiety
Answer B is correct.
The client’s priority nursing diagnosis is based on his risk for self-injury. Answers A, C, and D focus on the client’s psychosocial needs, which do not take priority over physiological needs; therefore, they are incorrect.
- The doctor has ordered Ampicillin 100mg every 6 hours IV push for an infant weighing 7kg. The suggested dose for infants is 25–50mg/kg/day in equally divided doses. The nurse should:
❍ A. Give the medication as ordered
❍ B. Give half the amount ordered
❍ C. Give the ordered amount q 12 hrs.
❍ D. Check the order with the doctor
Answer D is correct.
The recommended dose ranges from 175mg to 350mg per day based on the infant’s weight. The order as written calls for 400mg per day for an infant weighing 7kg; therefore, the nurse should check the order with the doctor before giving the medication. Answer A is incorrect because the dosage exceeds the recommended amount. Answers B and C are incorrect choices because they involve changing the doctor’s order.
- An elderly client is hospitalized for a transurethral prostatectomy. Which finding should be reported to the doctor immediately?
❍ A. Hourly urinary output of 40–50cc
❍ B. Bright red urine with many clots
❍ C. Dark red urine with few clots
❍ D. Requests for pain med q 4 hrs.
Answer B is correct.
Bright red bleeding with many clots indicates arterial bleeding that requires surgical intervention. Answer A is within normal limits, answer C indicates venous bleeding, which can be managed by nursing intervention, and answer D does not indicate excessive need for pain management that requires the doctor’s
attention; therefore, they are incorrect.
- Which statement by the parent of a child with sickle cell anemia indicates an understanding of the disease?
❍ A. “The pain he has is due to the presence of too many red blood cells.”
❍ B. “He will be able to go snow-skiing with his friends as long as he stays warm.”
❍ C. “He will need extra fluids in summer to prevent dehydration.”
❍ D. “There is very little chance that his brother will have
sickle cell.”
Answer C is correct.
The child will need additional fluids in summer to prevent dehydration that could lead to a sickle cell crises. Answer A is not a true statement; there-
fore, it is incorrect. Answer B is incorrect because the activity will create a greater oxygen demand and precipitate sickle cell crises. Answer D is not a true statement; therefore, it is incorrect.
- A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:
❍ A. Determine whether the ear infection has affected her hearing
❍ B. Make sure that she has taken all the antibiotic
❍ C. Document that the infection has completely cleared
❍ D. Obtain a new prescription, in case the infection recurs
Answer C is correct.
The client should be assessed following completion of antibiotic therapy to determine whether the infection has cleared. Answer A would be done if there are repeated instances of otitis media, answer B is incorrect because it will not determine whether the child has completed the medication, and answer D is incorrect because the purpose of the recheck is to determine whether the infection is gone.
- A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of Sydenham’s chorea?
❍ A. Irregular movements of the extremities and facial grimacing
❍ B. Painless swellings over the extensor surfaces of the joints
❍ C. Faint areas of red demarcation over the back and abdomen
❍ D. Swelling, inflammation, and effusion of the joints
Answer A is correct.
The child with Sydenham’s chorea will exhibit irregular movements of the extremities, facial grimacing, and labile moods. Answer B is incorrect because it describes subcutaneous nodules. Answer C is incorrect because it
describes erythema marginatum. Answer D is incorrect because it describes polymigratory arthritis.
- A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the tent is to:
❍ A. Prevent insensible water loss
❍ B. Provide a moist environment with oxygen at 30%
❍ C. Prevent dehydration and reduce fever
❍ D. Liquefy secretions and relieve laryngeal spasm
Answer D is correct.
The primary reason for placing a child with croup under a mist tent is to liquefy secretions and relieve laryngeal spasms. Answers A, B, and C are inaccurate statements; therefore, they are incorrect.
- The nurse is suctioning the tracheostomy of an adult client. The recommended pressure setting for performing tracheostomy suctioning on the adult client is:
❍ A. 40–60mmHg
❍ B. 60–80mmHg
❍ C. 80–120mmHg
❍ D. 120–140mmHg
Answer C is correct.
The recommended setting for performing tracheostomy suctioning on the adult client is 80–120mmHg. Answers A and B are incorrect because the amount of suction is too low. Answer D is incorrect because the amount of suction is excessive.
- A client is admitted with a diagnosis of myxedema. An initial assessment of the client would reveal the symptoms of:
❍ A. Slow pulse rate, weight loss, diarrhea, and cardiac failure
❍ B. Weight gain, lethargy, slowed speech, and decreased respiratory rate
❍ C. Rapid pulse, constipation, and bulging eyes
❍ D. Decreased body temperature, weight loss, and increased respirations
Answer B is correct.
