preparation for NCLEX 1

Question 1

Thirty-two children are brought to the emergency department after a school bus crash. Two children were killed along with the three people in the car who caused the crash. Before the clients arrive, in addition to ensuring that the hospital staff is prepared for the emergency, the nurse should anticipate carrying out which step?
a. calling the nearest crisis response team
b. alerting the news media
c. notifying the hospital volunteer office
d. calling the school to inform teachers of the crash

Answer 1

a. calling the nearest crisis response team.

The children and their families are at risk for experiencing a crisis. Disaster teams are available for crisis intervention in such emergencies. Usually, the news media monitors emergency radio frequencies and most likely are aware of the crash already. Although volunteers may help in some ways, they are not responsible for crisis intervention. Calling the school might be done, but the emergency issues take precedence.

Question 2

The health care provider prescribes phytonadione, 0.5 mg I.M., for a neonate born 30 minutes ago. The nurse has a solution containing 2 mg/ml. How many milliliters of solution should the nurse administer to achieve this dose? Record your answer using two decimal places.

Answer 2

To calculate the amount to give, set up the following equation and solve for X: 0.5 mg/X ml = 2 mg/1 ml X = 0.25 ml.

Question 3

The nurse is aware that a client receiving morphine sulfate intravenously post-surgical repair of a hip fracture may exhibit which outcome when getting out of bed for the first time?
a. postural or orthostatic hypotension
b. respiratory distress because of increased pain from movement
c. initial hypertension due to the medication administration 2 hours earlier
d. acute hip pain based on the movement

Answer 3

a. postural or orthostatic hypotension

After the administration of certain antihypertensives or opioids, the client’s neurocirculatory reflexes may have some difficulty adjusting to the force of gravity when assuming an upright position. Postural or orthostatic hypotension may then occur, causing a temporarily decreased blood supply to the brain. The client received analgesia, so pain should be controlled and the client’s blood pressure should be within normal range or slightly lower. Pain should not be acute.

Question 4

A client reports chronic lower back pain and fatigue, and has been seen by multiple care providers without relief of symptoms. The client insists that something is terribly wrong. Which action should the nurse take first?
a. Refer the client for a psychiatric evaluation.
b. Initiate group therapy for behavior modification.
c. Obtain a thorough health assessment to rule out physical illnesses.
d, Refer the client to physical therapy.

Answer 4

c. obtain thorough health assessment to rule out physical illnesses.

The first action by the nurse should be to take a thorough health assessment including laboratory studies to rule out physical illnesses. The other actions aren’t appropriate until a diagnosis is made.

Question 5

A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product?
a. no priming needed since blood products must be infused alone per current guidelines
b. dextrose 5% in water as this is considered an isotonic solution
c. lactated Ringer’s solution as this is considered an isotonic solution
d. normal saline solution as this is considered an isotonic solution

Answer 5

d. normal saline solution as this is considered an isotonic solution.

Normal saline solution is used for administering blood transfusions. Lactated Ringer’s solution or dextrose solutions may cause blood clotting or RBC hemolysis. Current guidelines do not indicate a “no priming” method without NSS.

Question 6

A 16-year-old client requires chemotherapy for leukemia. The client’s parents support the health care provider’s recommendation, but the client is refusing treatment. What is the nurse’s best initial action?

a. Advise the client to take the treatment because the health care provider knows best.
b. Inform the client that if the parents agree with the treatment plan, their consent will be honored.
c. Request that the health care provider thoroughly explain the benefits and consequences of treatment to the client.
d. Give advice to the client’s parents on the best method of convincing the client to take the treatment.

Answer 6

c. request that the health care provider thoroughly explain the benefits and consequences of treatment to the client.

The nurse has a responsibility to the client and should act as an advocate. In this situation, it is best, and most appropriate, for a 16-year-old client to understand the treatment being discussed. After a discussion and understanding, if the client refuses, then the client can be instructed that the decision of the parents will be honored. The other options do not demonstrate the nurse’s understanding of client advocacy and the client’s right to choice.

Question 7

A client is experiencing a flashback from the use of lysergic acid diethylamide (LSD). What should the nurse do?
a. Confront the client’s misperceptions.
b. Reassure the client while presenting reality.
c. Seclude the client until the flashback ends.
d. Challenge the client’s unrealistic statements.

Answer 7

b. reassure the client while presenting reality.

When a client is experiencing a flashback, the nurse should stay with the client, offer reassurance, and present reality in a nonthreatening manner to minimize the client’s anxiety and agitation. The client needs to be told that they are experiencing an effect from lysergic acid diethylamide and that they are safe and the flashback will end. Confronting the client’s misperceptions or challenging unrealistic statements could increase anxiety and agitation, possibly leading to aggressive behavior. Secluding the client until the flashback ends usually is not necessary or appropriate unless the client threatens or demonstrates aggression toward self or others.

Question 8

Several nurses from the medical unit access the electronic medical record of a well-known public official who was admitted to the emergency department. How should the nurse manager respond to the nurses regarding this situation?
a. “It is understandable that you would be interested in the official’s medical status.”
b. “Accessing the official’s medical record is a breach of confidentiality.”
c. “You must not share the information you learn with others outside this unit.”
d. “We must maintain the official’s confidentiality by denying that the official is a client here.”

Answer 8

b. “Accessing the official’s medical record is a breach of confidentiality.”

The only people entitled to access the medical record are those who require access for care delivery. The other answers condone the medical unit nurses’ breach of confidentiality and do not do anything to stop it from occurring. Clients identities are sometimes protected using pseudonyms or denial, but this is not routine or done simply because the client is well-known.

Question 9

A client has been placed in an isolation room and family members have stated that access to the client seems restricted. Which actions would be appropriate for the nurse to take to address this situation? Select all that apply.
a. a communication plan for the family and client
b. free access to the client for immediate family
c. a thorough explanation of the isolation procedures
d. acknowledgement of the family’s concerns
e. discontinued isolation procedures at the family’s request

Answer 9

a. a communication plan for the family and client.
c. a thorough explanation of the isolation procedures.
d. acknowledgement of the family’s concerns.

To ensure that everyone complies with the isolation procedures, the nurse should develop a communication plan with the family and client, provide thorough explanations about the importance of complying with the isolation procedures, and address family and client concerns. Allowing free access or discontinuing isolation procedures at the family’s request would be a safety violation.

Question 10

A client with obsessive-compulsive disorder who was admitted early yesterday morning must make their bed 22 times before they can have breakfast. Because of this behavior, the client missed having breakfast yesterday with the other clients. Which action should the nurse institute to help the client be on time for breakfast?

a. Tell the client to make their bed one time only.
b. Wake the client an hour earlier to perform their ritual.
c. Insist that the client stop their activity when it is time for breakfast.
d. Advise the client to have breakfast first before making the bed.

Answer 10

b. wake the client an hour earlier to perform their ritual.

The nurse should wake the client an hour earlier to perform their ritual so that they can be on time for breakfast with the other clients. The nurse provides the client with the time needed to perform rituals because the client needs to keep their anxiety in check. The nurse should never take away a ritual because panic will ensue. The nurse should work with the client later to slowly set limits on the frequency of the action.

Question 11

Which action performed by a nurse will increase the risk of liability? Select all that apply.
a. witnessing a client sign a consent for an ordered medical procedure
b. withholding a medication to clarify the ordered dosage
c. assisting a client on ordered bed rest to walk to the toilet
d. asking unlicensed assistive personnel to assess a client’s wound
e. providing information to a caller about a client’s diagnosis and treatment

Answer 11

c. assisting a client on ordered bed rest to walk to the toilet.
d. asking unlicensed assistive personnel to assess a client’s wound.
e. providing information to a caller about a client’s diagnosis and treatment.

Nursing standards of practice are stated within the nurse practice act of each state, territory, or province. These standards include scope of practice, delegation, professional ethics, and code of conduct. A nurse increases the risk of professional liability when performing activities outside of these standards. A nurse may not delegate a nursing task to a person, such as unlicensed assistive personnel, who does not have the proper training or skills to perform the task. The nurse should not act against health care provider orders without a professionally based reason, such as clarifying an order. Professional ethics requires protection of client privacy. Personal health information should not be provided to a caller without the client’s consent.

Question 12

The adult child of an older adult client reports that their parent just “stares off into space” more and more in the last several months but then eagerly smiles and nods once the child can get their attention. What additional assessment should the nurse make to better understand the client’s behavior?
a. dementia
b. hearing loss
c. frustration
d. depression

Answer 12

b. hearing loss

Blank looks, decreased attention span, positioning of the head toward sound, and smiling/nodding in agreement once attention is gained are all behaviors that indicate hearing loss in adults. It is common to confuse sensory deficits for a change in cognitive status such as dementia. The nurse should focus assessments of sensory function on considering any pathophysiology of existing or new-onset deficits and consider all client factors that might contribute to deficits. The blank looks do not indicate that this client is frustrated or depressed.

Question 13

The nurse is assessing a client with a spinal cord injury for the development of deep vein thrombosis. Which is the most effective way to determine deep vein thrombosis in this client?
a. Detect a positive Homans sign.
b. Rate the amount of pain.
c. Assess for tenderness.
d. Measure leg girth.

Answer 13

d. measure leg girth.

Measuring the leg girth is the most appropriate method because the usual signs, such as a positive Homans sign, pain, and tenderness, are not present. Other means of assessing for deep vein thrombosis in a client with a spinal cord injury are through a Doppler examination and impedance plethysmography.

Question 14

What is the best nursing response to a client who is experiencing an acute myocardial infarction (MI) and asks why the nurse is administering intravenous morphine?
a. “Morphine decreases the heart’s need for oxygen and also makes your heart not work as hard.”
b. “Morphine increases your heart’s ability to stretch and squeeze and decreases pain.”
c. “Morphine is a medication that is commonly administered for pain control.”
d. “Morphine decreases blood pressure and increases your heart’s ability to stretch.”

Answer 14

a. “Morphine decreases the heart’s need for oxygen and also makes your heart not work as hard.”

When given to treat acute MI, morphine eliminates pain, reduces preload and afterload, reduces vascular resistance, reduces cardiac workload, and reduces the oxygen demand of the heart. Morphine does not increase myocardial contractility, raise blood pressure, or increase preload or afterload.

Question 15

A client who has asthma is taking albuterol to treat bronchospasms. The nurse should assess the client for which adverse effect(s) that can occur as a result of taking this drug? Select all that apply.
a. lethargy
b. nausea
c. headache
d. nervousness
e. constipation

Answer 15

b. nausea
c. headache
d. nervousness

Albuterol is a beta-adrenergic agonist. Possible adverse effects include nausea, headache, and nervousness as well as insomnia and vomiting. Constipation is not associated with this drug. The client will not become lethargic; instead, the client may experience restlessness.

Question 16

A nurse is working as pediatric case manager on the pediatric orthopedic unit. The nurse takes what action as most representative of the responsibilities in this role?
a. Teaching parents about discharge plans.
b. Coordinating the client’s nursing care.
c. Ensuring the critical pathway related to care is followed.
d. Answering family questions regarding care.

Answer 16

c. ensuring the critical pathway related to care is followed.

Case managers follow a group of clients, ensuring that their care follows the appropriate critical pathway. These pathways contain a timeline designed to coordinate the multidisciplinary team toward a common goal of providing a short, safe, and healthy length of stay in the hospital. Case managers play an active role in discharge planning, but most often the primary nurse provides discharge teaching. Case managers often answer family questions, but this is not the primary role. Coordination of nursing care usually falls on the charge nurse.