Symptoms of myxedema include weight gain, lethargy, slow speech, and decreased respirations. Answers A and D do not describe symptoms associated with myxedema; therefore, they are incorrect. Answer C describes symptoms associated with Graves’s disease.
- Which statement describes the contagious stage of varicella?
❍ A. The contagious stage is 1 day before the onset of the rash until the appearance of vesicles.
❍ B. The contagious stage lasts during the vesicular and crusting stages of the lesions.
❍ C. The contagious stage is from the onset of the rash until the rash disappears.
❍ D. The contagious stage is 1 day before the onset of the rash until all the lesions are crusted.
Answer D is correct.
The contagious stage of varicella begins 24 hours before the onset of the rash and lasts until all the lesions are crusted. Answers A, B, and C are inaccurate regarding the time of contagion.
- The nurse is reviewing the results of a sweat test taken from a child with cystic fibrosis. Which finding supports the client’s diagnosis?
❍ A. A sweat potassium concentration less than 40mEq/L
❍ B. A sweat chloride concentration greater than 60mEq/L
❍ C. A sweat potassium concentration greater than 40mEq/L
❍ D. A sweat chloride concentration less than 40mEq/L
Answer B is correct.
The child with cystic fibrosis has sweat concentrations of chloride greater than 60mEq/L. Answers A and C are incorrect because they refer to potassium concentrations that are not used in making a diagnosis of cystic fibrosis. Answer D is incorrect because the sweat concentration of chloride is too low to be diagnostic.
- A client in labor has an order for Demerol (meperidine) 75 mg. IM to be administered 10 minutes before delivery. The nurse should:
❍ A. Wait until the client is placed on the delivery table and administer the medication
❍ B. Question the order
❍ C. Give the medication IM during the delivery to prevent pain from the episiotomy
❍ D. Give the medication as ordered
Answer B is correct.
The nurse should question the order because administering a narcotic so close to the time of delivery can result in respiratory depression in the newborn.
Answers A, C, and D are incorrect because giving the medication prior to or during delivery can cause respiratory depression in the newborn.
- Which of the following statements describes Piaget’s stage of concrete operations?
❍ A. Reflex activity proceeds to imitative behavior.
❍ B. The ability to see another’s point of view increases.
❍ C. Thought processes become more logical and coherent.
❍ D. The ability to think abstractly leads to logical conclusion.
Answer C is correct.
During concrete operations, the child’s thought processes become more logical and coherent. Answers A, B, and D are incorrect because they describe other types of development: sensorimotor, intuitive, and formal.
- A client admitted to the psychiatric unit claims to be the Pope and insists that he will not be kept away from his subjects. The most likely explanation for the client’s delusion is:
❍ A. A reaction formation
❍ B. A stressful event
❍ C. Low self-esteem
❍ D. Overwhelming anxiety
Answer C is correct.
Delusions of grandeur are associated with feelings of low self-esteem. Answer A is incorrect because reaction formation, a defense mechanism, is characterized by outward emotions that are the opposite of internal feelings. Answers B and D can cause an increase in the client’s delusions but do not explain their purpose; therefore, they are incorrect.
- Which of the following statements reflects Kohlberg’s theory of the moral development of the preschool-age child?
❍ A. Obeying adults is seen as correct behavior.
❍ B. Showing respect for parents is seen as important.
❍ C. Pleasing others is viewed as good behavior.
❍ D. Behavior is determined by consequences.
Answer D is correct.
According to Kohlberg, in the preconventional stage of development, the behavior of the preschool child is determined by the consequences of the behavior. Answers A, B, and C describe other stages of moral development; therefore, they are incorrect.
- The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?
❍ A. Reluctance to swallow
❍ B. Drooling of blood-tinged saliva
❍ C. An axillary temperature of 99°F
❍ D. Respiratory stridor
Answer D is correct.
Respiratory stridor is a symptom of partial airway obstruction. Answers A, B, and C are expected with a tonsillectomy; therefore, they are incorrect.
- The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort decreases when he:
❍ A. Avoids eating
❍ B. Rests in a recumbent position
❍ C. Eats a meal or snack
❍ D. Sits upright after eating
Answer C is correct.
Pain associated with duodenal ulcers is lessened if the client eats a meal or snack. Answer A is incorrect because it makes the pain worse. Answer B lessens the discomfort of dumping syndrome; therefore, it is incorrect. Answer D lessens the discomfort of gastroesophageal reflux; therefore, it is incorrect.
- The nurse is assessing a newborn in the well-baby nursery. Which finding should alert the nurse to the possibility of a cardiac anomaly?
❍ A. Diminished femoral pulses
❍ B. Harlequin’s sign
❍ C. Circumoral pallor
❍ D. Acrocyanosis
Answer A is correct.
Diminished femoral pulses are a sign of coarctation of the aorta. Answers B, C, and D are found in normal newborns and are not associated with cardiac anomaly.
- A 2-year-old is hospitalized with a diagnosis of Kawasaki’s disease. A severe complication of Kawasaki’s disease is:
❍ A. The development of Brushfield spots
❍ B. The eruption of Hutchinson’s teeth
❍ C. The development of coxa plana
❍ D. The creation of a giant aneurysm
Answer D is correct.
A severe complication associated with Kawasaki’s disease is the development of a giant aneurysm. Answers A, B, and C are incorrect because they
have no relationship to Kawasaki’s disease.
- The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
❍ A. Teaching the client to report a nosebleed
❍ B. Instructing the client to maintain strict bed rest
❍ C. Telling the client to notify the doctor of pedal edema
❍ D. Advising the client to avoid sodium sources in the diet
Answer A is correct.
A nosebleed in the client with mild preeclampsia may indicate that the client’s blood pressure is elevated. Answers B, C, and D are incorrect because the client will not need strict bed rest, pedal edema is common in the client with preeclampsia, and the client does not need to avoid sodium, although the client should limit or avoid high-sodium foods.
- The nurse is preparing to discharge a client who is taking an MAOI. The nurse should instruct the client to:
❍ A. Wear protective clothing and sunglasses when outside
❍ B. Avoid over-the-counter cold and hayfever preparations
❍ C. Drink at least eight glasses of water a day
❍ D. Increase his intake of high-quality protein
Answer B is correct.
The client taking an MAO inhibitor should avoid over-the-counter medications for colds and hayfever because many contain pseudoephedrine. Combining an MAO inhibitor with pseudoephedrine can result in extreme elevations in blood pressure. Answer A is incorrect because it refers to the client taking an antipsychotic medication such as Thorazine. Answer C is not specific to the client taking an MAO inhibitor and answer D does not apply to the question.
- Which of the following meal selections is appropriate for the client with celiac disease?
❍ A. Toast, jam, and apple juice
❍ B. Peanut butter cookies and milk
❍ C. Rice Krispies bar and milk
❍ D. Cheese pizza and Kool-Aid
Answer C is correct.
Foods containing rice or millet are permitted in the diet of the client with celiac disease. Answers A, B, and D are not permitted because they contain gluten, which exacerbates the symptoms of celiac disease; therefore, they are incorrect.
- A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client’s medication?
❍ A. The client complains of blurred vision.
❍ B. The client complains of increased thirst and increased urination.
❍ C. The client complains of increased weight gain over the past year.
❍ D. The client complains of rhinorrhea.
Answer B is correct.
Increased thirst and increased urination are signs of lithium toxicity. Answers A and D are not associated with the use of lithium; therefore, they are incorrect. Answer C is an expected side effect of the medication; therefore, it is incorrect.
- The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:
❍ A. Assess the urinary output
❍ B. Obtain arterial blood gases
❍ C. Perform a dextrostick
❍ D. Obtain a stool culture
Answer A is correct.
During dehydration, the kidneys compensate for electrolyte imbalance by retaining potassium. The nurse should check for urinary output before adding potassium to the IV fluid. Answer B is incorrect because it measures respiratory compensation caused by dehydration. Answers C and D do not apply to the use of intravenous fluid with potassium; therefore, they are incorrect.
- A 2-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:
❍ A. Will need to be repeated when the child is 4 years of age
❍ B. Is given to determine whether the child is susceptible to pertussis
❍ C. Is one of a series of injections that protects against diphtheria, pertussis, tetanus and H.influenza b
❍ D. Is a one-time injection that protects against measles, mumps, rubella and varicella
Answer C is correct.
The immunization protects the child against diphtheria, pertussis, tetanus, and H. influenza b. Answer A is incorrect because a second injection is given before 4 years of age. Answer B is not a true statement and answer D is not one-time injection, nor does it protect against measles, mumps, rubella, or varicella.
- A client with Addison’s disease has been receiving glucocorticoid therapy. Which finding indicates a need for dosage adjustment?
❍ A. Dryness of the skin and mucus membranes
❍ B. Dizziness when rising to a standing position
❍ C. A weight gain of 6 pounds in the past week
❍ D. Difficulty in remaining asleep
Answer C is correct.
A weight gain of 6 pounds in a week in the client taking glucocorticoids indicates that the dosage should be modified. Answers A and B are not specific to the question; therefore, they are incorrect. Answer D is an expected side effect of the medication; therefore, it is incorrect.