Question 17

A client is experiencing an acute schizophrenic episode. Vivid hallucinations are making the client agitated. The nurse’s best response at this time is to:
a. take the client’s vital signs.
b. explore the content of the client’s hallucinations.
c. tell the client their fear is unrealistic.
d. engage the client in reality-oriented activities.

Answer 17

b. explore the content of the client’s hallucinations.

Exploring the content of the hallucinations will help the nurse understand the client’s perspective on the current situation. The client shouldn’t be touched, such as when taking vital signs, without being told exactly what is going to happen. Debating with the client about the emotions isn’t therapeutic. When the client is calm, the nurse should engage the client in reality-based activities.

Question 18

A client with pancreatitis is admitted to the medical intensive care unit. Which nursing intervention is most appropriate?
a. providing generous servings at mealtime
b. reserving an antecubital site for a peripherally inserted central catheter (PICC)
c. providing the client with plenty of P.O. fluids
d. limiting I.V. fluid intake according to the health care provider’s order

Answer 18

b. reserving an antecubital site for a peripherally inserted central catheter (PICC).

Pancreatitis treatment typically involves resting the GI tract by maintaining nothing-by-mouth status. The nurse should reserve the antecubital site for a PICC, which enables the client to receive long-term total parenteral nutrition. Clients in the acute stages of pancreatitis also require large volumes of I.V. fluids to compensate for fluid loss.

Question 19

A client undergoes a barium swallow fluoroscopy that confirms gastroesophageal reflux disease (GERD). Based on this diagnosis, the client should be instructed to take which action? Select all that apply.

a. Follow a high-fat, low-fiber diet.
b. Avoid caffeine and carbonated beverages.
c. Sleep with the head of bed flat.
d. Stop smoking.
e. Take antacids 1 hour and 3 hours after meals.
f. Limit alcohol consumption to one drink per day.

Answer 19

b. avoid caffeine and carbonated beverages.
d. stop smoking.
e. take antacids 1 hour and 3 hours after meals.

The nurse should instruct the client with GERD to follow a low-fat, high-fiber diet. Caffeine, carbonated beverages, alcohol, and smoking should be avoided because they aggravate GERD. In addition, the client should take antacids as prescribed (typically 1 hour and 3 hours after meals and at bedtime). Lying down with the head of bed elevated, not flat, reduces intra-abdominal pressure, thereby reducing the symptoms of GERD.

Question 20

A nurse who works in a large, urban hospital provides care for a diverse client population. When performing skin assessments, the nurse modifies assessment practices for a certain client to identify clinically meaningful data. This practice is most justified by the fact that clients differ according to
a. race.
b. ethnicity.
c. culture.
d. preference.

Answer 20

a. race

Race (biologic variations) is a term used to categorize people with genetically shared physical characteristics. The biological variations necessitate differences in skin assessment, both in terms of technique and interpretation of results. Ethnicity and culture are psychosocial concepts that certainly have relationships to race but neither specifically warrants changes in integumentary assessments.

Question 21

The nurse is planning care for an infant with bronchiolitis who requires monitoring for dehydration. What is the most important intervention for the nurse to provide?
a. Daily weight
b. Blood levels every four hours
c. Urinalysis every eight hours
d. Weighing each diaper

Answer 21

a. daily weights

Weight is a good indicator of hydration in infants. Accurate measurement of intake and output is essential. Weighing diapers is a way of measuring output only. Blood levels may be obtained daily or every other day. A urinalysis every eight hours is not necessary. Urine specific gravities are recommended but can be obtained with diaper changes.

Question 22

While a client is being prepared for discharge, the nasogastric (NG) feeding tube becomes clogged. To remedy this problem and teach the client’s family how to deal with it at home, what should the nurse do?
a. Irrigate the tube with cola.
b. Advance the tube into the intestine.
c. Apply intermittent suction to the tube.
d. Withdraw the obstruction with a 30-ml syringe.

Answer 22

a. irrigate the tube with cola.

The nurse should irrigate the tube with cola because its effervescence and acidity are suited to the purpose, it’s inexpensive, and it’s readily available in most homes. Advancing the NG tube is inappropriate because the tube is designed to stay in the stomach and isn’t long enough to reach the intestines. Applying intermittent suction or using a syringe for aspiration is unlikely to dislodge the material clogging the tube but may create excess pressure. Intermittent suction may even collapse the tube.

Question 23

A nurse is caring for a 10-month-old weighing 17.6 lb (8 kg) who was admitted for dehydration. The infant has an IV of 5% dextrose in 0.45% saline infusing at the maintenance rate of 100 mL/kg per day for children weighing 22 lb (10 kg) or less. The infant has vomited five times in the last 3 hours and has had no wet diapers in the last 8 hours. The nurse informs the health care provider. Which prescription should the nurse question?

a. Increase the intravenous fluids to 45 mL per hour for 24 hours.
b. Keep the infant on nothing-by-mouth (NPO) status while vomiting persists.
c. Administer a 10 mL/kg fluid bolus of dextrose 25%.
d. Maintain strict intake and output (I&O), weighing all diapers.

Answer 23

c. administer a 10mL/kg fluid bolus of dextrose 25%

The infant needs a fluid bolus. A fluid bolus should consist of an isotonic fluid such as normal saline or lactated Ringer’s. Dextrose 25% is not an appropriate bolus for dehydrated children because it could cause a fluid shift that may result in cerebral edema and death; thus, the nurse should question the prescription. D5W0.45% normal saline is an appropriate IV fluid for infants. The rate is 1.5 times maintenance for this child and is appropriate for the first 24 hours if the child is dehydrated. Once hydration is adequate, the infant’s IV rate should be reduced to a maintenance rate. Vomiting is persistent, so it is appropriate for the child to be NPO. Strict I&O is an appropriate prescription for all dehydrated children.

Question 24

The nurse is caring for a client diagnosed with postpartum depression, which has had a significant impact on all members of the family. At the family’s request, the nurse will be attending sessions in which the therapist will provide systemic therapy. The nurse should teach the family to anticipate what focus during the therapy sessions?

a. alternative ways of thinking about the crisis
b. allowing family members to express their true feelings
c. dynamics and patterns of communication and interaction
d. underlying psychological factors that influence the situation

Answer 24

c. dynamics and patterns of communication and interaction.

Systemic therapy considers a family as a unit and recognizes that when one family member changes, other family members are affected. The therapist examines the attitudes, ideas, and problems of the family as a unit to determine how family dynamics influence a problem situation. Cognitive behavioral therapy focuses on changing thinking while psychodynamic therapy focuses on revealing the real reasons behind a problem. Supportive counseling allows the family to express their feelings.

Question 25

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to
a. increase the frequency of the catheterizations.
b. insert an indwelling urinary catheter.
c. place the client on fluid restrictions.
d. use a condom catheter instead of an invasive one.

Answer 25

a. increase the frequency of the catheterizations.

As a rule of practice, if intermittent catheterization for urine retention typically yields 500 ml or more, the frequency of catheterization should be increased. Indwelling catheterization is less preferred because of the risk of urinary tract infection and the loss of bladder tone. Fluid restrictions aren’t indicated in this case; the problem isn’t overhydration, rather it’s urine retention. A condom catheter doesn’t help empty the bladder of the client with urine retention.

Question 26

The nurse has received a shift report on a group of newborns. The nurse should make rounds on which client first?

a. a newborn who is large for gestational age (LGA) and who needs a repeat blood glucose prior to the next feeding in 15 minutes
b, a neonate born at 36 weeks’ gestation weighing 2270 g (2.27 kg) who is due to breastfeed for the first time in 15 minutes
c. a neonate who was born 24 hours ago by cesarean birth who had a respiratory rate of 62 breaths/min 30 minutes ago
d. a newborn who had a borderline low temperature and was double-wrapped with a hat 30 minutes ago to bring up the temperature

Answer 26

c. a neonate who was born 24 hours ago by cesarean birth who had a respiratory rate of 62 breaths/min 30 minutes ago.

The nurse should make rounds and first assess the neonate with the respiratory rate of 62 breaths/min. The respiratory rate is out of the normal range and needs reevaluation. The nurse should next assess the newborn with a borderline low temperature to determine if the newborn’s body temperature is increasing. The newborn who is LGA still has 15 minutes before being due for the feeding, and much can be accomplished by the nurse in that time. A 36-week newborn weighing 2270 g (2.27 kg) will need to be fed on time to maintain the blood glucose level.

Question 27

A nurse caring for a client with small-bowel obstruction should plan to implement which nursing intervention first?
a. administering pain medication
b. obtaining a blood sample for laboratory studies
c, preparing to insert a nasogastric (NG) tube
d. administering I.V. fluids

Answer 27

d. administering I.V. fluids

The nurse should first administer I.V. infusions containing normal saline solution and potassium to maintain fluid and electrolyte balance. For the client’s comfort and to assist in bowel decompression, the nurse should prepare to insert an NG tube next. A blood sample is then obtained for laboratory studies to help diagnose bowel obstruction and guide treatment. Blood studies usually include a complete blood count, serum electrolyte levels, and blood urea nitrogen level. Pain medication commonly is withheld until obstruction is diagnosed because analgesics can decrease intestinal motility.

Question 28

An adolescent client is admitted for surgical treatment of genital lesions. The client appears withdrawn. What action will the nurse use with the client’s care?

a. Acknowledge the embarrassment.
b. Encourage the family to limit visiting.
c. Have an assistant when providing care.
d. Focus on alternate methods of sexual gratification.

Answer 28

c. have an assistant when providing care.

It is important for the nurse to recognize that some clients are often modest or simply feel more comfortable with a chaperone or assistant present for intimate care needs. The nurse will need to explain and encourage family visitations. The nurse does not assume the client is embarrassed. The nurse must provide teaching in a way that the client can be receptive to understanding and not focus on sexual gratifications.

Question 29

A nurse is caring for a client who is in a catatonic state due to schizophrenia. Which nursing intervention would be most important in the care of this client?
a. Predict and fulfill client needs until the client is more active.
b. Attempt to engage the client in therapeutic conversations with members of the staff and other clients.
c. Assess the level of family functioning and availability of support systems.
d. Reorient the client as often as is required.

Answer 29

a. predict and fulfill client needs until the client is more active.

A client in a stuporous state may refuse to eat or drink, which can interfere with life functioning. Although engagement in communication, reorientation to reality, and family functioning are all important concerns, the priority for nursing care is to assess and intervene if the client refuses to eat and drink. Higher levels of care may be required, and it is a priority for the nurse to assess this state.

Question 30

A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions for avoiding future crises would the nurse provide to the child and family? Select all that apply.
a. Avoid foods high in folic acid.
b. Drink plenty of fluids.
c. Use cold packs to relieve joint pain.
d. Report a sore throat to an adult immediately.
e. Restrict activity to quiet board games.
f. Wash hands before meals and after playing.

Answer 30

b. drink plenty of fluids.
d. report a sore throat to an adult immediately.
f. wash hands before meals and after playing.

Sickle cell anemia is an autosomal recessive genetic disease passed down through families in which red blood cells form an abnormal sickle or crescent shape. Fluids would be encouraged to prevent stasis in the bloodstream, which can lead to sickling. Sore throats and all other cold symptoms would be reported promptly because they may indicate an infection, which can precipitate a crisis (red blood cells sickle and obstruct blood flow to tissues). Children with sickle cell anemia would learn appropriate measures to prevent infection, such as proper hand-washing techniques and good nutrition. Folic acid intake would be encouraged to help support new cell growth; new cells replace fragile sickled cells. Warm packs would be applied to promote comfort and relieve pain; cold packs cause vasoconstriction. The child would maintain an active, normal life but would avoid excessive exercise, which can precipitate an attack. When the child experiences a crisis, the child will typically limit activity according to the pain level.

Question 31

A client returns to the unit from a surgical procedure at 1500. The nurse receives the client, performs an assessment, and continues the plan of care. During the next shift, the nurse performs a review of health care provider orders for the past 24 hours and notes the nurse receiving the surgical client did not address or implement the postoperative orders. Which action by the nurse is appropriate?

a. Notify the charge nurse so an event report can be completed on this sentinel event.
b. Acknowledge and implement the missed orders since the client’s condition is unchanged.
c. Notify the health care provider that new orders are needed because the missed orders have expired.
d. Notify the surgical unit of the breakdown in communication that occurred when the client was transferred.

Answer 31

a. notify the charge nurse so an event report can be completed on this sentinel event.

The missed orders from the client’s transfer from surgery back to the unit resulted in a delay in care. This is defined as a sentinel event by The Joint Commission. Even if no harm came to the client as a result of this delay in care, leadership must still be notified, and an event report must still be completed. The nurse will need to acknowledge and implement orders if applicable and potentially notify the health care provider if clarifications are needed. However, the orders do not expire. The nurse also would not confront the unit the client was transferred from. A breakdown in communication regarding the orders may have occurred, but direct confrontation is not appropriate.

Question 32

A client has had a laparoscopic cholecystectomy. Which statement indicates that the client understands the nurse’s discharge instructions about activity restrictions?

a.“I’ll need to stay in bed the first 2 days I’m home.”
b. “I won’t be able to lift objects until 6 weeks after my surgery.”
c. ”I can return to my normal activities within 7 days.”
d. ”I should avoid sitting upright for 1 week after my surgery.”

Answer 32

c. “I can return to my normal activities within 7 days.”

Laparoscopic cholecystectomy is performed through a small incision at the umbilicus. Hospital stays postoperatively are minimal, and clients are encouraged to ambulate the day of the surgery. Clients typically resume all normal activities within 7 days of surgery. There will not be restrictions on lifting heavy objects, and there is no need to avoid sitting upright.

Question 33

The nurse has just discontinued an indwelling urinary catheter for a client on the second postoperative day following abdominal surgery. What is the nurse’s priority action in implementing a voiding trial for this client?
a. Conduct a bladder scan to assess for residual urine.
b. Provide education on the importance of bladder emptying.
c. Assess the client for bladder distention and pain.
d. Encourage a voiding attempt in 2 to 4 hours or if an urge to void is present.

Answer 33

d. encourage a voiding attempt in 2 to 4 hours or if an urge to void is present.

The nurse should encourage the client to urinate if the urge is felt or to attempt to void every 2 to 4 hours. This will assist in reestablishing the sensation to void following the use of an indwelling catheter and allow the nurse to conduct a voiding trial. The nurse would assess the client’s bladder for distention and pain to note if the bladder is full but would not necessarily do this at the initiation of the voiding trial. A bladder scan would be conducted to assess for postvoid residual urine, not immediately after the removal of the catheter. If there was urine noted on the bladder scan, the nurse would want to provide education to the client on the need to fully empty the bladder with urination.

Question 34

The client with Raynaud phenomenon has a skin ulcer on the forearm. The skin surrounding the ulcer is dry. The health care provider prescribed nitroglycerine cream. What should the nurse instruct the client about the purpose of nitroglycerine?

a. It treats pain.
b. It prevents an infection.
c. It promotes healing.
d. It softens the surrounding skin.

Answer 34

c. it promotes healing.

The nurse should instruct the client with Raynaud disease that nitroglycerine cream is used to promote healing by promoting vasodilation. The drug is not used in this instance to treat pain. The drug does not have properties to treat infection or soften the skin.

Question 35

A nurse is caring for a client with chronic pain. In planning care, what will the nurse focus on as part of incorporating spiritual health into the client’s plan for pain control?
a. the client’s sense of meaning and purpose as it relates to quality of life and pain
b. the client’s willingness to ask others to pray for the relief of the client’s pain
c. spiritually linked actions that the client has used to manage pain in the past
d. the client’s belief about the effects of positive spiritual thoughts on pain levels

Answer 35

c. spiritually linked actions that the client has used to manage pain in the past.

Religion and spirituality have been related to a client’s well-being when facing illness and disease. They can be powerful coping mechanisms when a client is facing life-or-death decisions, as well as chronic conditions such as pain if the client believes in the value of these links. The nurse is seeking interventions and, therefore, the client’s past use of spiritual practices for pain management is most relevant. General beliefs about abstract concepts such as meaning and purpose will not be directly helpful in informing interventions. The nurse should not focus on the client’s acceptance of prayer as this is making an assumption instead of exploring the client’s spiritual practices. Asking the client if they believe pain levels are affected by spiritual thoughts again makes an assumption instead of asking an open-ended, non-leading question about the client’s practices or beliefs.

Question 36

When providing discharge instructions to a client being discharged from the hospital, the nurse knows that specific interventions can promote cost-effective care. Which intervention(s) is appropriate during discharge teaching? Select all that apply.

a. Discuss the importance of filling new prescriptions and taking them as prescribed.
b. Ensure that the client has a follow-up appointment scheduled with the health care provider prior to discharge.
c. Confirm that the client has the means (financial, transportation) to get new prescriptions and to attend appointments.
d. Tell the client to return to the hospital for all follow-up concerns.
e. Educate the client on signs and symptoms that may be experienced and which level of care is appropriate for those situations.

Answer 36

a. discuss the importance of filling new prescriptions and taking them as prescribed.
b. ensure that the client has a follow-up appointment scheduled with the health care provider prior to discharge.
c. confirm that the client has the means (financial, transportation) to get new prescriptions and to attend appointments.
e. educate the client on signs and symptoms that may be experienced and which level of care is appropriate for those situation.

In this scenario, discharge teaching for cost-effective care focuses on ensuring the client has appropriate follow-up and continuity of care to prevent readmission to the hospital. Discussing the importance of filling and taking new prescriptions, scheduling follow-up appointments, and ensuring the client has the means to get prescriptions and attend appointments are all critical to ensuring the client continues to improve following discharge from the hospital and are appropriate interventions. Educating the client on signs and symptoms that may be experienced and when to seek medical care or emergency medical care for those symptoms is important to ensuring the client gets appropriate care and prevents deterioration of the condition.

Telling the client to return to the hospital for all concerns is not appropriate, as there are other, more cost-effective follow-up options most of the time, such as the client’s health care provider.

Question 37

The nurse assesses a 7-month-old infant’s growth and development. Which behavior would the nurse consider unusual?
a. drinking from a cup and spilling little of the liquid
b. raising the chest and upper abdomen off the bed with the hands
c. imitating sounds that the nurse makes
d. crying loudly in protest when the parent leaves the room

Answer 37

a. drinking from a cup and spilling little of the liquid.

Infants at age 7 months are not capable of drinking from a cup without spilling. At age 6 months, infants can partially lift their weight on their hands, enjoy imitating sounds, and are developing separation anxiety.

Question 38

A client with an amputation is learning how to apply a prosthetic limb. Which statement(s) made by the client indicates an increased risk for skin impairment? Select all that apply.

a. “I can clean and inspect the skin of my amputated leg weekly.”
b. “I will make sure the padding is all placed in the front of the stump.”
c. “I can wear a cotton garment with seams over the stump.”
d. ‘I will make sure the device is supportive but not too snug.”
e. “I don’t like wearing the prosthesis, but it helps me to walk.”

Answer 38

a. “I can clean and inspect the skin of my amputated leg weekly.”
b. “I will make sure the padding is all placed in the front of the stump.”
c. “I can wear a cotton garment with seams over the stump.”

The client with a prosthetic limb would want to clean and inspect the skin of the amputated limb daily to ensure skin integrity is maintained. Having the padding of the device distributed evenly can help prevent pressure on the skin with the device. Wearing a cotton garment between the skin and prosthesis that does not have seams also helps decrease pressure and friction on the limb. The client would not want the device to fit too tightly as this can create pressure on the skin that could lead to skin breakdown. While the client needs emotional support with the use of prosthetic limbs, this is not part of skin protection and prevention of skin breakdown.

Question 39

A client with a history of medication noncompliance is receiving outpatient treatment for schizophrenia. The health care provider is most likely to order which medication for this client?
a. chlorpromazine
b. imipramine
c. lithium carbonate
d. fluphenazine decanoate

Answer 39

d. fluphenazine decanoate

Fluphenazine decanoate is a long-acting antipsychotic agent administered by injection. Because it has a 4-week duration of action, it’s commonly ordered for outpatients with a history of medication noncompliance. Chlorpromazine, also an antipsychotic agent, must be administered daily to maintain adequate plasma levels, which necessitates compliance with the dosage schedule. Imipramine, a tricyclic antidepressant, and lithium carbonate, a mood stabilizer, are rarely used to treat clients with chronic schizophrenia.

Question 40

Which findings in a newborn would require the nurse to notify the health care provider? Select all that apply.
a. Epstein’s pearls
b. milia on the nose
c. positive Ortolani’s sign
d. positive Babinski’s sign
e. absence of Moro’s reflex

Answer 40

c. positive Ortolani’s sign
e. absence of Moro’s reflex

The nurse would be concerned about a positive Ortolani’s sign, which could indicate congenital hip dysplasia and the absence of Moro’s reflex. The rest of the findings are to be expected.

Question 41

The unit secretary who transcribes the health care provider’s (HCP’s) prescriptions asks the nurse to interpret an illegible prescription. The nurse should:
a, ask the client if they take this medication.
b. call the pharmacist to see if this is a drug the client takes.
c. contact the HCP to clarify the prescription.
d. tell the unit secretary what the prescription is and to rewrite it clearly.

Answer 41

c. contact the HCP to clarify the prescription.

Illegible writing is one of the most common reasons for medication errors. The nurse should contact the HCP to clarify the prescription. Neither the pharmacist, the nurse, nor the unit secretary can interpret or rewrite a prescription written by an HCP.

Question 42

A registered nurse is overseeing the care of clients in an acute mental health setting. Which task can the nurse delegate to an unlicensed assistive personnel?

a. Sterile dressing changes to a client’s lacerated wrists
b. Initial assessment of a client admitted with bulimia
c. Encouraging a client with depression to eat
d. Teaching a client with schizophrenia about medications

Answer 42

c. encouraging a client with depression to eat.

Unlicensed assistive personal (UAP) are able to complete tasks that are standard unchanging procedures. Encouraging a client with depression to eat is acceptable. UAP can not complete a sterile dressing change, initial assessment, or provide client education.

Question 43

Which finding indicates that a client with bipolar disorder, manic phase, is nearing readiness for discharge?
a. sleeping 4 hours per night
b. differentiating realistic self-image from grandiosity
c, suddenly telephoning their spouse and asking for a divorce
d. demonstrating a labile affect

Answer 43

b. differentiating realistic self-image from grandiosity.

The client is approaching discharge when they are able to differentiate between a realistic self-image and grandiosity. A client with mania typically has a high regard for self or an inflated self-image, seen as grandiosity. The ability to view oneself realistically demonstrates improvement. The client in a manic state exhibits a decreased need for sleep due to feelings of having boundless energy and increased activity. Sleeping 4 hours per night indicates that the client is still acutely ill.
Suddenly asking for a divorce could indicate the client’s poor judgment and inability to perceive the situation realistically.
A labile affect (an affect that quickly changes) is typically seen in the manic state. A client may be laughing or joking one minute, suddenly start to cry, and then quickly return to euphoria. A labile affect is an indication that the client is acutely ill.