- The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to:
❍ A. Applying an internal monitor
❍ B. Assessing fetal heart tones
❍ C. Assisting with epidural anesthesia
❍ D. Inserting a Foley catheter
Answer B is correct.
Assessing fetal heart tones reveals whether fetal distress
occurred with rupture of the membranes. Answers A, C, and D are later interventions; therefore, they are incorrect.
- The physician has prescribed Synthroid (levothyroxine) for a client with myxedema. Which statement indicates that the client understands the
nurse’s teaching regarding the medication?
❍ A. “I will take the medication each morning after breakfast.”
❍ B. “I will check my heart rate before taking the medication.”
❍ C. “I will report visual disturbances to my doctor.”
❍ D. “I will stop the medication if I develop gastric upset.”
Answer B is correct.
Synthroid (levothyroxine) increases metabolic rate and cardiac output. Adverse reactions include tachycardia and dysrhythmias; therefore, the client should be taught to check her heart rate before taking the medication. Answer A is incorrect because the client does not have to take the medication after breakfast. Answer C does not relate to the medication; therefore, it is incorrect. The medication should not be stopped because of gastric upset; therefore, Answer D is incorrect.
- The nurse is caring for a client with a radium implant for the treatment of cervical cancer. While caring for the client with a radioactive implant, the nurse should:
❍ A. Provide emotional support by spending additional time with the client
❍ B. Stand at the foot of the bed when talking to the client
❍ C. Avoid handling items used by the client
❍ D. Wear a badge to monitor the amount of time spent in the client’s room
Answer D is correct.
The nurse should wear a special badge when taking care of the client with a radioactive implant, to measure the amount of time spent in the room. The nurse should limit the time of radiation exposure; therefore, answer A is incorrect. Standing at the foot of the bed of a client with a radioactive cervical implant increases the nurse’s exposure to radiation; therefore, answer B is incorrect. The nurse does not have to avoid handling items used by the client; therefore, answer C is incorrect.
- The nurse is caring for a client hospitalized with bipolar disorder, manic phase who is taking lithium. Which of the following snacks would be best for the client with mania?
❍ A. Potato chips
❍ B. Diet cola
❍ C. Apple
❍ D. Milkshake
Answer D is correct.
The milkshake will provide needed calories and nutrients for the client with mania. Answers A, B, and C are incorrect choices because they do not provide as many calories or nutrients as the milkshake.
- The physician has prescribed imipramine (ToFranil) for a client with depression. The nurse should continue to monitor the client’s affect because the maximal effects of tricyclic antidepressant medication do not occur for:
❍ A. 48–72 hours
❍ B. 5–7 days
❍ C. 2–4 weeks
❍ D. 3–6 months
Answer D is correct.
The maximal effects from tricyclic antidepressants might not be achieved for up to 6 months after the medication is started. Answers A and B are incorrect because the time for maximal effects is too brief. Answer C is incorrect because it refers to the initial symptomatic relief rather than maximal effects.
- An elderly client with glaucoma has been prescribed Timoptic eyedrops. Timoptic should be used with caution in clients with a history of:
❍ A. Diabetes
❍ B. Gastric ulcers
❍ C. Emphysema
❍ D. Pancreatitis
Answer C is correct.
Beta blockers such as timolol (Timoptic) can cause bron-
chospasms in the client with chronic obstructive lung disease. Timoptic is not contraindicated for use in the client with diabetes, gastric ulcers, or pancreatitis; there-
fore, answers A, B, and D are incorrect.
- A 2-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?
❍ A. “Currant jelly” stools
❍ B. Projectile vomiting
❍ C. “Ribbonlike” stools
❍ D. Palpable mass over the flank
Answer A is correct.
The child with intussusception has stools that contain blood and mucus, which are described as “currant jelly” stools. Answer B is a symptom of pyloric stenosis; therefore, it is incorrect. Answer C is a symptom of Hirschsprungs; therefore, it is incorrect. Answer D is a symptom of Wilms tumor; therefore, it is incorrect.
- Which of the following findings would be expected in the infant with biliary atresia?
❍ A. Rapid weight gain and hepatomegaly
❍ B. Dark stools and poor weight gain
❍ C. Abdominal distention and poor weight gain
❍ D. Abdominal distention and rapid weight gain
Answer C is correct.
The infant with biliary atresia has abdominal distention, poor weight gain, and clay-colored stools. Answers A, B, and D do describe the symptoms associated with biliary atresia; therefore, they are incorrect.
- A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:
❍ A. Remove the unsightly markings with acetone or alcohol
❍ B. Cover the radiation site with loose gauze dressing
❍ C. Sprinkle baby powder over the radiated area
❍ D. Refrain from using soap or lotion on the marked area
Answer D is correct.