Question 44

The nurse is teaching a new parent about the feeding patterns of a newborn infant. Which of the following statements by the parent would the nurse recognize as the correct description of a feeding pattern for a formula-fed infant?
a. “Formula-fed infants experience shorter periods between feedings.”
b. “Formula-fed infants digest their milk more rapidly.”
c. “Formula-fed infants demand to feed every 1.5 to 3 hours.”
d. “Formula-fed infants usually feed every 3 to 4 hours.”

Answer 44

d. “Formula-fed infants usually feed every 3 to 4 hours.”

Formula is harder to digest than breast milk and therefore, babies typically feed less frequently than breastfed babies. Formula-fed infants should demand feedings every 3 to 4 hours compared to every 2 to 3 hours for breastfed babies.

Question 45

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The health care provider diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?
a. Acute pain related to biliary spasms
b. Deficient knowledge related to prevention of disease recurrence
c. Anxiety related to unknown outcome of hospitalization
d. Imbalanced nutrition: Less than body requirements related to biliary inflammation

Answer 45

a. Acute pain related to biliary spasm

The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can’t learn about prevention, may continue to experience anxiety, and can’t address nutritional concerns.

Question 46

A 10-year-old client underwent an appendectomy 24 hours ago. They are awake, alert, and oriented. The client tells the nurse they are experiencing pain. They have a prescription for morphine 1 to 2 mg as needed for pain. What is the priority nursing action in managing the child’s pain?

a. Change the child’s position in bed.
b. Determine the severity of the pain.
c. Administer 1 mg morphine as prescribed.
d. Perform a head-to-toe assessment.

Answer 46

b. determine the severity of the pain.

The child is in pain and needs intervention, but before the nurse can determine how to proceed, it is essential to know the severity of the client’s pain score to determine whether to give 1 or 2 mg of morphine. In addition, the nurse cannot evaluate the effectiveness of the pain medication if there is no pain score prior to administering the medication. Changing the child’s position and administering pain medication may be helpful to relieve the child’s pain, but the nurse must first know the severity of the pain before determining the appropriate intervention. The nurse must perform a head-to-toe assessment, but it is not the priority in managing the child’s pain.

Question 47

A client recovering from a stroke is prescribed a leg brace and needs to be transferred out of bed to a chair. Which action should the nurse take first before beginning this transfer?

a. Lower the head of the bed.
b. Assist the client to a sitting position in bed.
c. Roll the client away from the side of the transfer.
d. Apply the leg splint before beginning the transfer.

Answer 47

d. apply the leg splint before beginning the transfer.

It is recommended that any braces or devices the client wears to be applied before assisting the client out of bed. The head of the bed should be raised so that the client is in a sitting position before beginning the transfer. There is no reason to roll the client away from the side of the transfer. This would not facilitate the movement and could cause injury to both the client and nurse during the transfer.

Question 48

To promote early and efficient ambulation for a client after an above-the-knee amputation, the nurse is aware that the leg will need to be positioned in which way?
a. in a flexed position
b. extended and abducted
c. in functional alignment
d. slightly raised when moving the stump

Answer 48

c. in functional alignment

Muscles that originate at the vertebrae or pelvic girdle and insert on the femur act to abduct, adduct, flex, extend, and rotate the femur. Normal body alignment should be maintained because it facilitates the safe and efficient use of muscle groups for balance and stability. Functional alignment is essential for all bone repair.

Question 49

A community health nurse is planning to address the primary health needs of older adults living in their homes. What areas would the nurse assess first?
a. exercise patterns, nutrition, mobility, and safety
b. incidence of falls, resulting injuries, and rehabilitation needs
c. disease identification and management
d. medical visits and health care costs

Answer 49

a. exercise patterns, nutrition, mobility, and safety.

Assessing exercise patterns, nutrition, mobility, and safety provides teaching regarding health promotion and illness and injury prevention for older adult clients living in their homes. It is important to ensure that older adult clients are meeting their needs of exercise, nutrition, mobility, and safety to be able to manage in their own homes. These are the primary physical needs that could pose problems for older adult clients. Assessment of falls, injuries, and rehabilitation focuses only on mobility. Disease identification and management are important but do not address the most important factors that allow older adult clients to remain safe in their own homes. Medical visits are important, but they focus on health problems more than on meeting physical needs.

Question 50

A nurse is caring for a client receiving the fentanyl transdermal system for pain management. When applying a new system, the nurse should:
a. press the system in place for 30 to 60 seconds.
b. choose a site on the lower torso.
c. shave the application site before use.
d. apply the system immediately after removal from a package.

Answer 50

d. apply the system immediately after removal from a package.

The fentanyl transdermal system should be applied immediately after removal from the sealed package. The nurse should press the system firmly in place with the palm for 10 to 20 seconds, not 30 to 60 seconds, to make sure the contact is complete, especially around the edges. The system should be applied to non-irritated and nonirradiated skin on a flat surface of the upper torso. When reapplying a new system, the nurse should choose a different site. Hair at the application site should be clipped (not shaved) before application; the nurse should clean the site with clear water. Soaps, oils, lotions, alcohol, or other agents that might irritate the skin or alter its characteristics shouldn’t be used; the skin should be dried completely before application.

Question 51

A client in surgery has an endotracheal tube (ET) in place. The nurse should call a time-out if which requirement(s) are not in place? Select all that apply.

a. an identification band
b. postoperative pain medication
c. an intravenous (IV) line
d. oxygen administration
e. an anesthetist/anesthesiologist

Answer 51

a. an identification band.
c. an intravenous (IV) line.
d. oxygen administration.
e. an anesthetist/anesthesiologist

The nurse is responsible for the client’s safety in the operating room. The nurse should call a time-out if the client is not properly identified with an identification band. In addition, an IV line and oxygen should always be established when an ET tube is placed. This practice applies whenever a client’s airway is compromised enough for intubation to occur, not only in the operating room environment. An anesthetist or anesthesiologist should be present during surgery to manage the airway. Postoperative pain medication is administered in the recovery room.

Question 52

A nurse is caring for a client with cardiovascular disease (CVD) who was walking to the bathroom and fell. The nurse acknowledges that some key data was overlooked when assessing the client for fall risk. Which data obtained from the report could have contributed to the client’s risk for falls? Select all that apply.

a, decreased cardiac output with slow pulse
b. hearing aid required for chronic hearing loss
c, oral antibiotic prescribed for a tooth infection
d. evening confusion to time and place
e. intravenous diuretics prescribed for edema
f. orthostatic hypotension noted in history

Answer 52

a. decreased cardiac output with slow pulse.
d. evening confusion to time and place.
e. intravenous diuretics prescribed for edema.
f. orthostatic hypotension noted in history.

More than 60% of adults hospitalized with CVD have a moderate to high risk for falls. Falls are most often a result of multiple contributing factors. Medication effects, such as those from diuretics, can cause hypotension and increased urination. These effects place clients at risk for falls while moving quickly to the bathroom. Cognitive impairment can cause lack of judgment, which can alter a client’s ability to determine if an activity is risky. Orthostatic hypotension and decreased cardiac output decrease blood flow to the brain, and both contribute to falling as well. Antibiotics are not associated with increased risk for falls. Although visual impairment could contribute to falls, hearing impairment would not affect fall risk.

Question 53

The nurse is planning care for a client with hepatitis A. Information from which laboratory report will be helpful in planning care?
a. prolonged prothrombin time
b. decreased blood glucose level
c. elevated serum potassium level
d. decreased serum calcium level

Answer 53

a. prolonged prothrombin time.

The prothrombin time may be prolonged because of decreased absorption of vitamin K and decreased production of prothrombin by the liver. The client should be assessed carefully for bleeding tendencies. Blood glucose, serum potassium, and serum calcium levels are not affected by hepatitis.

Question 54

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by
a. first intention.
b. second intention.
c. third intention.
d. fourth intention.

Answer 54

a. first intention.

Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren’t approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren’t sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.

Question 55

The nurse cares for a client who has overdosed on phencyclidine (PCP). The nurse should be especially cautious about which client behavior?

a. visual hallucinations
b. violent behavior
c. bizarre behavior
d. loud screaming

Answer 55

b. violent behavior.

The nurse must be especially cautious when providing care to a client who has taken PCP because of unpredictable, violent behavior. The client can appear to be in a calm state or even in a coma, then become violent, and then return to a calm or comatose state. Visual hallucinations, bizarre behavior, and loud screaming are associated with PCP-intoxicated clients. However, the unpredictable, violent behavior presents a major issue of safety for clients and staff.

Question 56

A young child with a history of bronchial asthma is brought to the emergency department for the second time in a month with symptoms of audible expiratory wheezing and intercostal retractions. The parents voice frustration about repeated hospital visits. What teaching intervention is most important for the nurse to address with the parents?
a. educating the parents on dietary restrictions to control asthma
b. assuring the parents that young children will outgrow asthma
c. informing the parents that asthmatic episodes are easily treated
d. providing resources to aid in quitting if the parents are smokers

Answer 56

d. providing resources to aid in quitting if the parents are smokers.

Smoking is a main allergen that can initiate the inflammatory response in children with bronchial asthma. Few children with bronchial asthma will remain asymptomatic for the remainder of their lives. As many as one in two children who had childhood asthma and who are asymptomatic at 18 years of age are likely to have recurrent, symptomatic disease by age 26 years. Asthma usually persists as a low-grade, subclinical condition. Asthmatic episodes may be life threatening in all age groups.

Question 57

A client is diagnosed with a highly drug-resistant Klebsiella pneumonia. What priority information will the nurse include in the client’s teaching plan?
a. Washing hands before and after eating and as frequently as possible
b. Having the house cleaned with bleach solution
c. Completing antibiotics before discharge
d. Wearing a mask when talking with other people

Answer 57

a. washing hands before and after eating and as frequently as possible.

Clients should wash hands before and after they eat and as frequently as possible while hospitalized to reduce infections. Klebsiella is spread by person to person contact. The house does not need to cleaned with a bleach solution. The course of antibiotics may continue with discharge. There are no special precautions with a mask for the client because the bacteria does not spread through airborne means.

Question 58

A client in the postanesthesia care unit with a left below-the-knee amputation has pain in the left big toe. What should the nurse do first?
a. Tell the client it is impossible to feel the pain.
b. Show the client that the toes are not there.
c. Explain to the client that the pain is real.
d. Give the client the prescribed opioid analgesic.

Answer 58

d. give the client the prescribed opioid analgesic.

The nurse’s first action should be to administer the prescribed opioid analgesic to the client because this phenomenon is a phantom sensation and interventions should be provided to relieve it. Pain relief is the priority. Phantom sensation is a real sensation. It is incorrect and inappropriate to tell a client that it is impossible to feel the pain. Although it does relieve the client’s apprehensions to be told that phantom sensations are a real phenomenon, the client needs prompt treatment to relieve the pain sensation. Usually, phantom sensation will go away. However, showing the client that the toes are not there does nothing to provide the client with relief.

Question 59

A 26-year-old primiparous client is seen in the urgent care clinic 2 weeks after giving birth. The client, who is breastfeeding, is diagnosed with mastitis of the right breast. The client asks the nurse, “Can I continue breastfeeding?” What should the nurse should tell the client?

a. “You can continue to breastfeed, feeding your baby more frequently.”
b. “You can continue once your symptoms begin to decrease.”
c. “You must discontinue breastfeeding until antibiotic therapy is completed.”
d. “You must stop breastfeeding because the breast is contaminated.”

Answer 59

a. “You can continue to breastfeed, feeding your baby more frequently.”