The nurse should not use water, soap, or lotion on the area marked for radiation therapy. Answer A is incorrect because it would remove the marking. Answers B and C are not necessary for the client receiving radiation; therefore, they are incorrect.
- The blood alcohol concentration of a client admitted following a motor vehicle accident is 460mg/dL. The nurse should give priority to monitoring the client for:
❍ A. Loss of coordination
❍ B. Respiratory depression
❍ C. Visual hallucinations
❍ D. Tachycardia
Answer B is correct.
Blood alcohol concentrations of 400–600mg/dL are associated with respiratory depression, coma, and death. Answer A occurs with blood alcohol concentrations of 50mg/dL, which affects coordination and speech but does not cause respiratory depression; therefore, it is incorrect. Answers C and D are associated with alcohol withdrawal, not overdose; therefore, they are incorrect.
- The nurse is caring for a client with acromegaly. Following a transphenoidal hypophysectomy, the nurse should:
❍ A. Monitor the client’s blood sugar
❍ B. Suction the mouth and pharynx every hour
❍ C. Place the client in low Trendelenburg position
❍ D. Encourage the client to cough
Answer A is correct.
Following a hypophysectomy, the nurse should check the client’s blood sugar because insulin levels may rise rapidly resulting in hypoglycemia. Answer B is incorrect because suctioning should be avoided. Answer C is incorrect because the client’s head should be elevated to reduce pressure on the operative site. Answer D is
incorrect because coughing increases pressure on the operative site that can lead to a leak of cerebral spinal fluid.
- A client newly diagnosed with diabetes is started on Precose (acarbose). The nurse should tell the client that the medication should be taken:
❍ A. 1 hour before meals
❍ B. 30 minutes after meals
❍ C. With the first bite of a meal
❍ D. Daily at bedtime
Answer C is correct.
Acarbose is to be taken with the first bite of a meal. Answers A, B, and D are incorrect because they specify the wrong schedule for taking the medication.
- A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:
❍ A. Apply a lanolin-based lotion to the skin
❍ B. Wash the skin with water and pat dry
❍ C. Cover the area with a petroleum gauze
❍ D. Apply an occlusive dressing to the site
Answer B is correct.
The client going for therapy in the hyperbaric oxygen chamber requires no special skin care; therefore, washing the skin with water and patting it dry
are suitable. Lotions, petroleum products, perfumes, and occlusive dressings interfere with oxygenation of the skin; therefore, answers A, C, and D are incorrect.
- The physician has ordered DDAVP (desmopressin acetate) for a client with diabetes insipidus. Which finding indicates that the medication is having its intended effect?
❍ A. The client’s appetite has improved.
❍ B. The client’s morning blood sugar was 120mg/dL.
❍ C. The client’s urinary output has decreased.
❍ D. The client’s activity level has increased.
Answer C is correct.
Diabetes insipidus is characterized by excessive production of dilute urine. A decline in urinary output shows that the medication is having its intend-
ed effect. Answers A and D do not relate to the question; therefore, they are incorrect. Answer B refers to diabetes mellitus; therefore, it is incorrect.
- A client with pregnancy-induced hypertension is scheduled for a C-section. Before surgery, the nurse should keep the client:
❍ A. On her right side
❍ B. Supine with a small pillow
❍ C. On her left side
❍ D. In knee chest position
Answer C is correct.
Positioning the client on her left side will take pressure off the vena cava and allow better oxygenation of the fetus. Answers A and B do not relieve pressure on the vena cava; therefore, they are incorrect. Answer D is the preferred position for the client with a prolapsed cord; therefore, it is incorrect for this situation.
- The physician has prescribed Coumadin (sodium warfarin) for a client having transient ischemic attacks. Which laboratory test measures the therapeutic level of Coumadin?
❍ A. Prothrombin time
❍ B. Clot retraction time
❍ C. Partial thromboplastin time
❍ D. Bleeding time
Answer A is correct.
Prothrombin time measures the therapeutic level of Coumadin. Answer B is incorrect because it measures the quantity of each specific clotting factor. Answer C is incorrect because it measures the therapeutic level of heparin. Answer D is incorrect because it evaluates the vascular and platelet factors associated with hemostasis.
- An adolescent client with cystic acne has a prescription for Accutane (isotretinoin). Which lab work is needed before beginning the medication?
❍ A. Complete blood count
❍ B. Clean-catch urinalysis
❍ C. Liver profile
❍ D. Thyroid function test
Answer C is correct.
Accutane is made from concentrated vitamin A, a fat-soluble vitamin. Fat-soluble vitamins have the potential of being hepatotoxic, so a liver panel is needed. Answers A, B, and D do not relate to therapy with Accutane; therefore, they are incorrect.