The client being treated for mastitis should continue to breastfeed often, or at least every 2 to 3 hours. Treatment also includes bed rest, increased fluid intake, local heat application, analgesic agents, and antibiotic therapy. Continually emptying the breasts decreases the risk for engorgement or breast abscess. The client should not discontinue breastfeeding unless they choose to do so. The client may continue breastfeeding while receiving antibiotic therapy. Generally, the breast milk is not contaminated by the offending organism and is safe for the neonate.

Question 60

A client gave birth 2 days ago and has been given instructions on breast care for bottle-feeding birth parents. Which statement indicates that the nurse should reinforce the instructions to the client?

a. “I will wear a sports bra or a well-fitting bra for several days.”
b. “When showering, I will direct water onto my shoulders.”
c. “I will only use only water to clean my nipples.”
d. “I will use a breast pump to remove any milk that may appear.”

Answer 60

d. “I will use a breast pump to remove any milk that may appear.”

The use of a breast pump to remove milk is contraindicated in bottle-feeding clients. Nipple and breast stimulation and emptying of the breasts produce milk, rather than eliminate milk production. The bottle-feeding client is discouraged from stimulating the breasts in any way. A sports bra that is well fitting provides support and decreases stimulation (binders are not suggested). Having the water in a shower land on the shoulders of the client rather than the breasts also decreases stimulation. Only water is necessary to clean nipples when breastfeeding or bottle-feeding.

Question 60

The nurse teaches a group of adolescents about anorexia nervosa. The nurse should describe this disorder as being characterized by which factors?
a. excessive fear of becoming obese, near-normal weight, and a self-critical body image
b. obsession with the weight of others, chronic dieting, and an altered body image
c. extreme concern about dieting, calorie counting, and an unrealistic body image
d. intense fear of becoming obese, emaciation, and a disturbed body image

Answer 60

d. intense fear of becoming obese, emaciation, and a disturbed body image.

An intense fear of becoming obese, emaciation, and a disturbed body image all are considered to be characteristics of anorexia nervosa. Near-normal weight is not associated with anorexia. The weight of others is not a primary factor. “Concern about dieting” is not strong enough language to describe the control of food intake in the individual with anorexia nervosa.

Question 61

The nurse is caring for an expectant client who asks how decisions are made if complications place both the birth parent and fetus at risk. What ethical principle will the nurse cite when responding to the client’s question?
a. autonomy
b. justice
c. nonmaleficence
d. jurisprudence

Answer 61

a. autonomy

The principle of autonomy informs decisions when conflicts arise between maternal and fetal rights. The birth parent has the right to choose for themselves what they believe to be in their best interest versus the well-being of the fetus. This is the concept of self-determination, of being in charge of one’s person rather than another person determining what behavior or decision represents justice. Nonmaleficence refers to doing no harm. The client has the right to make choices that align with their belief system. Jurisprudence is the actual theory or study of law.

Question 62

A nurse making a home visit to an older adult client with limited mobility is reviewing home fire safety measures with the client and spouse. The client currently sleeps in a first-floor bedroom and uses a walker to ambulate. After teaching the client and spouse about these measures, the nurse determines that the teaching was successful based on which statement?

a. “We’ll have a family member change the batteries in our smoke detectors when they come by this week.”
b. “We will make sure that the cord to the heating pad is under the throw rug so I don’t trip over it.”
c. “I’ll move the space heater closer to my bed so I don’t have to keep the temperature so high.”
d. “I’ll make sure my walker is near the front door at night so I have it if I need to get out quickly.”

Answer 62

a. “We’ll have a family member change the batteries in our smoke detectors when they come by this week.”

Ensuring that smoke detectors are in working order is critical to fire safety. In addition, electrical appliances, such as heating pads, should be in good condition and functioning properly, with cords not positioned under carpets or rugs. Space heaters are a common cause of fires and should be at least 3 feet (0.9 meters) away from anything flammable, such as curtains, bedding, and furniture. Assistive devices (such as mobility aids, eyeglasses, and hearing aids), a flashlight, a telephone, and emergency numbers should be within reach at all times, should the need for escape be necessary.

Question 63

The caregivers of a school-aged client with a new diagnosis of ulcerative colitis ask the nurse how to manage the condition at school. How should the nurse respond? Select all that apply.

a. “Work with the school nurse to develop a plan.”
b. “The condition should not affect the child’s schooling.”
c. “Your child will need to drink plenty of liquids at school.”
d. “Your child should keep a change of clothing at school.”
d. “You should encourage your child to not eat lunch at school.”

Answer 63

a. “Work with the school nurse to develop a plan.”
c. “Your child will need to drink plenty of liquid at school.”
d. “Your child should keep a change of clothing at school.”

Ulcerative colitis is a chronic inflammatory bowel disorder with exacerbations and remissions. In ulcerative colitis the colon develops continuous ulcerations that cause the common symptoms of pain and bloody diarrhea. Drugs such as anti-inflammatory medications, antidiarrheals, and immunosuppressants have been used for management. A child with a chronic condition should have an action plan with the school nurse to provide needed medication and monitor symptoms. A change of clothing may be needed if clothing is soiled as a result of diarrhea. The child should be careful to avoid foods that increase symptoms (commonly raw vegetables, dairy products, and gas-producing foods such as beans, broccoli, or cabbage). Most school lunches are not individualized to a specific child. Liquids are important to prevent dehydration from diarrhea.

Question 64

The major goal of therapy in crisis intervention is to:
a. withdraw from the stress.
b. resolve the immediate problem.
c. decrease anxiety.
d. provide documentation of events.

Answer 64

b. resolve the immediate problem.

During a period of crisis, the major goal is to resolve the immediate problem, with hopes of getting the client to the level of functioning that existed before the crisis or to a higher level of functioning. Withdrawing from stress doesn’t address the immediate problem and isn’t therapeutic. The client’s anxiety will decrease after the immediate problem is resolved. Providing support and safety are necessary interventions while working toward accomplishing the goal. Documentation is necessary for maintaining accurate records of treatment; it isn’t a major goal.

Question 65

Nurses on a pediatric unit have developed a program to decrease the infection rate on the unit. What is an expected outcome of this quality improvement program?
a. evaluation of staff members’ performances
b. improvement in client outcomes
c. increases in efficiency of care
d. preparation for accreditation of the organization

Answer 65

b. improvement in client outcomes.

The goal of a quality improvement (QI) program is to ensure that the best care is delivered to clients and families. This can be achieved by attention to client outcomes. Staff performance evaluations should be completed according to institutional policy and focus on staff, not client outcomes. Improved care efficiency may be an aspect of quality client care, but it is not the primary outcome. Accreditation agencies have strict parameters to which an institution must adhere to ensure accreditation. QI is one method to demonstrate adherence to the parameters. The goal of QI is to ensure that the best care is delivered to clients and families, not to ensure accreditation.

Question 66

A client is grieving following a spontaneous abortion (miscarriage). They unexpectedly become pregnant again very quickly after the miscarriage, and is quickly able to move through their grief and become excited and happy about this pregnancy. Which type of grief did the client likely experience for their miscarriage?

a. Unresolved grief
b. Abbreviated grief
c. Anticipatory grief
d. Inhibited grief

Answer 66

b. abbreviated grief

Abbreviated grief is short in duration but sincere. It results in reconciliation of feelings. This client experienced a short but real period of grief following their miscarriage, but it was abbreviated likely due to becoming pregnant again quickly, thus “replacing” the loss. Unresolved grief is extended in length and severity; the grief does not resolve and can lead to dysfunctional grief. Inhibited grief is when someone does not show any typical signs of grief, which can be a conscious effort to keep the grief private. Inhibited grief can lead to physical manifestations when an individual does not allow oneself to grieve. This can cause dysfunctional grief. Anticipatory grief is grieving prior to the actual loss, which would not cause failure to reconcile feelings of grief.

Question 67

The home health nurse is visiting an 80-year-old client diagnosed with Alzheimer’s dementia. During the visit, the nurse notes bruising on the client’s face and upper arms in various shades of healing. The client is unable to communicate effectively because of the disease progression. What is the nurse’s responsibility in this situation? Select all that apply.

a. Bring up the suspected physical elder abuse with a trusted authority figure.
b. Try to convince the client to verbalize that there has been elder abuse.
c. Report the suspicion to the local Adult Protective Services Agency within 24 hours.
d. Monitor the situation during the subsequent home visits.
e. Do nothing because the nurse has no proof of actual wrongdoing or elder abuse by anyone.

Answer 67

a. bring up the suspected physical elder abuse with a trusted authority figure.
c. report the suspicion to the local Adult Protective Services Agency within 24 hours.
d. Monitor the situation during the subsequent home visits.

A nurse is a mandated reporter of elder abuse. If the nurse suspects elder abuse, they must report it to the local Adult Protective Services Agency. The nurse can protect seniors by bringing up the issue of elder abuse with a trusted authority member. While monitoring alone is not sufficient, the nurse would continue to monitor the situation. Trying to convince a client with dementia to report the abuse themselves is inappropriate. Doing nothing is not an appropriate nursing action.

Question 68

An 80-year-old client comes to the clinic reporting shortness of breath. When listening to the client’s lungs, the nurse hears crackles (intermittent, high- and low- pitched popping sounds in the lower bases of the lungs) during inspiration. In which conditions might the nurse auscultate crackles? Select all that apply.

a. epiglottitis
b. acute respiratory distress syndrome
c. pneumonia
d. pulmonary edema
e. cardiac tamponade

Answer 68

b. acute respiratory distress syndrome.
c. pneumonia.
d. pulmonary edema.

Crackles are typically heard on inspiration, can be low- or high-pitched, and occur when air is drawn through fluid in the lung’s passageways. They can be classified as fine or course. They may be present on auscultation in a client with acute respiratory distress syndrome, pneumonia, and pulmonary edema. Crackles are not heard in clients with epiglottitis or cardiac tamponade.

Question 69

A client with a history of chronic cystitis comes to an outpatient clinic with signs and symptoms of this disorder. To prevent cystitis from recurring, the nurse recommends maintaining an acid-ash diet to acidify the urine, thereby decreasing the rate of bacterial multiplication. On an acid-ash diet, the client must restrict which beverage?
a. cranberry juice
b. coffee
c. prune juice
d. milk

Answer 69

d. milk

A client on an acid-ash diet must avoid milk and milk products because these make the urine more alkaline, encouraging bacterial growth. Other foods to avoid on this diet include all vegetables except corn and lentils; all fruits except cranberries, plums, and prunes; and any food containing large amounts of potassium, sodium, calcium, or magnesium. Cranberry and prune juice are encouraged because they acidify the urine. Coffee and tea are considered neutral because they don’t alter the urine pH.

Question 70

A nurse working in the operating room smells smoke during a procedure, and a colleague reports that a small fire has broken out on the other side of the operating suite. Which action should the nurse take first?
a. Walk to the site of the fire to confirm the colleague’s report.
b. Pull the fire alarm on the wall.
c. Assist with moving the client’s bed to the hallway.
d. Retrieve the fire extinguisher and extinguish the fire.

Answer 70

c. assist with moving the client’s bed to the hallway.

Following the RACE acronym, the nurse’s priority is to rescue anyone who is in danger during a fire. The second step would be to activate the alarm by pulling the wall alarm and notifying emergency services using the facility protocol. Extinguishing the fire would be the last step and should only be attempted if the fire is small. The nurse would not want to walk to the site of the fire to obtain visual confirmation before acting as this could put the nurse in danger and delay the correct actions.

Question 71

An infant is to have moderate sedation for an outpatient procedure. The nurse knows that
a. the infant should respond to gentle tactile or verbal stimulation.
b. the infant’s reflexes will be decreased or absent.
c. the infant will remember the procedure.
d. the infant will need a patient-controlled analgesia (PCA) pump during sedation.