- Twenty-four hours after an uncomplicated labor and delivery, a client’s WBC is 12,000cu/mm. The elevation in the client’s WBC is most likely an indication of:
❍ A. A normal response to the birth process
❍ B. An acute bacterial infection
❍ C. A sexually transmitted virus
❍ D. Dehydration from being NPO during labor
Answer A is correct.
The client’s WBC is only slightly elevated and is most likely due to the birth process. Answer B is incorrect because the WBC would be more elevated if an acute bacterial infection was present. Answer C is incorrect because viral infections usually do not cause elevations in WBC. Answer D is incorrect because dehydration is not reflected by changes in the WBC.
- The home health nurse is visiting a client who plans to deliver her baby at home. Which statement by the client indicates an understanding regarding screening for phenylketonuria (PKU)?
❍ A. “I will need to take the baby to the clinic within 24 hours of delivery to have blood drawn.”
❍ B. “I will need to schedule a home visit for PKU screening when the baby is 3 days old.”
❍ C. “I will remind the midwife to save a specimen of cord blood for the PKU test.”
❍ D. “I will have the PKU test done when I take her for her first immunizations.”
Answer B is correct.
PKU screening is usually done on the third day of life. Answer A is incorrect because the baby will not have had sufficient time to ingest protein sources of phenylalanine. Answer C is incorrect because blood is obtained from a heel stick, not from cord blood. Answer D is incorrect because the first immunizations are done at 6 weeks of age, and by that time, brain damage will already have occurred if the baby has PKU.
- The physician has ordered intubation and mechanical ventilation for a client with periods of apnea following a closed head injury. Arterial blood gases reveal a pH of 7.47, PCO2 of 28, and HCO3 of 23. These findings
indicate that the client has:
❍ A. Respiratory acidosis
❍ B. Respiratory alkalosis
❍ C. Metabolic acidosis
❍ D. Metabolic alkalosis
Answer B is correct.
The client’s blood gases indicate respiratory alkalosis. Answers A, C, and D are not reflected by the client’s blood gases or present condition; therefore, they are incorrect.
- A client is diagnosed with emphysema and cor pulmonale. Which findings are characteristic of cor pulmonale?
❍ A. Hypoxia, shortness of breath, and exertional fatigue
❍ B. Weight loss, increased RBC, and fever
❍ C. Rales, edema, and enlarged spleen
❍ D. Edema of the lower extremities and distended neck veins
Answer D is correct.
Cor pulmonale, or right-sided heart failure, is characterized by edema of the legs and feet, enlarged liver, and distended neck veins. Answer A is
incorrect because the symptoms are those of left-sided heart failure and pulmonary edema. Answer B is not specific to the question; therefore, it is incorrect. Answer C is incorrect because it does not relate to cor pulmonale.
- A client with a laryngectomy returns from surgery with a nasogastric tube in place. The primary reason for placement of the nasogastric tube is to:
❍ A. Prevent swelling and dysphagia
❍ B. Decompress the stomach
❍ C. Prevent contamination of the suture line
❍ D. Promote healing of the oral mucosa
Answer C is correct.
The primary reason for the NG to is to allow for nourishment without contamination of the suture line. Answer A is not a true statement; therefore, it is incorrect. Answer B is incorrect because there is no mention of suction. Answer D is incorrect because the oral mucosa was not involved in the laryngectomy.
- The physician orders the removal of an in-dwelling catheter the second post-operative day for a client with a prostatectomy. The client complains of pain and dribbling of urine the first time he voids. The nurse should tell the client that:
❍ A. Using warm compresses over the bladder will lessen the discomfort.
❍ B. Perineal exercises will be started in a few days to help relieve his symptoms.
❍ C. If the symptoms don’t improve, the catheter will have to be reinserted.
❍ D. His complaints are common and will improve over the next few days.
Answer D is correct.
The client’s complaints are due to swelling associated with surgery and catheter placement. Answer A is incorrect because it will not relieve the client’s symptoms of pain and dribbling. Answer B is incorrect because perineal exercises will not help relieve the post-operative pain. Answer C is incorrect because the client’s complaints do not indicate the need for catheter reinsertion.
- A client with a right lobectomy is being transported from the intensive care unit to a medical unit. The nurse understands that the client’s chest drainage system:
❍ A. Can be disconnected from suction if the chest tube is clamped
❍ B. Can be disconnected from suction, but the chest tube should remain unclamped
❍ C. Must remain connected by means of a portable suction
❍ D. Must be kept even with the client’s shoulders during the transport
Answer B is correct.