Answer 71

a. the infant should respond to gentile tactile or verbal stimulation.

An infant under moderate sedation should respond to verbal or tactile stimuli. Infants under general anesthesia have decreased or absent reflexes. Infants who undergo general or moderate sedation rarely remember the procedure. PCA pumps aren’t used during sedation.

Question 72

A primigravid client whose cervix is 7 cm dilated with the fetus at 0 station and in a left occiput posterior (LOP) position has severe back pain. Which intervention is most indicated?
a. Provide firm pressure to the client’s sacral area.
b. Prepare the client for a cesarean birth.
c. Prepare the client for a precipitate birth.
d. Maintain the client in a left side-lying position.

Answer 72

a. provide firm pressure to the client’s sacral area.

The client who has back pain during labor experiences marked discomfort because the fetus is in an LOP position. This pain is much greater than when the fetus is in the anterior position because the fetal head impinges on the sacrum in the course of rotating to the anterior position. Application of firm pressure to the sacral area can help alleviate the pain. Problems of severe back pain during labor do not typically require a cesarean birth. The health care provider (HCP) may elect to do an episiotomy, but it is not necessarily required. It is unlikely that a primigravid client with a fetus in an LOP position will have a precipitous birth; rather, labor is usually more prolonged. A hands-and-knees position or a right side-lying position may help rotate the fetal head and thus alleviate some of the back pain.

Question 73

The nurse on the medical-surgical unit is providing care for four adult clients. For which client should the nurse most likely create a referral to another member of the health care team?
a. the client whose body mass index (BMI) is 14.5 and who has a recent history of weight loss
b. the client who has required breakthrough doses of analgesia 4 times in 24 hours.
c. the client who was admitted due to seizure activity after a recent change in their medication regimen
d. the client with community-acquired pneumonia who has PRN nebulizers prescribed

Answer 73

a. the client whose body mass index (BMI) is 14.5 and who has a recent history of weight loss.

A client with a BMI of 14.5 is significantly underweight. This fact, combined with recent weight loss, would likely necessitate a dietitian referral. The client with recent seizures and the client with pain would normally be treated by the medical team. A client with pneumonia may require a referral to respiratory therapy, but this would be more likely if the client was experiencing significant respiratory distress, which is not noted.

Question 74

A nursing student is assigned to care for a client with HIV. The student asks the staff nurse what precautions are necessary when measuring this client’s blood pressure. What is the best information to give the student?
a. wear gloves
b. wear a gown
c. use contact precautions
d. wash hands

Answer 74

d. wash hands

Because measuring blood pressure doesn’t involve contact with the client’s blood or secretions, the nursing student should wash the hands before proceeding.

Question 75

A client being treated for alcohol addiction is receiving thiamine. What is the expected outcome for using thiamine with this client?
a. Prevent the development of Wernicke encephalopathy.
b. Decrease the client’s withdrawal symptoms.
c. Aid the client in regaining strength sooner.
d. Promote the elimination of alcohol from the body faster.

Answer 75

a. Prevent the development of Wernicke encephalopathy.

Thiamine specifically prevents the development of Wernicke encephalopathy, a reversible amnestic disorder caused by a diet deficient in thiamine secondary to poor nutritional intake that commonly accompanies chronic alcohol use disorder. It is characterized by nystagmus, ataxia, and mental status changes. Because the client would rather drink alcohol than eat, the client is depleted of vitamins and nutrients. Alcohol also is an irritant that causes a “malabsorption syndrome” in which vitamins and nutrients are not absorbed properly in the gastrointestinal tract. Thiamine is not associated with decreasing withdrawal symptoms, helping clients regain their strength, or promoting elimination of alcohol from the body.

Question 76

Which health education topic is the priority when teaching parents ways to prevent urinary tract infections (UTIs) in their children?
a. Teach parents to promote adequate fluid intake.
b. Teach parents to limit the frequency of tub baths.
c, Encourage parents of male infants to avoid circumcision.
d. Educate parents about hand washing, and the use of alcohol-based hand sanitizers.

Answer 76

a. teach parents to promote adequate fluid intake.

Urinary stasis is a major cause of UTIs, and can be partially prevented by increasing fluid intake. Baths and hand hygiene are less significant factors in the development of UTIs. Urinary tract infections are increased in uncircumcised male infants under 1 year of age, but unaffected thereafter.

Question 77

A triage nurse is completing an initial assessment of several clients in the waiting room. Which client would the nurse see first?
a. a client who reports passing “some thick, red-tinged mucus when I urinated this morning”
b. a client who reports that the baby dropped lower into the pelvis, and who has to urinate more frequently
c. a client with uterine contractions who reports “they are getting stronger and closer now”
d. a client who is 12 days past the due date with cramping

Answer 77

c. a client with uterine contractions who reports “they are getting stronger and closer now.”

True labor is defined as the onset of regular uterine contractions that increase in frequency, intensity, and duration. The passing of the mucous plug (may be thick and red tinged) implies softening and effacement of the cervix, which is a sign of impending labor (24-48 hours prior), not true labor. Lightening (the fetus settles or drops into the pelvic inlet) is another sign of impending labor and may occur up to 2 weeks prior to birth. The client who is past the due date is showing no signs of distress.

Question 78

A client sustains a minor fracture to the left wrist. For which type of immobilization device should the nurse prepare teaching for this client?

a. cast
b. splint
c. brace
d. traction

Answer 78

b. splint

For a simple and stable fracture, a splint is used. This device is faster and easier to apply, is noncircumferential, will not compromise circulation, and can be easily removed to inspect the injury site. A cast is indicated for a more complicated fracture. A brace is used for long-term stabilization. Traction is used to align the bones of lower extremities and would not be indicated for a minor fracture of the wrist.

Question 79

The family of a client receiving hospice care takes a dinner break only to learn that the client died while they were absent from the bedside. What should the nurse do to console the family at this time?

a. Stay with the family while they view the body.
b. Explain that the time of death could not be predicted.
c. Discuss how the client is no longer in pain and is now at rest.
d. Allow the family to feel guilty for leaving the client to die alone.

Answer 79

a. stay with the family while they view the body.

The family may go to great lengths to ensure that their loved one will not die alone. However, despite the best intentions and efforts of the family and clinicians, the client may die at a time when no one is present. If the client dies while family members are not present, the family may express feelings of guilt and will need emotional support. This would be provided by staying with the family while they view the body. Even though the time of death cannot be predicted, some clients appear to “wait” until family members are away from the bedside to die. The family does not need to hear how the client is no longer in pain and at rest. The family needs emotional support. The family should not be permitted to feel guilty for leaving the client. The family should take rest periods away from the bedside in order to provide the best support to the client.

Question 80

When developing the teaching plan about illness for the parent of a preschooler, which information should the nurse include about how a preschooler perceives illness?
a. a necessary part of life
b. a test of self-worth
c. a punishment for wrongdoing
d. the will of God

Answer 80

c. a punishment for wrongdoing.

Preschool-age children may view illness as punishment for their fantasies. At this age children do not have the cognitive ability to separate fantasies from reality and may expect to be punished for their “evil thoughts.” Viewing illness as a necessary part of life requires a higher level of cognition than preschoolers possess. This view is seen in children of middle school age and older. Perceiving illness as a test of self-worth or as the will of God is more characteristic of adults.

Question 81

A client recovering from a drug overdose is interacting with the nurse and recounting their exploits at numerous parties they attended. Which action is most therapeutic?
a. allowing the client to continue with their stories
b. The nurse should tell the client they have heard the stories before
c. questioning the client further about their exploits
d. directing the conversation to realistic concerns

Answer 81

d. directing the conversation to realistic concerns.

The nurse directs the conversation to realistic concerns or issues to decrease denial and focus on rebuilding a substance-free life. Allowing the client to continue with the stories or questioning the client further about their exploits reinforces the denial. The nurse telling the client they have heard the stories before is nondirective. Additionally, these actions do nothing to help the client focus on rebuilding a substance-free life.

Question 82

A client with burns is to have a whirlpool bath and dressing change. What should the nurse do 30 minutes before the bath?
a. Soak the dressing.
b. Remove the dressing.
c. Administer an analgesic agent.
d. Slit the dressing with blunt scissors.

Answer 82

c. administer an analgesic agent.

Removing dressings from severe burns exposes sensitive nerve endings to the air, which is painful. The client should be given a prescribed analgesic agent about one-half hour before the dressing change to promote comfort. The other activities are done as part of the whirlpool and dressing change process and not one-half hour beforehand.

Question 83

During a taped shift report, the evening nurse reports that a client has been “annoying all evening, and has been demanding and on the call bell constantly.” The nurse manager of the unit overhears this part of the report. Which statements represent the best response by the nurse manager to the evening nurse?
a. “Your report was informative and should help the nurses taking over the care.”
b. “Your report was subjective and did not address the cause of the behavior.”
c. “Your report was accurate. Some of the other nurses have had similar problems.”
d. “Your report was too long. You need to learn to condense the important information.”

Answer 83

b. “Your report was subjective and did not address the cause of the behavior.”

The nurse’s report was subjective regarding the observed behavior of the client. It was value laden and did not establish the cause of the behavior, which could have been anything from anxiety to uncontrolled pain. The other options are incorrect because the report was not informative or constructive. It was subjective and inappropriate.

Question 84

The nurse is caring for a client with a head injury. Which client goal is most appropriate for the acute phase of a neurological injury?
a. The client will use the adaptive devices to assist with feeding.
b, The client’s vital signs will stabilize, returning to normal range.
c. The client’s skin will remain clean, dry, and intact.
d. The client will return to optimal level of functioning.

Answer 84

b. the client’s vital signs will stabilize, returning to normal range.

During the acute phase of a neurological injury, the goal of nursing management is to stabilize the client to prevent further neurological damage. A client goal would be to have the vital signs stabilize, indicating an improvement in status, and also returning to normal range. Using adaptive devices would occur in the recovery or chronic phase of a neurological deficit. The client’s skin and returning to optimal level of functioning is a goal for later in the recovery process.

Question 85

A client has been taking a decongestant for allergic rhinitis. Which finding suggests that the decongestant demonstrates maximum therapeutic effective?
a. oral dryness
b, increased tearing
c. reduced sneezing
d. headache improvement

Answer 85

c. reduced sneezing.

Decongestants relieve congestion and sneezing and reduce labored respiration rate. It is anticipated that decongestants dry the mucous membranes, these are commonly reported side effects. The anticipated therapeutic effect would be demonstrated with a decrease in sneezing.

Question 86

A client recovering from a stroke is prescribed a leg brace and needs to be transferred out of bed to a chair. Which action should the nurse take first before beginning this transfer?

a. Lower the head of the bed.
b. Assist the client to a sitting position in bed.
c. Roll the client away from the side of the transfer.
d. Apply the leg splint before beginning the transfer.

Answer 86

d. apply the leg splint before beginning the transfer.

It is recommended that any braces or devices the client wears to be applied before assisting the client out of bed. The head of the bed should be raised so that the client is in a sitting position before beginning the transfer. There is no reason to roll the client away from the side of the transfer. This would not facilitate the movement and could cause injury to both the client and nurse during the transfer.

Question 87

A child with heart disease starts on oral digoxin. When preparing to administer the medication, what should the nurse do first?
a. Check the last serum electrolyte results for the child.
b. Verify the dosage with the pharmacist.
c. Ask the parent if they are willing to administer the medication.
d. Teach the parent how to measure the child’s heart rate.

Answer 87

a. check the last serum electrolyte results for the child.