The chest-drainage system can be disconnected from suction, but the chest tube should remain unclamped to prevent a tension pneumothorax. Answer A is incorrect because it could result in a tension pneumothorax. Answer C is not a true statement; therefore, it is not correct. Answer D is incorrect because the chest drainage system should be kept lower than the client’s chest and shoulders.
- A nurse is caring for a client with a myocardial infarction. The nurse recognizes that the most common complication in the client following a myocardial infarction is:
❍ A. Right ventricular hypertrophy
❍ B. Cardiac dysrhythmia
❍ C. Left ventricular hypertrophy
❍ D. Hyperkalemia
Answer B is correct.
Cardiac dysrhythmias are the most common complication for the client with a myocardial infarction. Answers A and C do not relate to myocardial
infarction; therefore, they are incorrect. Answer D is incorrect because it is not the most common complication following a myocardial infarction.
- A client develops a temperature of 102°F following coronary artery bypass surgery. The nurse should notify the physician immediately because elevations in temperature:
❍ A. Increase cardiac output
❍ B. Indicate cardiac tamponade
❍ C. Decrease cardiac output
❍ D. Indicate graft rejection
Answer A is correct.
Elevations in temperature increase the cardiac output. Answer B is incorrect because temperature elevations are not associated with cardiac tamponade. Answer C is incorrect because temperature elevation does not decrease cardiac output. Answer D is incorrect because elevations in temperature in the client with a coronary artery bypass graft indicate inflammation, not necessarily graft rejection.
- The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with:
❍ A. Speaking and writing
❍ B. Comprehending spoken words
❍ C. Carrying out purposeful motor activity
❍ D. Recognizing and using an object correctly
Answer A is correct.
The client with expressive aphasia has trouble forming words that are understandable. Answer B is incorrect because it describes receptive aphasia. Answer C refers to apraxia and answer D refers to agnosia, so they are incorrect.
- A client receiving Parnate (tranylcypromine) is admitted in a hypertensive crisis. Which food is most likely to produce a hypertensive crisis when taken with the medication?
❍ A. Processed cheese
❍ B. Cottage cheese
❍ C. Cream cheese
❍ D. Cheddar cheese
Answer D is correct.
The client taking MAOI, including Parnate, should avoid eating aged cheeses, such as cheddar cheese, because a hypertensive crisis can result. Answer A is incorrect because processed cheese is less likely to produce a hypertensive crisis. Answers B and C do not cause a hypertensive crisis in the client taking an MAOI; therefore, they are incorrect.
- To prevent deformities of the knee joints in a client with an exacerbation of rheumatoid arthritis, the nurse should:
❍ A. Tell the client to remain on bed rest until swelling subsides
❍ B. Discourage passive range of motion because it will cause further swelling
❍ C. Encourage motion of the joint within the limits of pain
❍ D. Tell the client she will need joint immobilization for
2–3 weeks
Answer C is correct.
The client with rheumatoid arthritis needs to continue moving affected joints within the limits of pain. Answer A and D are incorrect because they will increase stiffness and joint disuse. Answer B is incorrect because, if done correctly, passive range-of-motion exercises will improve the use of affected joints.
- The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse
should:
❍ A. Apply a clean dressing to protect the wound
❍ B. Cover the exposed visera with a sterile saline gauze
❍ C. Gently replace the abdominal contents
❍ D. Cover the area with a petroleum gauze
Answer B is correct.
Exposed abdominal visera should be covered with a sterile saline-soaked gauze, and the doctor should be notified immediately. Answer A is incorrect because the dressing should be sterile, not clean. Answer C is incorrect because attempting to replace abdominal contents can cause greater injury and should be done only surgically. Answer D is incorrect because the area is kept moist only with sterile normal saline.
- A client is admitted to the emergency room with multiple injuries. What is the proper sequence for managing the client?
❍ A. Assess for head injuries, control hemorrhage, establish an airway, prevent hypovolemic shock
❍ B. Control hemorrhage, prevent hypovolemic shock, establishan airway, assess for head injuries
❍ C. Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries
❍ D. Prevent hypovolemic shock, assess for head injuries, establish an airway, control hemorrhage
Answer C is correct.
Using the ABCD approach to the client with multiple trauma the nurse in the ER would: establish an airway, determine whether the client is breathing, check circulation (control hemorrhage), and check for deficits (head injuries). Answers A, B, and D are incorrect because they are not in the appropriate sequence for maintaining life.
- The nurse is teaching the mother of a child with attention deficit disorder regarding the use of Ritalin (methylphenidate). The nurse recognizes that the mother understands her teaching when she states the importance of:
❍ A. Offering high-calorie snacks
❍ B. Watching for signs of infection
❍ C. Observing for signs of oversedation
❍ D. Using a sunscreen with an SPF of 30
Answer A is correct.