It is most important to know the child’s serum potassium level when administering digoxin. Digoxin increases contractility of the heart and increases renal perfusion, resulting in a diuretic effect with increased loss of potassium and sodium. Hypokalemia increases the risk of digoxin toxicity. Verifying the dosage is specified by facility policy and varies among facilities. Although the child may take the medication better from the parent than from the nurse, asking the parent to give the medication is not necessary. In addition, this would be done after the nurse has checked the electrolyte levels. Teaching the parent how to measure the child’s heart rate can be done at any time, not necessarily when preparing to give digoxin.

Question 88

A nurse is caring for a client who has returned to their room after a carotid endarterectomy. Which action should the nurse take first?
a. Ask the client if they have trouble breathing.
b. Take the client’s blood pressure.
c. Ask the client if they have a headache.
d. Place antiembolism stockings on the client.

Answer 88

a. Ask the client if they have trouble breathing.

The nurse should first assess the client’s breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren’t the nurse’s top priority.

Question 89

A nurse manager is meeting with the staff and reviewing the unit’s use of side rails with clients. Which statement by a staff member would lead the nurse manager to initiate corrective action?
a. “I raised side rails at night because my client was afraid of falling out of bed.”
b. “My client asked the rails to be raised to help them get out of bed.”
c. “The client told me the raised side rails made them feel more secure.”
d. “I raised the rails to stop my client from trying to get out of bed constantly.”

Answer 89

d. “I raised the rails to stop my client from trying to get out of bed constantly.”

A side rail may or may not be considered a restraint. A side rail is not considered a restraint if the client requests that it be raised to aid in getting in or out of bed. Some clients may request that side rails be used at night while they sleep so they feel more secure. Clients requesting side rails must be able to raise and lower the side rails themselves. Side rails that are raised with the intent to prevent the client from voluntarily attempting or actually getting out of bed would be considered a restraint. If the intent of raising the side rails is to prevent a client from inadvertently falling out of bed, or if the client lacks the physical ability to even attempt to get out of bed, side rails would not be considered a restraint.

Question 90

An adolescent girl is being treated for anogenital warts caused by the human papillomavirus (HPV). What is the nurse’s priority intervention for this client?
a. Educate the client about the need to adhere to antibiotic therapy.
b. Educate the client about the accompanying risk of cervical cancer.
c. Assess the client’s knowledge of hormonal contraceptives.
d. Assess the client for signs and symptoms of systemic infection.

Answer 90

b. educate the client about the accompanying risk of cervical cancer.

This client’s external lesions should be treated, and they should receive education regarding the relationship between HPV and cervical cancer. Antibiotics would be ineffective because of the viral etiology of HPV. Hormonal contraceptives are of no benefit, and HPV is not normally the cause of systemic infection.

Question 91

The nurse observes a constant gentle bubbling in the water-seal column of a water-seal chest drainage system. What should the nurse do next?

a. Continue monitoring as usual; this is expected.
b. Check the connectors between the chest and drainage tubes and where the drainage tube enters the chest drainage system.
c. Decrease the suction and continue observing the system for changes in bubbling during the next several hours.
d. Notify the health care provider (HCP).

Answer 91

b. check the connectors between the chest and drainage tubes and where the drainage tube enters the chest drainage system.

There should never be constant bubbling in the water-seal system; normally, the bubbling is intermittent. Constant bubbling in the water-seal bottle indicates an air leak, which means that less negative pressure is being exerted on the pleural space. Decreasing the suction will not reduce the leak. It is not necessary to notify the HCP until the system has been checked and the problem identified.

Question 92

A client with a new ileal conduit asks what the disadvantages are to this type of stoma. The nurse explains that the client may experience which disadvantage?
a. Stool continuously oozes from it.
b. Absorption of nutrients is diminished.
c. Peristalsis is greatly decreased.
d. Urine drains from it continuously.

Answer 92

d. urine drains from it continuously.

The ureters are implanted in a segment of the ileum, and urine drains continually because there is no sphincter. The other choices all reflect bowel-associated problems.

Question 93

To decrease the likelihood of bradyarrhythmias in children during endotracheal intubation, succinylcholine is used with which agent?
a, epinephrine
b. isoproterenol
c. atropine
d. lidocaine

Answer 93

c. atropine.

Succinylcholine is an ultra-short-acting depolarizing agent used for rapid-sequence intubation. Bradycardia can occur, especially in children. Atropine is the drug of choice in treating or preventing succinylcholine-induced bradycardia. Lidocaine is used in adults only. Epinephrine bolus and isoproterenol aren’t used in rapid-sequence intubation because of their profound cardiac effects.

Question 94

A client has been taking buspirone as prescribed for 2 days. Which client statement indicates the need for further teaching?
a. “This medication will help my tight, aching muscles.”
b. “I may not feel better for 7 to 10 days.”
c. “The drug does not cause physical dependence.”
d. “I can take the medication with food.”

Answer 94

a. “This medication will help my tight, aching muscles.”

Buspirone, a nonbenzodiazepine anxiolytic, is particularly effective in treating the cognitive symptoms of anxiety, such as worry, apprehension, difficulty with concentration, and irritability. Buspirone is not effective for the somatic symptoms of anxiety (muscle tension). Therapeutic effects may be experienced in 7 to 10 days, with full effects occurring in 3 to 4 weeks. This drug is not known to cause physical or psychological dependence. It can be taken with food or small meals to reduce gastrointestinal upset.

Question 95

At the 28th week visit, the prenatal client’s hemoglobin is 13 g/dl (130 g/L) (reference range 12-16 g/dl [120-160 g/L]). What is the best intervention?
a. Instruct the client on how to increase iron in their diet.
b. Reinforce that the client should continue taking prenatal vitamins for the entire pregnancy.
c. Request a prescription for ferrous sulfate in addition to the client’s prenatal vitamin.
d. Ask the client to keep a 3-day food diary.

Answer 95

b. reinforce that the client should continue taking prenatal vitamins for the entire pregnancy.

Pregnant clients with hemoglobin levels less than 11 g/dl (110 g/L) are considered to be anemic.
A hemoglobin level of 13 g/dl (130 g/L) is considered normal, so extra interventions to improve the client’s hemoglobin level are not needed.
The client should just be encouraged to continue taking prenatal vitamins for the entire length of the pregnancy to assure they continue to maintain a sufficient intake of iron.

Question 96

A client in labor shouts to the nurse, “My baby is coming right now! I feel like I have to push!” An immediate nursing assessment reveals that the head of the fetus is crowning. After asking another staff member to notify the health care provider and setting up for birth, which nursing intervention is most appropriate?
a. gently pulling at the baby’s head
b. holding the baby’s head back until the health care provider arrives
c, applying gentle pressure to the baby’s head
d. placing the birth parent in the Trendelenburg position until the health care provider arrives

Answer 96

c. applying gentle pressure to the baby’s head.

Gentle pressure applied to the neonate’s head as it’s delivered prevents rapid expulsion, which can cause brain damage to the neonate and perineal tearing in the birth parent. No one should ever pull at the neonate’s head or hold the head back. Placing the parent in the Trendelenburg position won’t halt labor and may cause respiratory difficulties.

Question 97

The nurse is caring for a client receiving digoxin who has begun vomiting and reports seeing colorful halos around the lights in the room. Which actions should the nurse implement? Select all that apply.

a. Discontinue administration of digoxin.
b. Begin continuous electrocardiographic monitoring.
c. Determine serum digoxin and electrolyte levels.
d. Insert nasogastric tube.
e. Administer low flow oxygen.

Answer 97

a. discontinue administration of digoxin.
b. begin continuous electrocardiographic monitoring.
c. determine serum digoxin and electrolyte levels.

Symptoms of digoxin toxicity include severe sinus bradycardia, colorful halos around lights, nausea, anorexia, and vomiting. If digoxin toxicity is suspected, the steps the nurse should implement include discontinue administration of drug; begin continuous electrocardiographic monitoring for cardiac dysrhythmias; administer any appropriate antidysrhythmic drugs as ordered; determine serum digoxin and electrolyte levels; administer potassium supplements for hypokalemia if indicated, as ordered; institute supportive therapy for gastrointestinal symptoms (nausea, vomiting, or diarrhea); and administer digoxin antidote (digoxin immune fab) if indicated, as ordered. Inserting a nasogastric tube or administering oxygen is not appropriate for digoxin toxicity.

Question 98

The incidence and prevalence of falls have recently increased in a long-term care facility, and the nurse will determine whether the facility’s practices around fall prevention are evidence based. The nurse should prioritize what evidence source?
a. a meta-analysis of randomized controlled trials (RCTs) about fall prevention
b. an RCT conducted in a similar facility
c. a cohort study following at least 100 participants over at least 5 years
d. expert opinion from a multidisciplinary committee whose mandate includes fall prevention

Answer 98

a. a meta-analysis of randomized controlled trials (RCTs) about fall prevention.

Evidence-based practice requires valid and reliable evidence sources. Evidence sources are prioritized according to a hierarchy, with meta-analyses and systematic reviews of RCTs being the highest level of evidence. Such reviews supersede findings from any one individual RCT. Individual RCTs are considered to be more powerful than cohort studies, which are in turn more powerful than expert opinion.

Question 99

Following a cesarean birth for abruptio placentae, a multigravid client tells the nurse, “I feel like such a failure. None of my other births were like this.” Which factor is most important for the nurse to consider when responding to the client?

a. The client will most likely have postpartum blues.
b. Maternal-infant bonding is likely to be difficult.
c. The client’s feeling of grief is a normal reaction.
d. This type of birth was necessary to save the client’s life.

Answer 99

c. The client’s feeling of grief is a normal reaction.

Feelings of loss, grief, and guilt are normal after a cesarean birth, particularly if it was not planned. The nurse should support the client, listen with empathy, and allow the client time to grieve. The likelihood of the client experiencing postpartum blues is not known, and no evidence is presented. Although maternal-infant bonding may be delayed owing to neonatal complications or maternal pain and subsequent medications, it should not be difficult. Although the nurse is aware that this type of birth was necessary to save the client’s life, using this as the basis for the response does not acknowledge the client’s feelings.

Question 100

A nurse is planning to implement nonpharmacological pain management strategies as part of a multimodal approach for managing the client’s pain. For which strategy does the nurse seek a prescription from the health care provider?
a. massage
b. application of an ice bag
c. distraction
d. deep breathing

Answer 100

b. application of an ice bag.

Application of cold or heat requires a health care provider’s prescription. The nurse can initiate massage, distraction, and deep breathing as pain management strategies.

Question 101

A client with syndrome of inappropriate antidiuretic hormone (SIADH) is experiencing lethargy, weakness, headache, and muscle aches. Which intervention is the nurse’s priority?
a. Administer declomycin.
b. Initiate seizure precautions.
c. Increase dietary salt intake.
d. Monitor serum osmolarity.

Answer 101

b. initiate seizure precautions.

SIADH causes the release of excessive ADH resulting in fluid retention and dilutional hyponatremia. The client is exhibiting symptoms of hyponatremia, which can lead to seizures. Thus the priority is to place client on seizure precautions. Although administering declomycin, increasing salt intake, and monitoring serum osmolarity are appropriate interventions, they are not the priority.

Question 102

An 18-year-old tells the nurse, “Everyone does it, so it’s all right,” to justify rule-breaking behavior. The nurse realizes that this is an example of which level or stage of moral reasoning development as described by Kohlberg?
a. preconventional
b. conventional
c. postconventional
d. autonomous

Answer 102

b. conventional.