Stimulant medications such as Ritalin tend to cause anorexia and weight loss in some children with ADHD. Providing high-calorie snacks will help the child maintain an appropriate weight. Answer B is incorrect because the medication does not mask infection. Answer C is incorrect because the medication is a central nervous system stimulant, not a depressant. Answer D has no relationship to the medication; therefore, it is incorrect.
- A home health nurse has several elderly clients in her case load. Which of the following clients is most likely to be a victim of elder abuse?
❍ A. A 76-year-old female with Alzheimer’s disease
❍ B. A 70-year-old male with diabetes mellitus
❍ C. A 64-year-old female with a hip replacement
❍ D. A 72-year-old male with Parkinson’s disease
Answer A is correct.
The most likely victim of elder abuse is the elderly female with a chronic, debilitating illness. Answers B, C, and D are less likely to be victims of elder abuse; therefore, they are incorrect.
- A camp nurse is applying sunscreen to a group of children enrolled in swim classes. Chemical sunscreens are most effective when applied:
❍ A. Just before sun exposure
❍ B. 5 minutes before sun exposure
❍ C. 15 minutes before sun exposure
❍ D. 30 minutes before sun exposure
Answer D is correct.
Sunscreens of at least an SPF of 15 should be applied 20–30 minutes before going into the sun. Answers A, B, and C are incorrect because they do
not allow sufficient time for sun protection.
- The physician has made a diagnosis of “shaken child” syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of “shaken child” syndrome?
❍ A. Fracture of the clavicle
❍ B. Periorbital bruising
❍ C. Retinal hemorrhages
❍ D. Fracture of the humerus
Answer C is correct.
Retinal hemorrhages are characteristically found in the child who has been violently shaken. Answers A, B, and D may result from trauma other than that related to abuse; therefore, they are incorrect.
- A post-operative client has an order for Demerol (meperidine) 75mg and Phenergan (promethazine) 25mg IM every 3–4 hours as needed for pain. The combination of the two medications produces a/an:
❍ A. Agonist effect
❍ B. Synergistic effect
❍ C. Antagonist effect
❍ D. Excitatory effect
Answer B is correct.
The combination of the two medications produces a synergistic effect (an effect greater than that of either drug used alone). Agonist effects are similar to those produced by chemicals normally present in the body; therefore, answer A is incorrect. Antagonist effects are those in which the actions of the drugs oppose one
another; therefore, answer C is incorrect. Answer D is incorrect because the drugs would have a combined depressing, not excitatory effect.
- Which obstetrical client is most likely to have an infant with respiratory distress syndrome?
❍ A. A 28-year-old with a history of alcohol use during the pregnancy
❍ B. A 24-year-old with a history of diabetes mellitus
❍ C. A 30-year-old with a history of smoking during the pregnancy
❍ D. A 32-year-old with a history of pregnancy-induced
hypertension
Answer B is correct.
The client with a history of diabetes is most likely to deliver a preterm large for gestational age newborn. These newborns often lack sufficient surfactant levels to prevent respiratory distress syndrome. Answers A, C, and D are less likely to have newborns with respiratory distress syndrome so they are incorrect choices.
- A client with a C4 spinal cord injury has been placed in traction with cervical tongs. Nursing care should include:
❍ A. Releasing the traction for 5 minutes each shift
❍ B. Loosening the pins if the client complains of headache
❍ C. Elevating the head of the bed 90°
❍ D. Performing sterile pin care as ordered
Answer D is correct.
Nursing care of the client with cervical tongs includes performance of sterile pin care and assessment of the site. Answers A, B, and C alter the traction and could result in serious injury or death of the client; therefore, they are incorrect.
- The nurse is assessing a client following a coronary artery bypass graft (CABG). The nurse should give priority to reporting:
❍ A. Chest drainage of 150mL in the past hour
❍ B. Confusion and restlessness
❍ C. Pallor and coolness of skin
❍ D. Urinary output of 40mL per hour
Answer A is correct.
Chest drainage greater than 100mL per hour is excessive, and the doctor should be notified regarding possible hemorrhage. Confusion and restlessness could be in response to pain, changes in oxygenation, or the emergence from anesthesia; therefore, answer B is incorrect. Answer C is incorrect because it is an expected finding in the client recently returning from a CABG. Answer D is within normal limits; therefore, it is incorrect.
- Before administering a client’s morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
❍ A. Record the pulse rate and administer the medication
❍ B. Administer the medication and monitor the heart rate
❍ C. Withhold the medication and notify the doctor
❍ D. Withhold the medication until the heart rate increases
Answer C is correct.
The medication should be withheld and the doctor should be notified. Answers A, B, and D are incorrect because they do not provide for the client’s safety.