Level two, stage three behaviors of Kohlberg’s conventional level of moral reasoning focus on the approval of others. Moral dilemmas are solved by the group standard, with an emphasis on conformity. Adolescents usually function at this level of moral development. Before entering school, children typically function at the preconventional level, which is characterized by avoiding punishment and obeying those who have power. Typically, adults function at the postconventional, or autonomous, stage of moral development, which is characterized by defining moral values and understanding that correct behavior is determined by society.

Question 103

At a home visit, the nurse assesses a neonate born vaginally 5 days prior. The infant was born at 41 weeks’ gestation. Which finding warrants further assessment?

a. frequent hiccups
b. loose, watery stool in the diaper
c. pink papular vesicles on the face
d. dry, peeling skin

Answer 103

b. loose, watery stool in the diaper.

A loose, watery stool in the diaper is indicative of diarrhea and needs immediate attention. The infant may become severely dehydrated quickly because of the higher percentage of water content per body weight in the neonate, compared with the adult. Frequent hiccups are considered normal in a neonate and do not warrant additional investigation. Pink papular vesicles (erythema toxicum) on the face are considered normal in a neonate and disappear without treatment. Dry, peeling skin is normal in a post-term neonate.

Question 104

The parents of a child with a tracheoesophageal fistula express feelings of guilt about their baby’s anomaly. Which approach by the nurse would best support the parents?
a. helping the parents accept their feelings as a normal reaction
b. explaining that the parents did nothing to cause the newborn’s defect
c. encouraging the parents to concentrate on planning their baby’s care
d. urging the parents to visit their newborn as often as possible

Answer 104

a. helping the parents accept their feelings as a normal reaction.

The parents of children born with defects often have feelings of guilt and ask what they might have done to cause the condition or how they might have avoided it. It is important to allow parents to express their feelings and accept these feelings as normal reactions. Explaining that the parents are not at fault would not be appropriate until they have dealt with their feelings of guilt. Encouraging long-term planning generally is of little benefit to parents who are emotionally distraught. Additionally, the parents may interpret this as ignoring their feelings and confirming that they played a role in causing their child’s anomaly. Urging the parents to visit their infant as often as possible would generally be of little help and could appear to the parents as though they are being “talked out” of their feelings.

Question 105

A coworker confides in the nurse that they had been a lifelong friend of a client who committed suicide. The coworker states: “We just saw each other last week. I can’t believe they killed themselves. They told me they wanted to give me their expensive necklace because our friendship meant so much to them. They seemed really happy and content. I knew they’d been feeling down the last few months. I should’ve known that something was wrong; I should’ve asked them about suicide.” The nurse determines the coworker is most likely experiencing which problem?

a. secondary traumatic stress
b. a boundary violation
c. compassion fatigue
d. moral distress

Answer 105

d. moral distress.

Moral distress occurs when one is unable to act because of internal or external constraints. The nurse is not able to change the way they interacted with their friend the last time they saw them and is feeling anguish.
Secondary traumatic stress is distress that is a result of hearing first-hand traumatic experiences from another person.
A boundary violation is behavior by a professional that has violated the limits of a professional–client relationship.
Compassion fatigue is disengagement on the part of the caregiving professional.

Question 106

The nurse is caring for a client experiencing panic post fireworks display over the holiday weekend. The client routinely takes a prescribed dose of alprazolam 1.5 mg p.o. t.i.d. An additional PRN dosage is also prescribed as 1.5 mg p.o. every 4 hours. The maximum daily dose is 8 mg. How many additional doses of the PRN medication might the client take safely?

Answer 106

The client would have a regularly prescribed dose of 1.5mg X 3 (tid)= 4.5mg. The client only has 2 doses or 3 mg possible to remain under the maximum dosage cap.

Question 107

A 17-year-old adolescent with a history of muscular dystrophy is admitted with aspiration pneumonia. The client’s medical history reveals that this is the third time in the past 6 months that the client has been diagnosed with pneumonia. Which topics should the nurse plan to address for teaching?
a. need to avoid crowds and large gatherings
b. need for good hand hygiene
c. need for a feeding tube
d. need for an advance directive

Answer 107

c. need for a feeding tube.

As muscular dystrophy progresses, the client becomes more susceptible to aspiration due to progressive decreasing ability to clear secretions and muscle weakness. A feeding tube will prevent problems with dysphagia resulting in aspiration. Avoiding crowds and hand hygiene might be a part of the overall teaching but are not a priority. All clients should be instructed regarding the need for an advance directive.

Question 108

A client with a history of obesity has come to the clinic seeking help to improve their health and prevent further weight cycling. When developing the care plan, the nurse should point out which factor to best assist this client?

a. identifying the client’s internal and external cues related to eating
b. referring the client to a nutritionist
c. explaining the health risks of being obese
d. suggesting a weight-loss management program

Answer 108

a. identifying the client’s internal and external cues related to eating.

If a client has lost and gained weight several times, identifying and recognizing internal and external cues related to eating would be the most important factor in stopping this process of weight cycling. Reinforcing the health risks of obesity would not be necessary as the client has proactively sought out care for weight management. A weight-loss management program and working with a nutritionist may be part of the care plan, but identifying the root causes of why past weight management has not worked would be the priority.

Question 109

The nurse is providing postsurgical care for a client who experienced a fall-related hip fracture. The client states, “The health care provider said I should quit smoking and that smoking can affect my ability to heal after this surgery. I don’t understand how my smoking matters that much.” Which response(s) by the nurse would be appropriate? Select all that apply.

a. “Smoking puts you at a higher risk for experiencing infection, which is already a potential complication after having surgery.”
b. “Not being able to smoke while in the hospital can affect your mental health status and put you at a higher risk for suicidal thoughts.”
c. “Your incision may not heal as quickly as in a client who does not smoke because smoking results in delayed healing.”
d. “Smoking typically affects a client’s motivation to regain functional ability following a surgical procedure.”
e. “The provider wants you to quit smoking for your overall health, but it doesn’t really affect your current postsurgical situation.”

Answer 109

a. “Smoking puts you at a higher risk for experiencing infection, which is already a potential complication after having surgery.”
c. “Your incision may not heal as quickly as in a client who does not smoke because smoking results in delayed healing.”

Complications associated with the physiological effects of nicotine may include an increased risk related to impaired heart and lung function, increased risk for infection, and potentially delayed wound healing. The nurse may offer the client a nicotine patch when they are admitted to the hospital to help provide some nicotine to the client and minimize cravings. While not smoking during hospitalization may affect the client’s overall mood, the client is not likely to be at a higher risk for suicidal thoughts. Smoking will not have an impact on the client’s motivation to regain functional ability after surgery.

Question 110

When approaching a family to discuss organ or tissue donation, a nurse should be mindful of which guideline?
a. Approaching a family can only take place with a health care provider’s approval or a written order.
b. Families may not be ready to participate in the discussion but it is necessary to discuss it with them given the limited amount of time for donation.
c. The requester may educate family members about brain death early in the organ donation process.
d. The facility should provide the family with an opportunity to speak with an organ procurement coordinator.

Answer 110

d. the facility should provide the family with an opportunity to speak with an organ procurement coordinator.

The facility should offer the family an opportunity to speak with an organ procurement coordinator who is knowledgeable about organ donation and who should have exceptional interpersonal skills for dealing with grieving family members. Health care provider support in the process is desirable but referral to the organ procurement organization does not require a health care provider’s consent or written order. The requestor must believe in the benefits of organ donation and support the process with a positive attitude. The possibility of speaking with an organ procurement coordinator should be introduced only after the family has been made aware of the client’s condition and prognosis. Approaching a family member who believes there’s still hope for recovery will likely result in a negative outcome.

Question 111

An older adult client comes to the clinic for an evaluation. The client tells the nurse, “Over the past year or so, I noticed that I’ve had to turn up the television a bit louder. And my family says that I’ve started talking louder when they’re around. It seems like my left side is worse than my right.” The nurse conducts a hearing screening based on the suspicion that the client may be experiencing presbycusis. Which finding would support the nurse’s suspicion?

a. A Weber test reveals sound lateralizes to the left ear.
b. A Rinne test shows air conduction longer than bone conduction.
c. Electronystagmography indicates vestibular dysfunction.
d. Otoscopy reveals otitis media.

Answer 111

b. A Rinne test shows air conduction longer than bone conduction.

Presbycusis is the most common type of sensorineural hearing loss and is a gradual loss of hearing in both ears occurring during the aging process. Based on the client’s report, the left ear seems worse than the right ear. Therefore with the Weber test, sound would lateralize to the nonaffected ear, which in this case would be the right ear (less affected than the left). If the hearing loss was conduction, the sound would lateralize to the affected (left) ear. With the Rinne test and sensorineural hearing loss, air conduction sound is heard longer than bone conduction sound. Vestibular function is not involved with presbycusis, so electronystagmography would not be indicated. Infection also would not be a finding suggesting presbycusis.

Question 112

If a client’s central venous catheter accidentally becomes disconnected, what should a nurse do first?
a. Call the health care provider.
b. Apply a dry sterile dressing to the site.
c. Clamp the catheter.
d. Tell the client to take and hold a deep breath.

Answer 112

c. clamp the catheter.

If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp. If a clamp isn’t available, the nurse may place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension set and restart the infusion. Calling the health care provider, applying a dry sterile dressing to the site, and telling the client to take a deep breath aren’t appropriate interventions at this time.

Question 113

A client with acquired immunodeficiency syndrome (AIDS) is ordered zidovudine, 200 mg P.O. every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?
a. “Take zidovudine with meals.”
b. “Take zidovudine on an empty stomach.”
c. “Take zidovudine every 4 hours around the clock.”
d “Take over-the-counter (OTC) drugs to treat minor adverse reactions.”

Answer 113

c. “Take zidovudine every 4 hours around the clock.”

To be effective, zidovudine must be taken every 4 hours around the clock. Food doesn’t affect absorption of this drug, so the client may take zidovudine either with food or on an empty stomach. To avoid serious drug interactions, the client should check with the health care provider before taking OTC medications.

Question 114

The nurse is receiving a client from the postanesthesia care unit after a splenectomy. After obtaining vital signs, what information should the nurse obtain next?
a. the presence of nasogastric drainage
b. the amount of urine drainage from the urinary catheter
c. the presence of blood or drainage on the dressing
d. the client’s pain level

Answer 114

c. the presence of blood or drainage on the dressing.

After a splenectomy, the client is at high risk for hypovolemia and hemorrhage. The dressing should be checked often; if drainage is present, a circle should be drawn around the drainage and the time noted to help determine how fast bleeding is occurring. The nasogastric tube should be connected, but this can wait until the dressing has been checked. A urinary catheter is not needed. The last pain medication administered and the client’s current pain level should be communicated in the hand-off-of-care report. Checking for hemorrhage is a greater priority than assessing pain level.

Question 115

A nurse has been called into a room by another nurse to assist with a client who is acting provocatively and overly dramatic. What action is most important for the nurse to take to assist the client in receiving appropriate care during this visit?
a. Communicate in a way that models the expected behavior of the client.
b. Ask the client if they have thoughts of suicide or a plan for dying.
c. Conduct a survey on the frequency of attention-seeking behavior by the client.
d. Listen to the client, and engage in meaningful heartfelt conversation.

Answer 115

a, communicate in a way that models the expected behavior of the client.

Clients who are displaying symptoms of histrionic personality disorder need to have appropriate communication modeled for them. Therefore, the nurse should use that approach to assist in the client receiving appropriate care. The nurse will assess the client for risk for suicide, but this is not the priority for this client. Understanding the frequency of attention-seeking behavior will be a piece of the assessment for this disorder, but it is not the priority for this exchange to occur. When engaging in a therapeutic relationship with a client, the nurse should actively listen to the client regarding their health care but does not need to necessarily engage in conversations that are meaningful and heartfelt.